First comes a sports injury. Then comes a prescription for pain-relieving opioids. Sometimes, the third step is drug abuse. Sports medicine professionals can play a key role in keeping athletes from going down this road.
This article first appeared in the March 2017 issue of Training & Conditioning.
By David Csillan
David Csillan, MS, LAT, ATC, is Athletic Trainer at Ewing (N.J.) High School and a member of the New Jersey State Interscholastic Athletic Association’s (NJSIAA) Sports Medicine Advisory Committee. He serves as the NATA District Secretaries/Treasurers Vice-Chair and NATA District 2 Secretary, as well as the NJSIAA Liaison with the NATA and NFHS. Csillan was inducted into the Athletic Trainers’ Society of New Jersey Hall of Fame in 2008 and received both the NATA’s Most Distinguished Athletic Trainer Award and Athletic Trainer Service Award in 2016. He can be reached at: firstname.lastname@example.org.
About 10 years ago, Cameron Burke, a freshman high school wrestler, set a goal of earning a college wrestling scholarship. During Cameron’s sophomore year, this dream faced a setback when he suffered two clavicle fractures—one of which required surgery.
Following treatment, Cameron was prescribed Percocet for the pain and continued to use the drug for a year. Eventually, he moved from Percocet to heroin. Once a stellar student enrolled in numerous AP classes, his grades dropped, and he lost his desire to wrestle. At this point, Cameron’s mother, Jennifer Weiss Burke, intervened and arranged for him to attend counseling.
Over the next two years, things seemed to be turning around for Cameron. That all changed one summer night in 2011. Cameron went out with his best friend, another former wrestler and heroin addict. They were using, and Cameron overdosed and passed away.
I first read about Cameron in the Youth Sports Safety Alliance’s April 2016 Newsletter. His mother, now the Executive Director of Healing Addictions in Our Community and Serenity Mesa Recovery Center, shared her son’s story to raise awareness about the connection between opioids, athletics, and adolescents.
It’s no secret that an opioid epidemic is ravaging communities nationwide, but not everyone understands how these drugs can affect athletes. Cameron Burke is just one of many young athletes whose life tragically ended as a result of opioid addiction triggered by a sports injury.
However, by establishing prevention initiatives and educating athletic trainers and other sports professionals about the dangers of opioids, we can keep future athletes from heading down the same path. The New Jersey State Interscholastic Athletic Association’s (NJSIAA) Sports Medicine Advisory Committee (SMAC) has recently taken steps in this direction.
GET THE FACTS
Before we discuss opioids and athletes, it’s important to go over the basics of opioids themselves. This category of drug includes prescription pain relievers, such as Percocet, Vicodin, Oxycontin, hydrocodone, codeine, and morphine to name a few. Opioids affect the nervous system’s neurotransmitters, blocking the brain’s ability to perceive pain. For this reason, they are often prescribed to patients following surgery or traumatic injury.
In the past, physicians didn’t think prescribing opioids for pain had any negative consequences. As a result, prescriptions written for opioids increased dramatically over time. In fact, a 2015 publication in the Journal of the American Academy of Orthopedic Surgeons revealed a 100 percent rise in narcotic pain prescriptions over the previous five years.
This is not necessarily a bad thing in and of itself. Yet, it becomes problematic when you consider that the illicit and highly addictive drug heroin is also classified as an opioid. Most experts agree that the abuse of prescription opioids is a gateway to heroin addiction. So once people became hooked on their opioid prescription but could no longer get it refilled, they often turned to the black market for pills or substituted them with heroin, which is usually a cheaper and more accessible alternative.
The results of this have been catastrophic. The Centers for Disease Control (CDC) reported more than 29,000 deaths nationwide from opioid misuse in 2014 alone. New Jersey has been hit particularly hard—according to a 2014 study by the CDC, the state’s heroin overdose death toll is triple the national average.
In light of these realities, the medical field has taken a close look at the opioid epidemic and developed concise definitions for use, misuse, and abuse to raise awareness about the signs of opioid dependency. Use refers to taking medication as prescribed, misuse applies to taking more medication than prescribed, and abuse is taking medication when it hasn’t been prescribed.
These words reflect the stages people go through as they become addicted. When they initially use opioids for pain, the drugs are most often taken as prescribed. As individuals build a tolerance to the dosage, more of the drug is needed to achieve the same level of pain-free comfort, and the drug is misused. Not long after, the brain rewires itself and causes users to believe the substance is needed for survival, leading to abuse.
ATHLETES AT RISK
So what’s the connection between athletes and opioid abuse? It starts with the rise of sport participation over the past three decades. More and more adolescents have been playing competitive sports at earlier ages, with some athletes specializing in a sport as young as age 10.
With this increased participation in formal athletic activity comes a rise in the potential for injury. And when injuries occur, many athletes opt for a physician evaluation in order to receive immediate pain relief that will allow them to get back to their sport quickly.
