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Louis Bien | August 3, 2016

Comfortably Numb: The NFL Fell In Love With a Painkiller It Barely Knew

Players have depended on Toradol injections to keep them on the field for two decades. Now, the NFL could be facing its next health crisis because of it.

In 2012, a doctor told Steelers offensive guard Chris Kemoeatu that he needed a kidney transplant, and needed it "tomorrow." Chris' older brother and then-Ravens defensive tackle Ma'ake was in the room. Both of their NFL careers ended at that meeting. Ma'ake was a perfect donor candidate, a 99 percent match.

"That was the first time a doctor said, 'If you don't get a transplant, you're going to die,'" Chris recalls.

The doctor told them that Chris' kidney was functioning at 10 to 15 percent, and that he should have been helped long ago, he remembers. Chris played seven seasons on a declining kidney. He didn't know he had a serious problem until he nearly died. Ma'ake remembers the doctor saying, "This is pretty much illegal, are you guys going to do something about this?"

They remember the doctor telling them that Chris' medical records suggested willful ignorance, that the Steelers most likely knew Chris' kidney was in poor health and let him play. Worse, Chris says they regularly injected him with Toradol, a potent non-steroidal anti inflammatory — an NSAID like Aleve, but much stronger — contraindicated for patients with renal problems, like Chris.

Four years later, the Kemoeatu brothers are preparing to take legal action. Chris claims that the Steelers injected him with Toradol weekly — on game days, during training camp and sometimes multiple times a week. He wasn't necessarily injured, but he did hurt. Toradol helped him feel less pain when he stepped on the field. He gave the Steelers 53 starts across a period when they won two Super Bowls. (The Steelers declined to comment for this story.)

"My first thought is, 'I'm on the verge of losing my brother,'" Ma'ake says. "‘My brother is going to die.'

"It was like somebody was trying to kill my brother."

Photo illustration: Brittany Holloway-Brown (Ronald Martinez/Getty Images)

Toradol found a place in professional sports shortly after it was approved by the Food and Drug Administration in 1989. It had a foothold in the NFL by Errict Rhett's rookie year in 1994. The former Buccaneers running back never imagined he'd need it, but by the second half of the season — after training camp, preseason and eight weeks of games — he says that he started hopping in line for a weekly Toradol shot alongside the veterans.

Perhaps the first outward mention of Toradol in the NFL was a 1995 Houston Chronicle story about the Oilers' medical staff. Even then, players like defensive back Steve Jackson were leery of the use of painkillers.

"If you have to take a shot, there's something wrong with you and you don't need to be out there playing," Jackson told the Chronicle. "Your body is telling you something is wrong and you're trying to cover it up. Sooner or later, something has to give."

Jackson's skepticism wasn't shared to the extent that players would forgo injections. By 1996, Rhett says almost the whole team was taking Toradol, and since the drug has had a regular presence around the NFL. A 2002 paper surveyed 30 NFL teams and 28 said they used Toradol, overwhelmingly on game days.

Left tackle Eugene Monroe, who retired at 29 in July, described the same line Rhett did, calling it the "T Train" in a story he wrote for the Players' Tribune in May. You might get injured during a game, he wrote, "but you feel nothing, so you do nothing."

Rhett remembers: "It's the weirdest line. It's like being in a cafeteria line. You just bend over, get a shot. You feel like a new person when you get out there."

Toradol was never meant to be used as former players describe it is in the NFL: Frequently, and as a proactive measure against pain. Joe Muchowski was directed in the mid 1970s to make something 10 times better than naproxen, the generic name for Aleve. His Syntex superiors even wanted to call it the Son of Naproxen, an emphasis that whatever Muchowski's compound was, it would be newer and stronger than an already effective painkiller.

One of Muchowski's earliest breakthroughs was nearly perfect. A colleague suggested a simple modification to a derivative of indomethacin, and the result was something he says was about 1,000 times more effective at relieving pain than aspirin when tested in mice and rats. There was one problem:

"It caused the animals to pass green urine," Muchowski says, which stopped the drug just short of clinical trials, to Muchowski's dismay: "I said this would have been a great thing to use at Christmas time."

Photo illustration: Brittany Holloway-Brown (Yuji Kotani/Getty Images)

Muchowski says he tried maybe 75 more compounds, but the best was yet another early formulation: ketorolac.

"It was every bit as good as the first compound we made, didn't cause green urine, and it quickly went into clinical trials and was found to be equivalent to morphine without the central side effects," Muchowski says. "It was much less irritating to the stomach lining than was naproxen. Basically, that was it."

Having discovered the molecule that would become Toradol, Muchowski tasked his team in Mexico with improving it. Robert Greenhouse spent eight years in Mexico and two in Palo Alto living with ketorolac as one of Muchowski's research leaders. His mission was to develop a drug that was powerful, safe and feasible to manufacture at scale.

"We developed a lot of basic chemistry in solving these problems and making molecules," Greenhouse says. "Part of the fun of medicinal chemistry is discovering new chemistry that you can use in the manufacture of drugs."

After clinical trials, Toradol was approved for sale roughly 25 years after it was dubbed the Son of Naproxen. It was indicated specifically for the relief of severe post-operative pain. Its regular use — say, 16 times a year for several years — has never been clinically studied as a result. Toradol was contraindicated for use beyond five continuous days,  reduced to two in its 2015 updated monograph. It comes with a black box warning from the FDA, the strongest that the administration requires, prohibiting its use in patients with preexisting renal problems or who are concurrently using other NSAIDs, a practice that former players — like Rhett and the Kemoeatu brothers — and former team doctors both say is common in the NFL.

After Toradol went to market, the people who actually made the drug rarely encountered it again except anecdotally. A chemist who worked for Greenhouse had a daughter who was a nurse, who had to get in touch to say how helpful the drug had been to her and her patients.

