NFL medical adviser's statement about published Washington University study

Statement from Dr. Lawrence S. Brown, NFL medical adviser:

"Undeniably, prescription abuse continues to be major public health problem in the United States. Publications that place this issue in the context of its significance to the public health of Americans are especially worthy. In this respect, the publication by Cottler et. al. has mixed results.

On the one hand, the focus of the article is upon retired athletes of America's most popular sport and the timing suggests an effort to direct the attention of Americans to a problem that should be substantially of greater concern to all Americans since many more non-athletes, by unintentional and intentional behaviors, contribute to the harm associated with prescription drug misuse/abuse. As a clinical-investigator and public health practitioner, I salute the intent, but regrettably, the article does not go far enough to explain the crucial issues associated with this increasing problem among all Americans, athletes and non-athletes.

Of merit are the lead investigator, her Washington University co-authors, and the reputable journal in which the article was published. While the article does include the affiliations of all the co-authors and their relationships to the source of funding, it is important to explain that this information allows the public to place in the appropriate context the roles of employees of a major non-governmental supporter in this scientific endeavor.

Given the very select population analyzed in this study, the study design and analysis are defensible. Nonetheless, it is important to note that this study underscores many of the remaining and outstanding issues in defining the scope of prescription drug misuse/abuse. Among these are how to define and measure the behavior under study. Although no gold standard exists, it would have been beneficial to advise the reading public that considerable debate exists in defining what is "misuse", "abuse", or even "non-medical use" and in determining the most valid methods of measuring the harmful or risky (and for some, illegal) behavior.

The major difficulty of this report lies in the conclusions drawn from the results. Although they acknowledge that the study sample is of retired NFL players, they consistently refer to "NFL players" in the "Discussion" section of the paper. This may lead many readers to believe that their findings are relevant to current NFL players, when in fact the policies and practices of the NFL and its players have evolved congruent with advances in medicine and science.

There are also various unfounded assumptions. For example, the authors acknowledged that only 36% (644 of 1788) of former NFL players participated in the study. Yet, they did not report any evidence to support that the 644 study participants were statistically similar (by any important variable, such as age, race, or years since retirement) to retirees who did not participate.

They make an assumption that their study may under-represent the extent of misuse among retirees because of "anecdotal information" from "qualitative interviews" interviews of retirees who did not participate performed by ESPN reporters. This is far from an acceptable scientific standard to validate the significance of findings in behavioral research. Anecdotal reports are generally accompanied with more caution than evidenced in this report.

I still contend that it is misleading to compare former NFL players with the general public, especially without the transparency of informing the readers that many high risk subpopulations are not included in these general public databases. A more appropriate setting would be where patients are treated legitimately for pain to ascertain the rates of prescription drug misuse/abuse comparing patients with and without an occupational history of participation in organized sports, matched for age and other factors known as risks for harmful substance use.

I do concur with the authors that much more information is necessary to understand the scope of one of America's major public health problems. I differ in the emphasis on former NFL players without addressing the remaining barriers to understanding and addressing prescription drug misuse or abuse in the US.

It would have been scientifically prudent and valuable to the public if the authors acknowledged that they are not sure how relevant their findings are to current NFL players. Such a statement would not deny that pain does occur or that therapeutic interventions (both pharmacologic and non-pharmacologic) are provided to players to address their pain. Indeed, today's NFL is a much different landscape than that existing 5 or more years ago. And, as scientific advances in prevention and treatment develop relative to pain and its consequences still further changes will occur.

While there is always room for growth, in 2011, the NFL has the most comprehensive approach within and outside of sports. Even if the NFL enhances its player education (in volume and frequency), tests all players monthly year-round, further restricts the use of pain killers to those prescribed by NFL providers, and continues the high and intensive standard of its treatment of identified players, this would be but a ripple in the ocean of the public health and addiction concerns pertaining to prescription drug misuse/abuse in the US. On the other hand, if all industries (within and outside of sports) implemented the current approach used by the NFL, I am convinced it would have a significant positive impact on prescription drug abuse in America."