The Berks-Mont News (http://www.berksmontnews.com)

Pain management in NFL spawns drug abuse culture


By Sally Jenkins and Rick Maese, The Washington Post

Monday, April 15, 2013

When Fred Smoot, a former Washington Redskins defensive back, fractured his sternum and had to spend four months sleeping in a recliner because he couldn’t lie flat, he said his team doctors gave him a choice: Miss the rest of the season or “figure out a way to play.” Worried about his livelihood, he made it on the football field each Sunday thanks to a syringe full of a drug called Toradol.
“Painkillers are like popping aspirin,” Smoot said. “They get to that point.”
When the throbbing in his surgically repaired right knee made it hard to walk, much less play, Chester Pitts, a former offensive lineman for the Houston Texans, found a way to prolong his career one more year: a cocktail of Toradol injections on Sundays, with anti-inflammatories and narcotic painkillers the other days of the week.
“If I was really hurting, I would take a mix,” he said. “I could do Tylenol with the Indocin or the Vicodin. Couldn’t do Vicodin with certain things. You could take one NSAID and one acetaminophen, whatever they said.”
When former Redskin Mark Schlereth, a veteran of 12 seasons and 29 surgeries, underwent a kidney-stone operation on a Sunday night and suited up for a game less than 24 hours later, he drew the strength to do so from a needle and pill bottle.
“I would strap a dog turd to it if I thought that would make me feel better,” he said. “Bottom line is, I’d do whatever I have to do. Have I had Toradol shots? Yes. Have I abused anti-inflammatories? Yes. Have I used painkillers? Yes. Have I got shot up with painkillers and Xylocaine and different things to numb areas so I can play? Yes. I’ve done it all.”
Jarring hits and injuries are an inherent part of the National Football League, and so too is the game’s complex — and potentially dangerous — system of managing pain. It’s an issue the league has grappled with for many years: a culture of prescription drug use and misuse that stretches from the locker room into retirement, and even on to coaching staffs, with uneven oversight or uniform guidelines. Numerous studies suggest the drugs that help many athletes take the field each Sunday can carry dangerous side effects, lead to lifelong addictions, expose them to further injury and compromise a delicate system that’s ripe for abuse.
Court records and interviews reveal that until recently some NFL teams either flouted or were ignorant of Drug Enforcement Agency laws governing the dispensing of painkillers. Moreover, The Washington Post surveyed more than 500 former players about their experiences with drugs in the NFL. One in four said he felt pressure from team doctors to take medication he was uncomfortable with.
The NFL’s most recently reported rate of opioid use — 7 percent — was three times higher than that of the general population, but the league’s defenders say that the NFL’s problem with prescription abuse is hardly unique. According to federal statistics, more than 2 million Americans are addicted to painkillers. Deaths caused by the overdose of prescription drugs exceeded motor vehicle deaths in 2009, according to the Centers for Disease Control and Prevention, and are responsible for more deaths than illegal street drugs, such as cocaine, heroin and amphetamines.
“The whole issue of pain meds is a big, important issue in our society well outside the NFL,” said Jeff Pash, the NFL’s executive vice president. “It’s something that needs to be addressed on a broad basis, not just in NFL, and it is something our doctors are looking at.”
The league’s widespread use of Toradol, in particular, offers a window on the game’s reliance on pills and needles. In The Post survey of retired players, 50 percent of those who retired in the 1990s or later reported using the controversial painkiller during their careers; roughly seven out of 10 who left the game in 2000 or later said they used the drug.
A 2000 survey of NFL physicians found that 28 of 30 teams used Toradol injections on game days. Another study two years later found an average of 15 pregame injections per team. Players describe pregame lines of as many as two dozen players deep waiting for a shot or a pill. “No doubt about it, I was in that line,” Hall of Famer Warren Sapp said. “They’re like Tic Tacs. You walked in, you got it and you played the game.”
