Athletes and Opioids

football player throwing the ball

Opioid addiction knows no bounds. It does not discriminate. Rich, poor, young, old — everyone is vulnerable. Women and men can get addicted. People of any ethnic or cultural background can get addicted. People you’d never expect to touch an illicit drug in their lives can go from perfectly managed prescription use to illicit drug misuse and criminal activity in a matter of months.

And every person who gets addicted to opioids then becomes a statistic in the opioid crisis.

But why?

Why opioids?

The most obvious answer is that they work.

They work very well — better than any other pain-relieving medication known to medical science. The reason they work so well is that they leverage the built-in, naturally occurring pain-relief mechanisms in our central nervous system. Over millennia, our bodies developed an endogenous (internal) opioid system to manage both short-term and long-term pain. Exogenous (external) opioids mimic the physical properties of endogenous opioids to achieve their effect — and that’s why they work so well.

They take the control knob on our natural pain-relief systems, crank it up past 11, and the result is that our pain not only goes away, but we also feel an enhanced sense of euphoria. The euphoria we feel when taking opioids is similar to the feelings of pleasure we derive from things like food and sex: it’s that basic to the human experience — and the volume knob and that opioid euphoria is also cranked up past 11.

That’s why it’s so easy for humans to get hooked on opioids. It’s a 1–2 punch — pain relief and euphoria — but it’s the first part — their effectiveness in relieving pain — that makes opioids, opioid abuse, and opioid addiction such a tough nut to crack: we don’t have anything better at relieving pain.

And it’s that first part that makes one specific population disproportionately vulnerable to opioid abuse and addiction: athletes.

Opioid Abuse and Sports

The phenomenon of opioid abuse among elite athletes is well-documented. The most visible case of opioid abuse, addiction, and subsequent recovery can be found in the story of Hall of Fame, All-Pro, Super Bowl winning quarterback Brett Favre. Favre developed an opioid use disorder (OUD) in the early 90s while playing for the Green Bay Packers. He began taking opioids to relieve pain from football-related injuries, and over the course of several years, developed a full-blown opioid addiction.

Favre himself says at the height of his addiction, he took 15 Vicodin at a time and a month’s worth in just two days.

Again, the question we ask is why.

Why do pro athletes — or athletes at all — continue to take a drug they know they’re addicted to and can cause long-term emotional, psychological, and physical damage?

We’ve already answered part of that question: opioids work.

The answer to the rest of the question is more complicated.

One complication is that many athletes actually do not know about or understand the dangers posed by prolonged exposure to drugs like opioids. Nor do they know about the dangers of long-term addiction to drugs of abuse, which opioids become when they’re used in ways that are not prescribed by a physician.

Another complication is the nature of sports: they’re competition oriented and the goal is to win. Therefore, any drug that can keep an athlete on the field and contributing to the success of the team is attractive to competitive athletes, no matter the consequences.

Yet another complication is the nature of athletes themselves: their identities — and for pro athletes, their livelihoods — are entwined, and in some cases, dependent on their ability to perform. This is true for the pros, but especially problematic for younger athletes for whom their entire social identity may revolve around their status as an athlete.

To explore this issue from an evidence-based, data-driven point of view, we’ll take a look at the latest statistics on the prevalence of opioid use and abuse among high school athletes, then talk about ways to ensure athletes at all levels of competition can use opioids to manage pain safely and sanely, i.e. without developing an addiction that can lead to long-term health problems, and in some cases, death.

Opioid Use and Athletes: The Statistics

We’ll focus our discussion on high school athletes, since the media is flush with information on opioid use among pro- and elite-level athletes. We’ll also address this young population first because they have less support, by default, than pro athletes. For instance, in the case of pro football quarterback Brett Favre, he entered a substance abuse treatment program through his employer, the Green Bay Packers, funded and administered by the National Football League. He had the support of a multi-billion-dollar industry behind his recovery — not to mention the fact that his team depended on his successful recovery to return to the field and keep winning games for them.

He did return to the field and they did continue to win games.

Which is an encouraging story that illustrates how an individual can fall deep into addiction, recover, then go on to live a successful and fulfilling life — with top-notch professional support and a group of people committed to their total recovery.

High school athletes, however, have no such industry behind them, and the teams they play for have neither the resources nor the financial incentive to help them recover from an opioid use disorder if they develop one.

Let’s take a look at the statistics published in three peer-reviewed journal articles:

· “Painfully Obvious: A Longitudinal Examination of Medical Use and Misuse of Opioid Medication Among Adolescent Sports Participants

· “Playing Through Pain: Sports Participation and Nonmedical Use of Opioid Medications Among Adolescents

· “Opioid Use in Athletes: A Systematic Review

The first study used information on more than 20,000 adolescents from the nationwide survey “Monitoring the Future” conducted in 2011. The second study used information collected from more than 1,500 students in a questionnaire called the Secondary Student Life Survey, administered between 2009 and 2012. The third study is a meta-analysis published in 2020 that includes data from over 225,000 high school, college, and professional athletes. Taken together, these three studies give us an idea of the context and scope of the problem.

