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Cautious opioid prescribing for college athletes

By: Dr. Victor Schwartz and Dr. Andrew Kolodny, New York University

Although rates have leveled off in the past two years, opioid pain medication prescriptions in the U.S. more than tripled from 1999 to 2011. There were nearly 207 million prescriptions written for opiates like oxycodone (Oxycontin) and hydrocodone (Vicodin) and related drugs in 2013.

The increase in opioid prescribing has been associated with parallel increases in opioid addiction and overdose deaths. In 2012, there were estimated to be 2.1 million people in the U.S. addicted to opioid painkillers and approximately 457,000 addicted to heroin. At the same time unintentional prescription opioid overdose deaths have quadrupled since 1999 rising from 1.4 deaths /100,000 people, to 5.4/100,000 in 2011. There were estimated to be 16,000 accidental deaths related to prescription opioid use in 2012 in the U.S.

With the arduous physical demands of training and competition, college athletes are at particularly high risk for acute pain from injuries. In the most recent NCAA survey , 23 percent of college athletes reported receiving a prescription for a pain medication and 6 percent reported using an opioid without a prescription in the prior year. The fact that student-athletes, who in general drink at rates similar to non-athlete student peers, tend to report higher rates of binge drinking than non-athlete students, only heightens that risk (Mind, Body and Sport, NCAA). Combining alcohol (or other potentially abused substances like tranquilizers) with prescription opioids, significantly increases risk of accidental overdose and death.

Given the widespread use and potential dangers associated with these medications, we would like to share some guidance about the prescription and use of these drugs in student-athletes. Some of the difficulty surrounding the proper use of these drugs stems from the fact that there are numerous misunderstandings about their usefulness and safety:

  • Many people believe that it takes a long time to develop physiological dependence to opioids. In fact, with daily use, dependence and tolerance (requiring higher doses to achieve the same level of pain relief) can develop in a matter of days or weeks.
  • Many clinicians believe that extended release or long acting formulations of these drugs are more effective and safer than the shorter-acting alternatives. There is no data to support these claims.
  • There is a common perception that opioid overdoses only occur among drug abusers and those attempting suicide. In fact, anyone using opioids is at risk for unintentional overdose and the risk increases when higher doses are taken or when opioids are combined with other central nervous system depressants (like tranquilizers or sleep medications) or alcohol.
  • Those who resume opioid use after a period of abstinence from regular use are at particularly high risk for accidental overdose. As noted above, when used regularly, people develop tolerance to the drug and require higher doses to achieve the same effect. When a person is abstinent for even a few days, they lose tolerance and a dose they had grown accustomed can become lethal.

Some suggestions for clinicians treating student-athletes’ painful injuries:

  • Avoid opioids whenever possible. Try a non-steroidal anti-inflammatory (NSAID). NSAIDs are quite effective for moderate pain and can help reduce fairly severe pain to a significant degree – especially when the pain is associated with inflammation (as in a severe sprain). Depending on the injury, care should be used because NSAIDs can increase the risk of bleeding. (Acetaminophen does not promote bleeding so is safe in this context).
  • Always explain that opioids are for time-limited use only. For severe acute pain from an injury, three days of opioid medication is often sufficient. Inform the student-athlete that these medicines should be reduced and stopped as soon as the severity of the pain has diminished sufficiently to switch to a non-steroidal anti-inflammatory drug.
  • Explain the risks and dangers of these medications in detail, including the risk of addiction and overdose.
  • Prescribe low doses and small quantities. While many insurance plans charge the same for a few pills as for a month’s supply, never give a student-athlete a month supply of the medicine when it is likely to only be needed for a few days. Giving a large supply at once increases the risk of overdose and drug diversion. We know that many people who misuse or abuse these drugs get them from friends who have extra supply or take them from a medicine cabinet where the medication has been left sitting.
  • Instruct athletes who receive prescriptions for opioids to keep them locked away in a safe place and not to tell friends that they have received this prescription. This again limits the risk of diversion or theft.
  • Don’t prescribe long acting or extended release opioids for acute pain or to opioid naïve patients. These formulations are more dangerous because they contain a large dose in each pill.
  • Athletes receiving opioid pain relievers should be monitored very closely to assess the status of their injury and to discontinue opioids as soon as possible.
  • Screen everyone for history of or current substance abuse, depression and other psychiatric disorders before starting opioids. Some patients with depression can present with somatic complaints of pain; their pain may resolve when the depression remits. When possible, opioids should be avoided in these groups. Keep in mind that some student-athletes may be reluctant to disclose a history of mental health or substance use problems. It is helpful to have obtained thorough medical histories.
  • Ask athletes who have received opioids to return unused opioid medication to their pharmacy.

While opioids certainly have a place in the array of options available to those managing injuries, they must be used with caution and in as limited a manner as is clinically feasible.

We hope that these suggestions will result in safer and more effective treatment of our student-athletes.

About the Authors

Dr. Victor Schwartz is medical director at The Jed Foundation, a leading non-profit dedicated to improving mental health and preventing suicide and substance abuse among college and university students. He is also associate clinical professor of psychiatry at NYU School of Medicine.

Dr. Andrew Kolodny is director of Physicians for Responsible Opioid Prescribing, Chief Medical Officer of Phoenix House, a national nonprofit addiction treatment organization, and is a research professor at the NYU Global Institute of Public Health.