Retired NFL players misuse painkillers more than general population, study finds

ScienceDaily (Jan. 30, 2011) — Retired NFL players use painkillers at a much higher rate than the rest of us, according to new research conducted by investigators at Washington University School of Medicine in St. Louis.

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The researchers say the brutal collisions and bone-jarring injuries associated with football often cause long-term pain, which contributes to continued use and abuse of painkilling medications.

The study is published online in the journal Drug and Alcohol Dependence. It involved 644 former NFL players who retired from football between 1979 and 2006. Researchers asked them about their overall health, level of pain, history of injuries, concussions and use of prescription pain pills.

The study found that 7 percent of the former players were currently using painkilling opioid drugs. That's more than four times the rate of opioid use in the general population. Opioids are commonly prescribed for their analgesic, or pain-relieving, properties. Medications that fall within this class of drugs include morphine, Vicodin, codeine and oxycodone.

"We asked about medications they used during their playing careers and whether they used the drugs as prescribed or whether they had ever taken them in a different way or for different reasons," says principal investigator Linda B. Cottler, PhD, professor of epidemiology in psychiatry at Washington University. "More than half used opioids during their NFL careers, and 71 percent had misused the drugs. That is, they had used the medication for a different reason or in a different way than it was prescribed, or taken painkillers that were prescribed for someone else."

Those who misused the drugs during their playing days were more likely to continue misusing them after retiring from football. Some 15 percent of those who misused the drugs as active players still were misusing them in retirement. Only 5 percent of former players who took the drugs as prescribed misused them after they retired from the NFL.

Cottler, director of the Epidemiology and Prevention Research Group in the Department of Psychiatry, says it's not clear from the study whether retired players became dependent on the drugs. What is clear from the survey, she says, is that retired NFL players continue to live with a lot of pain.

"The rate of current, severe pain is staggering," she says. "Among the men who currently use prescription opioids -- whether misused or not -- 75 percent said they had severe pain, and about 70 percent reported moderate-to-severe physical impairment."

Pain was one of the main predictors of current misuse. Another was undiagnosed concussion. Retired NFL players in the study experienced an average of nine concussions each. Some 49 percent had been diagnosed with a concussion at some point during their playing careers, but 81 percent suspected they had concussions that were not diagnosed. Some players believed they may have had up to 200 concussions during their playing days.

"Many of these players explained that they didn't want to see a physician about their concussions at the time," says Simone M. Cummings, PhD, a senior scientist in psychiatry who conducted phone interviews with the former players. "These men said they knew if they reported a concussion, they might not be allowed to play. And if you get taken out of a game too many times, you can lose your spot and get cut from the team."

She says players with suspected-but-undiagnosed concussions reported they borrowed pills from teammates, friends or relatives to treat the pain themselves, thus misusing opioids in an attempt to remain in the NFL. Although 37 percent of the retired players reported that they had received opioids only from a doctor, the other 63 percent who took the drugs during their NFL careers admitted that on occasion they got the medication from someone other than a physician.

Retired players currently misusing opioid drugs also are more likely to be heavy drinkers, according to Cottler.

"So these men are at elevated risk for potential overdose," she says. "They reported more than 14 drinks a week, and many were consuming at least 20 drinks per week, or the equivalent of about a fifth of liquor."

The ESPN sports television network commissioned the study, which also was funded by the National Institute on Drug Abuse. The ESPN program "Outside the Lines" spoke informally to many retired players about their use of painkillers. One reported taking up to 1,000 Vicodin tablets per month. Another reported ingesting 100 pills per day and spending more than $1,000 per week on painkillers.

Former St. Louis Rams offensive lineman Kyle Turley said in a statement to ESPN that he knew of many players who took drugs to help them deal with the pain inflicted by the injuries they sustained in the NFL.

"I know guys that have bought thousands of pills," Turley said. "Tons of guys would take Vicodin before a game."

The researchers say offensive linemen had particularly high rates of use and misuse of opioids.

