goblueram

January 3rd, 2013 at 2:49 PM ^

Did anyone force the players to take the drug?

As with all questions of drug legality, an individual should be allowed to take risks with their own body if they choose to, but has no right to put someone else in danger (i.e. drunk driving, or forcing someone else to take a drug).

Sinsemillaplease

January 3rd, 2013 at 2:55 PM ^

Look at the environment they're in and the stakes they play for. They're not in a position to readily make a sound decision or to question the advice of team doctors. There's a reason doctors take the hippocratic oath. They're in a position that grants them great influence over the health decisions of others.

Blue in Yarmouth

January 3rd, 2013 at 3:15 PM ^

This guy was twenty years old. If a Doctor explains to a 20 year old patient the possible effects of taking a drug and leaves the decision up to them I don't see a problem with that.What else would you expect a doctor to do, ask a 20 year olds mother for permission to give them a certain drug?

This isn't a new drug, or even one that is uncommonly used. The fact isthe  kid was adversely effected by the drug when thousands of people take it and have nothing go wrong, it was bad luck, but it happens. I wouldn't say the Doctor has done anything wrong if he has explain the potential effects to the person in question.

gopoohgo

January 3rd, 2013 at 6:10 PM ^

See below; this medication is a stronger, injectable NSAID, similar in mechanism of action to ibuprofen and naproxen.  ALL NSAIDs carry risks of thromboembolic events, bleeding, and renal failure.  

Next time you get a prescription look at the package insert and see all those lovely possible side effects and drug interactions; if you "expect a doctor to not offer a drug that he knows to have serious potential adverse effects" then you won't be taking ANY medication.

I've seen bleeding ulcers from too much asprin; renal failure from too much ibuprofen, liver failure from too much acetaminophen (and booze), strokes and pulmonary emboli in young women who smoke while taking birth control pills, etc. etc. etc. etc.

Obviously, the doctor owes the patient "informed consent" regarding risks and benefits of a procedure and what he/her is injecting into the patient; however, there is SOME onus on the patient to be just a tiny bit curious as to what the hell the doctor is sticking into them.  Willfull ignorance and lack of informed consent are two completely different subjects...

panthera leo fututio

January 3rd, 2013 at 7:00 PM ^

I get that just about every medical treatment carries some risk. My (likely naive) impression from reading the ABC article, though, is that the risks associated with the NSAID in question are unreasonably high when adminstered as it has been to football players.

I think the key point here is the environment under which consent is given. I think it's certainly likely that some players -- on reflection, with full information, and without any external pressures -- would chose to take the painkiller in order to play. But I also think that it would be extremely difficult, if not impossible, to adequately remove such external pressures or to distinguish between players who are making free and informed decisions from those who are taking on a risk because they feel that they have no other acceptible choice. Given this, I think it's on the university to just not offer (or to be extremely judicious about offering) the risky treatment.

EDIT: I'm open to being convinced that the treatment really isn't that risky and ought to be permitted. My main point of argument with some of the comments here is over the role of consent in situations like this.

RakeFight

January 3rd, 2013 at 4:33 PM ^

Totally depends on the dose.  Generally IM injections of this drug are every 6 hours, but that's at max dose... you could theoretically use a smaller dose and inject more frequently (although this ignores the pharmacokinetics of the drug, and may still be dangerous by exceeding toxic AUC serum levels, blah blah blah).

It sounds like the doctor/school is in trouble for not explaining potential risks of a prescription drug.  BUT if there's a burden of proof on their part that they have to show that this drug caused the heart attack, then that will be very difficult.  While other drugs in this class (NSAID) have been correlated (not causily linked) to thrombotic events including heart attack in elderly patients with other health conditions, this particular drug has never been correlated with such a complication, and this kid was a healthy young adult.  The chances that his heart attack was caused by this drug are slim to none in my MGoDoctor opinion.

That will be $500.

