Pain Management on the Sidelines Mark E. Lavallee, MD, CSCS, FACSM Director, York Sports Medicine Fellowship, York, PA Team Physician, Gettysburg College, Gettysburg, PA Chairman, USA Weightlifting, Sports Medicine Society, Colorado Springs, CO DISCLOSURES • I have no relevant conflicts of interest or business relationships in relation to the topic of this lecture. • Followed • All persons imaged in talk have given their consent

US Army Rangers HALO into ND Stadium with Game Ball

Ukraine lifter: 2013 Worlds, Wroclaw Poland What is our GOAL on the Sidelines?

• First do no harm (immediate or long-term) • TREAT the patient • Reduce pain; know the half-lives of the medications you are using • Enable / Enhance performance • Enhance recovery Derrick “Crash” Crass, 284 lbs in SNATCH Los Angeles, CA: 1984 Summer Olympic Games

REASON WHY YOU DO NOT INJECT CORTISONE AROUND PATELLA TENDON 1 DAY BEFORE MAX LIFT!!

https://www.youtube.com/watch?v=spMg5ro2BIU Janos Barayni, Hungarian Lifter 2008 Olympics, Beijing, China

148kg (325 lbs) Snatch (77 kg body weight class)

OBJECTIVES

At the end of this presentation, participants should understand • Goals of Sideline Pain Management • Aware of legal ramifications of pharmaceutical treatment on sidelines • Pros and cons for game day pain management decisions • What is “ok” and “not ok” to consider on the sideline • A team physician’s perspective LEGAL CONTROVERSY: Drug Enforcement Agency

• DEA and Team Doctor’s Schedule Medicine, October 2010 • San Diego Charger’s Doctor: David Chao, Orthopedic surgeon • “Then team doctor for the San Diego Chargers, was reviewed as a result of allegations he wrote 108 drug prescriptions to himself. Chao was eventually cleared, but stepped down from his position in 2013 amid pressure from the NFL Players' Association” International Business times, 2014 • No violation, though a “SHOT ACROSS THE BOW” • Expectation that ALL Scheduled Drugs meet same standards at Pharmacy • Packaging/labeling • Record of inventory • Record of dispensing • Secure location\

http://www.ibtimes.com/nfl-dea-raids-could-painkiller-investigation-result-criminal- David Chao, M.D charges-team-medical-1725069 LEGAL CONTROVERSY: Drug Enforcement Agency

• DEA and NFL - November 16th, 2014: DEA check ATCs/ Team Doctors gear • Tampa BAY at BWWI after playing Redskins • 49er’s at MetLife Stadium after playing NY Giants • Seatle SeaHawks at Kansas City • “The Drug Enforcement Administration is continuing its investigation of alleged mishandling of prescription drugs by NFL team doctors and medical staffs. Last Sunday the DEA surprised at least three NFL clubs by questioning medical personnel while their teams were attempting to clear TSA checkpoints in order to be allowed to board charter flights. • No additional on-site probes are scheduled, according to a law enforcement source, though that could certainly change, and the DEA was not seeking criminal charges during the inquiries. Sources said there were no bombshells found, and NFL teams were very cooperative with the investigation overall. There remains fact-finding going on and the DEA takes the charges, alleged in a civil suit filed by former players against the NFL, very seriously, with their investigation into the matter likely to go into 2015. • The administration is devoting considerable assets to the investigation, and last week's searches were devised as in all likelihood a one-time event, meant to catch teams off-guard and get a glimpse into whether all laws and protocols under the Controlled Substances Act – which strictly governs how and when prescriptions can be written and how substances can be brought across state lines – are being strictly adhered to.” CBS Sports Nov 2014 http://www.cbssports.com/nfl/writer/jason-la-canfora/24833345/dea-continues-to-probe-nfl- team-doctors-medical-staffs Crossing State Lines??? LEGAL CONTROVERSY: STATE LICENSES

• Can physicians treat when covering their team when crossing state lines? • FEDERAL BILL: S.2220 set forth by: • Senators John Thune (R-SD) • Amy Klobuchar (R-MN) • If successful, will provide clarity for team doctors who travel to different states to treat athletes on teams. • What does this mean for College, High School, Olympic, Professional team doctors? What type of pain are you treating?

