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Football and Opiates in America

Several football players in full gear appear on the ground. The central figure holds the football while other players behind him also reach for it and one player holds his helmet.

Injuries and pain have been, and remain, inseparable from modern American football. Image by © Royalty-Free/Corbis via Flickr

In 2016, five years after the Centers for Disease Control and Prevention (CDC) declared opiate-related morbidity and mortality a national epidemic, Senator John McCain called on Congress to look into ties between the epidemic and opiate use in sports. (Eugene Monroe, “Getting Off the ‘T’ Train, May 23, 2016)

Senator McCain’s proposal raised an intriguing question: Are there meaningful connections across the histories of sports and America’s long, complex embrace with opiates?

As a lifelong sports fan, I argue that American professional football merits scrutiny for a number of reasons.

First, both the opioid epidemic and the campaign to reduce concussions in football have required significant reassessment of pain and its management. In football, as in society more broadly, people are recalculating the risk and reward of opiates. Second, a comparative and intersectional history of medicine and sport yields meaningful insights. Both in the treatment of pain among the general population and the treatment of head trauma among professional football players, an alignment of financial and social incentives has caused caregivers, patients, and others to deviate from legal and medical standards. Finally, in the treatment of both pain and concussions, contemporary Americans join past generations in trying to manage molecules that, though indispensable to medicine, are formidable agents of dependence.

Because the experience of pain is central to the epidemic and to football, it is useful to look at how the understanding of pain, and the sport and industry of professional football, have evolved in post-World War II America. The following survey explores different dimensions of interrelated historical problems, but it is only a starting point.

After 1945, a diverse group of social scientists and clinicians—anesthesiologists, surgeons, and neurologists—led the gradual refashioning of a model of pain that had long prevailed.

For many centuries, pain had been understood medically as a straightforward, stimulus-and-response event within the nervous system.  Pain was an indispensable harbinger, reliable symptom, and frequent if variable accompaniment of many conditions and procedures.[1]

After World War II, a new concept slowly grew in influence. Pain became a distinct clinical entity, a disease in its own right, a complex biopsychosocial condition whose causes, courses, and treatment were often elusive and deeply individual. This model attributed importance to a person’s life history, attitudes, beliefs, and genetics in the pain experience. Individuality and chronicity increasingly defined pain while treatment became more diverse and customized. The defining clinical challenge expanded beyond acute pain to include the management of chronic pain.[2]

Ronald Melzack and Patrick Wall’s 1965 publication of the gate-control theory of pain codified this conceptual shift. In the 1970s, pain management clinics began to appear, often focusing on one approach—e.g., acupuncture, cognitive-behavioral therapy, or physical medicine—or a single condition, such as back pain. In 1993, just before a new generation of extended-release, high-potency opiate pain relievers led by OxyContin began to arrive, the American Medical Association certified pain medicine as a subspecialty within anesthesiology. At this time as well, the pharmaceutical industry, drug-policy reformers, and some patient advocates told clinicians that the new opiates were less addictive and should be used more aggressively to address a range of conditions, including chronic pain.[3]

At the same time as the clinical status of pain was shifting, professional football in America underwent a transformation just as dramatic. During the formative 1930s and 1940s, Michael MacCambridge writes, “[C]oaches believed that boys with the most difficult childhoods made the best football players. They were . . . more willing to administer and accept pain.” Before World War II the sport more closely resembled professional wrestling than the sleek and popular college game. But after the war, pro football evolved, becoming more than a threadbare oddity “played by oversized coal miners and West Texas psychopaths,” as a former player put it.[4]

The troubled behemoth that is now the National Football League (NFL) began to take shape in the late 1950s. It blended fierce competition, superb athleticism, and productive collaboration with America’s military, television, and film industries to become an entertainment empire and cultural touchstone. As recent controversies over NFL players kneeling for the national anthem have shown, the sport remains a charged venue for contests about individual expression, group allegiance, and the history of American race and criminal justice.

Pain and pain medication have played a crucial role in football’s evolution from low-rent sideshow to social powerhouse. An understanding of pain’s inevitability and the need to control it, as well as the advantages of fine-tuning players’ bodies and psyches, have shaped attitudes and behavior among players, coaches, and owners for decades. Operationally, this has meant that injured players urgently need to return to the field as quickly as possible. Waves of drug scandal and panic have played out in hundreds of stories of individual decline, its consequences, and its aftermaths. Amphetamine consumption has long been a part of football, as early-1970s revelations involving the San Diego Chargers made clear. Teams have generously distributed, and players have enthusiastically consumed, pain relievers, anti-inflammatories, and sedatives. There is a long history in the NFL of alcohol, cocaine, cannabis, and of course, performance-enhancer abuse. (SDNativeinTX, June 7, 2013; Brent Schrotenboer, “A detailed history,” September 21, 2008; Matt Bowen, June 12, 2014; “When Is a Drug not a Drug?: The NFL and Painkillers”; February 25, 2015. Patrick Hruby, “The Price of Pain,” Sports on Earth, May 21, 2014)

