There was a notable face missing at last fall's Ironman 70.3 World Championships in France. Instead of racing as expected, American Lauren Goss, 31, who had a string of wins at the distance and was feeling fit and ready to compete, was stuck on the sidelines. She'd been banned from competition for six months, lost her main sponsor and is mulling retirement.

All because she used a topical cream containing CBD (cannabidiol) for pain caused by a stress fracture in her foot. There's a tiny bit of THC in almost all CBD, and the over-the-counter cream was no different, but Goss said she didn't think it would be enough to tip her to test positive.

"I didn't think twice about the cream and used it twice a day for months," she says. "I assumed it would take something like smoking a joint close to race day to turn up enough THC for a positive result. I was shocked."

Such is the gray area that surrounds the use of cannabis products by athletes.

With increasing numbers of states allowing recreational and medicinal cannabis use, and CBD oils, creams and tinctures sold in stores across the country and online, athletes of all types are testing the waters to see how the substance might fit into their regimens for training aches and pains.

The retired and active big-name professionals who have declared their use of, or are involved with developing or promoting a business around cannabis, include former NFL players, mixed martial arts fighters, golfers, Olympic athletes, surfers and hockey players.

Until recently, the U.S. Anti-Doping Agency (USADA) and the World Anti-Doping Agency (WADA) disallowed any type of cannabis use among pro athletes. Both, however, have changed their list of banned substances in the past few years to make an exception for CBD — provided it has no more than a specified tiny amount of THC, the psychoactive component in cannabis that provides a "high" for people.

Despite its popularity, research is largely unclear on the effects of CBD for pain, stress and other conditions. The Food and Drug Administration has approved the use of CBD to treat only a rare, severe form of epilepsy, but for no other uses so far. It warns that some CBD products are being marketed with "unproven medical claims" and some may contain unhealthy contaminants.

The FDA recently released a statement that said it "recognizes the significant public interest in cannabis and cannabis-derived compounds, particularly CBD. However, there are many unanswered questions about the science, safety, and quality of products containing CBD."

Many athletes, however, have already reached their own conclusions.

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Floyd Landis is best known for his 2006 win at cycling's biggest race, the Tour de France, and subsequent disqualification for using performance-enhancing drugs. Of late, Landis is making headlines for his cannabis business that he launched in 2017.

Landis says he became interested in cannabis as a pain reliever after developing an addiction to opioids following hip surgery. A resident of Colorado when that state legalized marijuana products, he began experimenting with them to see if they might help.

"It's not something I was exposed to as an athlete, but it was effective in allowing me to wean off opioids," he says. "Now I use CBD daily as a pain reliever."

He says many athletes prefer "natural" alternatives for pain relief, and cannabis has an appeal for that reason. "Oftentimes, what limits athletes' progression in sport is pain," he says. To them, "cannabis appears relatively safe with few adverse side effects."

Landis acknowledges the lack of data about the medical uses of CBD. "Right now, it's mostly anecdotal," he says. "Topical products are popular with people who want to treat localized pain."

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Joanna Zeiger competed as a triathlete at the 2000 Sydney Olympic Games and in multiple Ironman and 70.3 World Championships. Today, at 49, she's an epidemiologist who studies cannabis. She says she became interested in the topic through her own experience using cannabis to deal with severe nerve pain resulting from a career-ending bike crash defending her title during the 2009 Ironman 70.3 World Championships.

After the crash, she suffered constant muscle spasms, nausea and insomnia. Zeiger was reticent to turn to cannabis because it had been on the USADA/WADA banned substance list. She was also leery of it because of her research at the University of Colorado at Boulder on drug use and abuse in adolescents and young adults. She finally relented at her husband's urging.

"It's been tough to find medicines I could tolerate — many had difficult side effects," she says. "But due to the stigma surrounding cannabis, I was hesitant to try it. It didn't occur to me that cannabis had a medical purpose."

She began with small doses of edibles — legal in her home state of Colorado — and found relief from both pain and nausea, along with better sleep.

"It was life-changing," she says. "But figuring out what dosages to take and when to take it was difficult. There wasn't much information out there. I had to do a lot of experimenting."

She became interested in learning how common cannabis use was among athletes and how it was being used. Through social media and email blasts, the Canna Research Group that Zeiger runs distributed a survey to 1,274 adult athletes, asking whether and how they used CBD and THC-containing products.

Not surprisingly, younger athletes tended to use THC and CBD products for recreational purposes, while athletes over 40 skewed more toward medicinal CBD use. Overall, however, "About 61% of the athletes indicated they use cannabis for pain, with 68% saying that cannabis improved their pain," Zeiger reports, "There were no differences in pain relief by age, but younger athletes reported better sleep and less anxiety with cannabis use than older athletes."

A recent meta-analysis, published in the Journal of the American Pharmacists Association, found that "cannabis and cannabinoids via certain routes of administration, could reduce [certain] kinds of pain." The review pointed out, however, that more studies are needed to "characterize the effects and routes of administration on analgesic safety and efficacy."

Zeiger acknowledges that more research is needed and hopes to find funding to support that. She would like her next study to focus on disease populations and how they use cannabis for relief to determine the efficacy and safety of cannabis for various health conditions.

Goss, meanwhile, hopes USADA and WADA will re-examine their usage rules for professionals like her.

"It's legal out of competition but not during, except for CBD," she says, "but if you're using a combo, the THC gets stored up in your body. I think the organizations need to make it legal or illegal at all times. It can't be something in between."

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