Opioid Use and Misuse Among Athletes

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Opioid addiction knows no bounds. It does not discriminate. Rich, poor, young, old – everyone is vulnerable. Women and men are vulnerable. People of any ethnic or cultural background are vulnerable. People you’d never expect to touch an illicit drug in their lives can go from perfectly managed prescription use to illicit drug abuse and criminal activity in a matter of months.

Every person who develops an opioid use disorder becomes a statistic in the opioid crisis.

But why?

Why opioids?

The most obvious answer is that they’re effective for treating short-term pain. The Mayo Clinic indicates opioids as a first-line option for managing the acute pain that accompanies broken bones, severe injury, or the pain that follows some surgeries and medical procedures. However, physicians do not consider opioids the most effective pain management strategy for chronic pain. They prefer medications like ibuprofen and acetaminophen, because those carry a much lower risk of addiction and other dangerous side effects.

How Opioids Work

But opioids do work very well – in certain situations. The reason they work so well is that they leverage the built-in, naturally occurring pain-relief mechanisms in our central nervous system. Over millennia, our bodies developed an endogenous (internal) opioid system to manage both short-term and long-term pain. Exogenous (external) opioids mimic the physical properties of endogenous opioids to achieve their effect. That’s why they work so well.

They take the control knob on our natural pain-relief systems and crank it up past 11. The result is that our pain not only goes away, but we also feel a sense of euphoria. The euphoria we feel when taking opioids is similar to the feelings of pleasure we derive from things like food and sex. It’s a basic part of the human experience. And the volume knob on opioid euphoria is also cranked up past 11.

That’s why humans get hooked on opioids so easily. It’s a one-two punch: pain relief and euphoria. But it’s the first part that makes opioids, opioid abuse, and opioid addiction such a tough nut to crack. We don’t have anything better at relieving short-term pain.

And it’s that first part that also makes one specific population disproportionately vulnerable to opioid abuse and addiction: athletes.

Opioid Misuse and Sports

The phenomenon of opioid abuse among elite athletes is well-documented. The most visible case of opioid abuse, addiction, and subsequent recovery can be found in the story of Hall of Fame, All-Pro, Super Bowl winning quarterback Brett Favre. Favre developed an opioid use disorder (OUD) in the early 90s while playing for the Green Bay Packers. He began taking opioids to relieve pain from football-related injuries. Then, over the course of several years, he developed a full-blown opioid addiction.

Favre himself says at the height of his addiction, he took up to 15 Vicodin a day. That’s about half a month’s worth of the medication.

In a single day.

Again, the question we ask is why.

Why do pro athletes – or athletes at all – continue to take a drug that’s addictive and can cause long-term emotional, psychological, and physical damage?

We’ve already answered part of that question: opioids work.

The answer to the rest of the question is more complicated.

One complication is that many athletes actually do not know about or understand the dangers posed by prolonged exposure to drugs like opioids. Nor do they know about the dangers of long-term addiction to drugs of abuse, which opioids become when used in ways that are not prescribed by a physician.

Another complication is the nature of sports. They’re competition oriented, and the goal is to win. Therefore, any drug that can keep an athlete on the field and contributing to the success of the team is attractive to competitive athletes, no matter the consequences.

Yet another complication is the nature of athletes themselves. Their identities – and for pro athletes, their livelihoods – are entwined, and in some cases dependent upon, their ability to perform. This is true for the pros, but especially problematic for younger athletes for whom their entire social identity may revolve around their status as an athlete.

To explore this issue from an evidence-based, data-driven point of view, we’ll take a look at the latest statistics on the prevalence of opioid use and abuse among high school athletes. Then we’ll talk about ways to ensure athletes at all levels of competition can use opioids to manage pain safely and sanely, i.e. without developing an addiction that can lead to long-term health problems, and in some cases, death.

Opioid Use and Athletes

We’ll focus our discussion high school athletes, since the media is flush with information on opioid use among pro athletes. We’ll also address this young population first because they have less support, by default, than pro athletes. Take Brett Favre, for instance. He entered a substance abuse treatment program supported his employer, the Green Bay Packers, had sponsored by the NFL. He had the support of a multi-billion-dollar industry behind his recovery. Not to mention the fact that his team depended on his successful recovery to return to the field and keep winning games for them.

He did return to the field and they did continue to win games.

