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Continued: NFL and pain: League zeros in on one pain medication

  • Article by: DAN WIEDERER , Star Tribune
  • Last update: August 22, 2012 - 6:31 AM

During a 13-season NFL career, defensive tackle Warren Sapp cherished those days he was close to pain-free, those games he could race onto the field with nothing but adrenaline pumping through his veins.

"I was in the trenches, boss, with contact every time," Sapp recalls. "And trust me, when I was feeling good, it was a great feeling to go into a ballgame without a shot, without a pill, without two Advil. Oh, man. Come on. I wanted it that way."

And when did that exhilarating, pain-free feeling typically wear off?

"About Week 3," Sapp said.

Life in the NFL is frequently an avalanche of pain -- often nagging, sometimes excruciating. To survive, a player's ability to suppress discomfort is mandatory. And often that requires a bit of medicinal magic on game day, the current drug of choice being Toradol, a nonsteroidal, anti-inflammatory drug.

For years, many NFL players have sought Toradol injections the same way college students slam Red Bull when pulling an all-nighter. But the drug, which surfaced in the league in the mid- to late 1990s, has potentially serious side effects that have prompted league officials to take a closer look at its use. According to multiple NFL sources, the league is giving serious consideration to outlawing Toradol, with the wheels in motion to implement a ban that may be put into effect immediately.

The NFL Physicians Society and the NFL Players Association have been pushing for greater restraint with how Toradol is used.

One of the bigger worries is that the drug -- while it is FDA-approved, currently legal in the NFL and functions similarly to Advil or Aleve -- hasn't been studied significantly enough for doctors and players to fully understand the long-term ramifications of overuse.

Complications associated with Toradol misuse include potential kidney failure, liver damage and gastrointestinal bleeding. There's also increased risk of heart attack and stroke.

More troublesome to the NFL is that Toradol inhibits platelet function, creating a danger of brain bleeding for players who suffer head injuries while the drug is in their system. More than 2,100 former players are involved in lawsuits alleging that the league insufficiently responded to concussions and the long-term implications of repeated brain trauma.

Dr. Thom Mayer, the NFLPA's medical director, said that offering Toradol to players who will be exposed to physical trauma "increases the risk of bleeding from that trauma. In addition, due to the anti-inflammatory and analgesic effect of the medication, the question must be raised whether the use of Toradol [also] increases the risk of additional injury."

According to the Food and Drug Administration, Toradol shouldn't be used for longer than five days consecutively. At present, that's not an issue in the NFL, where the drug is used almost exclusively on game days.

But some veteran players request and receive a Toradol injection before every game. That means some players receive 16 to 20 doses of Toradol over a four- to five-month span.

Vikings defensive tackle Kevin Williams said that for several seasons he has tried to take the shot before every game.

"I think a lot of us take it because we're just used to doing it," said Williams, approaching his 32nd birthday and entering his 10th NFL season. "It's a peace-of-mind thing for a lot of guys."

As Mayer suggests, that's evidence that too many players gravitate toward the drug as a preventative measure -- to mask the pain of injuries not yet suffered.

According to Mayer, the NFL Physicians Society Task Force recently drafted updated recommendations for Toradol usage. Those new guidelines sternly warn against the prophylactic use of the drug.

Furthermore, Mayer said, the task force guidelines indicate Toradol is only to be used by players listed on a team's latest injury report.

Said Mayer: "This task force recommendation is important as it, although indirectly, admits that the gratuitous use of Toradol to keep our players on the field is not, and was never, clinically sound."

'Like a sheet of armor'

Toradol was originally developed as a postoperative drug, used primarily to treat moderately severe acute pain. When injected into the bloodstream, it can begin working almost immediately, quelling whatever pain may be present.

That's been ideal for NFL players in need of a quick game-day fix. Equally important, the shot gives many players added confidence that they can perform worry-free, uninhibited by existing pain and able to more easily push through any new injuries that may occur.

"That ability to numb that pain even just a little makes a big difference," said Vikings defensive end Brian Robison.

Twenty-nine years old and heading into his sixth season, Robison said he rarely turns to medication to treat his pain. But sometimes there's little choice.

During his second year with the Vikings in 2008, Robison had arthroscopic surgery on his right knee in late-November, yet was back playing less than two weeks later. As a young and still unproven player, he knew he couldn't afford to stay off the field. So for three games, he said, he took a pregame Toradol shot to ease his discomfort and ensure he could contribute.

Many players request the injection much more frequently.

Former Vikings tight end Jim Kleinsasser, whose 13-year career ended in January, estimates he used Toradol before just about every game he played over his final five seasons.

"I was just getting old, honestly," Kleinsasser said. "There's a certain point in your career where you're going through the pounding of the season and getting through that week of practice and trying to get to that next game day. Toradol is part of what gets you back to playing the way you normally can."

And sometimes that injection can make all the difference. Former NFL star Torry Holt said he only took Toradol a handful of times throughout his 12-season NFL career. His first use came on the afternoon of the Super Bowl in 2000.

