Painkillers, NFL's other big problem

Editor's note: A group of former players has filed suit against the NFL, alleging the league's clubs pushed them to use painkillers without disclosing the risks of addiction. The new book "The King of Sports: Football's Impact on America," by ESPN.com columnist Gregg Easterbrook, contains a lengthy section on painkillers and the NFL.

Here are edited excerpts:

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Just as head trauma is coming into the light of day as a football problem, so is painkiller abuse. Professional football players are major consumers of three kinds of painkillers: Narcotic pills such as Vicodin, injected local anesthesia, and Toradol, an all-purpose pain reliever that a disturbing number of NFL players have injected even when they are feeling fine.

Ryan Leaf is renowned for being a draft bust. Chosen second overall in 1998, immediately after Peyton Manning, Leaf's NFL stay was brief. He tried to play for the San Diego Chargers with a broken wrist, making an existing injury worse; to get through this, Leaf took lots of painkillers and became an addict. Since leaving athletics in 2002, twice Leaf has pleaded guilty to felonies involving theft or illegal possession of narcotic painkillers. Currently he is serving a prison sentence in Montana.

Leaf is hardly alone among former football players in having problems with prescription narcotics. Tom McHale, who played for the Tampa Bay Buccaneers and Philadelphia Eagles, died in 2008 of an accidental overdose of painkillers. Craig Newsome, a former Green Bay Packers defensive back, told the Milwaukee Journal Sentinel in 2012 he became a painkiller addict. Newsome played in 53 NFL games, and left the sport with surgical scars on both knees and across his chest; Percocet was his response. Former Houston Oilers star Earl Campbell, who began walking with a cane in his 40s, left athletics as a painkiller addict: his scoliosis, which occurred naturally, was made worse by football contact, leaving him with chronic severe back pain. Walt Sweeney, a Pro Bowl offensive tackle for San Diego in the 1960s, in 1994 sued the NFL alleging his painkiller addiction was "directly related" to football injuries and to narcotics freely distributed by the Chargers. (Sweeney's claim won at the trial level; the NFL won on appeal.) In 2012, Ray Lucas, a former New York Jets and Miami Dolphins quarterback, told Toni Monkovic of the New York Times that after back and neck injuries, he became addicted to prescription painkillers, taking as many as 25 tablets a day: three or four daily is a normal dose.

Of course football players are hardly the only athletes to use pills to alleviate pain: tennis star Jennifer Capriati ruined a shoulder with high-velocity serves, became dependent on narcotics to dull the throbbing, and in 2010 was hospitalized after overdosing on prescription drugs. But incidence of painkiller use among football players is higher than among other athletes, given the nature of the sport's contact. A 2010 study led by Linda Cottler of the University of Florida found narcotic painkiller abuse by football players was about three times that for men of similar ages.

High school players seeking to obtain narcotic painkillers legally must get prescriptions at physician appointments that are not easy for minors to arrange, then go to pharmacies, most of which exact scrutiny on minors seeking controlled substances. Generally, NCAA team doctors prescribe narcotics grudgingly. These factors are thought to limit legal use of opioid painkillers among high school and college athletes. But in the pros, the pills are right in the locker room. All NFL teams retain physicians who examine players at team facilities, not at medical offices, and who may dispense painkillers legally from what is essentially a team's private stash.

Lawrence Brown, a Brooklyn specialist in addiction therapy, has since 1990 been the physician supervising NFL use of prescription drugs. Teams report to him as anonymized data - names removed -- the total amount of painkillers dispensed. Because incidence and types of injuries vary, and because doctors have different philosophies of pain management, some clubs may use narcotics liberally, others sparingly. But there are no controlling NFL rules on narcotics consumption, other than that it must occur legally, by prescription.

"Physicians work for the individual teams; the NFL as a league is not in the business of practicing medicine," Brown said. "Each team physician makes an individual decision about what is appropriate based on the condition of each patient. Their best-practices guidelines come from their medical societies, not from the league. There are no NFL standards for prescription drug use and no NFL best-practices rules about narcotics."

