T. LOUIS - Retired NFL players misuse opioid pain medications at a rate more than four times that of the general population, and new evidence suggests that is occurring because players misused the painkillers during their NFL careers, according to a study published online in Drug and Alcohol Dependence, a peer-reviewed, scientific journal.
The study, conducted by researchers at Washington University in St. Louis School of Medicine, is the first of painkiller use and misuse by former NFL players. Directed by Linda Cottler, a professor of epidemiology in Washington University's Department of Psychiatry, the study was commissioned by ESPN, with additional funding provided by the National Institute on Drug Abuse, a division of the U.S. Department of Health and Human Services.
"This is important because of the public health implications for players of sports all over the world," Cottler said of the research.
"Clearly, this study indicates we're not doing enough to care for our wounded and impaired athletes," said Dr. Wilson Compton, who served from 1995 to 2002 as a treating clinician in the NFL's substance abuse program and is now division director for NIDA.
• 52 percent of the retired players said they used prescription pain medication during their playing days. Of those, 71 percent said they misused the drugs then, and 15 percent of the misusers acknowledged misusing the medication within the past 30 days.
• Those who misused prescription painkillers while playing were three times more likely to misuse the drugs today than those who used the pills as prescribed while playing.
• 63 percent of the retired players who used prescription pain pills while playing obtained the medications from a nonmedical source: a teammate, coach, trainer, family member, dealer or the Internet.
Dr. Eric Strain, Drug and Alcohol Dependence editor-in-chief and director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins Center for Substance Abuse Treatment and Research, called the study results "important" and "valuable."
"I think it brings together two topic areas that carry a lot of weight in our culture today, that is sports and drug abuse," Strain said. The print edition of his journal will publish the research within three months.
Dr. Lawrence S. Brown, the NFL's medical adviser for substances of abuse, cast doubt on the research: "It is scientifically flawed to compare the general population with athletes, active or retired."
For the past 18 months, ESPN's "Outside the Lines" has examined the degree to which current and former NFL players use and misuse prescription pain medications. Through the review of numerous civil and criminal court cases and interviews with dozens of sources, including past and present NFL players, past and present NFL team physicians, drug counselors, substance abuse researchers, law enforcement officials and others, a clear picture emerges: NFL players are vulnerable to the addictive strand of painkilling drugs known as opiods.
The central component of ESPN's reporting is a first-of-its-kind study, commissioned by ESPN and conducted by researchers at Washington University, and published in the peer-reviewed, scientific journal Drug and Alcohol Dependence. That study, also partly funded by the National Institute on Drug Abuse, provides scientific data about the way former NFL players manage pain and the manner in which they use and misuse prescription painkillers to cope with it. The study: (subscription required).
Click for the NFL medical adviser's response.
Brown said comparing retired NFL players to the general population is like "comparing apples to oranges" and added that former NFL players understandably would be more susceptible to the misuse of painkillers simply due to their increased exposure to the drugs during their playing days.
"In the NFL and all sports, part of employment includes relief of pain because of the prevalence of injury," Brown said. "If you don't have the exposure, you're less likely to misuse."
Compton said comparing NFL players to the general population is valid.
"There's almost nothing that's exactly like a professional athlete so I'm not sure what the proper comparison is," Compton said. "I don't think it's scientifically flawed. We need to put it in some context."
From March to August 2010, Cottler's research team interviewed 644 former NFL players by telephone. The players who participated in the research retired from the NFL between 1979 and 2006, played an average of 7.6 seasons, and averaged 48 years in age. Researchers asked them a series of questions about their health, pain levels, NFL-related injuries and their use and misuse of prescription painkillers and other substances.
When asked about their prescription painkiller use within the past 30 days, 7 percent of the retired players surveyed said they either used more prescription pain medication than prescribed by their doctors, used the medication without a prescription at all, or both.
"That's a very large number in a population that, at that age, we wouldn't expect to see much use of these substances at all," Compton said. "Most typical 30- and 40-year olds aren't taking pain relievers, and they're not misusing them, so that's a much higher than expected rate."
The rate of current misuse of prescription pain medications within the general population age 26 and older is 1.6 percent, according to data from the National Survey on Drug Use and Health, an assessment conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the federal Department of Health and Human Services. The rate of misuse within the past 30 days for men older than 26 is 2.5 percent, according to the latest SAMHSA drug survey.
"[The former players] are three times as likely as men their age in the general population to be misusing prescription opioids right now. I think that's a lot," Cottler said.
The NFL's Brown said that drug-use statistics for the general population tend be artificially low because surveys typically do not include high-risk populations like prisoners or the homeless.
The Washington University study also focused on the retired players' past prescription drug use, including the period of their NFL careers.
Opioids are synthetic versions of opium. They have the ability to reduce pain but can also suppress breathing to a fatal degree when taken in excess. Examples of opioids are oxycodone (OxyContin®), hydrocodone (Vicodin®) and methadone. There has been at least a 10-fold increase in the medical use of opioid painkillers during the past 20 years because of a movement toward more aggressive management of pain. Because opioids cause euphoria, they have been associated increasingly with misuse and abuse.
