The Icy Dark Underbelly of Playing Through Pain

It’s Game 7 of the 1994 Stanley Cup Final between ice hockey teams Vancouver Canucks and New York Rangers. With the pinnacle of hockey success one single game away, Canucks captain Trevor Linden steps out onto the ice and leads his team into battle, under the glaring lights of Madison Square Garden and surrounded by the boos of 18,000 Rangers fans. Despite their eventual loss, Linden had gained utmost respect for playing the last few games with multiple broken ribs and costochondral separation, injuries that were unknown to the public during the time. 

A teammate later shared: “You can’t imagine what it’s like to hear your captain, in a room down the hall, screaming at the top of his lungs as they injected the needle into his rib cage. Knowing him, he probably thought we couldn’t hear. He would then walk into our dressing room like nothing had happened. That was inspirational.”

Stories like this aren’t rare in a professional sports setting where athletes often encounter intense physical demands. Playing through horrendous injuries such as a broken jaw, a skate slash to the face, or a punctured lung are all undeniably impressive true stories within hockey (1). But relying on a steady intake of painkillers in order to keep playing is a reckless decision that often leads to potential drug abuse, and yet we continue to applaud the heroics and glorify the toughness and grit as strength of character. In doing so, we perpetuate the notion that an integral part of hockey culture involves avoiding being seen as weak or unreliable, highlighting the ethical dilemmas of painkiller use and abuse, along with the accountability of medical professionals and players themselves.

While the National Hockey League (NHL) provides a Substance Abuse and Behavioral Health Program, some former players have shared their experiences regarding team doctors failing to provide benevolent care and neglecting player welfare. Facing pressure from all sides to keep players skating while trying to provide appropriate medical care requires a delicate balance, and is undoubtedly a tough position to be in. When medical decision-making starts tilting towards prioritising short-term pain relief over long term health and well-being, it can lead to an over-prescription of painkillers, potentially enabling chronic health risks and addiction (2).

The tragic death of Derek Boogaard from an accidental overdose of narcotics and alcohol in 2011 opened an investigation into his negligent medical treatment. Over the course of his shortened career, he received more than 100 prescriptions from more than a dozen team doctors, for thousands of pills including oxycodone, sedative-hypnotics (zolpidem/Ambien), benzodiazepines, and more (3). Two years prior to his death, the NHL placed him into its substance abuse program and cleared him to play a year later, provided he refrained from medications and submitted to random drug testing in accordance with an “Aftercare Program”. Despite being aware of his recurring addiction issues alongside increasingly erratic behaviour following repeated head trauma, team doctors continued writing the same prescriptions whenever Boogaard asked for them following injuries, often over text, without the need for consultation, and without noting it down in team medical files (4).

Boogaard’s case provided a glimpse into the dark underbelly of widespread painkiller abuse within the NHL, a world usually meticulously concealed from the public. While medical records often paint an incomplete picture, they raise a plethora of ethical concerns – from a seemingly lack of communication between team doctors regarding overlapping prescriptions to providing such ease of access to medications without requiring physical and mental health check-ups for someone with a known addiction problem (5). Addiction research and programs cite a 3-step process for addicts – detoxification, rehabilitation, and a heavy emphasis on continuity of care (6). Without a continuous rehabilitation plan and oversight from a primary physician, the league’s substance abuse program merely serves as a plaster over a gaping wound of unresolved issues.

Another ethical consideration in the dilemma of painkillers is the issue of informed consent within a provider-patient relationship (7). Good medical decision-making is a collaborative process between doctor and patient, with the latter fully informed on risks and adverse effects. The two-way discussion disappears in doctors who adopt a paternalistic approach, by making decisions for their patients without explicit consent or adequately informing them of alternate choices or potential harms (8). Former player Ryan Kesler revealed the lack of education on the risks of Toradol (ketorolac), an NSAID meant for short term usage of at most 5 days. It was prescribed to him for management of a chronic hip injury without any information on potential adverse consequences, so he took Toradol as prophylaxis ahead of matches, in fear of being labelled as “the guy who doesn’t battle through his injuries”. As a result of his repeated overuse, he developed an addiction, in addition to ulcerative colitis and a later diagnosis of Crohn’s disease (9) While medical professionals have a crucial role in providing all necessary details for informed decision making to occur, patients are also responsible for their own health – accountability ultimately involves both parties.

Addressing painkiller abuse in professional sports evidently requires a multifaceted approach to implement effective prevention and treatment strategies, with a shared responsibility between the league, players, and especially medical staff. Challenging established, deep-rooted cultural norms of playing through injuries in the name of toughness is a gradual process that should extend beyond the NHL and into junior leagues, cultivating healthy practices early on. It can begin with simply providing a safe space for athletes to share their addiction or mental health struggles, encouraging open conversations, and reducing stigma in seeking help. By promoting comprehensive education on safe pain management, alongside transparent guidelines regulating adherence to ethical prescription practices, the NHL can hopefully learn from its past and begin a new chapter of exhilarating hockey, fostering an environment that prioritises players’ long-term health and wellbeing.

References:

1. Aykroyd L. IIHF - Playing through pain [Internet]. IIHF International Ice Hockey Federation. 2019 [cited 2023 Dec 1]. Available from: https://www.iihf.com/en/news/13178/playing-through-pain

2. Vernec A, Pipe A, Slack A. A painful dilemma? Analgesic use in sport and the role of anti-doping. British Journal of Sports Medicine. 2017 Jul 6;51(17):1243–4.

3. Branch J. Derek Boogaard: A Brain “Going Bad.” The New York Times [Internet]. 2011 Dec 5; Available from: https://www.nytimes.com/2011/12/06/sports/hockey/derek-boogaard-a-brain-going-bad.html

4. Branch J. In Hockey Enforcer’s Descent, a Flood of Prescription Drugs. The New York Times [Internet]. 2012 Jun 4; Available from: https://www.nytimes.com/2012/06/04/sports/hockey/in-hockey-enforcers-descent-a-flood-of-prescription-drugs.html

5. Boogaard v. National Hockey League, No. 17-2355 (7th Cir. 2018) [Internet]. Justia Law. 2018. Available from: https://law.justia.com/cases/federal/appellate-courts/ca7/17-2355/17-2355-2018-05-25.html

6. McKay JR. Impact of Continuing Care on Recovery From Substance Use Disorder. Alcohol Research: Current Reviews. 2021;41(1).

7. Provider-Patient Relationship - MU School of Medicine [Internet]. medicine.missouri.edu. Available from: https://medicine.missouri.edu/centers-institutes-labs/health-ethics/faq/provider-patient-relationship#:~:text=The%20Paternalistic%20Model

8. Orchard JW, Dhillon MS. Short-Termism in Sport and Medicine: The Dilemma of Painkillers. Indian Journal of Orthopaedics [Internet]. 2020 Apr 14 [cited 2021 Nov 5];54(3):308–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205922/pdf/43465_2020_Article_96.pdf

9. Wyshynski G. Pain medicine led to health problems for Kesler [Internet]. ESPN.com. 2020. Available from: https://www.espn.com/nhl/story/_/id/29946533/former-player-ryan-kesler-says-there-lack-education-nhl-risks-pain-medications