Ep 184: Popping pills in elite youth sport - fact or fiction? with Julie Pedersen

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] Surveys of elite adult athletes suggest that athletes are pretty high consumers of pain medications, particularly non-steroidal anti-inflammatories. And while medications like paracetamol have a generally low risk profile, certainly compared with NSAIDs or opioids, using pain medications to mask an injury or to prevent pain might

[00:00:42] increase the risk of injury or even make an existing injury worse. And I think we can agree that none of that is good. My guest today is asking similar kinds of questions about how youth athletes use pain medications, including what they use, how, when and why.

[00:01:01] And the results might shock you. Julia Patterson is a physiotherapist and PhD student at the Department of Sports Science and Clinical Biomechanics at the University of Southern Denmark. Her research focuses on the use of analgesics in youth elite athletes, and she's aiming

[00:01:16] to understand the extent of use of pain medications and the socio-cultural influences on youth athletes' use of analgesics. Julia is committed to promoting safe sports practices, and her work aims to ensure safe use of analgesics among youth athletes. Julia Patterson, welcome to JOSPT Insights. Thank you, Claire.

[00:01:40] Julia, it's such a pleasure to have you join me on the podcast today because you've been surveying elite youth athletes about their use of pain medications, which for some people might seem like a slightly weird topic for JOSPT listeners who are

[00:01:53] rehab clinicians who are not necessarily prescribing painkillers. But this is, I think, a really important topic for rehabilitation clinicians, for anyone who's working with athletes, which is why I'm so excited to hear from you today.

[00:02:08] First, can you tell us who is the athlete population you've been working with? Yes, and thank you for having me, Claire. The athletes that I've been working with are young student athletes between 15 and 20 years of age who are enrolled in specialised elite sports classes.

[00:02:26] And in Denmark, we call it dual career programmes. And they allow these young student athletes to pursue an education and their participation in elite sports at the same time. So they really are at the top of their elite competition that they possibly can be for their age groups.

[00:02:42] So there are slight variations in their participation levels or competition levels. I just looked at the data before coming on here. And 90% of the athletes, they compete either on a national or international level. So some of them might only be competing at a regional level.

[00:02:59] So there are some slight variations in when these young athletes are adopted into these dual career programmes. But most of them are at the top of their age groups. And what did you find when you surveyed these athletes? What were the headlines of your study, Julia?

[00:03:16] So I think the headline is that analgesic use is common in young elite athletes. When we look at the data, we surveyed them every week for 36 weeks. So we have prospective data. And we saw that on average in any given week, 20% of young elite athletes use analgesics.

[00:03:33] And we also had a reference group of student controls. And with them, it was 23%. And then when we compare all these data points from the 36 weeks, we actually saw that the athletes had at any given time lower odds of analgesic use compared to the student controls.

[00:03:50] One in five, that's really, I don't know, to me, that seems very high for young people using pain medications. What was your thoughts when you saw these results, Julia? I think both me and my supervisors, we had the same thought as you, Claire,

[00:04:04] that it is actually quite a lot and it is only like a weekly average. So, of course, there is some more nuances in the data. And we're also looking into that. And it only represents the group-based estimates, 20%.

[00:04:16] And we think that's very high on a group level, that one in five use analgesics on a weekly basis. Do you have a sense of what kind of analgesics these student athletes or youth athletes are using, Julia? Yes. So the vast majority of the use was paracetamol.

[00:04:33] So that is actually quite good news. In my first PhD paper, it was a systematic review. We saw that in the international data on analgesic use in young athletes, it is very clear that NSAIDs is the most commonly used type of analgesic.

[00:04:49] It has a different risk profile compared to paracetamol. So we were quite surprised and heavily surprised to see that paracetamol was the most commonly used analgesic in a Danish setting. Why is it important for musculoskeletal rehabilitation clinicians, like physiotherapists, like athletic trainers, to know about how adolescents

[00:05:10] are using pain medications? I think there are several reasons why it is important for rehabilitation professionals to know about young athletes' use of analgesics. For example, in relation to the rehabilitation process, awareness of the use Canadian optimizing this process, for example,

[00:05:26] over-reliance of analgesics might mask symptoms that are crucial for diagnosing and monitoring the rehabilitation process. There's also the risk of misuse, and I think physios or medical doctors working with these young athletes can play a vital role in identifying

[00:05:43] early signs of this misuse and educating the young athletes about the risks of their use. I also think it's important to know about their use so you can collaborate with other health care providers so a physio maybe can

[00:05:57] reach out to a medical doctor or pharmacist to ensure a more holistic approach to these athletes' safety and their health, of course. And also in developing pain management plans, with this knowledge of their medication use, physios can develop a more comprehensive

[00:06:12] and personalized pain management plan and include non-pharmacological treatments like exercise, for example, instead of letting them just rely on analgesics for pain relief. I want to pick up on the idea of misusing pain medications, Julia. What do youth athletes understand about the risks or the harms

[00:06:31] of taking these medications? They don't know much, really. When we interviewed some of the athletes, the vast majority of them had a very limited knowledge on the potential harms that can be with using analgesics. And I think, interestingly, the most common thing that they brought up

[00:06:46] was that they were afraid of potentially sustaining an injury or getting a worse injury if they used analgesics to cover up symptoms of pain and injury. That was really the only, which is not a direct side effect, but something that can be associated with the use.

