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Prevention and Treatment of Opioid Abuse in Collegiate Athletes

Posted April 17, 2019

By Obie Benavides, MAT, LAT, ATC

In recent years, prevention and treatment of opioid abuse has become an important topic in our society. In 2016, opioid overdose deaths were 5 times higher than 1999, resulting in a staggering 42,249 lives lost.1 It has also been reported that from 1999 to 2011 consumption of oxycodone increased by nearly 500%.2 This significant increase in drug overdose deaths has been widespread across the nation, but 5 states have experienced substantial losses; West Virginia, Ohio, New Hampshire, Pennsylvania, and Kentucky are seeing death rates between 33.5 to 52.0 per 100,000.1

As Athletic Trainers (ATs), we regularly treat patients recovering from various surgical procedures and/or injuries; these patients are often prescribed pain medication, placing them at a higher risk for opioid abuse. More than 460,000 National Collegiate Athletic Association (NCAA) student-athletes compete in 24 sports every year.3 Kay et al reported a total of 3,183 severe injuries during the 2009–2010 through 2014–2015 academic years with 30% of these injuries resulting in surgery.3 While these numbers may seem alarming, in a 2013 national study of substance use behaviors among NCAA male athletes, nearly 2,000 reported taking prescription pain medication such as Vicodin and Percocet; this number included both medical and non-medical use (NMU).4

As healthcare professionals, ATs understand the complications associated with injuries and the effects they can have on a patient's physical and mental health. While we should always support our patients and provide quality care, we must be cognizant of the risk factors and signs and symptoms associated with opioid abuse, addiction and overdose. We must prevent abuse, addiction and overdose before they start. Therefore, ATs play a vital role in addressing this major public health problem through the prevention of abuse and promotion of safe opioid use.

Preventative strategies stand at the forefront in the fight against opioid abuse, addiction and overdose. Through the implementation and improvement of drug education, drug monitoring programs, promotion of safe opioid use and screenings, ATs can play a vital role in addressing this major public health problem while also improving patient outcomes.

NCAA/Institutional Drug Testing

While the current NCAA policy on drug testing aims to prevent student-athletes from drug use, there are discernible flaws. Per the NCAA protocol, the sole purpose of the their drug testing program is, “to deter student-athletes from using performance-enhancing drugs” and may, “impact the eligibility of student-athletes who try to cheat by using banned substances.”5 Despite the known negative effects of performance-enhancing drugs (PEDs), there are also significant health impacts of other substances such as prescribed pain medication, and ATs should advocate for the NCAA's drug-testing program to shift focus from an athletic performance perspective to the student-athlete’s health-related quality of life. Expansion of the NCAA drug-testing program would undoubtedly be associated with increases in expenditures; however, with the current state of the nation’s opioid abuse epidemic, monetary concerns should not be placed on an invaluable resource such as this.

From an organizational standpoint, only minimal adjustments to the present drug-testing program would be needed; currently, Drug Free Sport randomly selects student-athletes for testing, the institutions designee notifies the selected student-athletes, the student-athletes are then required to sign the Student-Athlete Notification Form, and then report at the testing facility on the date and time designated by the institutions designee.5

Similar to the NCAAs current drug-testing procedures, urinalysis would be used to identify those that may be misusing, abusing or addicted to narcotics. If the student-athlete tested positive for narcotics, rather than losing eligibility, the student-athlete would be flagged and required to enter an NCAA approved treatment program. In the case a student-athlete has had a medical procedure that called for prescription pain medication, the student-athlete should still be tested and the date of surgery along with the details of the prescription, such as number of pills and dosage, should be taken into consideration.

Guidelines to help identify possible misuse or abuse should be implemented. For instance, if a student-athlete is 8 weeks s/p and tests positive for narcotics, a medical exception would not be warranted, and the student-athlete would be required to enter a treatment program. As previously mentioned, there are known financial strains associated with drug testing; however, if institutions can implement in-house drug testing programs, this could potentially identify student-athletes who are misusing, abusing or addicted to narcotics and allow for faster intervention; testing would also assist in determining compliance to treatment plans for those required to enter treatment programs. Both drug testing options have great potential to improve the health and wellness of student-athletes through identifying groups or individuals that engage in the non-medical use (NMU) of prescription opioids, and preventing the negative outcomes associated with postoperative prescription pain medication and promoting safe opioid use.

