Playing through the pain: an investigation into painkiller use in rugby
Rugby World looks into the culture of painkiller use in rugby – from the lengths players may go to in order to stay on the field to potentially harmful social issues. This first appeared in the April 2017 issue of Rugby World magazine.
“OUR DOC used to walk around with a frisbee full of painkillers before the game.” It’s the kind of sentence that stops you in your steps, but as it was said during small talk at the buffet of a corporate box at a sevens event, it was enough to make you inhale a sausage roll.
The line was put out by an ex-Premiership stalwart, looking back with a wince. But it was a statement with queries tacked on, an invitation to answer doubts: Does this kind of thing still go on and if it does, is it really something worth worrying about as he did?
A few former gladiators were asked: “Am I barking up the wrong tree?” There was some reticence, yet in asking around about painkiller use in rugby there were often new, unexplored lines of inquiry to be teased out like inky black strands of silk. In the process we discussed pressure to play, stomach aches resulting from frequent use, those popping pills like candy and even the social abuse of painkillers.
We love the game, all fire and confrontation. But we had to ask about rugby’s relationship with pain…
GOING THROUGH THE WRINGER
ON A FARM in Stampriet, some 300 miles south of the Namibian capital Windhoek, in the middle of a drought, Jacques Burger finds a spot with some signal so he can talk. Burger is one of those men who embody ‘physicality’ – that word that only really exists in rugby. Some players put their hide on the line, but to have seen Burger throw himself into the fray was to see Wile E Coyote coming back with tyre tracks across his chest. Seven knee operations, three shoulder ops and a full cheekbone reconstruction due to the excesses of contact he’d taken on; if anyone can talk about playing through pain it’s the retired flanker.
“In my last three years, every day I took painkillers,” the Saracens icon says. “It was a way of life. It was mostly paracetamol and ibuprofen, but that can be hard for the stomach. Some guys take co-codamol but it made me sleepy. Celebrex is an anti-inflam (drug) that is easier on the stomach.
“I took them every day, but not every day now. In the last year I cut down a bit because the danger is it can lose its effect. I knew I’d stop playing, adjust. I was lucky. At Saracens the club docs were very wise and looked after you. I’ll not name names but there are some places where they take everything out of you.”
Burger aches to point out the professional, thorough manner his last club used with him. He is comfortable knowing that others receive the same fine treatment. But will is a powerful driver. Burger is aware there will be a legacy of him pummelling through rugby. He would change nothing. He loved it, even – especially – after long lay-offs, wondering if he’d play again. But it was hard getting him out on the grass.
“I wanted to be ready, powerful or managing things. I’d do anything and it takes its toll. It’s a tough one. There is no miracle drug to make it all better, just stuff that picks you up. You use it at your own discretion. If someone said of ibuprofen: ‘Take this’, I’d use it because getting through the pain was important.”
He issues a warning for youngsters never to take any pressure to play lying down. Make the most of your talents but accept nothing. As he says: “No one wants to see their childhood heroes at 50 as broken men.”
He will never tell kids not to play – he feels rugby builds you as a person. Burger’s game was powered by a desire to squeeze every last drop of blood out of his talents. But he also feels education and protection are a fundamental necessity for players. He wants everyone from club docs, World Rugby bods and the Rugby Players’ Association (RPA) to spread the word, so players know more about what is acceptable to put yourself through and what you should take.
Understandably some do push through games for the glory at stake. That was hard to ignore as news broke via L’Equipe that Racing 92’s Dan Carter, Joe Rokocoko and Juan Imhoff were under the scrutiny of French anti-doping authorities after testing positive for the use of banned corticosteroids in the build-up to last season’s Top 14 final against Toulon.
Given Carter’s fame, the story generated global coverage. The agent representing the All Black great and Rokocoko slammed the leak, with his men reportedly “disgusted and sickened” by it all. The players were cleared by the French federation as they had the appropriate Therapeutic Use Exemptions (TUEs) in place – ie, clearance from anti-doping agencies and their experts to use the injections.
Racing released a spiky statement that began: “The term corticosteroid has strong emotional connotations because it can correspond to immoral and illegal conduct. It also corresponds to legal conduct, justified by medical science.”