Creedence Tapes

January 3rd, 2013 at 4:09 PM ^

Damn, I sure hope he didn't cross his fingers when he took the oath. We should have him pinkie swear that he didn't do it on purpose too. 

Come on, its an Oath, it can be broken, wether purpousfully or not. It dosn't prevent doctors from making mistakes, or acting in bad faith. Just ask Michael Jackson's doctor, sure MJ made his own "decisions" but died because of it.

State Street

January 3rd, 2013 at 2:58 PM ^

Is it just me or is every college training staff incompetent?  We all saw what happened to Robert Woods midseason, the Matt Scott fiasco (clearly concussed, pukes, in for next play, scores touchdown, out for remainder of game and next one too), and countless other times where players are clearly concussed and allowed to remain in the game.

Did anyone watch the Belk Bowl?  In the first quarter a Duke DB cracks a receiver, lays motionless, gets up eventually, loses his balance and falls down.  He was back in the game the next play.  That to me is unacceptable and bordering on criminal.

Blue in Yarmouth

January 3rd, 2013 at 3:08 PM ^

I have been consistently questioning the competence of training staff within both college and pro sport for some time now. To be honest...I was surprised V. Smith returned after the Clowney hit. Not that I saw anything from him that would lead me to believe he was badly hurt...just that I thought it would be impossible not to be badly hurt after such a hit.

Then again, maybe he didn't return and I just couldn't see what numbers were on the field...

Blue in Yarmouth

January 3rd, 2013 at 3:05 PM ^

As a Doctor I share the potential side effects of drugs with patients regularly, but also disclose the potential of those side effects actually occurring. When you look at a drug label it puts absolutely everything when disclosing potential side effects because if they omit something and it occurs it could lead to a huge law suit. Just because one is listed doesn't mean it is very likely to occur.

Keeping that in mind I could see a physician telling a young player that there is a risk of heart attack, stroke etc etc etc, but those are very unlikely to occur in a person of your age and in your shape.

If that is the case I don't see a huge problem with it as it leaves the choice up to a 20 year old person to make. If they want to take the risk it shouldn't be an issue. 

Nosce Te Ipsum

January 3rd, 2013 at 3:22 PM ^

I feel like you're being really naive. Do you think a college fb player between the ages of 18-23 who is trying to play well enough to make the NFL is going to question what the medical staff is doing? The USC player who had the heart attack wasn't even told what it was. They just called it "The Shot". I'm sure that two injections within a short period of time isn't healthy either. We all love to hear how these players are like sons to their coaches and i'm sure that's how it is in some cases, but we've also seen how some coaches view players much differently and are only concerned with winning. I'd bet that the latter is much more prevalent than the former.

Blue in Yarmouth

January 3rd, 2013 at 3:33 PM ^

You say he was never told what he was being given, but if that's the case how does he know what he was given and how was he able to read the potential side effects of the drug off the label? It wouldn't be the first time someone made up a bogus claim to make some money.

Secondly, we trust people of this same age to drive 4000 pound vehicle at 100 km/h, elect our leaders, decide whether to drink and drive etc and we can't let them make an educated decision as to whether they want to take a pain killer or not (and notice I said educated, if they weren't informed I think there is an issue, which I stated previously).

Poeple make choices every day and use different criterea when evaluating the alternatives. If a person of this age is using the criterea you mention in your post, that isn't the physicians fault.  Poeple often have mixed up priorities, but at the end of the day you can't blame other people for those. I think(and practice under the belief) that an educated adult  can make a decision if properly informed. As a Doctor we don't force people to do anything, we just educate them as to what the alternatives are and let them choose.

Blue in Yarmouth

January 4th, 2013 at 7:44 AM ^

you said the USC player wasn't even told what it was, and his statement in the article said they only called it "the shot". Then he goes on to tell the reporter what it was and read the risks off the label...That just seems a little inconsistent to me.

