After our 2017 feature Playing Through The Pain, we return to the subject of chronic pain management in rugby. Now we ask: could there be new ways of approaching the issue?
PAIN WILL forever be a part of collision sport. We accept this now. But at some point, in another part of the world, some ask about the cost.
“We’ve done a lot of work and engaged with our former athletes and you almost have a direct correlation between (long-term) painkiller usage and things like depression and issues with mental health,” says George Atallah, of the NFL Players Association. “There is no doubt about that. And I think once we found a direct correlation between those things, that’s what triggered us to look at ways to prevent.
“You can clearly load up on a bunch of painkillers and play, or you might have to take them to get out of bed after you’ve had a collision. But what is the impact on your long-term mental health (if you do it repeatedly)?
“It is still a concern; it’s not fixed yet.”
The above is about American Football, not rugby, and looks more at long-term opioid use well beyond acute injury – in this part of the world we may be more familiar with opioids like codeine or tramadol which are not recommended for long-term, chronic pain management.
But there are a few reasons why we start there. Bear with us.
In 2017, Rugby World took a long look at the culture of painkiller use in our Playing Through The Pain feature. In the years since, the topic has washed in and out of public discourse. We have heard some former rugby internationals detail their broken histories of injuries and their relationships with pills and pain. They want to talk about their futures too.
So three years on, we had to come back to the topic. Not because of any sense of things worsening or to raise panic but to take a different view.
If we accept that pain is a given, that team medics should have players’ best interests at heart and that brave athletes must make peace with the aches of oncoming years, could we approach chronic pain management differently?
Which can mean looking at other sports, other treatments, other mindsets. And being wary of what athletes in rugby and other comparable competitions are exploring to alleviate their pain.
That brings us back to the NFL and quickly on to the discussion about using cannabis-based products.
The US sport does not adhere to the World Anti-Doping Agency’s code, while rugby does, but chat of weed is spreading. In March, a collective bargaining agreement for the NFL was reached that relaxed their rules on testing for cannabis.
Atallah, assistant executive director of external affairs, explains that in late 2017, the NFLPA set up a committee to look at cannabis but also opioid use, as part of a “wide-ranging look at pain management”. He says they also looked at training methodology, recovery methodology, nutrition. Then in January 2018, cannabidiol (CBD, a product that can be produced without the psychoactive compound tetrahydrocannabinol (THC), the part of cannabis that creates the ‘high’), was removed from WADA’s banned list, and it became possible for rugby players to use CBD products, including CBD oil.
The NFLPA formed their own task force, Atallah says, because so many people around their sport had competing interests. Politics is never far away, particularly with the issue of legalisation and varied approaches to cannabis across states and nations. But he adds, “We certainly talk to other sports and sports unions (about this issue). I think what I’m primarily trying to convey is that the athletes are the ones who are advocating to protect themselves. And the leagues don’t really push the envelope on this issue in a comprehensive way.
“I think we (collision sports) should all be learning from each other, yes.”
Again, the laws on what substances are prohibited in rugby and Football are very different, but in this instance it is being recommended that dialogues stretch across sports.
Glenn Healy, a former National Hockey League goaltender and current NHL Alumni Association president, would appreciate that.
“If someone’s got a better mousetrap than I do, please share it with me,” he says.
“We want to make tomorrow better than today for a whole bunch of players and making tomorrow better might mean something like more sleep, less anxiety, less depression, more functional integration with your world.
“I’m just looking for where I don’t have to come up with the answer to this question: ‘How did we get here with this player?’ How did it get to this?
“So your rugby player that was probably revered around the world, how do we get there with him? I don’t want to have another call from a wife or a kid saying, ‘I want my husband back’ or ‘I want my dad back’, because things are not going the way they should be going.”
Healy says that when it was announced that the NHLAA would partner with the Canopy Growth cannabis company in Canada, to look for alternative treatments, he expected a backlash from some disgusted members. But he claims all he heard were thanks “for going to the corners on this”.
This is another point where rugby players may be interested. Because the use of CBD is a hot topic in the sport. In August, researchers at Liverpool John Moores University found that more than 25% of 517 union and league players surveyed use or have used CBD oil (despite warnings not to – but more on that in our companion piece).
It is spoken about as a godsend. Yet as Dr Mark Ware, chief medical officer at Canopy Growth, says: “Unfortunately for CBD in particular there is nothing (by way of extensive research) on human pain and CBD. It’s astonishing that we don’t have data on that.