Which is an encouraging story that illustrates how an individual can fall deep into addiction, recover, then go on to live a successful and fulfilling life. It also illustrate the importance of professional support and a group of people committed their success.

High school athletes, however, have no such industry behind them, and the teams they play for have neither the resources nor the financial incentive to help them recover from an opioid use disorder if they develop one.

The Statistics on Opioids and Athletes

Let’s take a look at the statistics published in two peer-reviewed journal articles: “Painfully Obvious: A Longitudinal Examination of Medical Use and Misuse of Opioid Medication Among Adolescent Sports Participants,” and “Playing Through Pain: Sports Participation and Nonmedical Use of Opioid Medications Among Adolescents.” The former study used information on over 20,000 adolescents from the nationwide survey “Monitoring the Future” conducted in 2011, while the latter study used information collected from over 1,500 students in a questionnaire called the Secondary Student Life Survey, administered between 2009 and 2012. Taken together, these studies will give us an idea of the context and scope of the problem.

Here’s some general information about adolescents, athletes, and opioids offered by both studies:

  • Opioid prescriptions for adolescents almost doubled between 1994 and 1997.
  • About 7.5 million adolescents participate in scholastic sports each year.
  • Roughly 2 million injuries related to high school athletics occur each year.
    • A significant proportion of these injuries require medication to manage injury-related pain.
  • High school athletes are more likely to receive an opioid prescription than non-athletes.

That information sets the stage. Opioid prescriptions rates for adolescents are on the rise, millions of kids participate in high school sports, and about a quarter of them experience sports-related injuries.

Now, here’s specific data from the “Painfully Obvious” study. Male athletes are:

  • Almost twice as likely to receive an opioid prescription as female athletes and non-athletes
  • More than twice as likely to misuse prescription opioids than female athletes and non-athletes
  • At least four times as likely to use prescription opioids to get high than female athletes or non-athletes

The “Painfully Obvious” study found no association between athletic participation and opioid prescription rates, opioid misuse, or use of opioids to get high among female athletes. That’s an interesting wrinkle to the data that can be useful to clinicians working in addiction.

Now, for specific data from the “Playing Through Pain” study:

  • 15.2% of all high school seniors used some sort of prescription medication for non-medical purposes in the 12-month period before the survey
    • Acetaminophen + hydrocodone and oxycodone hydrochloride were used most often for non-medical purposes
  • 5.5 % of all high school athletes reported non-medical use of opioids in the 12-month period before the survey
  • Among high school athletes, football players and wrestlers were 50% more likely to use opioids for non-medical purposes than athletes participating in other sports.
  • Among high school athletes, those who participated in non-contact, non-impact sports showed no increased likelihood of using opioids for non-medical purposes.

This data is important for anyone working with adolescents, including coaches, teachers, school administrators, and of course, parents. It’s most important, though, for physicians working with adolescents.

How Doctors Can Help

The prime takeaways from this data lie in the identification of the categories of young athletes most vulnerable to opioid misuse and abuse. First, male athletes, overall, have an increased likelihood of misusing opioids, and therefore, developing an opioid use disorder. Next, athletes who participate in the two contact sports that have the highest rate of severe injury out of all high school sports – football and wrestling – are also at increased risk of opioid misuse.

It’s worth mentioning here that male participation in football and wrestling far outpaces female participation. That’s one logical explanation of the data in the “Painfully Obvious” study. However, participation in girl’s wrestling increases every year. And anyone who watches high school girls wrestle know they compete just as intensely as the boys.

Meaning that as participation in girl’s wrestling increases, the severe injury numbers for female high school athletes are also likely to increase. As that happens, physicians who treat them need to be aware that these girls may be at increased vulnerability for the misuse of opioids and opioid use disorder. Whether they will misuse opioids when injured, like their male counterparts, is unknown. It’s something to watch for over the next several years.

An Ounce of Prevention

The true key to solving the problem of opioid misuse among athletes is prophylaxis, primarily in the form of awareness. If they didn’t before, physicians now know the devastating consequences of playing loose with opioid prescriptions. It leads to an opioid crisis that kills tens of thousands of people a year. It throws individual lives and families into destructive and painful cycles of addiction. The data from these studies on opioid use and abuse among high school sports participants teaches doctors treating these young athletes – especially football players and wrestlers – that if a diagnosis indicates an opioid analgesic, they need to carefully monitor their patients for signs of overuse, misuse and addiction.

Otherwise, the consequences can be devastating.