Toradol is a nonsteroidal anti-inflammatory drug — not a narcotic — and though it’s not addictive, it’s available only with a prescription. It’s often used to manage post-operative pain, and the drug is considered dangerous enough that some European countries have banned it, while others administer it only in hospitals. Among the potential side effects of overuse are kidney damage and gastrointestinal bleeding. In the case of NFL players it can be particularly problematic because it deadens feeling, inhibiting an athlete’s ability to feel pain and sense injury.
Physicians say the potential for side effects is heightened by the overuse of Toradol or the “stacking” of multiple drugs. Several players interviewed for this story said they typically used Toradol in combination with other nonsteroidal anti-inflammatory drugs, or NSAIDs, over the course of a week.
Perhaps worst of all, because it is an anticoagulant, many fear it could exacerbate the effects of concussions. On that basis, as part of the massive concussion litigation brought by ex-players that the league is fighting in U.S. District Court, 11 former players have filed a lawsuit claiming their team doctors repeatedly treated them with Toradol without properly advising them of the dangers.
Despite warnings and mounting concerns, Toradol and a variety of other pain medications were used regularly last season, team physicians say. Andrew Brandt, who spent nearly a decade in the Green Bay Packers’ front office, likened it to armor.
“It’s part of their game-day routine,” said Brandt, who now works as an analyst for ESPN. “Just like getting taped.”
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When linebacker Scott Fujita, a 10-year veteran free agent who has played for the Kansas City Chiefs, New Orleans Saints and Cleveland Browns, was in his prime, he used prescription drugs four to five days a week in order to play. He estimates this put him on the low end of usage among his teammates.
On Thursdays, Fridays and Saturdays, Fujita might rely on Celebrex or another anti-inflammatory. If the pain from a specific injury was really bad, the linebacker might turn to Vicodin or Percocet. On Sundays, he’d get a Toradol shot before taking the field. Then with fresh aches and pains, he’d spend Mondays on another pill to help recovery. Tuesdays and Wednesdays, though, were always different — “your chance to detox a bit.”
“We called it DFW,” he said. “Drug-Free Wednesday.”
Fujita says he has suffered dozens of injuries during his career, from cuts requiring stitches to broken fingers to separated shoulders and torn muscles. To manage the constant pain, he has used “everything under the sun.”
Pain is the inescapable price of an NFL career, and a drug problem can easily become one, too. Retired NFL players misuse opioids at a rate more than four times that of their peers, according to a 2010 study of 644 league veterans by the Washington University School of Medicine in St. Louis. Even upon retirement, 15 percent of those who misused opioids during their careers continued to misuse, according to the study, even though they were no longer playing.
“People spend so much time talking about HGH, steroids, and I think these are the real performance enhancers,” Fujita said.
NFL doctors say they face a constant challenge in identifying players who legitimately need prescription painkillers, as opposed to those who want pain relief without a documentable injury. Anthony Casolaro, the Redskins’ team physician, said before he administers any pregame medication, he makes sure the player appeared on the week’s injury report and received treatment for a specific ailment.
But the Washington University School of Medicine study reflected the prevalence of prescription drug use and abuse in the league: 52 percent of respondents said they used opioids during their career. Of those, 71 percent reported “misuse” of them.
“Part of playing in the NFL is dealing with pain. People get hurt, people take painkillers, that’s just part of the game,” said Frank Mattiace, a former NFL player who’s now an addiction counselor and the executive director of the New Jersey-based New Pathway Counseling Services. “So you’re dealing with a double-edged sword. It’s such an ingrained part of their mentality.”
In a sport with short career spans and few guaranteed contracts, playing through pain is an understood job requirement. In The Post’s survey of former players, nearly nine in 10 reported playing games while hurt. Fifty-six percent said they did this “frequently.” Almost half of those who played through pain (49 percent) said they wished they had done so “less often,” and an overwhelming number — 68 percent — said they did not feel like they had a choice as to whether to play hurt.
