Well, it’s happened again. A USADA test at a New York cycling competition has again resulted in a sanction. This time it is Cesar Alberto Marte Arias who has tested positive for modafinil, which is essentially a stimulant (more on that below). By my count, this make USADA two for three when it comes to positives from in-competition testing in the area in the last two years. Many of you will remember the positive test of my former teammate David Anthony at the Gran Fondo New York just under two years ago. The subsequent tests at the GFNY the next year didn’t return any positive results, but the tests did give me the chance to share my pee and blood with the world.

What are we to make of USADA’s "winning percentage" in these tests? Is New York cycling a dirty cesspool of mutated monsters? Are the dopers being weeded out? Has USADA cannily targeted certain individuals? Does New York City water not only make tremendous bagels but does it also make one’s urine a colorful rainbow of illicit substances? To a certain degree, all of these things are true (Well, not the drinking water part, New York tap water is amongst the best drinking water in the country, it’s only when you come out here to Northern New Jersey that you can get drinking water with crunchy "flavor particles"). Yes, all evidence (positive test results) points to a certain percentage of New York racers "riding dirty" (How’s that for a timely reference?), but without testing every racer in New York, we cannot be sure of the percentage of racers that are clean and the percentage that are dirty. I do not think that the majority of racers are doping, but your guess is as good as mine when it comes to how many racers are racing with "extra help".

But all is not necessarily lost. If the testing is catching cheats, that means that the testing is working. Sure, it’s a bummer when riders get caught, but it’s better than those riders continuing their wily ways. That’s the cost of knowing the truth, and I’d rather know the truth than not know the truth.

And speaking of the truth, after Henry Francisco’s interview with Cesar, we heard some pretty familiar responses to Henry’s more pointed questions, so I enlisted the help of Dr. John Loehner (Medical Director at Montefiore Medical Center and Assistant Professor of Medicine at Albert Einstein College of Medicine) to get some more background on modafinil and Cesar’s allegations that perhaps a tainted supplement, a combination of supplements or the prospect of his body somehow producing modafinil naturally are the potential reasons for his positive test result. Here is Dr. Loehner’s response:

Modafinil is an atypical psychostimulant used for the treatment of sleep apnea syndrome, narcolepsy, and "shift work" sleep disorder. It’s also used for myotonic dystrophy syndrome, ADHD, excessive somnolence due to sedatives and opiates, and a few other conditions.  It’s atypical because it doesn’t work in quite the same way as other stimulants like Ritalin and amphetamines.  We don’t really know the exact mechanism but the current predominant hypothesis has it affecting dopamine levels in specific areas of the brain (different from known the known mechanisms of typical stimulants).  It’s metabolized by the liver and excreted via the kidneys.  It has a 15hr half life once ingested and gets broken down into modafinil acid which is what is found in the urine and picked up by testing. The metabolized acid form can be detected in urine for up to 2-3 days after ingestion. The unmetabolized form (some always makes into the urine) is only detectable for about 10hrs after ingestion. The urine assay for the acid is very good, a high specificity with a VERY low chance of getting a false positive.  There is no real cross reactivity with the test, meaning there are no other known substances that can react with the reagents used for it. A main reason for the high specificity.

There was a 2004 study of 15 healthy males done over the course of 5 weeks evaluating heart rate, time to exhaustion, and perceived effort with a control arm (no pills), a placebo arm (sugar pill), and a modafinil arm. It was a small study and it hasn’t been repeated but it showed a statistically significant improvement in all 3 parameters in the modafinil group. The medication has been used for performance enhancement in athletic competition for at least 10 years, particularly in sprint events in track and field. It is a banned substance by every athletic body and has no TUE status.  

Unlike clembuterol, which is used in the Chinese beef producing  cattle industry (I’m not inferring that Contador, and others who tested positive for this are innocent, just pointing out that for some substances, there may be confounding factors) I don’t know of any nonprescription product that uses or is produced in the same factory line as modafinil.  The likelihood of accidentally ingesting the substance is statistically negligible. It just isn’t plausible. This is also not a naturally produced molecule in the human body, nor are there precursors for this that are naturally produced and through some genetic quirk made into modafinil in vivo. It’s completely synthetic.

The positive test in this case, as in most, is disheartening and disappointing. One can certainly argue the efficacy of the drug regarding athletic performance—the study quoted above is not the final word on the subject and there is always the individual’s own physiology and biochemistry that influence the final effect.  However, for me, it’s not necessarily the end physiologic result that is at heart here, it’s the intent. Knowing the science and statistics of this, the only plausible way it was detected in his urine is if it was intentionally and knowingly taken. (Excluding outside sabotage or gross mishandling of the specimen. I’ve been tested and the current standard process is quite secure albeit not perfect.)

Hope this helps to bring some clarity. The emotional, cultural, and legal aspects of this are a different ball of wax and much more complex.

Dr. Loehner writes in the carefully (and rightly so) measured tones of a scientist, but I, on the other hand, am not a doctor, so I can be more blunt. Simply put, the test is solid, modafinil has been shown to have performance enhancing characteristics (although that’s debatable), they don’t make modafinil in the same places they make supplements, there’s no way you ingest Modafinil by accident, and if you produce modafinil naturally in your body, you are an android.

The modafinil was in Cesar’s body. It’s highly unlikely for a supplement to get tainted by modafinil (although many supplement companies are in all likelihood run by actual circus clowns, they are not the sort of clowns who also moonlight to produce prescription drugs), and there’s no combination of supplements that will magically turn into modafinil in the body. His excuses do not hold the slightest bit of water, but I cannot compel him to change his story. If he wants to claim he doesn’t know how the modafinil appeared in his urine, that’s his choice. We in the cycling world have heard all of these excuses before, and almost none of them have been true. Cesar has both science and history against him in this matter and it will take some extraordinary proof to support his claims, and if he has that proof, by all means he should share it.