Given this history, recent data on opiates in the sport are no shock.  Since 2011, academic research, legal documents, and investigative surveys by The Washington Post, Newsday, and Men’s Journal have shown that players frequently have been given and consumed opiates.  In retirement, NFL players, overall, have misused opiates at three times the national rate. Kyle Turley, a lineman who played for seven years, said that a doctor (not affiliated with Turley’s team) once offered to sell him 10,000 Vicodin pills for three dollars each. Turley declined.[5] (John Barr, “Painkiller Misuse Numbs NFL Pain” ESPN; Paul Solotaroff “The NFL’s Secret Drug Problem,” Men’s Journal; Robert Silverman, “The NFL Runs on Piles of Painkillers,” TheDailyBeast; “Prescription Painkiller Abuse Alive and Well in the NFL” Behavioral Health of the Palm Beaches, Inc.)

These issues continue to plague the sport. In 2014 Chris Borland won praise as a rookie linebacker for the San Francisco 49ers. At the end of the season Borland, who majored in history at the University of Wisconsin, retired, having concluded that football’s short-term rewards did not justify the long-term health risks.(Mark Fainaru-Wada and Steve Fainaru, “SF’s Borland Quits Over Safety Issues,” ESPN, March 17, 2015; Dan Hanzus, “San Francisco 49ers’ Chris Borland Retiring from NFL,” NFL, March 16, 2015)

The use of opiates in football has been widespread; yet, the sport remains but a small outpost in America’s long-standing involvement with opiates.

In 1804 the isolation of morphine, an opium alkaloid, launched a crucial period in this history.  Nineteenth-century Americans widely used opium, which was inexpensive, against coughs, stomach problems, insomnia, and much else. Historian Virginia Berridge has described opium as the aspirin of the nineteenth century. Clinicians and patients acknowledged its medical benefits, and even enthusiastic non-medical use was considered more quirky than pathological. During the Civil War, Union soldiers received about 10 million opium pills and two million ounces of opiates as powders and tinctures, while Confederate troops consumed roughly similar amounts. Design improvements after 1850 made syringes practical for battlefield use and spurred injection of morphine on both sides. Yet, twenty years after the war, the majority of American opium addicts were women, thanks largely to opium’s ubiquity in patent medicines. By the end of the century, Jill Jonnes writes, “[O]pium dens had become commonplace throughout America.”[6]

Two events in 1898 launched what some historians have called “the heroin century:” the Spanish-American War, after which the United States undertook new responsibilities in the Philippines, home to some 50,000 opium users, and the introduction of heroin by the Bayer Company as a remedy for coughs, dysentery, diarrhea, and morphine addiction. After 1900, national and international legal and regulatory opiate-control regimes began to take shape, and the profile of opiate users in the United States evolved across waves of heroin use between 1947-1955, 1968-1975, and after 1990.[7]

While some elements of the present epidemic, including certain therapies and the scope of media scrutiny, are novel, others bear a strong resemblance to these earlier crises. One is the ultimately empty promise that has marked the debut of opiates from heroin in 1898 to OxyContin in 1996: that new compounds are less addictive and at least as effective as available ones. For heroin and OxyContin, it took about four years for reports of dependence and addiction to reach the medical literature.[8]

Another persistent thread in the history of opiate addiction has been the role of race, ethnicity, and class in representations of drug use and the threats it poses.  Donald Trump launched his White House run by describing Mexico as a nation teeming with predatory, mobile drug dealers. The United States’ first anti-opium ordinance, passed in San Francisco in 1875, followed journalistic accounts of the exotic, dangerous, sexualized opium culture that was thought to be common among Chinese immigrants. Then, as now, opiates were represented as an ethnicized threat to white Americans.[9]

In the 1990s America’s opiate history entered a new phase with the debut of OxyContin and changing standards of pain management. Football began to change too, because former players had lived long enough to exhibit long-term effects of the game. Today’s opioid epidemic and the concussion crisis in football share historic roots. Their interconnections are just starting to come to light.

Steve Beitler is an historian of medicine whose work focuses on the history of drug policy, drug use, and pain. He received a doctorate in the History of Health Sciences from the University of California-San Francisco in 2016.

