Prescription drugs in sport: kill the pain, not the player

The use of prescription-only painkillers by athletes is hardly new, but debate about their (ab)use in Australia has recently been brought into focus by the emergency hospitalisation of South Sydney NRL players Aaron Gray and Dylan Walker, both of whom suffered a life-threatening reaction to a combination of controlled drugs. These athletes were recovering from post-season surgery to address injuries, with painkillers prescribed by their surgeons to assist with post-operative discomfort.

According to a Fairfax report, Gray and Walker had been prescribed the painkiller Targin, which they took. Inexplicably, they also consumed another painkiller, known as Tramadol. Thankfully, the athletes have recovered from their acute care, taking the time to publicly thank medical staff and to apologise for inadvertently causing the emergency. Just why the players took both drugs is the subject of an inquiry by the NRL Integrity Unit. This episode has certainly raised some confronting questions about the use and abuse of prescription drugs in the NRL.

Of course, sport and society are not separate. It is therefore crucial to note that the Australian Medical Association has described the misuse or abuse of prescription drugs as a “national emergency”. As an example, “of the 384 overdose deaths investigated by the Victorian coroner’s court in 2014, 82% of the deaths involved prescription drugs”. This is not an attempt to discount medication (ab)use challenges in sport, but rather to emphasise that there are multi-faceted society-wide problems in terms of prescription drugs.

Responding to crisis

While a case of n =1 hardly amounts to a league-wide catastrophe, NRL stakeholders and commentators have been polarised in the wake of the Gray-Walker episode: some have suggested that there is a prescription drugs ‘crisis’ in rugby league, while others refute such accusations as baseless in fact.

Although anecdote is no antidote to methodical research, the media was soon replete with stories by either current or former players and coaches about ‘widespread’ abuse of prescription medications. The problems varied: over-reliance on painkillers – even addiction; the misuse of prescription drugs for ‘recreational’ purposes (such as by mixing them with alcohol); and players turning to medically approved substances because they were warned off alcohol in-season as well as being subject to testing for illicit substances like marijuana, ecstacy and cocaine. Sensationally, one journalist even suggested that players were ‘stockpiling’ painkillers, then either handing them over to team mates or selling them, either of which is illegal.

As a counter to these alarming narratives, there was calm within the sport’s hierarchy. The Rugby League Players’ Association (RLPA) pointed to internal testing conducted on behalf of the NRL, with its findings having indicated no significant problems in terms of the drugs screened for: prescription relaxants – benzodiazepines, and prescription sleeping pills – zolpidems. This was also the position of NRL CEO Dave Smith, who said: “The [NRL testing] data does not suggest a widespread problem in rugby league”.The glaring problem with both arguments is that the NRL tests – and therefore the associated data – do not include opioid analgesics, such as Targin and Tramadol. Both the RLPA and Dave Smith were therefore asserting faith in a test that was not being conducted. Little wonder that that the NRL soon announced that “other [prescription] drugs could now be included in the [testing] process”, namely opioid analgesics.

The hair apparent

The NRL had performed a back flip with triple pike. Not only would they now test for opioid analgesics, they were going to adopt a new methodology for the biochemical surveillance of all prescription drugs – hair testing. Screening for drugs by strands of hair typically has the advantage of a longer diagnostic period – up to 90 days prior to the collection of a follicle. According to Nick Weeks, the Head of the NRL’s Integrity Unit, this was all part of a grand plan. He said that “the prospect of [prescription drug] hair testing has been the subject of discussion between the NRL and RLPA for several months”. That was convenient to say the least; during the Gray-Walker episode both the league and the players’ association waxed lyrical about the existing testing regime.

Employers testing employees for drugs is controversial from a civil liberties perspective, especially when there is no obvious risk to public safety, such as in the aviation and mining industries. According to the NRL, though, this is not intended to be a punitive approach, for the league’s Prescription Drug Policy, which began in 2014, has the “health and wellbeing of players” at its core. No surprise, then, that the South Sydney Football Club, for whom Gray and Walker play, have volunteered to pilot the hair testing program for the NRL.

Athlete safety: Beyond the NRL bubble

In the midst of the Gray-Walker emergency, a casual observer might have formed a view that rugby league is the only sport where prescription drug (ab)use might be problematic. However, even a cursory glance at the literature abroad suggests the use and abuse of painkillers (including anaesthetics) in elite competitions. While there is similar concern about player misuse of drugs, there is an emerging awareness of policy silences within sport that may compromise athlete safety.

According to a study published by the British Journal of Sports Medicine, “39% of players at the 2010 World Cup took pain medication before every game to help them play with an existing injury”. The drugs may have killed the pain, but what of the status of the injury post game? When the authors looked at the 2014 World Cup, the volume of painkillers and local anaesthetics had increased.

Similarly in the NFL, although the major talking point about player safety is concussion, there is growing realisation of the potential for painkillers to compromise the long-term well being of athletes. Some team doctors, critics allege, are part of the problem because they over-prescribe in the interests of getting a player back on the field quickly. This is also said to be evident in US amateur sport. In College football, “a vast arsenal of numbing agents, narcotics, and other painkillers [are] given to students-athletes in the training room”.Although the NCAA conducts “a periodic survey of drug use among college athletes”, prescription narcotics (i.e. opioid analgesics) are not listed.

This takes us full circle back to the NRL, for although the league and the RLPA wax lyrical about player welfare, what is their position on athletes being given local anaesthetics in order to take to the field? Precisely the same as that of the World Anti-Doping Agency, which has no objection to medically approved local anaesthetics – whether on game day or between matches. The case of Boyd Cordner is therefore interesting. Suffering a hip point injury in the lead up to the finals, the Daily Telegraph reported that the NRL backrower would “play out [the] season with painkilling injections”. So he did. And without any outcry from pundits that he might be putting his body at risk of aggravating the injury. As one physician who has worked with the NRL acknowledges, “degenerative arthritis of the hip … [is] common in professional football players”. Is killing the pain sparing the player?