They had the TUEs and everything was above board. But what of the culture where stars push through in order to shoot for silverware – this is simply human, right? When news of the Racing tests broke, I began chatting to David Flatman about his experiences. He had seen good people work around the clock to get players out on the field and he had good and bad experiences of painkilling and anti-inflammatory injections. He suffered an Achilles “blown to bits” because of a cortisone injection, but had others that were more effective. In his own words he would have taken a thousand injections if it meant more rugby. And anyway, most rugby players are just better at dealing with pain than your average Joe.
“I would agree with that,” says one-cap Wallaby Beau Robinson of players’ durability. The former Queensland Reds flanker, now at Doncaster Knights in the English Championship, had gone through hurting himself for the sake of possible gongs.
In 2012, after someone fell on him on a cold day in Auckland, he damaged his foot. For the rest of his season he played on it until it became a stress fracture. At the time the Aussie union had moved from having junior teams linked with franchises to centralised academies, so squads were smaller. But the Reds were reigning Super Rugby champions and backed themselves to go far again. In the end they were in the hunt for a home semi-final but fell to the Sharks before they got the chance. Was that season torturous?
“Well, a thing like that, with the foot, it’s going to be getting worse and worse with every step,” says Robinson. “I was missing training and wasn’t really training by the end. I had the option to get a scan during the June Test window but didn’t want to know how bad it was. It wouldn’t get better but I didn’t want to know the severity.”
Much like Flatman, Robinson believes he had all the best advice and recommendations and leeway. The importance of informed consent comes in here – he is an adult and he knew what he was risking. He did it anyway. He toughed it out because he wanted to. Much like the great Richie McCaw did in 2011, winning a World Cup on a broken foot. Robinson made his own call. He clarifies.
“It does come down to the individual and there are contact injuries you’ll not get in, say, football. But if you’ve got good medics they’ll take you through the options. They have your best interests at heart and are putting decisions in your hands, no pressure. Look, of course coaches can put pressure on the medical staff. At the Reds I always felt very comfortable. Had it been a different coach, a different team, who knows.”
There is the rub. Not everyone is fortunate enough to be treated brilliantly all the time. Particularly not when jobs are on the line. Some can be pressured to play, some can hide things. But there are also some hard, hard men asking serious questions now.
In France, Canadian bruiser Jamie Cudmore is pushing his Rugby Safety Network. He finds it horrifying that we can clap in delight as a player like James Horwill nearly gets his finger ripped off, then straps it up and insists on playing on. Or that, in some places he has heard of, clubs and wins are being put ahead of an individual’s welfare. He says he would not be able to count on his fingers how many times he and others have conspired to push him through to play by several means. “I wanted to play so they gave me the tools – strappings or injections. I’m a big boy and I took my decisions seriously. But I wanted to play and I’ll be a pretty decrepit old man.”
He’d love to see World Rugby make the bench bigger and for each team to have a full-time doctor who knows their group intimately. He also wants issues like major injuries and concussion to be taken a bit more seriously in some places, with more outside medical help potentially coming in to assist.
Then there is the issue of exploitation. Cudmore has “heard horror stories about the ProD2 and Fédérale 1 and 2”. There are rumours of referees’ reports on injuries, particularly concussions, being suppressed or rejected by club officials while some players are run into the ground.
Dan Leo, the retired Samoa lock and now campaigner for Pacific Island players’ rights, worries about young islanders being taken advantage of in such a manner. “You have to be aware of the cultural side of it,” he tells Rugby World. “Sometimes a (Pacific Islander) will say yes when they don’t really mean yes. They can be susceptible to being pressured. Then they can come into a macho environment where signs of weakness are not appreciated. It’s a dangerous industry, but then there is also the non-sustainable economy of the islands – if remittances were to stop from Pacific Islanders living abroad, it could collapse. Guys who don’t want to risk that can play through injuries. There may be pressure from coaches or clubs but I reckon the pressure to provide for those at home is a much heavier burden!”
With younger and younger players journeying around the world to earn a living, Leo wants to teach as many as possible to ask why; not just to accept unfavourable terms. He wants them to look after their bodies better, and he wants no to mean no. He mourns three Pacific Islanders who in the past three years felt their only way out from their desperate lifestyle was to take their own lives. And to a lesser extent, he has been frustrated by personal experiences where a club promised him time off that never materialised.
