Opioids overshadow athletic injuries

In my practice, we are seeing patients and their families being increasingly interested in gaining a competitive edge with regard to athletics. The off-season or dedicated rest period for many of our athletes is becoming obsolete. Children are training year-round, specializing in a single sport earlier on, and oftentimes playing for multiple teams at the same time in order to get ahead or even just keep up with their peers. One of the consequences of this is that our young athletes are running themselves down-pushing to be the best-at the cost of wear and tear on their bodies. Repetitive stress, fatigue, and poor technique lead to children suffering overuse injuries and put kids at risk for traumatic injury.

We see that the desire to compete and the pressure to stay in the game influence families' decisions when it comes to participation and treatment. We often hear of the athlete who has an upcoming showcase for college scouts, a play-off game, a huge tournament, or a big tryout that they can't miss or for which they "can't" stop training. A patient may have been pushing through pain for months or for multiple sports seasons, but they will present to the office seeking a quick solution, often in the form of pain-relief medication. Although most people take prescription medications appropriately, studies have shown that about 20% of young persons aged 12 to 17 years have used prescription drugs for nonmedical reasons.¹                                                       

Most opioids are not necessary

The reality is that the vast majority of our young athletes do not require strong painkillers for athletic injuries, and most can be managed with nonsteroidal anti-inflammatory medication. Stronger painkillers, such as opioids, may offer quick relief, consistent with the immediate-gratification mentality of our society: I want it now, fix it now, be stronger now. Our athletes want to be bigger, faster, stronger, and pain-free now.

Consider the old adage "no pain, no gain." This mentality continues to be taught to young athletes as they are encouraged to play through pain and prove their strength both mentally and physically. The internal and external pressure to compete and stay in the game overshadows the risk of taking pain medication, including opioids. Although the painkiller can temporarily eliminate the pain, we need to remember-as prescribers and as educators to the family-that it does not eliminate the injury. The opioid does not quicken healing.

More: Why playground injuries are on the rise

Opioid medications, such as oxycodone, morphine, hydromorphone, fentanyl and codeine, are narcotic drugs used for moderate or severe pain relief. Prescription of opioid analgesics has increased over the last 20 years. Research has shown that exposure to prescription opioids ranges from 22% to 45% in US high school students.² Adolescents in higher-impact sports such as football and wrestling have the highest severe injury rates³ and are more likely to be given prescription pain medications.⁴ However, exposure does not necessarily lead to misuse. A recent study in Pediatrics showed that daily participation in sports and exercise is likely a protective factor with respect to opioid misuse and risk of lifetime heroin use (using opioids as a gateway drug).⁵

Unfortunately, there is no way to determine the absolute risk of a patient becoming addicted to medication, misusing it, or abusing it. However, screening for a history of drug abuse and the presence of risk factors can help the community pediatrician in deciding what type of medication may be most appropriate for a patient's pain.

Assess risks before prescribing opioids

The Institute for Clinical Systems Improvement (ICSI) Acute Pain Assessment and Opioid Prescribing Protocol suggests assessing possible risks with the "ABCDPQRS" mnemonic⁶:

• Alcohol exposure;

• Benzodiazepines and other drug use;

• Clearance of the medication (any renal or hepatic issues);

• Delirium;

• Psychiatric comorbidities (personal and family);

• Query a prescription monitoring program;

• Respiratory issues; and

• Safety issues, because opioids are a controlled substance and there are dangers of driving or working while taking these medications.

The protocol is suggested for adult patients; however, its recommendations are helpful for any primary care provider, including suggestions for brief and comprehensive pain assessments, duration of treatment, and suggestions for how to answer difficult questions, explain addiction risk, and more.

Next: Why education is key to preventing harm

Discussion and shared decision making is critical. The patient and family need to be educated on the risks of opioid medication, even when using short term. Informed decision making as a team, including the patient, physician, and parents, provides education regarding the specific medication prescribed, the expected benefit of the medication, possible adverse effects, and the suspected time for injury recovery. Warning signs that would require immediate medical attention need to clearly stated.