Brown would not say what amount of narcotics the typical NFL team distributes in a year, other than to note, "Football players are more likely to experience pain than the population as a whole, so you would expect them to need prescription drugs." Asked if he had received any NFL team data that reflected a disturbing level of narcotics use, Brown gave this roundabout answer: "I have seen some data that needs improvement, but I have never seen anything that required reporting to the Drug Enforcement Administration."

Across health care, including in debate regarding the Affordable Care Act of 2010 ("ObamaCare"), there is controversy regarding whether there should be fixed standards of medical practice, or physicians should make decisions independently. Fair arguments can be offered for either position. Care standards allow for comparisons of therapeutic results, but medicine is as much art as science, so independent judgment is needed. In this context, the practical effect of pro football leadership saying the NFL "is not in the business of practicing medicine" is that a team physician is freed to dispense painkillers to get a player on the field, regardless of risk to long-term health.

Here, the difference between medical practice and workplace rules is central. The NFL should not mandate standards for how doctors set a broken limb, but can (and does) say, "Players are not allowed on the field with hard casts." By the same token, the NFL should not mandate how a physician interprets a player's pain, or what the best medication and dose may be. But the NFL could say, "Players are not allowed on the field less than 24 hours after taking prescription pain medication." Such a rule would meet the test of a workplace safety requirement.

By instead imposing no workplace rules regarding narcotics, the NFL both endangers the long-term health of its players, and allows them to perform on national television as though fearlessly immune to pain. Youth and high school players see an example that appears to be of men so tough, they laugh at pain. The message sent is that young players should use their own bodies recklessly.

According to the Centers for Disease Control, in 2000 there were more fatalities from illegal drug use than from painkiller abuse. By 2010, the positions had reversed: Nearly 17,000 Americans died after overdosing on opioid painkillers, compared to 7,000 deaths from cocaine and heroin. In the most recent year for which data are available, five times as many Americans died of painkiller overdoses as died in fires.

Distribution of narcotic painkillers has risen at a remarkable pace. A 2012 White House study found that between 1991 and 2011, total prescriptions written for narcotic painkillers rose from 79 million to 219 million. Some physicians' and patients-rights groups contend that in the past, pain has been under-medicated. Even if so, a 175 percent increase in narcotic painkiller distribution in 20 years sounds alarming. Declaring "rampant" painkiller overconsumption, in 2013 the Food and Drug Administration issued rules making opioids harder to obtain by prescription.

Most painkiller abuse problems stem from people's own bad choices, or from Big Pharma marketing: Aggressive promotion of Oxycontin roughly coincides with the surge in painkiller deaths. But having the nation's number-one sport being a major consumer of painkillers - athletes who gulp narcotics celebrated on television - could not have helped.

Austin King spent four years in the NFL as a backup for Tampa Bay and Atlanta, leaving football, as many do, a little before the four-year mark, when he would have become eligible for significant benefits via full vesting. Unless a player is a blue-chip starter, he is waived before he would vest, easily replaced by another starry-eyed fellow who'll do anything to make the NFL.

"There is a pervasive culture in football that you must do whatever it takes to get on the field," King says. "This is especially bad for the marginal players who know they can be replaced tomorrow. So you perform like a wild man on special teams, in order to impress the coaches. If you don't show the coaches you will play with pain and take crazy risks like throwing yourself into the wedge, they will replace you with somebody who will. Teams also pressure their injured marginal players to take a few snaps in practice. If you know they'll get rid of you unless you practice, you ask for painkillers."

King's problem was chronic shoulder pain. Before games, often he was injected with Marcaine or Lidocaine to numb his shoulders. Steve Tasker, a star of the Buffalo Bills' Super Bowl run of the 1990s and perhaps the best-ever special teams performer, told a sport forum in 2007, "There were occasions in my career where I had to get assistance, chemically, to play the game. An injection into some body part, so I could cope with the pain in order to play. There were occasions where I actually went to the training staff and said, 'Can you get me ready,' and they offered me the option [of local anesthesia]." Tasker went on to say that teams did not twist a player's arm to take injections; rather, it usually was the players who asked to be injected. He concluded, "Those are the kind of things that happen behind the scenes in the National Football League, that players would really rather not have made public."