As for the subject at hand, I just don't see a Doctor playing a role in the pressuer this kid was under. I'm not disputing the kid was under pressure and could have felt like it was the only choice, I just don't think the Doctor was a part of that, nor do I think it is their responsibility to determine why a particular patient makes a particular decision if they have explained the risk of a certain treatment.

I know you will say (like the article suggests) that according to the player the Doctor didn't explain the risks and THAT I would have a problem with. But with the inconsistencies of the plkayers statements in that article I would be a little skeptical that was actuially the case and therefore is the reason for my stance on the matter.

I could be wrong about my asssumptions, and if that is the case I would change my view of what has transpired here, but if the player was given the information necessary to make an informed decision I have a hard time blaming the Doctor. The football coaches and university...sure, the Doctor...that's a stretch. 

Sac Fly

January 3rd, 2013 at 3:06 PM ^

Ketorolac use is widespread in pro sports because it does what no other synthetic can do, and it's not a narcotic. Most players will take it without thinking too hard about what blocking hormones does to your body long term, because it will allow them to play on almost any injury.

RakeFight

January 3rd, 2013 at 4:41 PM ^

Not sure about a miracle, but it remains the only NSAID (Non-Steroidal Anti-Inflammatory Drug, similar to a strong ibuprofen or Alleve) that comes in a form that can be given injection or IV... therefore it works quickly and is quite effective with minimal side effects (compared to narcotics, anesthetics, etc).  It is used in the ER and hospital setting very frequently.

LSAClassOf2000

January 3rd, 2013 at 3:31 PM ^

They weren't kidding about a relative lack of guidance in the NCAA Division I Manual. Some classes of substances are, of course, banned outright, but it is possible to get exemptions for documented conditions provided you follow certain guidelines ("medically accepted practice", no intravenous injections - local anesthetics are on a "restricted" list).

Under Bylaw 10, which is "Unethical Conduct", there is one bullet which contains:

"Knowing involvement in providing a banned substance or impermissible supplement to student-athletes, or knowingly providing medications to student-athletes contrary to medical licensure, commonly accepted standards of care in sports medicine practice, or state and federal law."

Semi-related to this - there was a fight between the NFLPA and the NFL over the league requiring players to sign a waiver whenever Toradol (or its generic equivalent presumably) was used in a game situation, with the recommendation being that it "should not be injected (either intravenously or intramuscularly) except after an acute game-related injury in which significant visceral or central nervous system bleeding is not expected and where oral or intranasal pain medications are inadequate or not tolerated."

 

RakeFight

January 3rd, 2013 at 4:46 PM ^

Keep in mind that ibuprofen (Advil, Motrin) and naproxen (Alleve), which are the same type of medicines, have the same warnings.  It would be interesting to see if there would be as much controversy if the team doctor had given him Advil before the game.

gbdub

January 3rd, 2013 at 5:44 PM ^

Very much this. Note this line in the article:

In addition, like other drugs in its class, the generic Toradol label warns "may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction (heart attack), and stroke, which can be fatal."

Note that the article doesn't note that over the counter Advil is one of the drugs in this class (NSAIDs) and carries the same warning.

Now, I am no doctor, but know someone who takes Trorodol for occasional severe headaches. These are real potential side effects, but the risk is pretty low - this is not an unusually dangerous drug. The main thing with Torodol is that it cannot be used for prolonged periods (and is therefore prescription only). Otherwise, it is used safely and effectively very frequently.

As long as the doctors aren't misusing the drug, this is a clear case of journalistic sensationalism. Precisely the same sort of sensationalism got Vioxx pulled, much to the detriment of many arthritis sufferers.

gbdub

January 3rd, 2013 at 5:48 PM ^

I will note that taking painkillers to continue performing with an injury is usually a Bad Idea - pain is our bodies telling us to stop. But athletes being what they are I doubt we'll ever eradicate them. Just keep the doses where they should be and discuss the risks, as with any drug.

