During the National Football Conference championship game this January, during the Atlanta Falcons’ victory over the Green Bay Packers, Alex Mack, the Falcons’ center, broke his fibula for the second time. When he broke it for the first time, in 2014, doctors put a plate in his leg. The second break landed just above the plate. There was some concern that he would be unable to play in the Super Bowl two weeks later, since a player normally misses six to eight weeks with that type of injury. But on the day of the Super Bowl ESPN’s Adam Schefter reported that Mack would be given a painkiller shot. He started the game. It was the Super Bowl, after all, and football players are celebrated for playing through pain. (The Falcons did not respond to a request for comment.) “I just know his toughness and strength is so great,” the Falcons head coach, Dan Quinn, told reporters.
Mack’s endurance is extraordinary even for an N.F.L. player—he hadn’t missed a snap in more than five seasons before breaking his fibula for the first time—but his story is not atypical. Football is a game of inches, and it is also a game of blown Achilles tendons, torn A.C.L.s, dislocated elbows, strained labra, cracked ribs, separated AC joints, cuts, and contusions. Playing injured is part of the job, and so, too, sometimes, is taking painkillers. It’s one thing to shake it off when someone steps on your hand—even if that someone is three hundred and twenty-five pounds and wearing cleats. It’s another thing to play with a torn labrum or knees that will need replacing.
The public’s glimpse into the world of painkiller use usually comes when a player is celebrated for his toughness, like Mack, or in accounts that look at the costs of glory: stories of addiction, rampant prescription-drug use in N.F.L. locker rooms, and long-term damage. Painkillers have been a hallmark of post-career memoirs and of depictions of N.F.L. life for a long time. (“Better football through chemistry,” a wide receiver says as he gets a pain-numbing injection, in the film version of “North Dallas Forty,” Peter Gent’s novel based on his time playing for the Dallas Cowboys, in the nineteen-sixties.)
But a sealed court filing in a class-action lawsuit representing eighteen hundred former players, first reported on March 9th by the Washington Post, and then published in full by Deadspin, shifts the emphasis from the lurid stories of players to the more mundane accounts of doctors and trainers—conveyed in e-mails, task forces, Drug Enforcement Administration presentations, and conference calls. What emerges is in some ways even more eye-opening than the accounts of players getting stuck with needles in order to play with broken bones.
The lawsuit alleges that teams violated state and federal laws by transporting, handling, and distributing prescription painkillers, and that they created a culture in which doctors and staff members casually dispense controlled substances, overlooking their dangers in order to keep injured players on the field. According to the plaintiffs’ lawyers, the teams display a pattern of disregarding government regulations and normal medical practices, sometimes even after the violations have been pointed out. The class-action filing states that “every doctor deposed so far . . . has testified that they violated one or more” federal drug laws and regulations “while serving in their capacity as a team doctor.” (The N.F.L. issued a statement strongly denying the allegations in the lawsuit, calling them “simply wrong.”)
Setting aside the question of whether laws were violated—whether trainers handed out prescription pain pills, whether doctors transported and distributed controlled substances outside states where they were licensed, whether warnings were ignored—the suit highlights the almost untenable position of team medical staffs. The league, which has audacious financial ambitions—the N.F.L. commissioner, Roger Goodell, has said that his goal is twenty-five billion dollars in annual revenue by 2027, up from an expected fourteen billion dollars in 2017—has pushed for longer seasons and less recovery time between games. Teams want to minimize obstacles to putting their best players on the field, and one of the biggest obstacles is injury. Their doctors are at once healers and enablers, sworn to do no harm but employed to help send hurting men into harm’s way. In its statement, the league said, “The NFL clubs and their medical staffs continue to put the health and safety of our players first,” but, even if we set aside judgment about the league’s values and motivations, anyone who has watched professional football can tell that it is not particularly good for one’s health and safety.
What does it take to play in pain? There are probably as many answers as there are players. (A disclosure: I am engaged to one.) Some have a high pain threshold; others have a high tolerance for risk. Some are stoics; some are crazy. Some are bound by an ethic of toughness. When Alex Mack was injured, the N.F.L. Network reported that a Falcons source had said that, after the injury, Mack had told him, “I’m playing. Period.” Some players stand to make millions; others need the paycheck. Their jobs are tenuous, and their contracts are usually not guaranteed. In a Washington Post survey, nine out of ten former players said that they had played hurt, and sixty-eight per cent said that they had felt they had no choice. It’s part of the job.