Often, this pain relief comes in the form of prescribed opioids. Instead of conservative measures like ice and rest, use of these narcotics has become the first line of pain management for many sports-related injuries.
Once athletes start using opioids, they can easily become hooked. A recent University of Michigan study revealed a direct link between opioid prescriptions and the onset of addiction in athletes. It found that secondary school athletes were 33 percent more likely to be addicted to opioids than non-athletes, and male athletes in particular were four times as likely to be addicted than male non-athletes of the same age.
A PROACTIVE APPROACH
Concerned about the effects the opioid crisis has had on secondary school athletics, the NJSIAA’s SMAC developed recommendations for school districts and sports medicine professionals to follow. Created in May 2016, these recommendations take a three-prong approach to reducing opioid addiction:
• They support the state’s Prescription Monitoring Program, which allows physicians and pharmacists to track patients seeing multiple doctors for the same medication.
• They provide awareness to parents/guardians.
• They encourage education in the school community.
The recommendations include:
• Physicians should exercise extreme caution when prescribing opioids to student-athletes.
• While administering prescriptions, physicians should consider non-addictive alternatives, such as acetaminophen, non-steroidal anti-inflammatory medications, salicylates, cryotherapy, and transcutaneous electric nerve stimulation.
• Opioids must be prescribed only for serious injuries eliciting extreme pain. The prescription must not exceed a week or be available for automatic refills.
• The opioid prescription must include detailed information on use, as well as specific warnings about abuse and the associated risks.
• Opioids should never be given directly to student-athletes and should never be administered in an unsupervised manner.
• Treating physicians and/or parents/guardians should notify the school nurse and/or athletic trainer about all opioid prescriptions.
• Every school district needs to develop a specific, detailed policy addressing this issue.
• School districts should implement drug-monitoring programs, with an emphasis on identifying students who seem to exhibit signs of opioid abuse.
Spearheading the recommendations was the SMAC’s Chair, John “Jack” Kripsak, DO, Director of Sports Medicine at Somerset Medical Center in Somerville, N.J. “Studies indicate about 80 percent of heroin users started out by abusing narcotic painkillers,” he says. “[This] statistic makes it frighteningly clear what the stakes are in this battle. It’s an emergency now, and no doubt we need to implement new strategies in our schools to turn the tide.”
The NJSIAA has no way to enforce its recommendations with physicians. Yet, our hope is that by bringing this topic to the forefront and educating the public at the grassroots level, medical providers will opt for more conservative methods of managing athletes’ pain.
For instance, St. Joseph’s Regional Medical Center in Paterson, N.J. has been following opioid alternative protocols for patients arriving with acute pain. The program has reduced the number of incoming patients prescribed opioids by 75 percent. Physicians at St. Joseph’s are now instructed to recommend using ice, acetaminophen, anti-inflammatory drugs, and procedures that block nerve pain instead of prescription narcotics.
Although the SMAC’s recommendations are fairly new, we are already seeing positive feedback throughout the state. For example, former New Jersey Governor and current State Senator Richard Codey fully supports our work.
“By recommending this list of specific protocols, the [SMAC] is intensifying the ongoing battle against prescription drug abuse,” he says. “With so many of our young people now at risk, it’s crucial that groups with connections and resources push hard to identify solutions.”
ATHLETIC TRAINERS’ ROLE
With our recommendations in place, the SMAC is looking for partners to curb the opioid crisis among secondary school athletes in our state. Athletic trainers are one of our primary allies.
A full-time athletic trainer at a school can help monitor the health of student-athletes daily. Because of this, they are usually the first to recognize when something isn’t quite right. As such, they can have an important role in preventing and/or reporting opioid abuse.
A great place to start is understanding the warning signs indicating a possible addiction to opioids. In the early stages of abuse, the athlete may exhibit unprovoked nausea and/or vomiting. However, as they develop a tolerance to the drug, those signs will diminish. Constipation is not uncommon, although the athlete may be unlikely to report this. One of the most significant indications of a possible opioid addiction is a sudden decrease in the athlete’s level of functioning or interest in their sport.
If an athletic trainer notices any of these warning signs in a secondary school athlete, best practices call for student referral to the appropriate professional on staff. It’s important to not keep the situation a secret between the athlete and athletic trainer. The school may designate the nurse, substance abuse counselor, school psychologist, or guidance counselor as the point person for this issue. Once the athlete is referred, the athletic trainer may serve on the crisis team depending on their role established by the school district.
Athletic trainers can also educate others. They can review the SMAC’s recommendations with their athletes, coaches, and parents during preseason meetings and teach about the dangers of opioid abuse in sports medicine classes. School districts can create informational pamphlets for athletic trainers to share, which could include links to educational websites and phone numbers for area crisis centers.
Furthermore, one of the SMAC’s recommendations calls for school districts to develop their own drug-monitoring programs. Athletic trainers ought to be a key player along with the treating physician, school nurse, substance abuse counselor, school psychologist, and guidance counselor. They can assist in educating the coaching staff on opioid abuse and reinforce the school district’s referral policy.