Injected anesthesia was common in football of the early postwar era: Players would have their knees injected so they could perform fearlessly. Since pain is the body's signal that harm is occurring, numbing a joint masks damage that can lead to later-life problems, including early-onset arthritis. "Some of the guys I know who are in their 50s and 60s who played, and now have orthopedic problems, getting injections before games must be part of the reason," says Tony Dungy, who won the Super Bowl as head coach of the Indianapolis Colts in 2007.

Rising awareness of the drawbacks of numbing joints before a game is believed to have led to declining occurrence of injected local anesthesia, though the NFL does not collect data on injected anesthesia use. Andrew Tucker, team physician of the Baltimore Ravens, told me in 2006 he sometimes performs gameday injections to numb hip pointers, a condition that is painful but not especially serious. Tucker said he considers it unethical to inject anesthesia into a player's knees or ankles. But the NFL imposes no restrictions: Other NFL team physicians are free to conclude that such injections are ethical.

King reports that numbing shots into the shoulder "really hurt, the other guys, even NFL players, they make a face when somebody gets a large needle into a joint in the locker room. But lots of them line up for Toradol with B12. That's an easy shot, into the butt, you hardly feel a thing. The guys waiting in line for Toradol would look away when they saw me about to get the big needle into a joint."

And there are lots of guys in line for Toradol.

Toradol is the trade name for Ketorolac, an amped-up version of the non-steroidal anti-inflammatory found in Aleve, an over-the-counter painkiller. Toradol becomes a lot more potent than Aleve when injected rather than swallowed, and is available only by prescription.

A 2002 study found that all but two NFL teams inject players with Toradol on gamedays. How many of the players? The NFL will not release the numbers. Dungy says, "Practically everybody in the NFL is using Toradol."

Here's the thing -- Toradol in the NFL typically is not used to treat injuries. Rather, NFL players get shot up with the drug when they are feeling fine, in order to reduce sensitivity to pain. This allows them to perform with abandon, producing fantastic plays but also causing long-term health harm -- while sending young people the wrong message, that violent activity does not hurt. Football will always be a risky sport with ferocious collisions. But audiences don't know the extent to which NFL trainers employ Toradol to drug up players before they go onto the field.

In 2012 the National Football League Physicians Society issued a memorandum recommending Toradol be administered solely to treat existing injuries, not as a prophylactic against gameday pain. The society further recommended that Toradol be given only to players whose names are disclosed on the team's weekly injury list, and be administered orally rather than injected.

But important as "the National Football League Physicians Society" may sound, the panel has no authority. Anthony Yates, a past NFLPS president and team doctor for the Pittsburgh Steelers, told me the Toradol memorandum is strictly advisory. If teams ignore the advice, nothing happens. "Each NFL team physician is free to practice medicine as he or she sees fit," Yates said, adding that he'd heard BCS-caliber colleges were beginning to inject players with Toradol.

Since any responsible physician makes notes or dictation before giving an injection or prescribing drugs, and members of the National Athletic Trainers Association are told to keep therapy notes, total use of narcotic painkillers, Toradol and anesthesia injections could be tallied by the NFL and disclosed to the public, without jeopardizing the privacy of players. Publication of anonymized data is the essence of modern medical research. There is no reason the NFL could not publish anonymized data about painkillers -- no reason, other than that the league would be embarrassed.

The NFL does publish an elaborate weekly disclosure of the likely-to-play status of players who are nursing injuries: classifying players by name as doubtful, questionable or probable. Vegas casinos and offshore betting parlors are avid consumers of this information. There's a lot of money in sports wagering, and the NFL is keenly concerned with money. So the league ensures the broad dissemination of football medical information that can be used to make money. But the league discloses nothing about use of narcotic painkillers or injected-anesthesia. Bad for business.

The suicide of former NFL star Junior Seau was a major news story in spring of 2012. The day Seau pulled the trigger, I had been interviewing Keith McCants: taken one selection before Seau in the 1990 NFL draft, and who played the same position, linebacker.