[00:07:02] That was what they brought up. That's also what we see in the literature that young people in general and also young athletes, they have a very low knowledge of analgesics, how to use them and also the potential side effects.

[00:07:15] How do you suggest that clinicians who work with youth athletes approach talking with athletes, helping understand or helping athletes better understand how to use these medications? When it's appropriate, when it's not? And then how the clinicians work with the athletes to implement

[00:07:32] effective strategies and plans to manage their musculoskeletal pain. And of course, some of that might involve using analgesic medications. I think it's a bit bigger than simply popping the pills, so to speak, isn't it? Yeah, yeah, I agree.

[00:07:46] I think it's very important for clinicians to stress that long-term development, athletic development is more important than the short-term performance. If the goal is for a young athlete to become a professional senior athlete and also to structure the plan to manage musculoskeletal pain around this long-term perspective.

[00:08:04] And that is really to ensure that these young athletes can remain strong and healthy and injury free for as long as possible to allow them to continuously develop as athletes. In our qualitative data, we actually also saw that many young athletes, they really appreciate when their physiotherapists have

[00:08:22] this long-term perspective and really focus on the rehabilitation when they are injured. So I think that that aspect seems to be crucial when working with this population. And especially in regards to analgesic use, I think it's when they use it to manage musculoskeletal pain,

[00:08:39] I think it's important that health professionals, they recognize and they address the socio-cultural factors that influence this analgesic use among youth elite athletes. And they should approach these discussions around pain medication use with sensitivity to the cultural norms, values and beliefs

[00:08:54] that we have found to be present within different sport environments. Julia, what would a safe and effective plan look like, particularly when we're thinking about the socio-cultural context of different sporting environments in different ages of athletes? Yeah, so I think when you are planning a rehabilitation process

[00:09:16] or a way of managing musculoskeletal pain, I think it's very important to individualize the approach to the individual athlete. And of course, it differs if you're working with a 15-year-old athlete or a 20-year-old athlete. A 20-year-old is an adult and consent and can make an informed

[00:09:33] decision way better than a 15-year-old. And what we find is that regardless of age, they are very focused on availability and performance. They want to be available for every single match in every single competition and they want to perform.

[00:09:47] And that is regardless of whether or not they are injured or they are sick or they are in good health. So I think what could be a safe and effective approach is to, when you are a health professional, assess the injury,

[00:10:02] assess the pain, come up with a good plan to release structure to see if can this injury progress or can this pain develop into an injury? If not, I think it is perfectly fine to use analgesics to manage a little bit of pain.

[00:10:20] But if you are in doubt that this can really progress into something worse, I think it's more important that the athlete can actually feel their symptoms, feel like when is the pain developing into something that I cannot train with or compete with

[00:10:34] and then maybe withdraw and focus on rehabilitation. So I think analgesics can be used safely, effectively and also ethically. Elite sports is an area where lots of people have pain, they have injuries and sometimes you can compete and you can train with those injuries and with that pain

[00:10:53] and it's fine to use analgesics sometimes but it's very much dependent on the situation and I think the most important thing is to consider the potential long-term effects, especially when working with young people because we don't have Danish dates on this

[00:11:08] but international data show that only between 5% and 30% of young elite athletes actually progress into being senior elite athletes, which means that the vast majority of these young people they have to find another job, they have to find something different to do and spend their lives doing

[00:11:24] and I don't think they should do that with away symptoms by the age of 25 or shoulder pain or they have to maybe choose their job based on their knee pain or shoulder pain or something like consequences from an injury they had when they were 15.

[00:11:40] It's such a great point, Julia. It's that whole, it's more of a lifespan approach of thinking, helping the athlete to think through what are the consequences for later on in life and when you're young, we all know how hard that is.

[00:11:53] You live in the moment, you feel like, oh, that's never gonna happen to me and as you say, it will happen to some of these athletes and for many of them, as you say, there's not a solid career, at least a lifestyle sustaining career

[00:12:08] and it's not gonna happen in sports so helping people navigate that is a really important part of the health professional's role. I wanna talk a little bit about where these athletes are getting their information about medications. You're in Denmark and I think in Denmark,

[00:12:26] there are quite strict rules about advertising or not advertising medications. We have quite a few people who listen to us from the states and in the US, do you have a sense from these athletes about where their information is coming from? As you say, Clyde, we don't advertise

[00:12:43] for pain medication in Denmark and there are very strict rules about the amount that you can buy at a time. So with your standard over-the-counter analgesics like NSAIDs or paracetamol, you can buy 10 pills at a time, that's it. And prescription analgesics

[00:13:00] are very difficult to get a hold of. You don't just go to your doctor and get opioids. For example, there are very strict regulations regarding that. So what I think from speaking to these athletes is that it's very much, they are taught something from home.

[00:13:15] Many people have paracetamol around at home and that's what most people in Denmark use. That's what the pharmacies recommend that you buy over-the-counter because of the risk profile that is better than NSAIDs for example. And that is what is most commonly sold here in Denmark, that is paracetamol.

