Are you in pain?

Men's Health (UK) - - Painkiller Abuse -

Not emo­tional hurt or trauma, but tan­gi­ble, phys­i­cal pain. You know what we’re talk­ing about: that twinge in your knee that pre­vents you from step­ping onto the five-a-side pitch; the sharp shin splints that turn ev­ery week­end 5K into an ex­cru­ci­at­ing en­durance event; the deep DOMS that pre­vents you from per­form­ing even the sim­plest of tasks with­out a wince. Any­one who has ever trained or played sport – whether team or in­di­vid­ual, am­a­teur or elite – has felt this pain. Bumps and bruises, aches and strains, nig­gles of all shapes, sizes and sever­i­ties: th­ese are the nag­ging bug­bears that all ath­letes live with on a daily ba­sis.

Now, what if you could make that pain go away? What if there was a lit­tle white pill you could sim­ply swal­low be­fore a big race or match that could deaden your dis­com­fort, al­low­ing you to per­form at your peak, al­most if not to­tally painfree? What if that same lit­tle white pill could ease the ache of your post-match re­cov­ery, too? Bet­ter yet, what if that pill was ap­par­ently safe and per­fectly le­gal? Not only that, but avail­able over the counter at all good chemists, cor­ner shops and even su­per­mar­kets, priced at 35p for a packet of 16. Well, you’d take it, wouldn’t you?

Of course you would. And, of course, you do. In re­cent years, parac­eta­mol, ibupro­fen and as­pirin have be­come as much a part of a sports­man’s kit bag as caffeine gels and post-work­out pro­tein shakes. It’s an in­dus­try that’s now worth £591 mil­lion to the UK econ­omy and their use is so com­mon it’s not so much an epidemic as it is en­demic. This year’s BBC State of Sport sur­vey re­vealed that about two thirds of am­a­teur ath­letes take non­pre­scrip­tion anti-in­flam­ma­to­ries, ei­ther to en­able them to per­form at the best of their abil­ity, or to sup­port their re­cov­ery.

But could it be that th­ese pills – cheaper than bot­tled water and eas­ier to come by – are not the painkilling panaceas we take them to be? And, by tak­ing them even on a weekly ba­sis, could you be do­ing your body more harm than good? Re­cent re­search sug­gests we have a prob­lem on our hands – a very big prob­lem. So per­haps the ul­ti­mate ques­tion is this: when the short-term re­wards for pop­ping painkillers are so great, how do you be­gin to rec­on­cile a gen­uine con­cern for your fu­ture wel­fare with the de­sire for in­stant re­lief?

A Dan­ger­ous Game

The higher up the sport­ing lad­der you climb, the big­ger the re­wards, and thus the greater the pres­sure on ath­letes to play with­out pain. From foot­ball to cy­cling, rugby to athletics, painkiller abuse is rife. Take golf­ing leg­end Tiger

Woods, who was re­cently or­dered to at­tend re­hab af­ter be­ing caught driv­ing dan­ger­ously while un­der the in­flu­ence of five sep­a­rate painkillers. Or Daniel Awde who, in a bid to qual­ify for the Lon­don 2012 Olympics, was tak­ing up to 14 tablets a day to mask the pain of a knee in­jury. “Within the athletics com­mu­nity it was a run­ning joke that a lot of ath­letes were hav­ing ibupro­fen for break­fast, lunch and din­ner,” he would later tell the BBC.

Cru­cially, none of th­ese meds ap­pear on a World Anti-dop­ing Au­thor­ity (WADA) banned sub­stances list. Now ex­perts are con­cerned about the long-term im­pact of this self-med­i­ca­tion. Data col­lected by Jiri Dvo­rak, the former chief med­i­cal of­fi­cer at FIFA, showed that half the foot­ballers in FIFA tour­na­ments be­tween 1998 and 2014 had been reg­u­larly us­ing non-pre­scrip­tion painkillers. This, said Dvo­rak, was ac­cepted as “part of the game” – a part that could prove fa­tal.