Source: "Unintentional Drug Poisoning in the United States," a report by the Centers for Disease Control and Prevention
When asked about their prescription painkiller use while playing in the NFL, 52 percent of the retired players said they used prescription pain medication then, while 48 percent said they never used the drugs while playing. Of the players who said they used prescription painkillers while in the NFL, 71 percent admitted misusing the drugs, and 15 percent admitted to misusing prescription pain medications within the past 30 days.
Researchers found retired players who misused prescription painkillers while playing in the NFL were three times more likely to misuse the drugs today than those who used the pills as prescribed while playing.
"That's pretty amazing that misuse now is determined by whether [the former players] misused while in the NFL," Cottler said.
"People will often continue to use drugs for reasons that are different than the reasons that they started using them," said Strain. "My concern would be that these players start using these drugs for pain-relieving purposes but then could find that they're unable to function without the use of these drugs."
Dan Johnson, who played tight end for the Miami Dolphins in the mid-1980s, said he became addicted to painkillers after two back surgeries that were necessary because of injuries he suffered as a player.
"I was taking about a thousand Vicodins a month," he said. "You know, people go 'That's impossible. You're crazy.' No, that was exactly what I was taking."
He said he acquired the drugs through acquaintances, over the Internet and from overseas shipments.
He broke so many bones during his playing days that teammates called him "The King of Pain." Yet his addiction to painkillers had him contemplating suicide.
"A few times," he said, struggling to control his emotions.
Johnson said he ended his addiction with the help of Suboxone, a narcotic used to treat opioid dependence.
The Washington University researchers found that 63 percent of the retired players who used prescription pain pills while playing in the NFL obtained the medications from a nonmedical source.
"The large number who took [painkillers] outside the supervision of their primary physician was very concerning," Compton said. "It tells us that we're not doing a good enough job of evaluating, treating and managing pain in these players. If they were getting good pain control they shouldn't be taking [painkillers] from other people."
Only a doctor who is a registrant with the Drug Enforcement Administration can dispense prescription pain medication, said Rusty Payne, a DEA spokesman.
Yet many current and former players interviewed by ESPN said it was commonplace for players to get prescription painkillers from sources outside of NFL locker rooms, either from unscrupulous doctors or drug dealers.
"I know guys that have bought thousands of pills. Tons of guys would take Vicodin before a game," said Kyle Turley, a former offensive lineman with the Saints, Rams and Chiefs, who was one of the 644 participants in the study.
According to the Washington University researchers, three main variables predicted the current misuse of prescription pain medications by retired players versus nonuse: significant pain, undiagnosed concussions and heavy drinking.
"We were shocked to learn that [current prescription painkiller] misuse is really associated with undiagnosed concussions, and heavy drinking," Cottler said.
Of those former NFL players who said they did not currently use prescription painkillers within the past 30 days, 8 percent had 20 or more drinks in that same period. Of the retired players who said they misused opioids in the past 30 days, 27 percent had 20 or more drinks in that same time period.
"There's a major concern that the risk of overdose and death is markedly increased if you're drinking on top of taking painkillers," Compton said. "That would be the No. 1 concern I would have. Some of these men are reporting very heavy levels of alcohol consumption."
"Mixing alcohol and pain pills, that's really scary," said Bob Newton, a former lead counselor at the Betty Ford Clinic in Rancho Mirage, Calif. Newton is also a former offensive lineman who played 11 years for the Chicago Bears and Seattle Seahawks.
In 1983, after his retirement, Newton said he successfully battled an addiction to alcohol and drugs during a stint in rehab. He began working in the chemical dependency field in 1986 and retired from the Betty Ford Clinic at the end of December.
"Taking pain medication and alcohol on top of it, that's where people overdose," Newton said. "I'd see that two to three times a year at the Betty Ford Clinic."
Newton said more than two dozen former NFL players had been through drug and alcohol counseling during his time at the Betty Ford Clinic and other treatment facilities.
"[Retired] players were at high risk due to their pain issues and disability issues," he said. Of the players who sought treatment, Newton said most were addicted to multiple substances, not just prescription pain medications.
The study found that moderate to severe pain proved to be a strong indicator of current painkiller misuse.
Of those players who reported no use of prescription painkillers within the past 30 days, 68 percent said they lived with moderate to severe pain. Of the players who misused the drugs, 96 percent reported experiencing moderate to severe pain.
The researchers found NFL-related knee injuries were the most common source of pain cited by the former players who said they currently misused prescription painkillers.
According to sources cited by the Washington University researchers, 26 percent of the general population suffers from some level of pain. But of the 644 former NFL players surveyed, 93 percent suffered some level of pain, and 73 percent described their pain as moderate to severe.
