Are you in pain?
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.