International footballers 'play on painkillers'

England's footballers could be putting their health at risk “over what has been described as painkiller ‘abuse’”, the Daily Mail has said. Its story coincides with the kick-off of the 2012 European Championship in Poland and Ukraine. The Mail said that 39% of players at the 2010 World Cup took pain medication before every game to help them play with an existing injury.

The study behind this story provides a snapshot of the medications used in the 72 hours before each match during the 2010 World Cup in South Africa. More than two-thirds of footballers taking part in the World Cup used any sort of prescribed medication at some point, with 60.3% taking painkilling drugs at least once. Before their team’s match, just under half the players were taking some sort of medication, regardless of whether they were playing. Most of these players were taking anti-inflammatory drugs. These findings demonstrate a slight increase in use compared with previous World Cups in 2006 in Germany and 2002 in Japan and South Korea.

This study shows the high use of medications, mostly anti-inflammatories, before each game in the World Cup. However, little more can be concluded from this observational study, and certainly not enough to support the claim that players are “abusing” medication. We do not know the reasons why these medications were taken, or the doses taken, and no assumptions can be made about the players’ longer-term health. The authors say that prescribing may not be consistent with advice in sporting guidelines, but this cannot be evaluated from this report.

Where did the story come from?

This research was funded by FIFA (Fédération Internationale de Football Association) and carried out by the FIFA Medical Assessment and Research Center in Switzerland. The study was published in the peer-reviewed British Journal of Sports Medicine.

Several papers reported that players are “abusing” painkillers. This coverage appears to be based on a quote from study author and FIFA chief medical officer Professor Jiri Dvorak. From the research presented, we cannot say that international footballers are “abusing” painkillers, as the medication may have been prescribed by the teams’ medical staff. However, the news coverage was generally representative of this study. Most news reports discussed the longer-term health and career implications for the players, which cannot be assessed on the basis of this study alone.

A statement on FIFA’s website said that some players may use painkillers to mask the pain of an existing problem and that this may be “dangerous”. FIFA’s website also says that “in high-intensity exercise like football, players' kidneys are continuously working hard, making them more vulnerable to damage from strong drugs”.

What kind of research was this?

This was an observational study where doctors of the teams participating in the 2010 FIFA World Cup provided a list of prescribed medications used by each player within the 72 hours before each match.

The researchers say previous reports have documented medication use by international football players, Olympic contestants and other sporting competitors. They say these have demonstrated that use of painkillers can go against sporting guidelines developed to guide sports physicians’ prescribing of anti-inflammatory drugs. This study looked at prescribing during the 2010 FIFA World Cup in South Africa and compared it with previous competitions in 2006 and 2002.

What did the research involve?

The published journal report describes the methods only briefly. Researchers say that during the 2010 World Cup, each team’s doctor recorded the prescribed medications used by each player during the 72 hours preceding each match. It is not clear who prescribed the medication or whether the players took other non-prescribed medication. Researchers categorised the drugs as:

NSAIDs (non-steroidal anti-inflammatories, such as ibuprofen)
analgesics (painkillers, not further specified but likely to include simple painkillers like paracetamol)
injected corticosteroids and local anaesthetics
muscle relaxants
respiratory drugs (likely to include asthma medication, such as salbutamol)
medication for gastrointestinal and antimicrobial purposes
others

Each of the 32 countries that took part in the tournament nominated 23 players (in total, 736 players in the tournament). There were 64 matches (2,944 player matches, which included all players regardless of whether they played). The authors calculated:

medication use per player (average use per player per match or per tournament)
number of individual players reported to be using medication (per match or per tournament)

What were the basic results?

The authors found that 71.7% of players (528 out of 736) took some sort of medication at some point during the 2010 World Cup, and 60.3% (444 out of 736) took painkilling drugs at least once. Just under half the players (48.2%, 1,418 out of 2,944) took some sort of medication in the 72 hours before their team’s match, regardless of whether they were playing. In total, 34.6% of players (1,020 out of 2,944) took NSAIDs and 6.4% (189 out of 2,944) took another sort of painkiller.

Almost half of all medications prescribed were NSAIDs (49.0%). Other painkillers made up 10.5% of prescriptions, local anaesthetic injections 2.3%, muscle relaxants 3.8%, and corticosteroid injections were given to 2.4% of players.

The authors observed that significantly more medications were used during the finals than during the qualifying round of matches and that players from North America and South America used more medications than players from other continents.

Medication use during the 2010 World Cup showed a slight, but not statistically significant, increase on previous years:

During the 2006 World Cup, 69.0% of players took medication at some point, and 42.7% took some sort of medication before their team’s match regardless of whether they were playing.
During the 2002 World Cup, 67.9% of players took medication at some point, and 45.3% took some sort of medication before their team’s match regardless of whether they were playing.

However, the number of players taking NSAIDs per match increased significantly.

How did the researchers interpret the results?

The authors concluded that medication use, particularly NSAIDs, reported by the team doctors in international football is increasing compared to previous reports. For certain teams, they said that systematic prescribing of medication before every match appeared to be the norm.

The authors said that these findings should encourage efforts to try to understand and address this “potentially disastrous” practice in professional sports.

Conclusion

This study provides a snapshot of the medications used in the 72 hours before each match during the 2010 World Cup. The report shows that 71.7% of footballers taking part in the World Cup (528 out of 736) took medication at some point, and 60.3% (444 out of 736) took painkilling drugs at least once. Nearly half the players (48.2%, 1,418 out of 2,944) were taking some sort of medication in the 72 hours before their team’s match regardless of whether they were playing. Most of these players (1,020) took anti-inflammatory drugs.

This study demonstrates the widespread use of medication, particularly anti-inflammatory drugs, by football players before each game in the World Cup. Little more can be concluded from this briefly reported observational study. We do not know the reasons why these medications were prescribed, the doses taken, or what other non-prescription drugs may have been taken. Though the authors say that prescribing may not be consistent with advice in sporting guidelines, this cannot be demonstrated further from this report. Although reference is made to medication use in other sporting competitions, no assumptions can be made from this report about the use of medication in other sports, such athletics events at the forthcoming London 2012 Olympics.

The authors rightly conclude that these findings should encourage efforts to understand and address the current use of pain-relief and anti-inflammatory medications in professional sports.