As a key mem­ber of Eng­land’s 2003 Rugby World Cup-win­ning side, former flanker Lewis ‘Mad Dog’ Moody took more painkillers dur­ing his 16-year ca­reer than he cares to re­mem­ber. In rugby, more than most sports, the op­por­tu­nity for in­jury is high, and you don’t ac­quire a nick­name like Mad Dog with­out putting your body on the line. “It was just the norm,” he says. “Painkillers and anti-in­flam­ma­to­ries were al­ways avail­able post-train­ing and post-match. When you come into a sport straight out of school, if the nor­mal course of ac­tion is to take parac­eta­mol and an­ti­in­flamms if you’ve been con­cussed, if you have a tweaked ham­string… you do as you’re told.”

In hind­sight, Moody can see that his painkiller use had turned into abuse. At the time, he ac­knowl­edges, med­i­cal staff at club and na­tional sides would warn play­ers about the dan­gers of overuse. But th­ese were ath­letes in the prime of their ca­reers, play­ing for the high­est sport­ing stakes. Pre­dictably, words of warn­ing fell on deaf ears. “Back then, there was a more flip­pant ap­proach to how you take painkillers. I re­mem­ber be­ing warned about the ef­fects of cer­tain drugs. But as a young man who thinks he’s in­vin­ci­ble, and in a ma­cho sport, you’d do any­thing to be fit – you don’t want to miss out and give some­one else the op­por­tu­nity [to play] and pos­si­bly lose your spot. You’d do what­ever it took.”

The pal­pa­ble em­bar­rass­ment in Moody’s voice turns to dis­be­lief as he con­sid­ers the harm he in­flicted upon him­self. “When you look back it’s in­san­ity, be­cause the amount of im­pact those anti-in­flamms have on your colon and the lin­ing of your stom­ach is sig­nif­i­cant.” Moody isn’t talk­ing in gen­er­al­i­ties here; he’s speak­ing from ex­pe­ri­ence. It was in 2005, with the Lions tour to New Zealand a mat­ter of months away, that the symp­toms started: un­bear­able stom­ach cramps, a sud­den, des­per­ate need to empty his bow­els, and a se­vere loss of blood ev­ery time he did so. The di­ag­no­sis was clear: Moody had de­vel­oped ul­cer­a­tive col­i­tis, where painful ul­cers de­velop in the bow­els. Its on­set, he main­tains, was a di­rect re­sult of his over­the-top use of over-the-counter pain re­lief. To cope, Moody ini­tially dealt with it the only way he knew how: he took more meds.

In 2007, in the build up to the Rugby World Cup in France, Moody reached peak painkiller, tak­ing drugs mid­week to get through train­ing, then be­fore and af­ter matches on the week­ends. Play­ing through the pain, he was one of the stars of the World Cup fi­nals, but his body was bro­ken. It was only af­ter de­cid­ing to go cold turkey on all forms of med­i­ca­tion that the symp­toms of his col­i­tis be­gan to clear up. Th­ese days, five years into his re­tire­ment, he is symp­tom-free.

In­flam­ma­tory Is­sue

It took a ca­reer-threat­en­ing ill­ness for Moody to wake up to the dan­gers that he and his team­mates had been ex­pos­ing them­selves to. And that’s hardly sur­pris­ing. Af­ter all, how could some­thing sold for pen­nies in ev­ery chemist in Bri­tain with the ex­press pur­pose of mak­ing you well ac­tu­ally be bad for you?

It’s tempt­ing to dis­miss Moody’s ex­am­ple as an ex­treme case. As for the likes of Tiger Woods and Daniel Awde, well, they were, by their own ad­mis­sions, ad­dicted. They craved painkillers. You, on the other hand, you’re dif­fer­ent – isn’t that right? You just take them as and when they’re needed, in smaller doses. Sadly, you’re prob­a­bly wrong. The chances are that the way you’re us­ing painkillers – par­tic­u­larly pop­u­lar anti-in­flam­ma­to­ries such as ibupro­fen – is all wrong.