ATs and Drug Education/Physician – Patient Education

ATs in the college/university setting are in unique positions that allow them to establish quality relationships with student-athletes, and it is this rapport that can improve education or counseling practices between physicians and patients. Although providers typically provide patients with homecare instructions and side-effects associated with prescription opioids, ATs can contribute to the education component through developing their own policies and practices to assure safe and effective postoperative pain control of their student-athletes.

ATs, along with the treating physician, should create a patient-centered plan and goals for the management of postoperative pain.6Plans should be developed and reviewed prior to surgery and include information on how pain will be reported and assessed (ex. verbal rating scales , numerical rating scales and visual analogue scales, etc.) and establishing realistic goals for pain control.6 ATs should inform their patients, prior to and in the days after surgery, that a level of discomfort is expected following the procedure.7 Additionally, ATs should inform patients to expect that pain management will likely not result in complete alleviation of pain, but rather allows them to function.7 Lastly, to assist in the preparation for recovery, ATs should counsel patients on the potential sources of pain along with expected length of pain or discomfort.7

As ATs continue to promote the safe use of all medications, there is great potential to assist in the opioid epidemic by educating patients on proper disposal of their unused opioid medications. On average, patients, consume only 33% of their opioid prescriptions and typically results in patients holding onto a large amount of leftover narcotics; by ATs educating and promoting proper disposal of medication, the risk of divergent use, abuse and misuse can be greatly reduced.7,8 To inform patients on where to dispose of medication, ATs can use The Drug Enforcement Agency website that provides a listing of medication disposal locations (https://apps.deadiversion.usdoj.gov/pubdispsearch/).7

ATs and Monitoring Programs for Prescription Opioids

Current prescription drug monitoring programs (PDMP) are in effect across the U.S; PDMPs are electronic databases that track prescriptions and dispensation of controlled substances across each respective State.7,9 Prescribers access their State’s PDMP and are required to review past and current prescriptions filled by the patient.7,9 Following the implementation in New York, there was a 75% reduction in patients seeing multiple prescribers to obtain the same controlled drug.7,9 ATs and their athletic departments can use PDMPs as a framework to develop and implement a monitoring program that fits their needs and available resources. Prescription monitoring programs in the college/university setting could collect information on the student-athlete such as the prescriber/physician, drug name, dose and amount of medicine dispensed (number of refills). Although this may be time consuming and implementation will likely have complications, this may provide ATs insight into possible opioid abuse practices.9

Use of Patient-Rated Outcome Measures

There are several avenues ATs can explore to better understand and monitor their patients’ pain and recovery. In addition to proper education and monitoring programs, ATs can utilize disablement models and patient-rated outcome measures (PROMs) to improve the way they track and treat pain. PROMs will provide ATs with information to better understand the patient's perceived pain levels, determine effective interventions and better evaluate the impact an injury or illness has on a patient's overall health and wellness.10,11 Use of these measures are key in providing patient-centered care and play a meaningful role in decision-making that does not focus on solely on impairments.10,11

ATs and Identification of Seekers/Abusers

In order to create effective prevention and intervention programs, and avoid the devastating outcomes associated with misuse, abuse and addiction of prescription opioids, ATs must have complete understanding and awareness of signs and symptoms that may indicate potential issues of prescription opioids. ATs in the college/university setting typically spend extended periods of time with student-athletes, and it is this familiarity that can assist in identifying drug-seeking or aberrant behaviors that signal a substance abuse disorder. These behaviors include but are not limited to failing to comply with a prescribed regimen, frequently “losing” prescribed medications and seeking prescriptions from other clinicians. If any of these behaviors are noticed or reported, ATs should immediately begin more rigorous monitoring and plan for interventions such as counseling.12

Risk factors associated with opioid misuse and abuse should also be well understood by ATs. A study by Cottler LB, et al on former NFL players showed younger and Caucasian players had an increased risk for opioid use during their careers, offensive linemen were 2 times more likely to use opioids, and those that reported knee injuries were more likely to use narcotics.13 Additionally, it has been reported that D-I football players are more likely to misuse non-prescription pain medication and while the effects may not be life threatening, this may serve as a warning sign for these student-athletes seeking prescription pain medication.14 Lastly, ATs must familiarize themselves with the side effects of prescription opioids, even when taken as directed; side effects of this narcotic include tolerance, physical dependence, increased sensitivity to pain, constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, depression, itching, sweating, low testosterone and respiratory depression.15