In a footnote, the legal filing anticipates the argument that the players “share” responsibility for the overuse of painkillers, because it is also in their interests to minimize pain. That is why, the filing argues, “our society, through federal and state laws discussed in detail here, has taken the decision away from the patient.” Health-care providers make the decision to authorize the use of a painkiller, not the patient. We don’t normally think of someone like Mack as a patient, but when he’s in a doctor’s care he is.
In the N.F.L., doctors seem to decide in favor of painkillers a lot. In 2012 alone, N.F.L. teams prescribed an average of 5,777 doses of nonsteroidal anti-inflammatory drugs and 2,270 doses of controlled substances to their players. “Those numbers could average out to about six to seven pain pills or injections a week per player over the course of a typical NFL season,” Rick Maese writes in the Post, “but sports medicine experts noted that it’s unlikely the drugs were distributed evenly over the entire roster and just as unlikely that team logs represent the full extent of medications players seek out to manage pain.” That year, according to a memo from Lawrence Brown, an N.F.L. medical adviser, to Anthony Yates, the Steelers’ team doctor, the Steelers prescribed 7,442 doses of NSAIDs and 2,123 doses of controlled medications—which ranked them tenth and fourteenth in the league, respectively.
In the filing, Bud Carpenter, a Buffalo Bills trainer who is now the director of the team’s athletic-training operations, testified that he saw team doctors giving players injections without telling them what the medications were, or what the side effects or long-term consequences could be. “We are aware of this lawsuit and it is our policy not to comment on pending litigation,” the Bills said in a statement. Some of the players’ accounts echo Carpenter’s. They had no expectation of informed consent, they allege, and doctors did not always make an effort to obtain it. The players say that they were given opioids at high dosages for long periods, putting them at high risk of addiction. In the fall of 2014, federal agents made unexpected visits to several N.F.L. teams, questioning doctors and inspecting the bags of medical staffs, looking for mishandled prescription painkillers. Nothing much turned up in those surprise visits, either because there wasn’t much to find—or because the raids might not have been a surprise after all. The complaint alleges that a D.E.A. employee had tipped off the teams.
“Can you have your office fax me a copy of your DEA certificate to me?” the Cincinnati Bengals head trainer, Paul Sparling, wrote in an e-mail that was dated August 24, 2009, which is cited in the filing. “I need it for my records when the NFL ‘pill counters’ come to see if we are doing things right. Don’t worry, I’m pretty good at keeping them off the trail!”
The “pill counters” may have had a lot of pills to count. In a 2010 e-mail, Sparling noted that “we, for example rarely dispense more than 12-20 Vicodine [sic] 5/500 a game, whereas I know others that will routinely dispense 90+ each game.” (The Bengals declined to comment.)
The N.F.L. is not alone in its reliance on opioid pain medications like Vicodin; in 2012, according to the C.D.C., American health-care providers wrote two hundred and fifty-nine million prescriptions for opioids, and between 2002 and 2012 expenses for outpatient opioid prescriptions rose a hundred and twenty per cent. Unsurprisingly, opioid-related deaths have risen, too. But one of the arguments of the suit is that pain-medication use among N.F.L. athletes can be thought of somewhat differently than among the general public. Addiction is not the only concern. The reason for using painkillers in the N.F.L., after all, is not only to relieve pain but to allow players to endure more of it by continuing to play.
The use of Toradol, a nonsteroidal anti-inflammatory most commonly used in hospitals after surgery to deaden the body to pain, is highlighted in both the Post’s story and the suit. Unlike Vicodin and other opioids, Toradol is not habit-forming. It can have very rare but dangerous side effects, like internal bleeding, but in a sport where one possible side effect is a broken neck, an unlikely problem probably doesn’t count for much. A few years ago, it emerged that some players were taking the drug prophylactically, so that they could keep playing without much trouble if, say, they sprained an ankle. As Eugene Monroe, who retired last year, wrote on the Players’ Tribune, “You feel nothing, so you do nothing.” In 2014, a survey of twenty-seven teams found that more than half the active roster per team took at least one dose of Toradol per game. Before games, so many players line up for shots of Toradol that players call it the “T train.”
A 2012 task force on Toradol recommended changes in the way the drug was used, but it ultimately deferred to the discretion of doctors. The N.F.L., it recognized, had “unique clinical challenges.”
In other words, it’s part of the job. The public glorifies players for playing in pain, for their heroic efforts to win. This lawsuit raises questions of legality, the independence of doctors, the disclosure of risks, and the responsibilities of employers. Four members of Congress have asked the D.E.A. and the N.F.L. for more information about painkiller use. But one tension, I suspect, will be harder to work out, because it runs not only through football but through our body politic: what does it mean to be tough, and who gets to decide?