“I’m a sports physi­cian, so my ma­jor co­hort of pa­tients is the recre­ational ath­lete,” says Dr Ajai Seth, a con­sul­tant at the Queen El­iz­a­beth Hos­pi­tal in Birm­ing­ham. “Gen­er­ally, peo­ple have no real un­der­stand­ing of how an­ti­in­flam­ma­to­ries work. I see a lot of pa­tients with stress in­juries and stress frac­tures. A lot of the time this can be put down to poor diet or over-train­ing, but the vast ma­jor­ity of the time it’s be­cause they

“As a young man who thinks he’s in­vin­ci­ble, you do what­ever it takes”

take a fair amount of anti-in­flam­ma­to­ries as well.” In other words, far from aid­ing re­cov­ery, anti-in­flam­ma­to­ries are of­ten re­spon­si­ble for ex­ac­er­bat­ing in­juries.

The key is­sue, says Seth, is ig­no­rance. “Non-steroidal anti-in­flam­ma­to­ries block a sub­stance called prostaglandin, which pro­duces in­flam­ma­tion in the body. In­flam­ma­tion your body needs in or­der to heal. So, let’s say you’re play­ing ten­nis and you sprain your an­kle. It be­comes swollen be­cause of prostaglandin.” So, what do you do about it? You pop a cou­ple of Nuro­fen and let the swelling go down. Then pop a cou­ple more when you get home to take the edge off the pain, un­til you’re back on court a week later. This, says Seth, is where we’re es­sen­tially mis­un­der­stand­ing the role of in­flam­ma­tion. “What prostaglandin does is, firstly, stop you from us­ing your an­kle be­cause it’s painful. In this re­spect, pain is a pro­tec­tive mech­a­nism.” In other words, if you can’t put weight on it you can’t make the in­jury worse.

But that’s just the half of it. “Sec­ondly, prostaglandin helps the tis­sues heal. When they heal they be­come stronger. But if you’re do­ing a half-marathon, say, and you take a cou­ple of ibupro­fen be­fore you run, you’re not letting your bone adapt. Do that over a long pe­riod of time, and you put your­self at higher risk of in­jury.”

It gets worse. “Anti-in­flam­ma­to­ries af­fect lots of sys­tems within your body,” says Seth. “It’s not just the bones and lig­a­ments; taken over a long pe­riod, they can in­crease your risk of heart at­tack, kid­ney dam­age and bowel prob­lems.”

The Watch List

Of course, most peo­ple are dan­ger­ously, al­beit un­der­stand­ably, un­aware of th­ese risks. If a doc­tor pre­scribes you a course of med­i­ca­tion, you’re told how to take it. You might even read the small-print about the po­ten­tial side ef­fects. But when it comes to over-the- counter painkillers, it’s un­likely the server be­hind the chemist’s counter is go­ing to talk you through the rec­om­mended dosage. That’s prob­lem­atic be­cause the less we un­der­stand about the drugs we’re tak­ing, the more we’ll con­tinue to take them.

But if th­ese pills are so bad for us, and so many ath­letes are tak­ing such large amounts of them, then why not sim­ply cut the cord? There are al­ready dozens of banned sub­stances on WADA’S ev­er­length­en­ing list. Surely the an­swer, to pro­tect the health of ath­letes across the sport­ing spec­trum, is sim­ply to add a few more? How­ever, the prob­lem with this ap­proach is, in a word, preva­lence.

“Painkillers are one of the most com­monly used drugs by ath­letes in sport,” says Nick Wo­jek, head of science and medicine at the or­gan­i­sa­tion UK Anti-dop­ing (UKAD). “And the main rea­son why that’s the case is pre­cisely be­cause they’re not pro­hib­ited sub­stances. Con­se­quently, peo­ple see no harm.” It’s the caffeine co­nun­drum all over again. Count­less stud­ies have shown caffeine to have sub­stan­tial, quan­tifi­able per­for­manceen­hanc­ing qual­i­ties. To this day, WADA is ex­plor­ing how and whether it could ban ath­letes from con­sum­ing caffeine pre-com­pe­ti­tion. But the re­al­ity of en­forc­ing such a pol­icy would be far­ci­cal; will ath­letes re­ceive two-year dop­ing bans for knock­ing back a dou­ble espresso dur­ing a train­ing camp? Will a can of Coke be clas­si­fied as con­tra­band?