Read next: THE PROBLEMS WITH CBD OIL EXPLAINED
“With THC: different story. There’s way more information on neuropathic pain, spasticity, nausea, anxiety – there’s a ton of stuff. Some of it’s small and it’s not super strong but at least there’s data, there are trials that suggest THC is a pretty good analgesic in chronic pain management.
“But with CBD the jury’s still out.”
It’s perhaps not what some will want to hear. But in a sea of anecdotes, the scientists will want more. And it’s understandable why.
Information about the risks of CBD use are out there – as with the Liverpool John Moores report. But the same study highlights that professional athletes are seeking out the products.
Ware describes this as being athlete-driven, adding that something similar is being observed in clinics, with chronic pain sufferers who “will use and say ‘I don’t care if there’s no evidence, I’m trying it if it’s working for me’.”
Ware wants to see more regulations around CBD products across the board. So people know what they’re getting. Then he would like quality observational studies on why people are using the product and what they get from it. And he wants frank conversations with active players about this.
The biggest hurdle to progress in research here, he says, is the hard-wired notion of ‘the spirit of sport’.
“They (governing bodies) don’t want elite athletes to be seen as cannabis users,” Ware says. “And so we’re right back at that stigma again. The pro athlete who’s using cannabis to recover is not a pothead, junkie or druggie. They are a highly-functioning, highly-qualified individual who’s trying to perform and has found a way to do that.
“That conversation needs to happen in order for us to crack that stigma and stop looking at the ‘spirit of sport’, like somehow these athletes are lesser humans because they’re using. It’s okay for us to inject them with steroids and lidocaine and get them back on the field, but God forbid they should take a kind of gummy after a game. To me that’s the breaking point.”
As of January 2021, WADA will have a new code, with a new approach to cannabis use.
The new rule says that the period of ineligibility will be reduced to a flat three months for any athlete that can prove the substance was taken out of competition and was unrelated to sport performance. The athlete can then reduce the period of ineligibility down to one month if they satisfactorily complete a substance of abuse treatment programme, approved by the relevant anti-doping organisation.
In addition, if an athlete can establish that in-competition use of the drug was unrelated to sport performance, then the violation will not be considered intentional, which means a two-year ban will be handed out.
However, the approach to cannabis use around the world is evolving and WADA must be mindful of that. And as the number of known, naturally-occurring cannabinoids grows, and more companies look to develop products, WADA must be quick to react.
Yet when asked if they would ever relax their approach for the sake of more research into pain relief, WADA’s science director Dr Olivier Rabin tells Rugby World: “Not so much, and there are good scientific reasons supporting the current approach.
“There’s a wealth of research in the field. Several research institutes in the world, like the National Institute of Drug Abuse in the US, and many other organisations that look at this from a social or societal standpoint, rather than from the sport perspective.
“So some evidence on substances we are dealing with are usually fairly well-known. It’s more a matter of what rules we want to implement, and how the science really applies to the particular field of anti-doping.
“There are many sectors of research where, despite the limited resources we have, we are very active in. But with this one in particular, we think there is some good research out there and this is typically an area where we rely more on others’ research and apply the outcomes to a very, very specific question that relates to anti-doping.”
Of course that doesn’t mean we cannot continue to change the conversation about how we face pain.
IN 2019, former Newcastle, Yorkshire and London Welsh back-row Ed Williamson told Martha Kelner of Sky News all about his troubles with opioid addiction as a player.
Today, he lives in France and throws himself into art. He has had a catalogue of surgeries, and while he still has an emergency box of ‘odds and sods’ painkillers left over from so many scrapes with the scalpel, he has tried other methods of gaining relief.
“I was always really tight and around the time around my neck operation last year, in the nine months leading up to that I couldn’t turn my neck to the left, past a couple of degrees,” he says. “My traps were ridiculously tense.
“I smoked a bit of weed and over the next hour they eased off just enough for me to relax, breath a little bit. It was enough just to be a little bit less tense in my neck and my head.
“It might have been just a nice, temporary release of the tensions and pain that I had. Which I would have got with the painkillers. But then the problem I had with the painkillers was also getting a lot of residual effects.”
The heart palpitations scared him when he was on tramadol. His sleep was broken and when he was in bed, he describes it more as a trance than sleep. He would grind his jaw for hours.
“It’s pretty easy to fall off the wagon,” he says when asked about the hooks some medications can get into you.