In the springtime of life, McCants was a breathtaking athlete. Born in Mobile, Alabama, as a prep star he made all-state in football and in basketball. McCants became an All-American at the University of Alabama. A feared defender, he was among the first linebackers to be both very strong and very fast, his 4.5 in the 40-yard dash then-unprecedented for a 260-pound man. McCants was chosen by the Tampa Bay Buccaneers with the fourth selection of the 1990 draft, signing a contract with a $4.4 million bonus (in today's dollars), at the time the largest bonus ever accorded a defensive player.

When McCants arrived at the Bucs training camp, the team was struggling to sell tickets, having not reached the playoffs in nearly a decade. He played well but did not reach the Pro Bowl, leading to whispers about this highly drafted performer being a bust. It did not help that head coaches were fired each of his first two seasons. Doing the firing was owner Hugh Culverhouse, whose high living caused recurrent problems with the team's finances. This was shortly before the 1993 labor peace deal caused NFL television revenues to begin their meteoric rise. Today, NFL teams with losing records are profitable. At the time, an NFL owner's lifestyle depended on ticket sales.

For the 1992 season, Culverhouse hired Sam Wyche as coach. Wyche was under intense pressure to win, in order to generate box-office results; McCants was under intense pressure to become a star. In an early 1992 game at Detroit, McCants suffered a compound fracture of a clavicle. McCants says the injury was wrapped and injected with local anesthesia, and he returned to the contest. Tampa Bay won, improving to 3-1, with McCants playing in great pain.

A broken clavicle is not a severe injury, though normally entails several weeks of rest. McCants says he was pressured to take no time off, and the only way to do so was narcotics. "There is a fine line between pain and being injured," McCants says. "Football players must play hurt, that's how the sport is. But to play injured is wrong, and I should have refused."

NFL athletes are expected to play through pain, both so their teams win and to show manhood. Players expect of each other, as much as coaches demand this. When Chicago Bears quarterback Jay Cutler left the 2011 NFC Championship Game with an injury, then watched the second half from the Bears' sideline moving around without apparent difficulty, he was widely ridiculed, by sportswriters and by other NFL players, as not man enough. If he can't stand up, maybe he needs medical attention. If he's walking around, get his a-- into the game!

The pressure to play through pain filters down from the NFL, where performers are well-compensated, to college and high school, where there is only pain.

"I should not have taken painkillers the way I did, but once I started taking them, I needed more and more, and went downhill," McCants says. "Narcotics like Percocet lead to cocaine. I was not doing drugs to get high, I was doing drugs to control pain. A lot of NFL players fall into this trap. They know they are easily replaced, so they get injected or ask for pills. The coach can claim he was never informed, the trainer can say the player was making a voluntary choice. By the time you leave the sport, you are hooked on dope.

"No coach ever told me I was required to take narcotics," McCants says. "What they told me was that if I did not play, I would be waived. Then 10 minutes later the trainer came around and offered painkillers. You figure it out."

Gulping pills, McCants tried his best. The Buccaneers went 2-10 for the remainder of the season, after which McCants was released, scapegoated for yet another disappointing outcome for the franchise. Over the next three years, McCants appeared sporadically for the Atlanta Falcons and Arizona Cardinals. Frequent knee surgeries robbed McCants of his famed acceleration. With the Cardinals, McCants scored two defensive touchdowns, but did not generate sacks as a player in his position should. After the 1995 season, he was waived out of football -- taking with him orthopedic problems and addiction.

In the years that followed football, McCants would not make smart choices. Three times he was convicted on drug charges, involving painkillers obtained illegally or cocaine, often sought by painkiller addicts. McCants lost the millions he'd made and lost his Greek-god physique. By his mid-forties, McCants was obese, walked with a cane, and was in and out of halfway houses. His health insurance had ended on the final day he was waived. At the time, the NFL provided no coverage at all for former players; today coverage is available, but only for the minority who stay in the league long enough to vest.

In the end, McCants was tossed into the trash by football. He wasn't the first and won't be the last. Other athletes have faced the same set of issues, and handled themselves better. But painkiller addiction colored his chance of moving on with his life.

"You're competing against players on dope, so you have to be on dope," McCants says. "The NFL absolutely does not want the public knowing the amount of narcotics used in the locker room. If the numbers were published, there would be intense pressure from Congress to reduce drug use by the NFL."