With pain management such a constant challenge in NFL training rooms, football teams buy drugs in bulk. William Barr, the director of New York University’s Langone Medical Center, served as a concussion consultant for the New York Jets from 1995 to 2004. He recalls experiencing a headache and requesting aspirin from team trainers.
“They said, ‘Go over there and it will deal with your headache,’ “ Barr said. “There was a huge candy jar of Toradol.”
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The Food and Drug Administration in 1989 approved a new NSAID called ketorolac, which hit the market as Toradol. The FDA now lists more than 25 makers of it.
Toradol’s fast-acting properties can be alluring in a business where job security is directly tied to health and a player’s ability to perform. An intramuscular injection can have onset within 10 minutes, peaking within an hour and showing a half-life of 61/2 hours, according to studies.
“Once you get your first one, you realize, wow, you can play pretty pain-free for the entire game,” said Tyoka Jackson, a former defensive end who played in the NFL from 1994 to 2006. “So whatever’s ailing you, you don’t feel.”
A spokesman for Roche, which was first to put the drug on the market, declined to discuss the drug’s use in football, instead referring to the FDA’s recommendations. “It should be used for the short-term treatment of moderate to severe pain in adults,” Chris Vancheri, the spokesman, said in an email. “It is usually used before or after medical procedures or after surgery.”
While the drug’s potency and possible side effects worry some physicians, it’s the misuse of Toradol that’s particularly worrisome to doctors such as Victor Ibrahim, a team physician for D.C. United, who is also director of the Performance and Musculoskeletal Regeneration Center in Washington.
In The Post’s survey of ex-players, nearly eight in 10 of past Toradol users said they took the drug as a masking agent, intended to dull the pain they expected to feel during games. “When you mask pain and give a patient a false sense of a cure, you potentially expose them to further harm,” Ibrahim said.
Joe Horn, a wide receiver who played in the NFL from 1996 to 2007, said toward the end of his career he used Toradol most every Sunday, sometimes “just in case I got injured. In case something happened, I could still make it through the game.”
Team physicians, he said, never discussed with him possible side effects, which serves as a central complaint in a lawsuit that Horn and 10 other former players have filed against the NFL. The plaintiffs say that because of its blood-thinning properties, Toradol use could have aggravated the effects of concussions suffered during their playing careers.
Several physicians, though, said further studies and research are needed to understand the extent of any such dangers.
“I think that’s a theoretical risk,” said neurologist Michael Yochelson, the medical director for MedStar National Rehabilitation Hospital, “particularly if you’re taking it beyond the recommended frequency that it might put you at a slightly increased risk for a bleed if you were to have a significant head impact.”
The league has become increasingly sensitive to issues surrounding the drug, to the point that last season some NFL physicians attempted to get players to sign Toradol releases protecting them from liability “for any injury, damage or death sustained” from using it. The NFL Players Association filed a grievance against the league and NFL management council in December, demanding the waivers be nullified.
“I don’t know where these waivers came from, but they’re unethical,” said Thom Mayer, the union’s medical director. “I know they go against the prime concept that we’re going to do the right thing for the patient, not the right thing for the people who take care of the patient.”
NFL spokesman Greg Aiello said that to the league’s knowledge only one team physician distributed waivers, and the union has not requested a date for a hearing.
Because the NFL had no guidelines pertaining to Toradol usage, last year Matt Matava, the St. Louis Rams’ team physician and president-elect of the NFL Physician’s Society, took a closer look at the drug and its side effects, balancing the risks with the potential benefits. While his ensuing report noted that “each team physician is ultimately free to practice medicine as he or she feels is in the best interest of the patient,” he issued a set of recommendations, including that Toradol shouldn’t be used prophylactically; it should be limited to those with a known injury; it shouldn’t be used in any form for more than five days; and it shouldn’t be used concurrently with other NSAIDs.
