NFL team physicians say Toradol use in game has changed
In 2004 when San Francisco 49ers Pro Bowl center Jeremy Newberry discussed Toradol, a non-narcotic drug he was using to ease the constant pain in his damaged right knee, he boasted, “That stuff is awesome.”
Five years later Newberry reiterated, “This stuff works.”
Today he is among hundreds of former players suing the NFL, claiming Toradol and other painkillers led to long-term disabilities. Newberry has been quoted as saying his kidneys function at “30 percent.”
Kidney damage is among possible side effects of Toradol — a nonsteroidal, anti-inflammatory drug (NSAID) — especially when used beyond prescribed dosages, medical experts said. Doctors affiliated with NFL teams and other sports said recent recommendations have resulted in changes in how the drug is administered.
“You don't give this chronically,” Steelers team doctor Jim Bradley said. “You can give it one time, and you don't need to give it any more during the week.”
Currently, Steelers players must appear on an official injury list to be allowed a pregame dosage in “the lowest amounts we can give that would be effective,” Bradley said. He said other team physicians follow similar guidelines. With rare exception, he said, a player who needs Toradol gets one dose per week.
“We do not give Toradol out during the week for practice,” Bradley said. “We wanted to change the idea of taking it when you don't have anything wrong with you. You're not going to get it just because you're going to get sore.”
Newberry and other players such ex-Steelers safety Mike Logan have said Toradol was made available indiscriminately before games, via injection or orally, and that the risks were not explained. Bradley said he cannot address Logan's comments, but he said the culture has changed. Logan played with the Steelers from 2001-06.
“Our policy has evolved as we learned how to do certain things better,” Bradley said. “Not just Toradol. Everything continues to evolve. It never stays the same. It's hard to hold on to something from 10 years ago when it's constantly evolving.”
In general, “the benefits outweigh the risks when it's used properly,” said Steven Cohen, a medical doctor who is professor of anesthesiology, physical medicine and rehabilitation at Johns Hopkins School of Medicine in Baltimore and the Uniformed Services University of the Health Sciences in Bethesda, Md.
“Every drug has a side effect,” Bradley said. “Aspirin has side effects.”
Cohen termed Toradol as “very effective” compared with other NSAIDs.
“It's not recommended for mild pain,” he said. “And it's not recommended for everyday chronic pain. It's given for acute pain.”
Approved by the FDA in 1989, Toradol (generically known as ketorolac tromethamine) was introduced as a postoperative drug. It since has been used by millions of patients, including President Bill Clinton, who took Toradol in 1997 after he fell at the Florida home of golfer Greg Norman and tore a tendon above his right knee. Clinton was given the drug after the injury and again following surgery.
Bradley said a major appeal of Toradol is that it is not addictive.
“We do everything we can to get away from narcotics,” he said. “Everything.”
St. Louis Rams team doctor Matthew Matava, president of the NFL Physician Society, authored a 2012 report that addressed Toradol. It was published the year after a dozen NFL players sued the league over claims similar to those in the current lawsuit.
The report said Toradol generally is safe and effective but made recommendations regarding how the drug should be used. Among them were that only doctors should administer the drug and that pregame use “to reduce the anticipated pain during, as well as after, competition” should be discouraged.
One reason is Toradol's blood-thinning capabilities. Because of that, “When you have a traumatic injury, the risk is enhanced,” Matava said.
Matava and Bradley, a past president of the NFL Physician Society, said players today are better informed. Bradley said each Steelers player gets a sheet of paper listing all the side effects, including warnings about mixing Toradol with other NSAIDs such as aspirin and ibuprofen.
“They will not get this drug unless they see it, understand it and sign it,” he said.
The Rams and Steelers are among several teams that no longer inject Toradol unless a player cannot take it orally. Bradley and Matava agree that, contrary to conventional wisdom, the drug works faster when taken orally than when injected into the buttocks.
There also is a public-relations issue. Matava's 2012 report acknowledges that, while injections into the muscle are medically safe, they have “been unfavorably viewed by the media and public” as necessary for players getting ready for a game.
“The perception of NFL players getting ‘shot up' before competition has shed an unfavorable light on the NFL” and team physicians, the report noted.
Bradley calls it “the stigma of the needle.”
Restricting Toradol as a preventive drug prior to competition is not confined to the NFL.
Los Angeles Dodgers team physician Neal ElAttrache said several Major League Baseball teams also are cutting back, and some do not use it at all.
“A lot of players have gotten into the culture of asking for or expecting Toradol as a medication to prevent pain during competition,” said ElAttrache, who grew up in Mt. Pleasant and graduated from Pitt's medical school. “That is not the right condition to use it.”
Toradol is prescribed to baseball players, mostly pitchers, “who have an injury that is medically safe to play with before the symptoms go away,” ElAttrache said.
He said the Dodgers dispense it conservatively, as do other teams. In the past, he said, “No question the use (in baseball) was more liberal and done without a lot of thought.”
Administered properly, he said, “It's a very useful drug.”
Bob Cohn is a staff writer for Trib Total Media. Reach him at firstname.lastname@example.org.