UM2k1

January 3rd, 2013 at 6:08 PM ^

I have been takin IM toradol (ketorolac) injections for about 10 years for migraines. I had to stop due to kidney failure for a short period, but other than that, I have had the drug and syringes at my disposal for self medication. The great upside of this drug is unlike opioids, there is no addiction issue, and they do not affect your mental acuity. Also, several opioids are mixed with acetaminophen, which can cause liver damage (NSAIDs are mostly metabolized in the kidneys). I have taken 2 30mg doses an hour apart several times, and have not had a heart attack (I'm also 33 yrs old, obese and severely out of shape).

YakAttack

January 3rd, 2013 at 7:45 PM ^

for a Pharmacology class. There are doctors in places like Australia and Sweden that use Toradol in place of things like IV morphine and oral doses of hydrocodone and tramadol. The downside is that there is an upswing in Toradol overuse since Ultram became controlled.

NYC Blue

January 3rd, 2013 at 8:06 PM ^

The press just found out about Toradol, so they have decieded to make this the issue of the month.

As a doctor who specializes in kidney disease, I can tell you that there is no doubt a risk from ketorlac (Toradol) to cause kidney failue.  NSAIDs other than aspirin (Motrin/Ibuprofen, naproxen etc) have all been associated with both kidney disease and heart disease (aspirin has some protective effects against heart disease, but still can cause kidney failure).  While ketorlac is considered stronger and more importantly, can be given intravenously to provide immediate relief from pain, there is no data that it has a higher risk of causing either kidney disease or heart disease than the other drugs in the class.

Now, the other thing to consider, is what is the alternative to their use?  As was mentioned above, the use of NSAIDs in place of narcotics like morphine is generally considered a very good thing.

If, on the other  hand, they are given these medications for no reason (i.e. the alternative is no medication at all) then they clearly are being mis-used.

Now again, I have patients that have put themselves into renal failure with the overuse of NSAIDs, but if you ban ketorlac, you should ban aspirin, motrin etc (basically everything but tylenol) because the data is the same.

YakAttack

January 3rd, 2013 at 8:53 PM ^

people equate non-opioid NSAIDs as being harmless. Making Toradol a CIV would eliminate much of the abuse, but in a clinical, or inpatient setting, it wouldnt make a difference for a while. Doctors often prescribe their "go to" meds, and it takes a lot to change those preferences. Fentanyl and hydromorphone are used more than I ever imagined. And having been on Dilaudid, it should knock out anything that ails you. So seeing a patient go from that to Fentanyl is shocking. Not unnecessary, just surprising.

gbdub

January 4th, 2013 at 8:50 AM ^

I'm not saying its harmless, I'm saying that the sensationalism of the article is overblown. They are trying to make it seem like this is some exotic ultra dangerous superdrug that only unscrupulous docs doing anything to win would use. It's clearly nothing of the sort.

bjk

January 4th, 2013 at 11:33 AM ^

from the above:

Newberry said Toradol "makes you feel like Superman for three hours," but the 35-year-old now is suffering from Stage 3 kidney failure that doctors attribute to Toradol.

"I think they're playing Russian roulette basically," Pierce Scranton, former Seahawks team doctor, told Kremer. "You are describing a patient population of football players who on a chronic basis are using Toradal just to play, and that's outside of the FDA guideline. In essence that would be construed as off label and not used for what its intended use was."

Tater

January 4th, 2013 at 1:15 AM ^

Does anyone expect a player in the world's most macho sport to turn down a painkiller that would enable him to get on the field and play?  Players are in no position to make the right decision here, because of the possible locker room backlash if they say "no."

It's up to the doctor to do what is in the best interests of the patient, but many coaches just find doctors whose definitions are closer to "best interests of the team right now."  This has been a problem in football for a long time.  A 20 year-old who simply wants to get on the field and play doesn't have the perspective to realize how badly it is going to suck when he can hardly walk at 40, or when he is 50 with early-onset dementia.