“We just said, ‘Listen, this is what the literature has suggested is out there, this is what our recommendations are based on the synthesis of the literature,’ “ Matava said. “ ‘Do with Toradol as you see fit.’ “
While Matava stopped short of advising 31 other team doctors to stop using Toradol, he has essentially eliminated the drug from his own locker room. In 2001, the Rams averaged six pregame Toradol injections, which increased to 16 over the next 10 seasons. Because use had become so widespread, Matava wasn’t sure how players would react when he stopped administering the drug.
“We had two players come up to me at the very first game and said, ‘I’m here for my Toradol shot,’ “ Matava recalled. “I said, ‘We’re not using it anymore.’ ‘Okay, can I have something else?’ I never heard one more word about it the rest of the season.”
Matava said the NFL Physician’s Society recently conducted a league-wide survey, and though he would not release the specific results, he said overall Toradol use last season was down. The survey was done anonymously, so the extent of Toradol usage from team to team is only known anecdotally. Teams such as the Rams, Packers, Falcons and Redskins, for example, say they avoid using the drug whenever possible.
“It’s dramatically dropped,” said Casolaro, the Redskins’ doctor who has been with the team since 1999. “The truth is, I don’t think it was ever a harm, nor do I still think it is.”
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The inconsistent use of prescription drugs from team to team highlights how varied practices can be across the league. The NFL’s protocols, standards and enforcement have not always been consistent with federal laws governing prescription drugs.
Many of the lapses in the league’s complicated system were on display in the spring of 2009 in New Orleans. During a four-month stretch, the Saints’ team trainers noticed Vicodin pills had gone missing. On April 28, 2009, according to a civil complaint later filed in state district court, the team’s director of security, a former FBI agent named Geoffrey Santini, was notified. At the instruction of Saints General Manager Mickey Loomis, Santini installed a pair of hidden cameras in the Saints’ training room.
The footage in the first video is in full color, grainy but unmistakable. Saints assistant head coach Joe Vitt, wearing khaki shorts and a black long-sleeved team shirt, can be seen unlocking a metal cabinet in the trainer’s office. Unaware that he’s being recorded, Vitt removes a bottle and pours pills into his hand before locking the cabinet and exiting the room.
There are two more video clips from the ensuing days that clearly show Vitt alone in the office, unlocking a cabinet and helping himself to a handful of prescription painkillers. The locks were quickly changed and one final video captured Vitt’s failed attempt to get inside the cabinet.
Not long after, Santini called Loomis to discuss the situation and recorded the conversation. During the exchange, the two discussed to what authority they must answer.
“Mickey, I am just telling you that is not how it works,” Santini says. “The law is there.”
“We are not talking about the law,” Loomis responds. “We are talking about the league.”
The videos and recorded conversations, much of them reviewed by The Post, have become evidence in a DEA investigation that is now in the hands of the U.S. Attorney’s office in New Orleans. The case is still open and, according to people with knowledge of the situation, federal authorities are weighing a hefty fine against the Saints for violating laws governing the proper storage, control and dispensing of prescription drugs.
Only a properly licensed pharmacy may store prescription drugs, and they must be properly secured and counted pill by pill in federally reported logs, according to DEA regulations. Only physicians can administer them. It is illegal for anyone else, including athletic trainers or coaches, to control or hand them out. In an effort to comply, the NFL subjects teams to annual pill audits, requiring them to report every dosage. But the system is far from fail-safe. In the Saints’ training room, as the video showed, access to the drug cabinet was relatively unchecked and those with access could scoop out pills by the handful.
After Vitt was caught on camera, the team’s trainers initially seemed to underappreciate the severity of what had happened and explained to Santini in recorded conversations that they intended to falsify the counts in their drug logs. “Our numbers will be right. . . . We are going back and adjusting, you know, these discrepancies and crediting Vitt,” Scottie Patton, the head trainer, told Santini.