“But it’s not like what you see on TV. It’s not like heroin addicts. If I took a tramadol now, it would ease the pain in my shoulder. I’d feel a bit better and then at the end of the day it would come back.
“The problem for me is that the pain is so intense that you don’t ever want to not have it (tramadol) in your system. Does that make sense?”
It does, and it’s pretty scary.
Williamson adds that he appreciates some will say ‘World’s smallest violin, mate,’ on this subject. He enjoyed his time in rugby, and it can offer a brilliant living to you, if you excel. But having to give up the game after a long career is stressful enough, without dealing with long-term pain.
In his recent autobiography The Hurt, Dylan Hartley claims he missed 1,320 days through injury during a 15-year career. He gives many details on a mangled body. In his own book, James Haskell writes that he “had it relatively easy but I still wake up in pain every day, and can’t run anymore”. He also describes secretly injecting anti-inflammatories into his buttock before one International, just to get through the game.
There are other anecdotes out there and they all vary. Not everyone turns to painkillers, either.
“I think I’ve probably had a bad back since I was 18 years old and I’ve still got it now, to be fair,” 44-cap English tighthead Davey Wilson tells Rugby World. “I can’t really get rid of it. I’ve tried a few bits and bobs. But I go for a little walk now and I get the numb leg, the numb foot, stuff like that. A lot of pain down the leg.
“It’s really annoying and it becomes the thing you are managing day to day. Some days you’re good, some days you’re walking the little lad to school and you have to sit down on the way back until you can feel your foot again.
“It’s a brutal job rugby – you pay for it when you’re playing and you pay for it afterwards as well!”
Wilson, 35, is studying to be a physiotherapist in the North-East now. He has always wanted to understand his body, his pain, he admits. But despite his continued issues he refuses to take painkillers today. Short-term distractions are not the answer for him.
The ex-prop feels that after years of being catered for, some former players can be oblivious to the fine, free healthcare options available to them, they just have to learn to wait like the rest of us. However, he agrees with those who feel aftercare in rugby is something that really needs looking at.
He says that in the last six or seven years, in his experience, team medics have been conscious of how they handle pain medication and done so admirably. It’s a point repeated by Adam Balding, former Leicester, Gloucester and Falcons back-row and current Birmingham Moseley DoR, who also tells us: “credit where credit’s due, I do you feel that welfare for players has improved dramatically over the years and should be recognised, I think it’s important that the voice of the players is being heard a lot more than it used to be.”
But after 15 years of handing your body over to the game, Wilson says, there should be someone or some group to help guide retired pros looking to manage their chronic pain, to help them find the right help with the NHS while they juggle decisions on what’s next. Giving up can become suddenly isolating.
He certainly had to think long and hard about his options – being an electrician or plumber, operating in tight spaces, was out of the question when he considered what would hurt the most.
Both Wilson and Williamson do agree, though, that players must take some personal responsibility when looking ahead. There is a balance to be had between your own planning and aftercare.
Wilson believes in the power of exercise to help. Williamson talks of how looking after nutrition, stretching, rehab and prehab may have helped him more further down the line had he wired in sooner. He also knows of more than a few players who have no lingering issues with pain following retirement, and he believes those were the early adopters of the all-round approach.
Williamson adds: “When it (cannabis) does eventually become legal – and I hope it does – I wouldn’t recommend a player smokes a couple of joints before a game. But maybe it’s worth looking into some edibles or stronger, high-potency CBD oils? Not around games but just to manage pain throughout the week.”
Researchers already want to understand what is already legal, better. In August, the National Institute for Health and Care Excellence (NICE) said there was “little or no evidence” to say commonly used drugs for chronic primary pain – paracetamol, ketamine, corticosteroids, anaesthetic/corticosteroid combinations, or antipsychotics – made any difference to a subject’s quality of life, pain or psychological distress.
Anyway, even further ahead of all of that, Williamson believes it would be beneficial to simply talk about alternative approaches to pain management. Even just as an exercise to get pros speaking to one another.
He is not the only one.
“THERE’S THIS sort of idea that in sport, chronic pain doesn’t exist,” says Richmond Stace, physiotherapist turned pain coach.
“It exists everywhere in every level of society, it just has different terms. Sports medicine teams are fantastic at dealing with acute injuries and pitchside scenarios, but the model is just not the right one for dealing with ongoing problems or recurring problems or chronic pain.”
Stace, who worked with England Women in the early 2000s, says that he became disillusioned with “patching people up” as a physio. The idea is that we all buy into the notion that pain must be related to an injury in that specific location where it hurts, and focusing treatment on that one area will fix the problem.
