Saturday, April 14, 2012

Use of Painkiller Toradol Before Games Raises Concerns -

When Mets pitcher R. A. Dickey partly tore the plantar fascia in his right foot last May, he turned to a treatment that in recent years has become a go-to elixir for professional baseball and football players: Toradol, an injectable anti-inflammatory drug.

"It certainly helped, especially in the first months after the injury," said Dickey, who received injections in his buttocks before about 12 starts. "I don't think it's a panacea, but it helps you get where you have to go."

But some medical experts are concerned about the ways sports teams are using Toradol because so little is known about its possible long-term effects on athletes.

No data are available on the use of the drug by athletes, so it is unclear how frequently Toradol injections are provided and for what ailments, and whether players are told of the potential side effects — all of which has caused tension and a growing awareness among sports medicine experts. Concerns over its widespread use in baseball compelled at least two team doctors to stop using it, according to a medical staff member of a major league team who spoke on condition of anonymity so as not to implicate his team.

"It puts those of us who do sports medicine in a tough position," said Dr. Jessica F. Butts, a physician focused on family and sports medicine at Indiana University Health. "The decision to play is a tough one. There are some things that are black and white, but there are a lot of sports injuries that are in a gray zone, especially in professional sports and college sports, where so much is on the line."

Dr. Gary Green, the medical director for Major League Baseball, said discussions about Toradol came up every year and "there's certainly differences among physicians about how it's administered." But, he said, "it's not a controversy, but a difference of opinions." The drug has "a good analgesic impact," he said, and the side effects are well known.

Toradol, a brand name for ketorolac, is among a family of drugs called nonsteroidal anti-inflammatory drugs. Doctors put it in the same class as ibuprofen (like Advil) and Aleve. But unlike those drugs, Toradol can be injected, as well as taken orally, and can act more quickly. It is most commonly used in emergency rooms and post-operation wards to help patients manage short-term inflammation and pain, but athletes are turning to it to deal with inflammation and pain.

The use of Toradol, which is made by a number of drug manufacturers, was at the center of a lawsuit filed in December by a dozen retired N.F.L. players who said the league and its teams repeatedly and indiscriminately administered the drug before and during games, thus worsening injuries like concussions. (The league disputed the claims.)

The suit claimed that the use of Toradol was rampant in the N.F.L., with players lining up in their locker rooms before games to receive injections, a process the players called a cattle call. According to the complaint, no warnings were given and there was "no distinguishing between different medical conditions of the players, and regardless of whether the player had an injury of any kind."

Dr. Scott Rodeo, the associate team physician of the New York Giants, said that in the National Football League, Toradol "became prevalent to the point where players expected it and used it prophylactically." Some players, he said, "barely think of them as medicine."

Dr. Rodeo said Toradol first surfaced in football locker rooms in the mid-1990s. He said he was aware of the side effects, including how the drug could lead to increased bleeding, as well as gastrointestinal damage. There is also an ever-present risk of infection from an injection.

But when the drug is given occasionally to young, healthy players, the risks appear to be low, he said, adding that up to 40 percent of the Giants players received a shot on game days.

Dr. Rodeo and other doctors noted the risks associated with cumulative doses of Toradol, like kidney damage, one reason some doctors are curtailing its use. Others want to avoid a slippery slope, in which a player who uses Toradol on game days asks for additional shots after the game or on practice days. Many sports leagues largely let team physicians decide how and when to prescribe the drug, which leaves an opportunity for misuse.

"The limit I'm worried about is, does it dull the pain so much that it dulls the body part they've injured?" said Dr. Carla C. Keirns, a medical ethicist at Stony Brook University, adding that athletes could be prone to reinjury because the warning signs of pain are muted.

In baseball, it is most popular among starting pitchers because the repetitive movements in pitching can cause damage as the season progresses. The risk of abuse and experiencing side effects is reduced because they pitch every fifth or sixth day.

The medical staff member of a major league team who spoke on condition of anonymity said Toradol was first used by baseball players about a decade ago and quickly soared in popularity. At one point, perhaps two or three of a team's five starting pitchers used Toradol regularly, the staff member said, but in recent years the prevalence has waned, and now one or two starting pitchers might receive regular injections.

Because team physicians do not regularly travel with their teams, players on visiting teams may have to ask the home team's doctor for injections. Problems can arise if the home team's doctors are reluctant to dispense Toradol, said Dr. Andrew Gregory, a team physician at Vanderbilt University who works with the United States Olympic volleyball team.

"If we say no, they can claim we're trying to help the home team," Dr. Gregory said. "But we don't know about the visiting athlete and his history."

Although Toradol is not a banned substance or classified as a narcotic, many players, trainers and coaches remain skittish about discussing it.

Pitcher Jered Weaver of the Los Angeles Angels called Toradol "an in-clubhouse thing" and declined to say whether he had used it. Reliever Brad Lidge of the Washington Nationals said he had not used Toradol, but knew there were potential long-term consequences. Some other pitchers interviewed in various clubhouses declined to answer questions about the drug.

Newsday first reported the use of Toradol among Mets pitchers.

About 10 years ago there was a movement against the use of anti-inflammatory pills among professional basketball players after Alonzo Mourning, the Miami Heat's All-Star center, was found to have a kidney disorder. He said he believed that long-term use of anti-inflammatories contributed to his disease, though medical experts said the pills did not cause kidney disease.

Dickey is among the players who believe Toradol is more effective than taking over-the-counter pain pills. He said he believed the injections helped keep him on the field to pitch 2082/3 innings last season, despite his injured foot. Some doctors, though, said athletes might believe Toradol to be more effective only because of the way it is commonly administered.

"Any athlete you ask, they will guarantee that the injection is better than the oral pills, but that hasn't really panned out in the research," said Dr. Tanya Hagen, the director of the University of Pittsburgh Medical Center Shadyside Primary Care Sports Medicine Fellowship. "The needle is mightier than the pill."