[00:13:29] So they get lots of knowledge and like the culture around using analgesics from home. And when they are starting as young athletes, nine, 10, 11 years old, of course they're gonna be part of the culture in their sport or their club as well.

[00:13:44] And one thing that we found that I found quite alarming was the many stories when I spoke to these athletes where the many stories of coaches pressuring young athletes to use analgesics. When they are injured, when they are sick and if they don't tell them directly,

[00:14:00] you have to use this, they just like quietly expects it. No one really talks about it but they know that the coach expects them to be available. Again, this availability theme is very central to this discussion. They expect them to be available

[00:14:16] when you are injured or you're in pain or you're ill and you have to be at a practice or you have to be at a competition, then they use analgesics. So they kind of have this, they learn something from home, they learn something from their sport environment.

[00:14:30] And they don't really learn anything from health professionals or in school or anywhere where you could maybe think that they would get some valuable and correct information. It seems to be more based on what is the culture and what have we always done kind of approach.

[00:14:49] We've been speaking a lot about what the health professional can do and that's appropriate. This is a JOSPT Insights podcast. We focus on healthcare providers. I think from what I'm hearing from you, Julia, it sounds like parents and coaches have a big role to play here

[00:15:08] in supporting healthy relationships with pain medications for youth athletes. So what advice would you give to coaches and parents based on what you found in your work? In regards to the coach, these young athletes, they told us very varying stories on their coaches' approach to analgesics.

[00:15:28] Some told us that they had very strict rules in the club that if you needed analgesics, you were not allowed to compete, you were not allowed to train, but then they would just take it at home before coming to practice.

[00:15:40] But then at least the club or the team, they had a very clear policy. I think that's a good thing, that's very positive. And on the other spectrum, there were many of these coaches that would just pressure young athletes to use analgesics.

[00:15:54] So I think it's important that a coach, in collaboration with medical professionals, like a medical doctor, a physiotherapist, a pharmacist, they establish a policy on, it doesn't even have to be team level, but at a club level. What is our policy? What is our approach to using analgesics?

[00:16:13] When, what, why and how will we be using analgesics? I think that would be very important to streamline it and to ensure that all young athletes are treated ethically. And I think that's the main issue right now with what I hear from these young athletes

[00:16:28] is that it is very unethical use of analgesics coming from the coach. So I think it's important to collaborate with people who know something about this to establish a policy. And to parents, I think it's very important that they talk to their children about analgesic use,

[00:16:44] especially in racing to their sport. And if they suspect that something negative is going on to talk to the coach or talk to a management in the club about this, because some of these young people, some of them, I would say children, told me the most horrible stories

[00:17:03] regarding analgesic use in their club. And I think it's important for parents to know what is going on when your parent or when your child is under the age of 18. So I think it's important for parents to know what's going on, talk to their children about it,

[00:17:17] talk to people within the sports environment about it. Yeah, absolutely. Now, as we start to wrap up, Julia, I'm interested in what the plans are for follow-up and for ongoing research in this area. What have you got in the pipeline? So throughout this interview,

[00:17:35] I've been talking about interviews we did with the athletes. And that is, that data's not published yet, but we are just finishing up this mixed methods manuscript where we are looking into analgesic use in different types of sports. And then we are mixing that with focus group interviews,

[00:17:52] where we're talking about the social cultural influences on the use. And that is the next study in line with the paper that is published in JUSPT. We have all these group-based estimates. We can see what analgesic looks like on a group level.

[00:18:05] What type of analgesics do they use? Why do they use it? Now we're going one step further to see, it's nice to know why they use analgesics, but there are some underlying mechanisms that we cannot see or find when using quantitative methods.

[00:18:20] We can only inquire about those with qualitative methods. So we are mixing these two methods to see what actually drives analgesic use. And I think we have very interesting data coming out on that. And then the next paper, again, we're applying a group-based trajectory modeling

[00:18:37] to see the different subgroups of users. As I said, right now we have only presented the group-based estimates. And of course there are nuances to this. There are most likely young athletes who use analgesics all the time. There are most likely a lot of them

[00:18:53] who don't use anything at all. And we want to identify these different trajectories to see if there is an issue, how many athletes is actually involved and what are their characteristics? That's what's next for me. And then based on those data,

[00:19:09] we're gonna decide if we're gonna try to intervene, but we can only do that when we know who are the athletes subgroups that we're talking about, who has an inappropriate use of analgesics. Because it doesn't look like we need to intervene on a group level,

[00:19:25] but we need to identify who has an inappropriate usage pattern and then maybe do something about that. So great to have a sneak peek into the future of where your research is headed, Julia. Thank you for sharing it with us.

[00:19:39] And thank you to you and to the team for all of the important work you're doing here to help us as clinicians. Many of us are coaches and parents as well to help us really support our youth, our youngest athletes

[00:19:54] to get the most out of their careers in a healthy way. So thank you, Julia Pedersen for joining me on JOSPT Insights. Thank you for having me, Claire. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues of musculoskeletal rehabilitation

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