Cudmore sums up his view succinctly: “Playing hurt is one thing. Playing injured has got to stop.”
THE MEDICAL IMPACT
Lewis Moody cannot prove it, but he is certain the amount of painkillers and anti-inflammatories he took as a player contributed to him developing chronic inflammation of the colon: ulcerative colitis. It was something he kept to himself at first, but in time he had to change his whole life to factor in the pain and unpredictability of his using the toilet.
He explains his hardship. “It wasn’t until 2005 that I got diagnosed with colitis. I had horrific stomach cramp. There was blood left there in the toilet.
“I was taking drugs so I could play, like ibuprofen and diclofenac. It was like I was a walking medicine cabinet. I don’t think I’d change much about my life, but I would probably change my lax approach to this.
“I remember one story. We were on a bus. It was almost like a kind of challenge to see how many ‘smarties’ we could take. Around then I was 27 or 28, in 2008, and I would be s****ing myself, essentially. Losing blood, losing weight. I certainly didn’t understand that. I didn’t ask questions then.
“I don’t think you’ll ever change the single-minded sportsman, but I think they could be better informed (about the risks of taking such pills). You want to play, no bother, but what about when you’re 40? Make guys aware now that they have a choice but they must also take advice. Not everyone will struggle but why take a risk?”
Although Moody’s recollections may shock, he is not the only one who has had gut trouble. Burger took extra medication due to his painkiller use. Remember Celebrex was easier on his tummy than ibuprofen? The build-up of pills caused him some stomach ache.
Another tough cookie, Paul O’Connell, mentioned this issue in his book The Battle. He wrote: “In that little battle with my own body, anti-inflammatories were my friend. After taking Difene, I felt like I could play for another five years.
“Towards the end of my career, for a Saturday game I took Difene on Friday and Saturday. It was like a miracle drug, except it could disagree with my stomach. So I took Zoton, an indigestion tablet that dissolves on the tongue and lines the stomach. By kick-off the body felt – at least for a while – pretty much symptom-free. No aches, no pains, nothing.
“I was always conscious that anti-inflammatories needed to be taken in moderation. I hated it whenever I had to take Difene to play. Rugby needs to exert vigilance over legal painkilling medication, because when people’s livelihoods are at stake it’s human nature that some will go too far and do themselves long-term harm chasing short-term goals.”
Painkillers are advertised on public transport. People pop ibuprofen as a quick fix. I certainly have. But Celebrex and ibuprofen are non-steroidal anti-inflammatory drugs (NSAIDs). All NSAIDs are associated with gastro-intestinal toxicity, ulcers and bleeding – in some terrible cases, renal failure – though Celebrex has slightly fewer side-effects. Co-codamol is paracetamol and codeine combined… and here’s a fun fact: although it’s a weak opioid, 5-15% of codeine is metabolised to morphine after ingestion.
THEN WE get into the juicier stuff, where panels, governing bodies, rules and testers get involved. As with the Racing three.
According to WADA’s rules, glucocorticoids – like our mate cortisone – are prohibited in-competition, whether they are taken orally, through an intra-muscular injection, rectally or via intravenous drip. However, if a player needs an intra-muscular injection in-competition they can apply for a TUE to the relevant authority – here national-level players go to UK Anti-Doping (UKAD); international-level players will apply to World Rugby.
The decision to grant a TUE comes down to a panel, with, say, three medical experts judging. Asked if this process could speed up at all, UKAD pointed to WADA’s rules: “The TUE Committee shall decide whether or not to grant the application as soon as possible, and usually (ie, unless exceptional circumstances apply) within no more than 21 days of receipt of a complete application.”
World Rugby’s regulations give a time frame of up to 30 days. According to UKAD, a decision normally comes in quicker anyway, depending on the nature of the application and when the athlete next plays. The window to administer any injection shuts 12 hours before kick-off.
When asked for further comment on painkiller use in rugby, a representative of World Rugby said they felt this was an ethical issue rather than one of doping, and as such was linked to individual risk management strategies. Giving direct advice is a union and club matter, they suggested, though they intoned that education is key and they strongly supported WADA’s stances.