I find it helpful to provide a brief information sheet so that the family can review what has been discussed after leaving the office and have it as a reference if any concerns arise. Additional helpful resources for parents are available at the Partnership for Drug-Free Kids website (www.drugfree.org/resources), including free e-books and fact sheets (such as Preventing Teen Abuse of Prescription Drugs).

Education is the key to prevent harm

Our current medical system puts pressure on physicians to see more patients and oftentimes does not allocate much time for patient and family education. However, it is crucial that we do not give in and just write a quick prescription to "fix" the pain and send these patients on their way. Consider that masking the pain is a ticket to play for some, meaning: The pain is gone. I feel good. I can play tonight. However, the injury is still there. They may not "feel it," but the player with the torn anterior cruciate ligament (ACL), for example, is still playing with the torn ACL.

As physicians, we certainly have a desire to relieve suffering and help our patients, but our oath of "do no harm" must be paramount. We owe it to our patients to educate them regarding adverse effects, the risk of addiction, the potential harm of masking pain, and playing with injury. Whereas we all want to please our patients and satisfy our families, overprescribing painkillers is a real issue that we are seeing not only in the urban environment but very commonly in suburban and rural communities. The reality is that this is an epidemic across all socioeconomic levels. Access is becoming easier, and the drive to compete and be accepted seems to be intensifying. However, the quick fix is not an answer that we should promote to our young patients (or their parents).

Next: Face masks and the brain

It is important for the community pediatrician to take time to determine the cause of injury in an adolescent athlete. Is this an overuse injury because of repetitive stress and/or lack of recovery time, or is it a traumatic acute injury? I often find that most overuse injuries can be initially treated with a combination of modified activity (or complete rest) from the aggravating activity, nonsteroidal anti-inflammatory medication, icing and/or heat, and use of supportive devices such as bracing or taping. I strongly think that this should be the first line of care for the majority of chronic injuries or overuse injuries. If there is a more traumatic, acute issue, stronger medication may be appropriate in the short term. For example, consider a 3-day supply of a low-dose, short-acting opioid with a well-defined plan to follow up after that time to reassess the patient. Long-acting, extended-release opioid medications should not be prescribed.

Physicians need to become more knowledgeable about the indications for and against prescribing opioids. We need to work hard at trying to prevent abuse and harm while still ensuring proper treatment of pain. By upping our game in the office, we can help keep our kids safely in the game or on the sidelines when appropriate.

REFERENCES

US Department of Health and Human Services. Prescription drugs: abuse and addiction. National Institute on Drug Abuse. NIH publication number 11-4881.

. Published July 2001. Revised October 2011. Accessed August 26, 2016.

2.    Fortuna RJ, Robbins BW, Caiola E, Joynt M, Halterman JS. Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics. 2010;126(6):1108-1116.

3.    Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005-2007. Am J Sports Med. 2009;37(9):1798-1805.

4.    Veliz PT, Boyd C, McCabe SE. Playing through pain: sports participation and nonmedical use of opioid medications among adolescents. Am J Public Health. 2013;103(5):e28-e30.

5.    Veliz P, Boyd CJ, McCabe SE. Nonmedical prescription opioid and heroin use among adolescents who engage in sports and exercise. Pediatrics. 2016;138(2):pii:e20160677.

6.    Thorson D, Biewen P, Bonte B, et al; Institute for Clinical Systems Improvement. Acute pain assessment and opioid prescribing protocol. https://www.icsi.org/_asset/dyp5wm/Opioids.pdf. Published January 2014. Accessed August 26, 2016.

Dr Frye serves as teaching faculty for the Michigan State University College of Human Medicine, East Lansing, and also is a nonsurgical pediatric orthopedics and sports medicine physician in Grand Blanc, MI. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.