Pain Killers in the NFL: What You May Not Know

It's a dark issue, the "dark side of sports". We hear that term used all the time when the issue of painkillers and steroids in pro sports are brought to light. We read the skewed statistics of NFL player pain killer use, the dangers of addiction and long-term health effects. And all the while the NFL as a governing body does nothing.

But is that really the truth of it?

Let's first take a moment to step back and look at the current state of the league. We're looking at a limited pool of highly talented athletes, all doing whatever they can to land a (very exclusive) NFL roster spot or earn a guaranteed contract. You're talking about the livelihoods of men who have families, bills to pay, and all the things any of us have to deal with on a daily basis. So first put yourself in the shoes of one of these gifted individuals, and ask yourself what you would do to succeed. What we're talking about today isn't about HGH or Anabolic Steroids (though from the way it's pushed to the public one could hardly tell the difference); we're talking about measures taken to mitigate pain in a league where it is a given, and a society where pain management is the most misunderstood and stigmatized medical specialty in existence.

I will do my very best to be impartial in this discussion, for that is the vital aspect of any valid debate. I have had the opportunity to see both sides of this ongoing issue, brought to light yet again in the latest suit filed by former NFL players against the league concerning the negligence that caused them to endure long-term health effects and "blame" for becoming addicted to pain killing medications. I have seen former pro athletes come and go in the doctor's office, and their variety is as much a factor to consider as any. To really have an educated discussion, we must first define exactly what it is we're speaking of; and the importance of that cannot be understated since it in itself is so often misunderstood by the public at large.

The Difference Between Addiction and Dependence

There are numerous schools of thought on the mechanism of addiction. Most forward-thinking addiction specialists are gravitating towards a congenital factor playing the major role in addiction; that is, some individuals are born with greater tendencies toward addictive behavior or "addictive personalities". Think of it like a light switch; once its turned on, it's almost impossible to shut off again. This is the nature off addiction. It is this theory that holds that the substance of abuse is largely irrelevant, and that such persons are more susceptible to become addicted to any substance. Modern medicine tests for this personality trait with the implementation of exam questionnaires like the SOAPR.

Most of the confusion surrounding addiction, at least in the eyes of the public, is that it is mixed up with dependence. Whether you like it or not, dependency is a physiological reaction to any substance the human body encounters. While the degrees vary greatly depending on the substance in question, the human body will develop dependence on just about anything it regularly is exposed to. In this case, pain killers cause a dependence in it's users, made greater as the dose and frequency increases. In the same mechanism the body will develop to blood pressure medication like Lisinopril, persons will undergo a withdrawal if they suddenly stop usage. The same is true of alcohol, tobacco, etc. This process takes only a few days of usage from pain killers to begin. The withdrawal from pain medications is NON-LETHAL, less than can be said of alcohol or benzodiazepines. This is dependence at it's core. It is not the same thing as addiction.

The next thing we need to define is the mechanism of action and effects, good and bad, of the drugs in question.

Pain Killers

Just as pain management as a specialty is misunderstood, no medications face such a stigma as pain killers. In the media, they are lumped together and viewed with the same scrutiny and notoriety as illicit street drugs. For the sake of this article, and for the fact that I don't have enough time or space to go into great depth, let's take a quick crash course on these medications. They can be separated into several easy to define categories.

Schedule II - These are your "strong-agonist" pain medications. These include your Oxy and Hydromorphone, etc, better known by their brand names of Oxycodone and Dilaudid, as well as your straight morphine tablets. These kinds of medications are prescribed for severe pain, and usually we are talking about inside hospitals after horrific car wrecks, malignant cancer pain, and post lumbar surgery type situations, to name a few.

Schedule III - These are the drugs in question (for the most part), your "weak-agonists". These include Vicodin, Lortab, and Norco (Hydrocodone-Acetaminophen combos), Vicoprofen (Hydrocodone-Ibuprofen combo), and drugs like Buprenorphine (which is used for pain treatment and alcohol/substance abuse patients).

These schedules are based on addiction potential, thus, your schedule I's include illegal drugs like Ecstasy and Heroin. The Vicodin prevalence in the NFL is not a surprise, and it's not unique to the league either.

Since 2010, many new laws regarding the governance of pain killing medications have been enacted and enforced by the DEA, who have and still are weeding out "bad doctors," those who were the source of pill mills that led to the boom of prescription drug addiction in the US over the past several decades in the first place. We are subjected to statistics claiming higher death tolls on pain medication overdose than illegal street drugs, without looking at the relative availability of both of these categories of substance, you are missing the boat entirely.

The new restrictions were far easier on weaker medications like Vicodin than they were on the Schedule II's. This, coupled with the readily available supply and low price tag, make it a favorite of senior citizens and NFL players alike for treatment of their pain.

So what long-lasting effects are players referring to when they talk about these medications? The primary concern of Vicodin lies not in the pain killing agent itself, but in the acetaminophen component. When taken even at normal doses (3 to 4 a day maximum), the liver can be overtaxed, considering each tablet contains around 300-350mg of Acetaminophen. Over time, this can cause long-standing liver conditions. The same applies to the Ibuprofen combo medications, except that they take their toll on the kidneys instead. The pain medications the players decided to take on their own volition have few long-lasting medical effects on the body, far less than concussions for instance.

Non-Acute Anesthesia and Toridol

Toridal is always mentioned when this topic arises, so let's address it. Toridol is non-narcotic drug used for anti-inflammatory purposes usually in post op care. NFL players were lining up pre-game for Toridol injections to numb the pain they anticipated enduring during the upcoming game, like a super-ibuprofen. But the blood thinning nature of this drug, like any anti-inflammatory medication, causes concerns regarding concussion risk and long term kidney damage, and is being all but phased out of NFL locker rooms. It's also worth noting that Toridol is not addictive in it's nature.