An official spokesman stated: “World Rugby’s priority is player welfare and, as demonstrated by our published research (in October), the appropriate management of individual player load and recovery following injury is key to injury prevention.
“Matches account for 70-75% of injuries and players are at greatest risk of injury when returning from injury or when injuries are unresolved. It is therefore appropriate that teams do not do anything that increases the chance of injury to high-risk players and this would be generally well adhered.”
All unions approached to discuss the level of painkiller use within their systems agreed that players’ interests are at the heart of their plans. While in one instance it was suggested there was not enough data to comment on specifics, another made clear that when it came to prescription drugs the agreed manufacturer’s guidelines in place for dosage and those set out by WADA were adhered to. It was stated that players were made aware of what they were being given and why.
An additional note came from the SRU’s Dr James Robson who finished: “The correct use of analgesics (pain relievers) has its use in the game, as they do in society more widely, but if we can resolve an injury through other means then we’ll also investigate that.”
NOT ACCEPTING THE STATUS QUO
IT IS heartening to hear governing bodies and unions say they want injury risk to be decreased and that players are treated as any patient should be. However, it could be difficult to keep track of it all. As Richard Ings, former CEO of Australian Sports Anti-Doping Authority, insists, the important question is: “Does this sport have a definable, responsible, measurable policy on monitoring painkiller use and injections?”
Ings wonders why WADA went from once having prohibition for painkilling injections to now having some leeway. Banning a substance comes down to three things, he says: If they are performance enhancing; if they are potentially damaging to an athlete; if their use contravenes integrity in sport.
“Sport at the elite level is very demanding. You are expected to play well, you handle more pressure, you may have to play to keep a contract, and commercial interests are significantly raised. This is how performance-enhancing drugs slip into sport. Painkillers are not banned by WADA, but what are the rules and regulations? What are the standards within the sport? To combat that you need a really good club environment and a governing body with clear protocols and a culture in place. What about a no-needle policy outside of club doctors? The Australian Football League has a strong no-needle policy in place and though it is hard to enforce, at least it appears an effort is being made.”
The human cost of keeping players playing can be easily dismissed in a game where, at the elite end, for every young man or woman dropping out there is a willing replacement. They might not be as good – which may lead to key players being called on more often – but if someone’s out they can be easy to ignore.
Look at Andrew Coombs, once of the Dragons and Wales. He has had eight knee operations in the wake of a dislocated patella. The 32-year-old former forward will likely have two more operations. He has had extreme issues with his injuries but although he was on the region’s group medical insurance policy, he is no longer a Dragons employee and the club no longer have medical treatment insurance. Coombs is paying thousands of pounds more than he hoped to.
There is more. For the past 14 months, after many operations, his body is worn down. He is ill incredibly often. Every little thing knocks him off his stride. He must deal with chronic pain and regularly discussing pain management strategies with consultants. This is the toll playing the game can have. You could argue that is the risk all players run, willingly. But what can we say about the lifestyle leading to up to this?
“My locker was full of medication just to get through training,” Coombs reveals. “You become your own chemist in a way. I saw players go to the local GP away from the club. I certainly did. I suffered from a bad back and remember getting naproxen and diclofenac – you just want to stay in the job for as long as possible.”
Coombs has memories of a coach screaming at him to “just f*** off!” when he pulled out of a captain’s run, in pain. He has seen physios, diligent medics with welfare at the heart of their thinking, being pressured to put players on the park.
Coombs came to the pro game relatively late, at 25, so had no problem fighting his corner. But like Moody he wants young athletes who slide into the top of the sport early to know they can stand up for themselves. He regularly meets with other players spat out of the pro machine. It’s hard not to view these broken players as collateral.
Ings believes there is only so much responsibility an athlete can take – that their education is third on a list behind professional and ethical medical support at source and appropriate protocols and cultures at the level of governance. But then Coombs and Burger both suggest there is one other area where education and outside monitoring is needed – when players are sent home from the hospital after major surgeries. Because sometimes these guys are the most at risk…
EBEN JOUBERT has enjoyed setting up a family life in The Hague. As an Afrikaaner with a German wife, the language barrier has not proved too strenuous to cope with and it’s great to settle after a pro rugby trip that took him from Pretoria to the fringes of the Blue Bulls and then on to Otago’s provincial side. But all of this pales in comparison to his personal journey.