Caffeine is sim­ply too main­stream to pro­hibit, and so too are painkillers. How to po­lice the use of some­thing that any Tom, Dick or Tiger can get his hands on in ev­ery branch of Boots is the sort of ques­tion that keeps Wo­jek up at night. “It would be very dif­fi­cult to reg­u­late them, sim­ply be­cause they’re so ac­ces­si­ble,” he af­firms. “There’s a cul­ture with painkillers... you just go down to the chemist, buy them and take them. To con­trol that be­hav­iour through sanc­tions and tra­di­tional anti- dop­ing reg­u­la­tions would be vir­tu­ally im­pos­si­ble.”

Small Print

All of this doubt­less makes for trou­bling read­ing. But are all over-the- counter painkillers re­ally that bad? Should we be raid­ing our gym bags and medicine cup­boards, round­ing up half-fin­ished pack­ets of Anadin and flush­ing them down the toi­let? No, is the short an­swer. But the only way to stay safe from harm in the long-run is to learn how and when to use them op­ti­mally.

“If you’re go­ing to use non­s­teroidal anti-in­flam­ma­to­ries, ide­ally seek ad­vice from a doc­tor to guide you through why you’re tak­ing them and how long you should be tak­ing them for,” says Seth. “And re­mem­ber that they’re only ever meant to be used dur­ing the acute phase – that’s the im­me­di­ate in­jury phase, of 24-48 hours. You need to get out of the mind­set where an­ti­in­flam­ma­to­ries are be­ing used as a means of re­cov­ery in ei­ther a pro­longed or ha­bit­ual way. And they cer­tainly should never be used pro­phy­lac­ti­cally [when you haven’t got an in­jury but want to avoid pain]. That’s the worst thing you can do. If you’re re­ly­ing on painkillers, then

“To con­trol this kind of be­hav­iour with sanc­tions is nearly im­pos­si­ble”

you’re do­ing some­thing wrong. You’re not re­hab­bing prop­erly; your strength and con­di­tion­ing pro­gramme isn’t right; there’s some­thing miss­ing from your train­ing rou­tine, and that’s man­i­fest­ing it­self as pain. You’ve got to look at the big­ger pic­ture and ask your­self why you’re in pain in the first place.”

Find­ing The Line

The bur­den of stay­ing safe and healthy, then, lies not with team doc­tors or in­ter­na­tional au­thor­i­ties such as WADA, but with you, and each in­di­vid­ual ath­lete. And that’s what’s per­haps most con­cern­ing. Be­cause all ath­letes, whether mo­ti­vated by hap­pi­ness or glory, tak­ing part or tak­ing home mil­lions in prize money, want to com­pete. And they will gen­er­ally do what­ever they can within their means to meet that end. Ask a se­ri­ous com­peti­tor not to take a seem­ingly be­nign pill that will help him get through the day be­cause it might well ham­per him fur­ther down the line, and that’s a warn­ing that will too of­ten go un­heeded.

Know­ing the trou­ble they’ve caused, Moody now steers clear of painkillers at all costs. But he can’t es­cape the fact that tak­ing them was what en­abled him to over­come the post-op pain of a ma­jor shoul­der surgery in ad­vance of the 2003 Rugby World Cup… which he went on to win. And it was painkillers that, four years later, helped him mask the agony of a se­ries of re­cur­ring in­juries just in time to make it to the grand fi­nal of the 2007 com­pe­ti­tion. So, if he could go back and do things dif­fer­ently, given what painkillers have done for his body – and for his ca­reer – would he?

“It may sound strange, but I would have done it again,” he ad­mits with un­char­ac­ter­is­tic sheep­ish­ness. “The op­por­tu­nity to play in World Cup fi­nals doesn’t come around very of­ten. Would I have done things dif­fer­ently if I had more in­for­ma­tion? I don’t have an an­swer for that. All I know is that you play a sport that you love, and if you have the op­por­tu­nity to play at the high­est level, then you do any­thing and ev­ery­thing to be fit enough to give your­self the op­por­tu­nity to play. That’s cer­tainly what we did at the time, and I’d be hard pressed to change that.” And, what­ever stage you’re com­pet­ing on, that, gentle­men, is the painful truth.

IN­TER­NAL DAM­AGE CAN BE INSIDIOUS – BREAK THE HABIT BE­FORE IT SETS IN

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