Nov 4, 2021
Steering Student-Athletes Away from Opioids for Pain Management
The American College of Sports Medicine

Athletes at all levels and ages commonly experience pain during practice and in competition. Identifying and appropriately managing acute and chronic pain is fundamental for short- and long-term health. This is especially true for adolescent athletes in whom inadequate or inappropriate pain management can lead to a lifetime of consequences including an increased risk of opioid misuse. A team physician consensus statement released by the American College of Sports Medicine (ACSM) and five other professional sports medicine organizations shared guidelines to identify and manage pain in athletes ages 10 to 18. It urged team physicians and pediatricians to use nonpharmacologic treatments before prescribing opioids. 

“Adolescents are often initially exposed to opioids through prescriptions to treat pain,” said Stanley A. Herring, M.D., FACSM, the facilitator of the team physician project-based alliance and a clinical professor in the Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery at the University of Washington in Seattle. “This paper gives health care providers, including team physicians, pediatricians and athletic trainers, a roadmap to navigate the diagnosis and treatment of chronic and acute pain in adolescent athletes.”

opioidsThe statement, titled “Select Issues in Pain Management for the Youth and Adolescent Athlete,” presents epidemiological data about the incidence and prevalence of pain in adolescents, defines acute and chronic pain, as well as provides recommendations to diagnose and treat both.

The pain experience in the youth and adolescent athlete is affected by ongoing physiological and psychological growth and development.

“When assessing and treating pediatric pain, it’s important to consider where young people are from a developmental standpoint and how family behaviors and dynamics may influence the pain experience. It also is imperative to address pediatric pain appropriately to decrease the likelihood of developing persistent or chronic pain issues into adulthood,” said Karen E. Weiss, Ph.D., L.P., a pediatric pain psychologist at Seattle Children’s Hospital and associate professor at the University of Washington School of Medicine.

Of concern are recent reports of prescription opioid use in high school and adolescent-age students. In a study of high school seniors, 8% and 12% of female and male athletes, respectively, reported the use of prescription opioids in the past year. The use of prescribed opioids among high school students before graduation has been associated with the risk of misuse of opioids after graduation. In addition, male adolescents participating in organized sports are 10 times as likely to unintentionally misuse opioids, twice as likely to be prescribed opioids, and 4 times more likely to use opioids intentionally for recreational purposes. Twenty-five percent of college-age athletes report the use of prescription opioids over a one-year period; approximately one in four report using opioids without a prescription.

Athletes often have a unique relationship with pain. Athletic injury or illness and the associated pain generated are often accepted consequences of participation in sports. However, the athlete’s psychological response to pain is affected by their perception of the illness or injury-producing pain; the effect of pain on short- and long-term abilities and goals; the athlete’s life activities outside of sports; expectations, whether real or imagined, for treatment; and relationship with the athletic and/or mental health care network.

Youth and adolescents who do not have effective strategies to cope with distress are at increased risk of using maladaptive approaches that are damaging (i.e. misuse of prescription medication, self-medication). When athletes attempt various pain management strategies but continue to struggle with pain, they may question the competency of the athletic care network.

Suggested interventions focus on comprehensive nonpharmacological, pharmacological, and psychosocial treatments based on the athlete, the injury, and the demands of the sport.

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For acute pain, team physicians and pediatricians should:  

  • Understand that the diagnostic process must evaluate all aspects (anatomical and psychosocial) of pain causation
  • Understand that nonpharmacological treatments are fundamental to treat acute and post-acute pain from injuries
  • Understand that medications, in particular, opioids if prescribed, should be utilized at the lowest effective dose for the shortest duration
  • Recognize the signs and symptoms of potential problematic opioid use
  • Understand the role of exercise to improve pain and function from acute injury
  • Educate athletes and parents so that pain management goals are well understood and realistic

For chronic pain, they should:

  • Understand that treatment is best offered as part of an interdisciplinary approach
  • Understand that a multimodal care plan (e.g., exercise, nutrition, cognitive-behavioral techniques, relaxation, improved sleep) is safer, possibly more effective, and probably more durable than pharmaceuticals
  • Understand that opioids should not be used in this age population without specialty consultation
  • Educate student-athletes and parents regarding what pain is and how it is relieved because expectations and misunderstandings affect response to treatment

ACSM collaborated with the American Academy of Family Physicians, the American Academy of Orthopaedic Surgeons, the American Medical Society for Sports Medicine, the American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine to develop this statement.

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