"The offensive linemen were twice as likely as other players to use or misuse prescription pain medicines during their NFL careers," Cottler says. "In addition, this group tends to be overweight and have cardiovascular problems, so they represent a group of former players whose health probably should be monitored closely."

In fact, Cottler says it would be a good idea to continue monitoring everyone who has played in the NFL. She says this study revealed that some 47 percent of retired players reported having three or more serious injuries during their NFL careers, and 61 percent said they had knee injuries. Over half, 55 percent, reported that an injury ended their careers.

"These are elite athletes who were in great physical condition when their playing careers began," she says. "At the start of their careers, 88 percent of these men said they were in excellent health. By the time they retired, that number had fallen to 18 percent, primarily due to injuries. And after retirement, their health continued to decline. Only 13 percent reported that they currently are in excellent health. They are dealing with a lot of injuries and subsequent pain from their playing days. That's why they continue to use and misuse pain medicines."

Cottler LB (WU), Abdallah AB (WU), Cummings SM (WU), Barr J (ESPN), Banks R (ESPN), Forchheimer R (ESPN). Injury, pain and prescription opioid use among former NFL football players, Drug and Alcohol Dependence, vol. 113(3), Jan. 28, 2011.

This work was commissioned and supported by a grant from ESPN, with additional funding from the National Institute on Drug Abuse of the National Institutes of Health.

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Rural underage binge drinkers put their health at risk, German study finds

ScienceDaily (Feb. 6, 2011) — Binge drinking is often considered to be a problem of towns and cities but new research published in BioMed Central's open access journal BMC Public Health shows that binge drinking in rural areas is more of a problem than previously thought.

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Dr Carolin Donath, from the Psychiatric University Clinic Erlangen, looked at the drinking patterns of over 44,000 15 and 16 year olds in Germany and found that more than 93% of the young people from the countryside and over 86% of those from urban areas had tried alcohol. Of the adolescents who had drunk alcohol in the last month, 78% from rural areas and 74% from cities admitted to binge drinking (5 or more drinks at one time).

Dr Carolin Donath says that, "Whilst there is awareness of the problems of binge drinking in towns and cities, this study demonstrates that both drinking and binge drinking are as much of a problem for rural teenagers."

Binge drinking in school children has social ramifications as well as increasing health risks. Not only does alcohol abuse affect school work, and hence job prospects, but being drunk increases the likelihood of accidents among traffic and of unsafe sexual behaviour. This pattern of drinking also causes long term damage to the brain resulting in permanent brain damage, including memory problems and cognitive defects, and increasing risk of heart disease and cancer.

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Advanced macular degeneration is associated with an increased risk of bleeding stroke, study finds

ScienceDaily (Feb. 10, 2011) — Older people with late-stage, age-related macular degeneration (AMD) appear to be at increased risk of brain hemorrhage (bleeding stroke), but not stroke caused by brain infarction (blood clot), according to research presented at the American Stroke Association's International Stroke Conference 2011.

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"Other studies have found there are more strokes in older individuals with late AMD, but ours is the first to look at the specific types of strokes," said Renske G. Wieberdink, M.D., study researcher and epidemiologist at Erasmus Medical Center in Rotterdam, the Netherlands. "We found the association is with brain hemorrhage, but not brain infarction."

AMD is degeneration of the macula, which is the part of the retina responsible for the sharp, central vision needed to read or drive. Because the macula primarily is affected in AMD, central vision loss may occur. Age-related macular degeneration usually produces a slow, painless loss of vision. Early signs of vision loss from AMD include shadowy areas in your central vision or unusually fuzzy or distorted vision.

Because the number of brain hemorrhages observed in the study was small, the findings will need to be corroborated in a larger group, Wieberdink said.

"These findings should be considered preliminary," she said. "Patients and physicians must be very careful not to over-interpret them. We don't know why there are more brain hemorrhages in these patients or what the relationship with AMD might be. This does not mean that all patients with late-stage AMD will develop brain hemorrhage."

Beginning in 1990, the Rotterdam Study is a prospective, population-based cohort investigation into factors that determine the occurrence of cardiovascular, neurological, ophthalmological, endocrinological and psychiatric diseases in older people.