Holt was a rookie with the Rams and had separated the acromioclavicular (AC) joint in his right shoulder during St. Louis' NFC Championship Game win. It was the kind of injury, coupled with bruised ribs, that caused pain so severe that Holt admitted he would have considered sitting out several regular-season games.

But the Super Bowl? With little hesitance, Holt asked for and received a Toradol shot.

"I felt like new money," Holt said. "You get that shot and you feel like you're 18, 19 years old. It's like a sheet of armor. I was a new man."

Several hours later, after making seven catches for 109 yards, including a 9-yard touchdown grab, Holt was also a Super Bowl champion with the Rams edging the Titans 23-16.

Everything about the day felt great. Until the Toradol faded.

"It was very, very, very painful once that medication wore off," Holt said. "When you get that Toradol shot, you feel like you have a whole new body on you. At the same time, you're just tearing away at the problem you have. Masking the pain allows you to get through the game. But the pain is still there, and you'll have to deal with it afterwards."

Veterans first

Exact data on the prevalence of Toradol use in the NFL is unavailable, protected by medical confidentiality laws. The Star Tribune interviewed 18 current and former players for this story, and the consensus estimate is that at least 10 players per team per game will receive a Toradol shot before taking the field. That number, players say, can swell toward two dozen players, depending on the time of the season, the age dynamics of the roster and the team's overall health.

Veterans are more likely to need the shot. And often, younger players are even dissuaded from treating their aches and pains with the injection.

Former fullback Tony Richardson said he used Toradol on a weekly basis in-season for his final seven or eight years in the league. That included stints with the Chiefs, Vikings and Jets.

"I've seen trainers tell players straight up, 'Look, you're too young to get a Toradol shot. Get out of here,'" Richardson said. "A young guy with a serious injury might need it. But a young guy [in general]? We wouldn't even let him in the line. It was like, 'Get out of here. You don't need this.'''

Dr. Lawrence Brown, the NFL drug program's administrator, contends it is difficult to make a blanket statement on how much Toradol use is too much, a medical assessment Brown said should be made on a patient-by-patient basis.

That deflects much of the responsibility toward team physicians and the players themselves. And players, often not knowing any better, will frequently steer toward the treatment that gets them back on the field as quickly and pain-free as possible.

Former Vikings Chris Walsh and Sean Berton were among 12 former players filing a lawsuit against the NFL last December. In that suit, Toradol is prominently mentioned, with the plaintiffs alleging the drug may have prevented them from feeling concussions they suffered while playing.

"Ask the NFL, ask their lawyers: before these players were given these drugs, were they taken into a room and given a sheet of paper to read what these drugs might do to them and then given the opportunity to say yes or no?'' said former Pro Bowl receiver Joe Horn, one of the 12 players involved in the suit. "If their answer is, 'No, we did not,' then guess what, you are at fault. Simple as that."

Vikings medical personnel say they have taken a proactive approach to educating players on Toradol's benefits and harms. At training camp every summer, head athletic trainer Eric Sugarman delivers a presentation on the drug.

In order to receive a Toradol injection before a game, Vikings players must first receive approval from a team physician. Vikings players are also required to sign a waiver once per season, acknowledging they understand the risks.

Said Sugarman: "We have never told a player of ours he has to use Toradol. Never. Absolutely not. Now if a guy elects to use Toradol for whatever reason, he has to have informed consent."

Education needed

But will NFL players, so driven to make sure they're available to play the next game with the least pain possible, take the time to read and digest the fine print?

In an interview last winter with HBO, Bears linebacker Brian Urlacher said he's always thought of his regular Toradol injections like they were "like a flu shot."

Kevin Williams' rationale for feeling safe about his recurrent Toradol use?

"I don't think if you took it 16 times, it would have an [adverse] affect on you over the long run," he said. "That's my mindset anyway. ... You've got to realize, man, us NFL guys have a very small window to play this game. And you're always wired and talking about playing to the best of your ability and having success while you can. Because you won't have it long. You can't last forever."

Richardson, a former member of the NFL Players Association's executive committee, is pushing for players to receive more education on all pain-related drugs. Over the past half-decade, he points out, the league and its players have become more aggressive with their initiatives to address concussion-related issues.

"We've opened the door for that whole whistleblower deal," Richardson said. "If you see one of your buddies and he's not looking right in the eyes, you need to talk to the doctor and get [your teammate] to the sidelines and sit him down versus allowing guys to play through that. Same with these pain medications. We need more awareness.''

Whether awareness will lead players to change their mindset is a question that awaits an answer.

"As a player, I don't have perspective," Sapp said. "I want to play. I don't know anything other than my team needs me, it's Sunday, it's game day, I've got to play. We're always going to go that way. ... That's all we know. That's the way the game was taught to us from the time we were knee-high to a jackrabbit. That's the way the game was played before us. We need to change it going forward."

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