Featured March 2021

Playing through the pain

How should painkillers be used in the NRL?

Rugby league is built on the image of the gladiator. The player battered, bruised and bloodied hauling himself off the ground for one more tackle, one more run.

It’s John Sattler playing with a broken jaw. Cooper Cronk with a broken shoulder. Sam Burgess with a broken cheek.

It’s Johnathan Thurston landing a match-winning conversion in his final match with Queensland, virtually unable to use one of his arms.

There’s a famous quote from United States Marine Lieutenant General Chesty Puller:

“Pain is weakness leaving the body.”

You can bet that quote has been painted in gyms and repeated at training sessions around the world.

But is playing through the pain really something that should be celebrated among our athletes?

Like the realisation that playing with a concussion and repeated head knocks can have serious long term health effects, could rugby league be barreling towards a similar case when it comes to retired players and their injuries?

Dealing with pain

Dr Nial Wheate is an Associate Professor of Pharmacy at the University of Sydney who explains that painkillers are not a modern invention and have been around for thousands of years.

“Opioid based medicines have been used for thousands of years. The earliest reported use was in 3,400 BC. For modern times, Fentanyl was invented in the 1960s. Oxycodone was invented in the 1910s. Weaker pain killers were aspirin (1890s), paracetamol (1870s) and ibuprofen (1960s).”

Painkilling injections have been part and parcel of the game for decades.

It’s common to hear a player has gone off the field to receive an injection to allow them to continue playing.

How is the risk of further injury balanced with a player wanting to continue on the field? 

And what are the ethics of players and medical staff using painkilling injections to enable those players to take the field who otherwise wouldn’t be able to compete?

Physical concerns

Daryl Adair is an Associate Professor of Sport Management from the University of Technology Sydney who says the use of painkillers needs to be a decision made between players, coaching staff and medical professionals and take into account the impact an injured player can have on their team during a match.

“Athletes typically want to play at every opportunity, even if injured. This is especially so if they feel external pressure to line up, notwithstanding an injury. Medical staff will obviously make assessments about whether an athlete can play through an injury, along with the risk of aggravating such an injury by playing. Players may try to disguise an injury, gritting their teeth and attempting to rally week in, week out.

“A message that coaches and medical staff can reiterate to players is that, as a general rule, healthy bodies that are fully functional are much more likely to win games than battered bodies that are not fully functional.”

Associate Professor Adair does add an important caveat though. Given these athletes are professionals, the context of their injury and the use of painkilling injections needs to be taken into account.

“Context is critical: if it’s a final there is no tomorrow, as we saw with Cooper Cronk’s extraordinary (though very risky) efforts to play in the NRL Grand Final a couple of seasons ago.”

Dr Wheate adds that the use of painkillers can lead to longer-term injuries given the body’s natural injury coping mechanisms have been masked.

“If athletes use painkillers to continue competing they run the risk of making their injuries worse and causing themselves serious harm by pushing their body past what it could normally stand. They’re likely to end up injured for a longer period of time, or get a permanent injury,” he says.

The difficulty in determining long term risk to athletes is a lack of data available to medical experts.

Dr John Orchard from the University of Sydney was recently involved in a study published in the Clinical Journal of Sports Medicine.

His research found there were mixed results when using painkilling injections for professional athletes.

In a Twitter thread, Dr Orchard explains there needs to be further research, however the results indicate a relatively low risk of long term issues if injections are used to treat an injury to the shoulder’s A/C joint. 

The A/C joint is a particularly painful injury, often caused by a compression of the shoulder joint, however many players play through low grade tears to the A/C joint by using painkilling injections.

He does caution against using injections for plantar fascia injuries (bottom of the foot), while also suggesting medical professionals utilise ultrasound when injecting the ribs to avoid a collapsed lung, as happened to Tyrod Taylor from the LA Chargers during the 2020 NFL season. 

Dr Orchard suggests against injecting players who are suffering knee injuries as there is a high incidence of osteoarthritis in the joint and the connection between injections and the chronic condition could be made during the player’s retirement.

Similarly to Associate Professor Adair, Dr Orchard, whose resume includes stints with Cricket Australia, the NRL and Sydney Roosters, does say that matches such as State of Origin and Grand Finals could be a consideration for utilising injections in those cases.

Ethical considerations

Adair believes while local anaesthetics used in sport are allowed under the World Anti Doping Authority code, he views the use of the drugs as contrary to a doctor’s commitment to “doing no harm”.