The researchers tallied stroke incidence among 6,207 participants 55 years and older. All of the participants were stroke-free at the study's outset. AMD was assessed during scheduled eye examinations, and participants with the condition were divided into five different stages of AMD, and whether their condition was wet AMD or dry AMD. Participants were tracked for an average of 13 years. Of the 726 persons who suffered a stroke in that time, 397 were brain infarctions, 59 were brain hemorrhages and the stroke type was not available for 270.

Late AMD (stage 4) was associated with a 56 percent increased risk of any type of stroke. Late AMD, both the dry and the wet form, was strongly associated with more than six times the risk of brain hemorrhage, but not with brain infarction. Early AMD (stages 1-3) did not increase the risk of any stroke. Associations were adjusted for possible confounders, such as diabetes, blood pressure, anti-hypertensive medications, smoking status, body mass index, alcohol use and C-reactive protein levels.

"We cannot yet say if there is a common causal pathway or mechanism of action yet -- this association needs to be further investigated," Wieberdink said. "But I don't think it is a causal relationship. It seems more likely that late AMD and brain hemorrhage both result from some as yet unknown common mechanism."

If the findings are replicated, it may be possible to develop some stratification of risk among such patients, Wieberdink said.

Co-authors are: Lintje Ho, M.D.; Kamran Ikram, M.D., Ph.D.; Peter Koudstaal, M.D., Ph.D.; Albert Hofman, M.D., Ph.D.; Hans Vingerling, M.D., Ph.D.; and Monique Breteler, M.D., Ph.D. Author disclosers and funding information are on the abstract.

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New U.S. national study finds boxing injuries on the rise; Youth head injury rates also concerning

ScienceDaily (Mar. 2, 2011) — The risk and nature of injury in the sport of boxing has generated a great deal of controversy in the medical community, especially in relation to youth boxing. A new study, conducted by researchers in the Center for Injury Research and Policy of The Research Institute at Nationwide Children's Hospital, examined boxing injuries among participants 6 years of age and older from 1990 to 2008.

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During the 19-year study period, an average of 8,700 boxing injuries were treated in United States emergency departments each year, and approximately 2,500 of those injuries were to children and adolescents 6 to 17 years of age. The number of boxing injuries each year increased 211 percent during the study, climbing from 5,361 injuries in 1990 to nearly 17,000 injuries in 2008.

According to the study, released online February 28, 2011 by the American Journal of Preventive Medicine, the most common injury diagnosis was a fracture (28 percent). The hand was the most frequently injured body region (33 percent), followed by the head and neck (23 percent). While the majority of injuries occurred at a sports or recreation facility (54 percent), one-third of the injuries (34 percent) occurred at home.

The most concerning discovery from the study was the similar proportion of concussions/closed head injuries (CHIs) among the age groups (9 percent among 12-17 year olds, 8 percent among 18-24 year olds and 9 percent among 25-34 year olds).

"We expected a smaller proportion of concussions/CHIs among younger boxers, since they generate a lower punch force," said Gary Smith, MD, DrPH, senior author of the study and director of the Center for Injury Research and Policy at Nationwide Children's Hospital. "The fact that young boxers are experiencing a similar proportion of concussions and CHI's as older boxers is extremely concerning given the potential risk of developing chronic traumatic encephalopathy (CTE) with repetitive brain trauma. These repetitive blows to the head may be placing boxers under 18 years of age at risk for neurological impairment and psychological problems due to CTE."

The findings from this study support the position of medical societies that oppose boxing, especially among youth.

"Although there is risk of injury with most sports, boxing is unique because participants are rewarded for intentionally striking their opponent in the face and head with the intent of harming or incapacitating them," said Dr. Smith, also a professor of Pediatrics at The Ohio State University College of Medicine. "The increasing number of boxing injuries, coupled with the potential long-term consequences of these injuries, suggests that increased injury prevention efforts are needed."