For other Process essays on the history of sport, see commentary on the history of Latino and Mexican boxing, the 1952 Olympic Games, and more

[1] K.D. Keele, Anatomies of Pain (Springfield, IL: Charles C. Thomas, 1957). Roselyne Rey, The History of Pain, trans. Louise Elliott Wallace, J. A. Cadden, and S. W. Cadden (Cambridge, MA: Harvard University Press, 1998); Thomas Dormandy, The Worst of Evils: The Fight Against Pain (New Haven: Yale University Press, 2006); Ronald Melzack and Patrick Wall The Challenge of Pain, Updated Second Edition (New York: Penguin Books, 1991); Isabelle Baszanger, Inventing Pain Medicine: From the Laboratory to the Clinic (New Brunswick: Rutgers University Press, 1998).

[2] Michael R. Bond, Pain: Its Nature, Analysis and Treatment, Second Edition (Edinburgh: Churchill Livingstone, 1984); Joanna Bourke, The Story of Pain: From Prayer to Painkillers (Oxford: Oxford University Press, 2014); Keith Wailoo, Pain: A Political History (Baltimore: Johns Hopkins University Press, 2014); Harold Merskey, John Loeser, and Ronald Dubner, eds. The Paths of Pain, 1975-2005 (Seattle: IASP Press, 2005).

[3] Fernando Cervero, “The Gate Theory, Then and Now” in The Paths of Pain, Merskey, et al., 33-46; M. C. Clarke and J. E. Morin. “Pain Clinic Records: A Comprehensive Form and Computerized Database,” The Clinical Journal of Pain, 9 (1993):131-34; Herta Flor, Thomas Fydrich, and Dennis C. Turk. “Efficacy of multidisciplinary pain treatment centers: a meta-analytic review.” Pain 49 (1992): 221-30; Joseph S. Hudson and Thomas Pratt, “Pain Clinics: Their Value to the General Practitioner,” Southern Medical Journal, 72 (no. 7, July 1979): 845; Ronald Melzack and Joel Katz, “The Gate Control Theory: Reaching for the Brain,” in Pain: Psychological Perspectives, ed Thomas Hadjistavropoulos and Kenneth D. Craig (Mahwah, NJ: Lawrence Erlbaum Associates, 2004), 13-35; Melzack and Wall, Challenge of Pain; Ronald Melzack, “Evolution of the Neuromatrix Theory of Pain: The Prithvi Raj Lecture, Presented at the Third World Congress of World Institute of Pain,” Pain Practice, 5, (Issue 2, 2005): 85-94; Patrick D. Wall, Pain: The Science of Suffering (New York: Columbia University Press, 2000).

[4] Michael MacCambridge, America’s Game: The Epic Story of How Pro Football Captured a Nation (New York: Simon & Schuster, 2004); Michael Oriard, Brand NFL: Making and Selling America’s Favorite Sport (Chapel Hill: The University of North Carolina Press, 2007).

[5] Linda B. Cottler, et al. “Injury, pain, and prescription opioid use among former National Football League (NFL) players,” Drug and Alcohol Dependence, 116 (2011): 188-94.

[6] Thomas Dormandy, Opium: Reality’s Dark Dream (New Haven: Yale University Press, 2012); Martin Booth, Opium: A History (New York: St. Martin’s Griffin, 1996); Pierre-Arnaud Chouvy, Opium: Uncovering the Politics of the Poppy (Cambridge, MA: Harvard University Press, 2010); Jill Jonnes, Hep-Cats, Narcs, and Pipe Dreams: A History of America’s Romance with Illegal Drugs (New York: Scribner, 1996); H. Wayne Morgan, Yesterday’s Addicts: American Society and Drug Abuse, 1865-1920 (Norman: University of Oklahoma Press, 1974); Barbara Hodgson, Opium: A Portrait of the Heavenly Demon (Vancouver: Greystone Books, 1999); Tom Carnwath and Ian Smith, Heroin Century (New York: Routledge, 2002); Martin S. Pernick, A Calculus of Suffering: Pain and Anesthesia in Nineteenth-Century America (New York: Columbia University Press, 1985); Geoffrey Harding, Opiate Addiction, Morality and Medicine: From Moral Illness to Pathological Disease (New York: St. Martin’s Press, 1988).

[7] David F. Musto, The American Disease: Origins of Narcotic Control, third edition (Oxford: Oxford University Press, 1999); David F. Musto, ed. Drugs in America: A Documentary History (New York: New York University Press, 2002); David T. Courtwright, Dark Paradise: A History of Opiate Addiction in America (Cambridge, MA: Harvard University Press, 2001); David T. Courtwright, Forces of Habit: Drugs and the Making of the Modern World (Cambridge, MA: Harvard University Press, 2001).

[8] Dormandy, Worst of Evils, 363, 435, 486; Dormandy, Opium, 235-40, 255-60, 269-78.

[9] Musto, American Disease, 3, 6, 11, 17, 28-30; Booth, Opium, 127-134, 139-173, 191-198; Chouvy, Opium, 28-45, 146-50, 152-60, 170-87.