In 2010, in a Ranfurly Shield tie against Southland, a scrum collapsed and tighthead Kees Meeuws fell on the flanker, dislocating Joubert’s shoulder. Eventually he went for reconstruction, hoping it would begin his healing process. But months of torment followed.
He recalls: “After my operation the surgeon went to Europe for eight weeks. I didn’t get better. I was in the worst possible pain – I thought it’d never go. They thought it was just nerve damage so another doctor prescribed me with amitriptyline and gabapentin. But it didn’t help. After two weeks it was still no use.
“In New Zealand they still prescribe methadone (for pain management) and I had been on morphine in hospital – they just upped my dosage. So I had been on methadone and had oxycodone. I had to do it, it was never a choice. I needed the high number of pills to maintain my sanity. When my surgeon came back and heard what I was taking, his face went white. After all of this he pretty much marched me to hospital to clear out some infections. I had six operations in three weeks. They took the screw out of my shoulder as it turned out that’s where the infection was. They had to get me off everything to do that and I said, ‘Aw great, no painkillers.’ When they stopped it my body went into serious withdrawal. By five o’clock that first day I couldn’t stop shaking.”
The upshot of all of this? “I was addicted.”
According to Joubert, with his surgeon away he got three different diagnoses from three different docs. The pain was so bad he barely slept. He struggled on, trying not to be soft, and took massive doses. If he was sat watching TV he’d pop a pill, think nothing more of it. He needed it.
Back in South Africa for Christmas, he decided to kick the habit and aimed for a return to play. He managed to wean himself off the pills in a fight Rob Nichol of the New Zealand Rugby Players’ Association (NZRPA) tells Rugby World deserves our strongest praise. Joubert is happy to share his story and is grateful for the “special” help he got from Nichol and Dave Gibson of the NZRPA and Dr Simon McMahon, his surgeon. He feels it’s important to shine a light on what is an enormous social issue – in 2016 the head of addiction charity DrugWise said of prescription painkiller abuse in the UK: “We are in the midst of a great public health disaster, which is killing hundreds of people a year and ruining the lives of millions.”
When in serious pain, you can understand how some fall into abuse. But Joubert also touches on a social snare when he mentions “blueys” in passing.
To understand what this means, Rugby World spoke to a man with Super Rugby and Champions Cup experience who wished to remain anonymous. He explains that taking sleeping pills – blueys – like diazepam on a night out engenders lightheadedness. Staying awake is the thrill. But it can become slippery.
“In no way do I want this to sound like a good thing,” he warns. “It’s absolute naivety but it is an issue. Maybe only a few dudes per team try it once but there are men who go out and try something stronger. It’s not widespread and they never think they’ll get addicted, but I know a few players who are and who always try to source it.
“My first experience came when I was injured and was given codeine. It was my first real experience of prescription drugs. It changed my perception. I didn’t take a lot but it made me feel funny.
“I remember one time I got prescribed tramadol. At the time it made me feel like I had no worries in the world. It took me away from myself, changed my mindset. I remember being injured and in my spare time looking for a buzz. I ended up taking more. You see other guys who are injured – ‘Hey mate, if you’re not taking any…’ No, you can’t have more.
“Your body adapts quickly. This creates an issue. It is irresponsible and genuinely naïve and it’s about people recognising this. You take this stuff and then you need to double the dosage to feel the same. That’s why prescription meds are addictive. You get a buzz from tramadol initially and then you have to take more. You’re bored and you try it again but it’s not the same… you need more. That’s the trap.”
THERE IS something in the tone of the last source that pleads for watchfulness. I wracked my brains. With Cudmore wanting a bigger bench, Ings on a no-needle policy, and a few asking for stronger monitoring of players returning from surgery, I considered whether I needed bazooka-style bullet points highlighting what I feel we can do about this. But in straining to pin a firm list down, the answer hit me hard: I don’t have to.
From the off the point was to make one big statement: It’s time to seriously talk about this.
The ills of playing through pain and of any excessive painkiller use may not negatively affect the majority, but awareness that an issue does exist is key. Going back to my original source with this, he ended with one simple sentiment: “I hope it helps.”