Another issue has been the use of local anesthesia pre-game to numb the body to pain, especially in painful joints. In this regard I would question the ethics of the performing physician. This type of anesthetic, along with any pain medication or treatment, is not to be used in a prophylactic fashion; it is used to treat pain when it's there; not in anticipation of. Leading NFL physios have echoed this very sentiment, and while the NFL's physician board have very little if any authority, their code of ethics is governed by the same boards that monitor physician licenses nationwide.

Lastly, before we move on; I would like to explain the differences between steroid injections. The media likes to lump these together as well, which is inherently misleading. There are few similarities between anti-inflammatory steroids like Cortisone and anabolic varieties used to build muscle. If administered in the accepted protocol, anti-inflammatory steroid injections (like Cortisone, Prednisolone, etc) have clinical proof of effect, and very few if any long term side effects. Beyond this, their use has been overblown by a media who doesn't understand what they do. Players with serious injuries would not be treated with steroid injections anyway due to their inherent (and temporary) immunosupression, which delays healing.

The NFL

So where does the league stand at the present time? And better, yet, where do you? There have been slews of reports coming forward every so often about the rampant use/abuse of pain killing medications being used at the pro football level. But there is a real dearth of bipartisan evaluation, and of education on pain management in general.

The suits brought forth by players have their merits, as pointed out by basically every journalist that's broached the subject. You have long-term addiction potential to consider, increased risk of concussions (with Toridol), and the long-term implications of heavy NSAID (Non-Steroidal-Anti-Inflammatory) use. However, I think there is a severe lack of accountability on behalf of the players that is being overlooked for the sake of posterity. Individuals are quick to blame the league, but less so to take responsibility for their own actions.

The crackdown, which has already been in full effect, has been on the issue of team's dispensing painkillers, intended or not, on site, which is illegal in the United States and most all Western Nations. New Orleans Saints coaches, Joe Vitt and Sean Payton were named in a sizable investigation of the team in 2010, where he Vitt was seen on multiple occasions via security camera accessing a cabinet in the trainer's room and taking handfuls of Vicodin out as he pleased. SI did a fairly good job in going into detail. One thing I would, for all sake of sanity, push towards the NFL and it's franchise members; is a stop to the dispense of any and all narcotic medications on-site. It's illegal in the rest of the country for a reason, and to obtain them anywhere but the prescription of a legitimate physician's office is to invite abuse.

The NFL may not have punished the Saints to the degree which some would like, but it is more active in pursuing these illegalities than the media would have the public believe; the image they pervade of the aloof giant of industry that cares for nothing but the bottom line. The NFL certainly are paying attention, so they can protect their wallets. The massive concussion suit that went through the ringer last year was impact enough for the league to take medical concerns seriously. Regardless, the truth of the matter is that NFL teams and their owners, need to be held to a higher standard, and stop passing the buck to the league.

You hear very little regarding the arrest of Colts owner Jim Irsay, which was only recent. The charges placed upon him would incur the wrath of the NFL if it had been a player. We would be talking about suspensions, fines. Instead, we've heard relatively nothing about it, and Irsay was allowed to oversee the draft process, OTA's, etc, without any apparent ramifications.

More than a handful of studies have revealed that players themselves were the ones requesting painkillers in the first place, not the team doctors or coaches. The players know the risks that come along with any medication. Just look on the flip-side of your bottle of Tylenol and you'll see for yourself the side effects.

The most recent NFL suits bring to light the increased rate of opioid (narcotic) use of NFL players (ca. 7%) vs the general public (less than 2%). This is akin to comparing apples to oranges. I can personally guarantee that the public at large, if introduced to the contact vigors of professional football on a daily basis, would take some kind of pain reliever. I don't think there can be any serious debate about that. Beyond this the NFL has shown serious signs of becoming stricter regarding the policies of injury lists, and indeed many league physicians have stated plainly that they refuse to treat any unlisted injuries, or prescribe painkillers to a player not on the weekly injury report. There are steps the league is taking to make teams more accountable for listing player injuries, making sure officials and teams alike are taking the proper precautions for concussions as well as players returning from injury, and the appropriate testing of players for substances not on their approved list. All these progressions have been swept under the rug by a contingent of former players and media blitzers who single out the league as an easy scapegoat.

Like any governing body, the NFL should certainly be subject to the same rules as the rest of the nation regarding medical policy and the jurisdiction of Doctors and the law. But in that case, the same applies to both the players and the teams, especially physicians on NFL franchise retainers.

NFL players are humans, and with that they carry the same tendencies concerning addictive personalities and all the myriad medical conditions that can arise. The fact that players are exposed to painkillers at a higher rate than the general public is reason alone that the rate of their use in the NFL are much higher. Still, the image of "every player in the NFL is on painkillers" survives, and it couldn't be more false, that is, unless you're counting NSAID's as painkillers. In that scenario just about every physical laborer in the US is "hooked".

In the end of the day, of course pain killers can be dangerous if used inappropriately, as with practically any drug. But to blame the NFL at large for their use is ignoring the bigger picture. Ultimately, my goal is simply to bring to light the general misunderstanding of pain management and pain medications, especially as it relates to players and teams at the pro level. While ideal treatment of pain centers around the tenets of physical therapy and interventional treatment (like injections and nerve blocks), pain medications have their uses, those that shouldn't be demonized because they are not understood.

I'l leave you to be the judge of the NFL's role in all this. But we should all take it upon ourselves to be educated before we blast the league for any and all issues that arise from this physical game we all know and love.