With chronic pain, he says, there needs to be more.
“The first thing that needs to happen is to create some time and some space to really talk to a player,” Stace says. “But of course it also then depends on the player’s view because they’ve been brought up in this culture – a lot of players will still be thinking that the pain is very much related to something in their knee or their back.
“It takes a brave person to think, ‘well actually, my emotional state plays a huge role in this pain. My expectations, my dreams, my hopes play a huge role’. When it comes to research, there are lots of studies being done on all of these things, so what we’re talking about here might sound different or ‘alternative’, but with research on pain and these dimensions on it, there’s a lot out there.”
He jokes that things would not get so deep so early with athletes – you need to build up to the big issues. Stace does also say that with acute injury, current accepted practice and painkiller use in the first instance is important. But he is not alone in wanting to step away from the traditional approach when it comes to the chronic.
Physiotherapist and lecturer Mike Stewart (alongside Dr Ware) helped put together the International Olympic Committee’s IOC consensus statement on pain management in elite athletes paper that came out in 2017. He is also fascinated with the language we use. For example, he has found that in some situations, in sport or in the military, discussions around injury and pain can include insult and punishment for the perceived ‘weakness’.
It is also a very Western approach, he says, to be bombarded with talk of a healthcare scare followed by a fix. There is a sense of the restitutional about it. We all want a silver bullet to instantly take the pain away.
Yet in the absence of this, he says, we see certain approaches to treating pain repeat over and over: when you go beyond the acute, it’s painkillers as the small troops. Then if pain lingers, send in the tanks of physio treatment and injections. Lingering still? The nuclear option is surgery.
For him, seeing youngsters with laundry lists of surgeries is tantamount to medical negligence.
Stewart believes that looking at acceptance commitment therapy, cognitive behavioural therapy and mindfulness is a good place to start (Harlequins, for example, use a mindfulness coach). And we need to consider the language we use. As he explains: “Studies here in the UK have found that 99% of the undergraduate hours that clinicians spend training for is based in pathology, biomechanics, anatomy. So that leaves less than 1% of the hours that these people spend in training for psychology, communication skills, looking at how to build resilience and self-efficacy. Which is crucial in sport.
“Look at somebody who keeps getting recurring injuries and then they feel like their bodies are falling apart and they essentially don’t have the skills to deal with these really complex, challenging problems. Which are (hard) enough outside of a sporting environment but put them into sport and it sort of magnifies.”
Think of the stresses a young star faces. Pressure to perform, to earn, to win, and then you interact with the world around you and, gasp, have you had a look at social media, mate? Perhaps it does magnify. And yet, in some spaces, at the highest level, are we divorcing physical trauma with mental trauma and vice versa?
Dr Darren Britton is a sports psychologist and lecturer at Solent University. “Psychology now is being integrated a lot better at every single level of organisations, be it with clubs or national governing bodies or whatever. So rather than psychology operating in these little silos, it’s being integrated into every aspect of the organisation,” he says.
“It still has a long way to go. I would say there’s still a lot of inconsistency. Some sports organisations do psychology really, really well. There are others who still are years behind in how they integrate psychology and psychologists into what they do.
“Some will still operate with the same old approach of weaving psychologists in one day a week to have a chat with this person or that person. Rather than seeing it as something that actually needs to be integrated into everything that goes on within the organisation.
“For years the stereotype was of a psychologist being a fixer, a firefighter. If you’ve got a problem you go to the sports psychologist, rather than sports psychology being seen as proactive.”
The fear is that in dire financial times, this aspect is the easiest to cut. You may just bring in your fixer less and less.
In the first instance, Dr Britton believes pro clubs should work with figures with certain qualifications as standard – from the British Psychological Society or British Association of Sports and Exercise Sciences – and registered with the Health and Care Professions Council (HCPC), rather than, say, the popular public speaker.
He says that increased stress levels can increase the risk of injury, with increased muscle tension, the effect on concentration and missing cues, the impact on sleep and other mechanisms. So prepare to address that. Stewart would like to see sports medics actively updating their understanding of chronic pain and whole non-medical staff (like coaches and others) buying into that too.
The idea of the ‘holistic’ may make you wince. But as we consider how far understanding of certain medications is still to come, and if we accept that exceptional sports medics continually seek to improve, would it be better for more to now embrace the psychological side and address how we talk about pain as well?
Perhaps it is just the right small step. For now.
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