Most teams now use a third-party company, registered with the DEA, that delivers prescription medication to team facilities and NFL stadiums, and maintain detailed drug logs. Using computer software, the substances can then be tracked by both the NFL and the third-party company. About half the NFL teams use a firm named SportPharm, and a spokeswoman for the company said several teams are mandated by the league to use its services to keep their operations in proper order.
In 2009, the Saints used a system that was a bit simpler. A Vicodin prescription by Saints team physician John Amoss was filled at a local Walgreens, according to court records, listing the patient as “New Orleans Saints.”
The Saints declined to comment for this article or make Loomis, Vitt, Patton or Amoss available for comment. In a June 2009 recorded conversation, Loomis said Vitt was seeing a counselor and was in the care of a doctor. “We got him on the path of correction,” he said. Loomis also made clear that he didn’t think Vitt was abusing painkillers: “I am telling you what the doctor said: Joe is not a drug addict with a drug problem.”
Despite earlier talk of falsifying records, in the recorded conversation, Santini appears to convince Loomis that the team would be violating the law and they’d all be subject to prosecution if they tried to fix the books or cover up the issue. “I’m not for breaking the law, I am for reporting this,” the general manager said. “I’m also trying to do a solution that doesn’t get Joe in a lot of hot water because I think we are on a path. This issue corrected.”
Vitt, who served as the Saints interim head coach last season, agreed in U.S. District Court to enter what’s known as a pre-trial diversion program, a form of probation for first-time offenders in which he fulfilled certain obligations for 12 months, ranging from paying a fine to undergoing education, according to two people familiar with the agreement.
Santini resigned from the Saints organization on Aug. 16, 2009, and filed a lawsuit against the team eight months later. The case was moved to arbitration and the sides privately settled, but the allegations had already caught the eyes of federal authorities. Investigators with the DEA unearthed a number of violations with the Saints’ operation, according to people familiar with the situation, and worked with the team to bring the organization into better compliance.
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About five years ago, Casolaro, the Redskins’ physician, said he learned of an Atlanta doctor who flew to the Washington area midweek to meet with and provide treatment for a Redskins player. Casolaro passed the information to league security, which informed the man he wasn’t licensed to practice medicine in Virginia.
“He never came back,” Casolaro said.
The incident highlights an age-old dilemma NFL medical personnel face. Team physicians who would like to rely less on pain medications wrestle with the alternative: The pain exists, therefore so does the need for painkillers. As Casolaro said, “If we don’t give them a drug that they’re allowed to have, will they go get it from outside? And what will they get?”
It’s a legitimate concern: The Washington University School of Medicine study found that of players who misuse pain medication, 63 percent said they obtained their pills from a source other than a doctor.
The demand isn’t spurred solely by a chemical addiction. Toradol isn’t a narcotic, but the 2002 study of the drug’s usage in the NFL found several teams reporting a “psychological addiction” to game-day injections.
“Because you rely so much on the instant pain relief,” said Ibrahim, the D.C. United doctor, “people can become habituated to it.”
Wilson Compton, a division director at the National Institute of Drug Abuse and a former clinician in the league’s substance abuse program, says the reality is that NFL players simply deal with more pain than the average citizen. The Washington University School of Medicine study found that only 13 percent of players reported their overall health to be excellent, while 81 percent reported feeling “moderate to severe” pain daily.
Compton was struck “by the quantity and extent of painful conditions the players who retired are experiencing. . . . This tells us that their bodies suffer extraordinary stress and disruption.”
Further study is needed of what doctors and athletes are really using to treat pain, Compton says — how much are they using, and why? For instance, Compton asks, are players also seeking medication from their personal physicians?
“It’s helpful to have research,” he said, “so there really is some medical and health information about the long term, and it isn’t just considering, ‘What can I do to get through the next seven days?’ “
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Julie Tate and Capital Insight Director Jon Cohen and pollsters Peyton M. Craighill, Scott Clement and Kimberly Hines contributed to this report.