Painkillers, NFL's other big problem

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.