This is the first nationally representative study to examine boxing injuries treated in emergency departments. Data for this study were obtained from the National Electronic Injury Surveillance System (NEISS), which is operated by the U.S. Consumer Product Safety Commission. The NEISS dataset provides information on consumer product-related and sports and recreation-related injuries treated in hospital emergency departments across the country. Boxing participation data were obtained from the Superstudy of Sports Participation.

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CT scans are frequently unnecessary after head injury in children, large study finds

ScienceDaily (May 9, 2011) — Overall, roughly half of U.S. children taken to hospital emergency departments (EDs) for a head injury receive a head CT scan, often to ease worried parents' concerns. Yet true traumatic brain injury is uncommon. A multi-center study of more than 40,000 children with minor blunt head trauma, led by Children's Hospital Boston and UC Davis, shows that allowing a period of observation can reduce the use of head CT by as much as half without compromising care -- and without exposing children to ionizing radiation.

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Results appear in the June 2011 issue of Pediatrics (published online May 9).

"Only a small percentage of children with blunt head trauma really have something serious going on," says Lise Nigrovic, MD, MPH, of Children's Hospital Boston, who co-led the study with Nathan Kuppermann, MD, MPH, chair of the Department of Emergency Medicine at UC Davis. "If you can be watched in the ED for a few hours, you may not need a CT."

This change in practice would not only be cost-saving, but is better medicine, the researchers say.

Nigrovic, Kuppermann and colleagues analyzed the outcomes of children presenting at 25 different emergency departments, as part of a large prospective study conducted by the Pediatric Emergency Care Applied Research Network (PECARN). Of 40,113 children whose records could be analyzed, 5,433 (14 percent) were observed before making a decision about CT use. Observation times varied, as did the severity of head trauma.

Overall, the children who were observed had a lower rate of CT than those not observed (31 vs. 35 percent). When the researchers matched the observed and non-observed groups for severity of head injury and the practice style of different hospitals, this difference was more pronounced: The likelihood of a CT scan in the observed group was about half that of similar non-observed patients (odds ratio, 0.53). In particular, children whose symptoms improved during observation were less likely to eventually have CT.

Allowing for an observation period did not compromise safety, the study found: Clinically important traumatic brain injury -- resulting in death, neurosurgical intervention, intubation for more than 24 hours or hospital admission for two nights or more -- was equally uncommon in the observed and non-observed groups (0.75 vs. 0.87 percent).

Nigrovic and Kuppermann note that cranial CT itself presents additional risks for children. Children's growing brain tissue is more sensitive to ionizing radiation than adults', and because of their longer life expectancy, their lifetime risk of developing a radiation-induced malignancy is greater.

"CT isn't bad if you really need, but you don't want to use it in children who are at low risk for having a significant injury," says Nigrovic. "For parents, this means spending a couple of extra hours in the ED in exchange for not getting a CT. It's the children in the middle risk groups -- those who don't appear totally normal, but whose injury isn't obviously severe -- for whom observation can really help."

The researchers were unable to determine the actual length of time the children were observed in the ED, a question they would like to investigate in the future. Practice guidelines from the American Academy of Pediatrics recommend a child be carefully observed for 4 to 6 hours after injury.

"There is a clear need to develop appropriate and safe guidelines for decreasing the number of inappropriate head CT scans that we do on children," says Kuppermann. "The results of this analysis demonstrate that a period of observation before deciding to use head CT scans on many injured children can spare children from inappropriate radiation when it is not called for, while not increasing the risk of missing important brain injuries."

Nigrovic offers the following general guidelines for parents whose child has a head injury:

Check with your primary care clinician before taking the child to the ED. If your child has headache, vomiting and/or confusion, or symptoms that worsen over time, an ED visit is appropriate. The ED clinician may reasonably choose to observe your child for several hours once you arrive before deciding about a head CT. The change of symptoms over time is an important factor in deciding whether to obtain a cranial CT.

The study was funded by the Health Resources and Services Administration/Maternal and Child Health Bureau, Division of Research, Training, and Education, and the Emergency Medical Services of Children Program.

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