“Local anaesthetics in sport are approved by WADA and have long been part of professional sport. Intuitively, this seems contrary to the ‘do no harm’ mantra of club doctors. This is because players are being artificially prevented from responding to pain by using the body’s natural defence mechanisms.

“Pain indicates something is wrong: if you damage an ankle, the optimal path to recovery is the use of ice to reduce swelling and immobilisation of the joint. A painkilling jab and athlete sent back on the field, is contrary to medical procedure and risks aggravating an injury,” says Adair.

He also suggests that perhaps painkillers shouldn’t be permitted by WADA, with the drugs assisting athletes to perform when their bodies normally wouldn’t allow them to.

“My view is that painkilling injections are performance enhancers and should be banned on match day. They contravene two pillars of the WADA Code: unnatural performance enhancement and risk to athletes’ health. The typical defence of painkilling injections is that they do not allow an athlete to perform beyond their ‘natural’ ability. 

“However, there are all manner of challenges for athletes on the field of play, whether fatigue, soreness, or injury, all of which are a ‘natural’ part of play. The athlete performs in context, not in respect of their optimal potential. Painkillers decontextualise athlete performance,” he says.     

In recent years, the use of painkillers in professional sport has attracted controversy. In 2017 Sky Sports’ Phil Clarke called on Super League and the Rugby Football League to ban all pain killing injections before games. 

At the same time former Great Britain captain Danny Sculthorpe admitted to being addicted to the painkiller Fentanyl during his career. In an interview with the BBC Sculthorpe said pain killers became a normal part of his routine and he added Fentanyl following a back injury.

Painkillers became a large problem in the United States, with the NFL fighting a 2017 lawsuit due to alleged over-prescription of painkillers to players with many stating they became addicted. The lawsuit stated that in 2012 each team, on average, prescribed 5,777 doses of anti-inflammatories and 2,270 doses of narcotics. That works out to roughly 150 doses per player in a calendar year.

While no such accusations have been made against the NRL, Adair says Australian sport as a whole has to be careful when it comes to the prescribing of pain killing medications as he believes the incidents of overuse in Australia are under-reported.

“I have no doubt that the use of painkillers – whether opioids or anaesthetic injections – are an under-reported problem in contact sports in Australia. It stands to reason given what we already know about athlete self-medication, doctor over-prescription, and painkiller (opioid) addiction in American football.

“Australian rugby league players need to be made much more aware of challenges to their health and wellbeing from the overuse of painkillers. Past players can certainly vouch for that and ought to be encouraged to speak in open forum to the RLPA and clubs.”

He also compares the use of painkillers to how the view on concussion changed in the past decade.

“As we know, the concussion challenge in contact sports was not openly discussed until recent times, with policy emerging in the wake of significant health problems for athletes. In painkillers there is also risk to athlete wellbeing, but in some ways they present a more difficult diagnostic challenge. 

“Concussion is (often) observed in terms of player contact on the field. There are now return to play protocols. Painkillers are administered out of public sight. The protocols for administering them (or otherwise) are not as clear.”

The NRL and RLPA have worked closely on player safety with a policy in place to manage the administering of medications to players, with a tighter focus on painkillers following the case of Dylan Walker and Aaron Gray overdosing on prescription drugs. 

It’s understood the NRL currently tests for Benzodiazepines such as Valium and Zolpidems including Stilnox as well as stronger substances such as Tramadol.

The policies and guidelines have been developed by independent experts in consultation with the NRL and club medical staff. 

Analysis

The use of painkilling injections have long been a part of professional sport, with the NRL, given its physical nature, readily using painkillers to have players return to the field.

The use of those medications invites an intriguing discussion on the morality and ethics of professional sport.

Is it okay to risk a player’s long term health for short term gain?

Quite often the player is involved in that decision and prepared to face the consequences.

However, Associate Professor Adair adds a wrinkle with his belief that those medications are performance enhancers. Without them, that player wouldn’t be able to even take the field.

Yet, the World Anti Doping Authority has softened its stance on the use of recreational drugs so it seems unlikely it would move to ban painkilling injections.

Ultimately, the use of these drugs has to be on a case-by-case basis. It would be irresponsible to be needling a player up for a trial game, but, like Cooper Cronk, probably an accepted practice in important games.

Meanwhile Dr Orchard’s research indicates that the use of injections very much depends on which part of the body is injured.

Is this something that should be left to the club doctors, medical staff and players, or something that needs more oversight from the NRL and potentially Sports Integrity Australia?

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