• CHRONIC • ACUTE • MSK • Muscule/tendon • NEUROLOGIC • Bone • CEPHALGIA • Joint • VISCERAL • Neurologic • GYN • Cephalgia • UROLOGIC • Visceral What are going to use to treat the PAIN?

• PHARMACOLOGIC • NON-PHARMACOLOGIC • NSAID's • Acupuncture/ Dry Needling • Acetaminophen • OMT/Manipulation • Narcotics • Modalities (ICE/Phono/Ionoto) • Biofeedback PHARMACOLOGIC : ACETAMINOPHEN

• OTHER NAMES: • PROS: • APAP • decrease gastric irritation • Paracetamol • Not inhibit platelets • MECHANISM: • Pain relief • Not completely known • CONS: • No anti-inflammatory • The primary mechanism of action • Liver toxicity at large dose is believed to be inhibition of cyclooxygenase (COX), with a • SAFETY: predominant effect on COX-2. • Excellent • Pregnancy-approved • LEGAL • Non-scheduled PHARMACOLOGIC : NSAIDs

• ORAL • PROS • Ibuprofen • Very good pain control • Naprosyn • Some inexpensive • Diclofenac • Quick response • Mobic • CONS • INJECTABLE • Effect gastric irritation • Ketorolac • Inhibit platelets (unless COX-2) • TOPICAL • SAFETY • Diclofenac (patch/cream) • good • Compounded mixtures • LEGAL: non-scheduled PHARMACOLOGIC: OTHER

• ANALGESICS • PROS • Lidocaine • Good pain control • Patch • Different deliver systems • Injectable • topical • CONS • • Often expensive NSSRIs • Often has side-effects • Cymbalta • SAFETY • DISSOCIATIVE • Good-poor • Ketamine (IM/IV) • LEGAL • SEDATIVE • If contains scheduled (BZD/ • Benzodiazapines Ketamine) PHARMACOLOGIC: NARCOTICS

• ORAL • PROS • Tramadol • Low abuse potential (TRAMADOL) • Acetaminophen/ Codiene (T#3) • Great pain control • Acetaminophen/ Hydrocodone • Not inhibit platelets • NORCO, Vicodin, • Low cost (T#3) • OXYCONTIN • CONS • INJECTABLE • High Abuse potential (NARCOTICS) • TOPICAL • Expensive (brand specific)

• SAFETY • poor • LEGAL • Scheduled Considering doing an INJECTION?

• Where are you injecting? • Why are you injecting it? • Who are you injecting? RISKS

• It doesn’t work • It makes the situation worse • Infection & other complications • Side effects • More significant injury This Team Physician’s Approach

• AGE • KIDS/ADOLESCENTS • ADULTS • MASTERS ATHLETE

• LEVEL OF COMPETITOR • School-age, HA, College, Olympic, Pro • VENUE • Practice, regional, national, international This Team Physician’s Bias

• If is NOT in my GAME BOX, I do not • What I no longer carry in my GAME use it. BOX as of 2011 • ORAL • Tylenol #3 (PO) • Tylenol, Naproxen, Ibuprofen, • Vicodin (PO) • INJECTABLE • Morphine Sulfate (IM) • Lidocaine, Bupivicaine, Ketorolac, • Tramadol (PO) Phenergan • • TOPICAL: Diazepam (PO/IM) • Diclofenac patch, lidocaine (Patch/Cream) • Ketoprofen • RECTAL SUPPOSITORY • Phenergan • OTHER • Accupuncture needles (30g 30mm/40mm) This Team Physician’s Bias

• What I'll inject • What I won't inject • Ketorolac IM • Corticosteroids intra-articular • Anesthetic intra-articular with 7 days of competition (only in mature high level athletes) • Phenergan IM/IV • Dry Needle IM Thank You REFERENCES

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