ATs and Treatment

In addition to side effects and drug-seeking behaviors, ATs must prepare themselves to identify and treat a patient suffering from an opioid overdose. As previously mentioned, a side effect of opioid use is respiratory depression which can lead to death; therefore, ATs should be aware of these common symptoms associated with an opioid overdose: pinpoint pupils, loss of consciousness, pale or cold skin, limp body, choking/gurgling sounds and shallow breathing.16 Due to respiratory depression, a person experiencing an opioid overdose may present with a distinct labored breathing sound referred to as the “death rattle” and is indicative the person is near death, CPR should be immediately administered and 911 should be called.16

In July of 2016 President Obama signed into law the Comprehensive Addiction and Recovery Act; the actions of this law supported policies to expand and develop programs to address opioid abuse, prevention, treatment and recovery. Funding offered states the opportunity to purchase and distribute naloxone, an opioid antagonist used to reverse respiratory depression; with these funds training was also provided primarily to first responders.17 As ATs in the secondary and college/university settings, we are placed in prime position to help decrease opioid abuse and save those experiencing an overdose; therefore, as a profession we should advocate for proposals to increase access of naloxone training and administration to practicing ATs.

ATs are able to develop genuine long-lasting relationships with student-athletes and if there is suspicion a student-athlete may be misusing or abusing prescription opioids, talk to them. The close relationship that already exists will ease the conversation, and ultimately a few minutes of an uncomfortable conversation may just save a life. In addition to monitoring, testing and education, our position as ATs allows for great potential to reverse the epidemic of opioid abuse and assist in efforts to save the lives of young, educated and talented student-athletes.

Resources

1. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017/ CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov (Links to an external site.)Links to an external site.

2. Kolodny A, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu. Rev. Public Health. 2015;36:559–74.

3. Kay MC, et al. The epidemiology of severe injuries sustained by national collegiate athletic association student-athletes, 2009-2010 through 2014-2105. J Athl Train. 2017;53(2):117-128.

4. Buckman JF, Farris SG, Yusko DA. A national study of substance use behaviors among NCAA male athletes who use banned performance enhancing substances. Drug Alcohol Depend. 2013;131(0):50-55.

5. Powell R. NCAA Drug Testing Program. NCAA.org - The Official Site of the NCAA. http://www.ncaa.org/sport-science-institute/ncaa-drug-testing-program. Published December 6, 2017. Accessed April 20, 2018.

6. Chou R, et al. Guidelines on the management of postoperative pain. J Pain. 2016;17(2): 131-157.

7. Yorkgitis BK, Brat GA. Postoperative opioid prescribing: getting it rightt. ‎Am. J. Surg. 2018; 215:707-711.

8. Hasak JM, et al. Empowering post-surgical patients to improve opioid disposal: a before and after quality improvement study. J Am Coll Surg. 2017;226(3): 235-240.

9. Han KL. Strategies to prevent opioid misuse, abuse, and diversion that may also reduce the associated costs. Am Health Drug Benefits. 2011;4(2): 107-114.

10. Valier AR, Jennings AL, Parsons JT, Vela LI. Benefits of and barriers to using patient-rated outcome measures in athletic training. J Athl Train. 2014; 49(5):674-83.

11. Snyder AR, et al. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: disablement models. J Athl Train. 2008; 43(4): 428–436.

12. Kaye AD, et al. Prescription opioid abuse in chronic pain: a updated review of opioid abuse predictors and strategies to curb opioid abuse(part 2). Pain Physician. 2017; 20:S111-E133.

13. Cottler LB, et al. Injury, pain, and presciption opioid use among former national football league (nfl) players. Drug Alcohol Depend. 2011;116(1-3): 188-194.

14. Stache S, Close JD, Mehallo C, Fayock, K. Nonpresciption pain medication use in collegiate athletes: a comparison of samples.Physician Sportsmed. 2014; 42(2): 19-23

15. Opioid Overdose. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/opioids/prescribed.html. Published August 29, 2017. Accessed April 24, 2018.

16. Opioid Overdose Prevention Toolkit. SAMHSA. https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA16-4742. Published January 1, 2016. Accessed April 27, 2018.

17. Fact Sheet: Obama Administration Announces Additional Actions to Address the Prescription Opioid Abuse and Heroin Epidemic. National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additional-actions-address. Accessed April 26, 2018.

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