Here’s some general information about adolescents, athletes, and opioids offered by the studies:

· Opioid prescriptions for adolescents almost doubled between 1994 and 1997.

· About 7.5 million adolescents participate in scholastic sports each year.

· Roughly 2 million injuries related to high school athletics occur each year.

o A significant proportion of these injuries require medication to manage injury-related pain.

· High school athletes are more likely to receive an opioid prescription than non-athletes.

That information sets the stage: opioid prescriptions for adolescents on the rise, millions of kids participating in high school sports, and about a quarter of them experiencing sports-related injuries.

Now, here’s specific data from the “Painfully Obvious” study:

· Male athletes are almost twice as likely to receive an opioid prescription as female athletes and non-athletes.

· Male athletes are more than twice as likely to misuse prescription opioids than female athletes and non-athletes.

· Male athletes are at least four times as likely to use prescription opioids to get high than female athletes or non-athletes.

The “Painfully Obvious” study found no association between athletic participation and opioid prescription rates, opioid misuse, or use of opioids to get high among female athletes. That’s an interesting wrinkle to the data that can be useful to clinicians working in addiction.

Now, for specific data from the “Playing Through Pain” study:

· 15.2% of all high school seniors used some sort of prescription medication for non-medical purposes in the 12-month period before the survey.

o Acetaminophen + hydrocodone and oxycodone hydrochloride were used most often for non-medical purposes.

· 5.5% of all high school athletes reported non-medical use of opioids in the 12-month period before the survey.

· Among high school athletes, football players and wrestlers were 50% more likely to use opioids for non-medical purposes than athletes participating in other sports.

· Among high school athletes, those who participated in non-contact, non-impact sports — i.e. all sports aside from football and wrestling — showed no increased likelihood of using opioids for non-medical purposes.

And now here’s the relevant information from the third study, the meta-analysis on more than 225,000 athletes:

· Prevalence of opioid use at any given time among professional athletes: 4.4%-4.7%

· Prevalence of opioid use at any time over a career in the National Football League (NFL): 52%

· Prevalence of opioid use at any time during high school by a high school athlete: 28%-46%

· Caucasian players are at increased risk of opioid misuse.

· Players in contact sport are at increased risk of opioid misuse: hockey, football (American), wrestling

· Unemployed retired professional athletes are at increased risk of opioid misuse.

· Professional athletes with undiagnosed concussions are at increased risk of opioid misuse.

This data is important for anyone working with adolescents, including coaches, teachers, school administrators, and of course, parents. It’s most important, though, for physicians working with athletes of any age or gender — particularly athletes who participate in contact sports like football (American), hockey, and/or wrestling.

How Doctors Can Help

The prime takeaways from this data lie in the identification of the categories of young athletes most vulnerable to opioid misuse and abuse. First, male athletes, overall, have an increased likelihood of misusing opioids, and therefore, developing an opioid use disorder. Next, athletes who participate in the two contact sports that have the highest rate of severe injury out of all high school sports — football and wrestling — are also at increased risk of opioid misuse leading to addiction.

It’s worth mentioning here that of all high school sports, football and wrestling are the two traditionally dominated by males: that’s one logical explanation of the data presented in the “Painfully Obvious” study. However, it’s also worth mentioning that nationwide, girl’s wrestling is increasing in both popularity and participation — and anyone who’s watched high school girls wrestle know they compete just as intensely as boys.

Meaning that as participation in girl’s wrestling increases, the severe injury numbers for female high school athletes are also likely to increase. As that happens, physicians who treat them need to be aware that these girls may be at increased vulnerability for the misuse of opioids and opioid use disorder. Whether they will misuse opioids like their male counterparts remains to be seen — but it’s something to watch for over the next several years.

The true key to solving the problem of opioid misuse among athletes is prophylaxis, primarily in the form of awareness. If they didn’t before, physicians now know the devastating consequences of playing loose with opioid prescriptions: an opioid crisis that kills tens of thousands of people a year and throws individual lives and families into destructive and painful cycles of addiction. The data from these studies on opioid use and abuse among high school sports participants teaches doctors treating these young athletes — especially football players and wrestlers — that if an opioid pain reliever is indicated, they need to carefully monitor their patients for signs of overuse, misuse and addiction: otherwise, the consequences can be devastating.



Christopher Johnston, MD, ABPM-ADM

Christopher Johnston, MD, ABPM-ADM, is the Chief Medical Officer for Pinnacle Treatment Centers and has practiced addiction medicine for the past 15 years