Helping to develop a school’s drug-monitoring program also ensures that athletic trainers will know when one of their athletes is prescribed opioids. This will give them the ability to monitor usage and keep in contact with the treating physician with regard to any necessary medication weaning.
In confirmed cases of opioid abuse, athletic trainers can act as an educator for both the athlete and their family. The family may require assistance in locating treatment and therapy centers or might just need a shoulder to lean on. If or when the athlete attempts to return to their sport following recovery from opioid addiction, athletic trainers will need to maintain continued correspondence with their treating physician regarding competition stresses and the fear of re-injury.
Just as athletic trainers can play a role in opioid abuse prevention and intervention, they must be prepared for a catastrophic outcome from addiction, as well. This often manifests in the form of respiratory depression—when opioids send a signal to the brain to stop the heart and lungs. If a dose is too extreme, respirations will cease.
Fortunately, medication has been developed to stop these overdoses. Naloxone, often sold under the brand name Narcan, is very effective at reversing overdoses when administered in time. Many first responders carry the drug, and it’s now being supplied to school nurses and athletic trainers in some areas. The NATA supports proposals to increase access to and training for administering naloxone.
As opioid addiction continues to spread, it is time for lawmakers, medical professionals, state athletic associations, athletic trainers, school communities, and concerned organizations to join together and address it at the grassroots level. We have that responsibility to the student-athletes of today so they can become our leaders of tomorrow.
A SLIPPERY SLOPE
When athletes show signs of an opioid addiction, athletic trainers must be prepared to intervene. This case study shows how one athletic trainer helped a struggling athlete.
By Julie Alexander
As athletic trainers, we are prepared to help our athletes with many different health issues. But one that we may not be prepared for is narcotic drug addiction following a major injury or surgery. I recently encountered this problem with “Alex,” a male athlete here at St. Cloud State University.
Alex had suffered a severe ankle injury that required a couple of weeks of rest and rehabilitation. During this time, he was prescribed a 10-day dose of Vicodin for pain relief and to help him sleep at night. I was aware that he was taking this painkiller, and he tolerated the medication well.
After returning to the playing field, Alex had a follow-up appointment with the doctor and asked for a refill of Vicodin, as his ankle was sore from resuming activity. He was given a second prescription for seven days to be used as needed.
It was around this time that I noted Alex seemed more withdrawn and irritable than normal, a conclusion the head coach agreed with. When talking with Alex, he denied being depressed but admitted that he was unhappy with his on-field performance and felt his ankle was holding him back.
Once Alex’s second prescription was finished, he asked the attending physician for more pain medication, but the physician denied him. Despite this refusal, Alex insisted on having something for the pain, which alarmed me. Instead of getting another Vicodin prescription, however, he was directed to take over-the-counter ibuprofen.
Alex’s behavior continued to change. He became more withdrawn and secretive about what medications he was taking, and he started missing treatment and rehabilitation appointments.
These red flags moved the head coach, assistant coach, and I to meet with Alex. We outlined a plan to voice our concerns for his welfare, allow him to talk about any issues, and detail the steps we wanted him to take to resolve the problem. Yet, the meeting didn’t go according to plan—Alex denied having any problems with drugs and was quite defensive.
Unsure of our next step, the coaches and I decided to talk to Alex’s teammates. They revealed that his alcohol consumption had increased after his injury—another red flag. This pushed us to have a second meeting with him where we again voiced our concerns about his behavior. Fortunately, he admitted that he was having some difficulty handling the injury and was willing to get help.
The coaches and I then outlined a series of expectations that would help get Alex back on track. The first step involved a referral to the campus drug-counseling center for an evaluation. This was a confidential assessment, and the only information we received from it was an acknowledgement that Alex had fulfilled his appointment. The second condition was he could no longer miss treatment and rehabilitation sessions.
Over the next two weeks, Alex’s attitude and behavior improved, and he did not skip any athletic training appointments. He continued to receive counseling and was referred to an attending physician to monitor his medication use, as he was still taking ibuprofen. Alex voluntarily communicated with me when he had appointments but did not talk about what they entailed.
Alex proceeded through the rest of the season without incident. In hindsight, I think the first meeting with him didn’t go as planned because athletes rarely like to admit they can’t handle a problem. Since we talked to his friends and they saw an issue with his behavior, as well, it may have led Alex to view our second meeting differently.
As a result of my experience with Alex, I now counsel all athletes who have been prescribed painkillers on the consequences of misusing them and the addictive properties they can have. Our team physicians also have a heightened awareness of the possible negative consequences of narcotic use and prescribe them sparingly. In the future, I will continue to be on the lookout for any red flags of addiction so that I can facilitate the appropriate referral to ensure the best care for my athletes.
Julie Alexander, ATC, is Head Athletic Trainer at St. Cloud State University. She can be reached at: email@example.com.