In terms of how they described their overall health, 88 percent of the retired players surveyed said they had excellent health before entering the NFL. Just 13 percent described their health as excellent at the time of the phone survey.
Strain, who wrote a commentary on the study for his publication, said the Washington University study is not without its limitations. He noted that the study's definition of misuse, for example, should be kept in the appropriate context. Misuse is defined as someone using more painkillers than prescribed, using them without a prescription or obtaining painkillers from a non-medical source.
"Misuse could be somebody who's misused on a very small number of occasions outside of a medical prescription," Strain said. "I think it's critically important to keep that in mind as this study is being considered."
On playing through pain
"The stress to play is high, even if injured! You don't complain because there is always someone to take your place if you don't perform. People don't understand the amount of stress that is put on players to play. So you play through your pain."
"It's what you have to do to play. You have to play through injuries. In last five years, I got a shot of Toradol before EVERY game. People keep playing because they're unsure of their future. They have little real career training and many players don't know what to do without football."
"Ninety-nine percent of the guys played when they would not have played if their jobs were protected. There was no job security and too much pressure to play. You could lose your job if you didn't play while hurt."
On opioid use
"To get meds, opioids, all players had to do was ask the team doctor and they would give medicines, no questions asked."
"They used to give us the pills. We didn't need a [prescription]. I had to take shots to play and after games they would dump three or four Percocets in my hands to take for the ride home."
"Back when I played, it wasn't as regulated. Whatever you needed, you got. If you were in pain, you got something. We didn't know what we were taking -- they just gave it to us."
"After every game, at least two of us had a concussion. It was part of everyday play. How are you going to monitor this? Players are not going to tell you they have a concussion. Concussions were at every practice and every game."
"It's a violent game. There are no helmets or pads that [are] going to change the average NFL career span of 3.2 years. I have respect for the game, but really, there's no protection. You want to win. I'm 55, and I worry about my short-term memory. I have to look at a name two and three times. I used to be pretty good with names. Now I worry what's going to happen with my head, especially with all the hype I've read about head injuries in the past 18 to 24 months."
"Back then, I wanted to play so badly I played nine hard years. I had a lot of concussion-type injuries, but I didn't tell anyone. I had amnesia that one time but didn't report it. It went away. I didn't have any lasting repercussions as a result of it."
Cottler noted that her research team did a separate analysis to determine the frequency of prescription painkiller misuse by retired players.
"We found that there were very few men who only did it once or twice," Cottler said. "Most of the people misused on a regular basis."
Strain said the Washington University researchers used what are widely considered to be accepted criteria for understanding levels of prescription drug use and misuse and that any limitations presented by the researchers' definition of misuse are "not unique to this study."
When asked for possible solutions, Newton said NFL players should be required to have screenings "to see the extent to which they are predisposed to the risk of addiction."
Strain said the only way for NFL officials to definitively know the extent of painkiller use and misuse by current players is to aggressively test for the drugs.
"That's why this is a useful study, because it suggests that maybe this is something [the NFL] should consider doing," Strain said. "At least consider doing it on a pilot basis and see what's happening."
The NFL's Brown said the league is aggressive in this area.
"The NFL has the most intrusive drug testing of any sport," he said.
Brown said the abuse of prescription pain medication falls under the NFL's substance abuse policy, and the league goes beyond federal workplace standards in its testing for the drugs.
"We are more likely to identify an individual who is abusing prescription pain medications so that increases the likelihood that they [the players] would not abuse it," Brown said.
Current and former NFL players told "Outside the Lines" that the NFL's focus on performance-enhancing drugs makes it easy to pass the league's scheduled test for street drugs (those same tests are also designed to detect prescription painkiller abuse). Players said they know about the annual test well in advance.
"We call it the IQ test, 'cause if you fail it, then you're stupid," one said.
NFL spokesman Greg Aiello said the players only know about the test within a four-month window -- that the test can come at any time during that period.
For NIDA's Compton, the study results are a reminder that more could be done to assist retired NFL players in pain.
"I think that a key message [for the NFL and NFL Players Association] is the importance of providing a comprehensive and thorough evaluation of pain and providing ongoing intervention early and after retirement," he said. "I don't know whether the league or the players' association has been aware of just how extensive these issues are."
A representative of the NFL Players Association declined to comment until he sees the full study.
For Cottler, the greatest cause for concern raised by the research is the data linking so many risk factors to the NFL-related pain experienced by the retired players who took part in the study: heavy drinking, undiagnosed concussions and misuse of prescription pain pills.
Of the retired players who admitted to misusing prescription painkillers within the past 30 days, 98 percent said they suffered from undiagnosed concussions compared with 79 percent of those players who did not currently use prescription pain medication.
"[The misuse] can lead to more serious problems, including overdose and addiction," Cottler said.
John Barr is a reporter in ESPN's Enterprise Unit. He can be reached through email firstname.lastname@example.org. Enterprise Unit producer Rayna Banks contributed to this report.
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