"But there it is: It's used in a hospital setting," Greenhouse says. "It's not used in a locker room somewhere before a game, and they have very strict controlled doses, and they have to write it down."

"And so I looked into it, and I regard that as drug abuse. If you use it in a way that it was not intended, if you use it in a way that actually is harmful to the person, that in my mind is drug abuse." – Robert Greenhouse

Both Greenhouse and Muchowski were drawn to chemistry by the problem solving and the creativity inherent in it. At some point the chemistry ends, however, and the drug is given to people who run the risk of co-opting its use. Greenhouse says he learned about Toradol's use in sports when his daughter showed him stories like one in the New York Times about then-Mets pitcher R.A. Dickey, who used Toradol to pitch through torn plantar fascia in his right foot.

"She goes, ‘Well, did you have something to do with Toradol? Because it's terrible what they're doing with it,'" Greenhouse says. "And so I looked into it, and I regard that as drug abuse. If you use it in a way that it was not intended, if you use it in a way that actually is harmful to the person, that in my mind is drug abuse."

Through clinical testing, Muchowski knew that Toradol had the potential to be misused, and that, clinically, there's a reason why the FDA sets the guidelines it does. A former colleague in Palo Alto first showed him how Toradol was being used in sports by pointing out the same sort of stories that Greenhouse had been reading.

"I thought whoever is responsible for this should have been incarcerated."

He says: "When I was told about this, I said, 'My goodness, this is the stupidest thing I've ever heard of and these guys should be jailed.'"

Photo illustration: Brittany Holloway-Brown (Doug Pensinger/Getty Images)

Toradol is a very good drug. It works quickly, especially as an injection. Its analgesic effect lasts four to six hours, though players have claimed it can last until the next day. More importantly, Toradol almost eliminates the need for opiates, which have the insidious side effect of addiction.

The study of the long-term use of milder NSAIDs suggests that Toradol's effect on the kidneys could be transient — all NSAIDs affect kidneys acutely, but stop taking them and normal function returns. But no one can say for sure, and even the people dedicated to studying and treating kidneys don't agree. Dr. David Goldfarb, director of the kidney stone prevention program at NYU Langone Medical Center, says he has a more "liberal" view of Toradol among nephrologists. He says that Toradol can be prescribed to patients with chronic kidney disease, provided their doctors do regular blood work to monitor kidney function.

"There might be an immediate decrease in kidney function, a small change, but we're not talking about somebody having kidney failure and needing dialysis," Goldfarb says. "I'd expect that to be reversible, and I'd expect that once-a-week use to be, I would think it's safe.

"But I'm not telling you I know where there's data, because I haven't read about this as of today."

In normal populations, regular use of Toradol would not even be considered, but athletes who need to play to earn their next paycheck will be more inclined to take it.

Nephrologists like Dr. Nathaniel Berman and Dr. Frank Liu at New York-Presbyterian Hospital's Rogosin Institute are more cautious. It's not just that Toradol affects the kidneys — and it should be noted, it increases the risk of internal bleeding and cardiovascular issues, as well — but that its long-term effect on the renal system isn't clear even decades after being approved for use, and may not be for a while.

"Many years, even," Berman says. "And Toradol just hasn't been around that long. For all we know — and there's no reason to think this one way or another — but for all we know these patients are going to start popping up with moderate kidney disease 12 years after their playing years, 14 years, and we just haven't seen it yet."

The uncertainty of Toradol's risk leaves its use open to interpretation. In normal populations, regular use of Toradol would not even be considered, but athletes who need to play to earn their next paycheck will be more inclined to take it.

"Everything in medicine is benefit and risk," Liu says. "If the benefit-risk ratio in the eyes of the player is taken into account, then it seems reasonable to me to give it to them."

But, Liu adds, "nobody really knows, because the thing we use to measure kidney function is, I would say, notoriously not sensitive."

Doctors measure kidney health through creatinine, a byproduct of muscles filtered from blood through the kidneys. If creatinine levels in urine are high, it may be a sign that the kidneys' filtration system isn't working correctly. A number of benign factors affect creatinine measurement, however. Football players, for example, have a lot of muscle mass and suffer regular muscle damage, elevating their creatinine levels and making them appear, by one measure, unhealthy.

Conversely, the fact that humans have two kidneys can mask deficiencies. If one kidney is operating at 50 percent, creatinine levels may not spike if the other kidney is essentially operating at 150 percent of its normal capacity to compensate. In the short-term, the body appears to function normally. Later on, the body may suffer more because problems went long undetected.

A professional athlete's line of work can put a lot of stress on the kidneys. Dehydration and salt loss magnify the side effects of NSAIDs, the regular use of which has never been studied in athletic populations in a significant way, according to Dr. Qais Al-Awqati, a professor of nephrology and medicine at Columbia University.

"Repeated injury to the kidney by giving Toradol in the presence of salt and water loss, does that actually cause kidney disease — permanent kidney disease? I don't know," Al-Awqati says. "There is no evidence as far as I know. It's plausible, but there's no evidence that one can talk about really."

Where independent nephrologists seem to agree is that Toradol shouldn't be used if possible, and only in response to severe pain.

"What I would generally say is, ‘Take as little as possible, take it when you really need it, try not to take it every day,'" Goldfarb says. "‘Do other things to try to deal with the pain.'"

Photo illustration: Brittany Holloway-Brown (Drew Hallowell/Getty Images)

In July, a California judge allowed a lawsuit filed by more than 1,500 former players alleging that NFL teams have been illegally procuring and distributing painkillers for decades. It unearthed stories of Toradol abuse. Former tight end Troy Sadowski alleged that the Steelers told him that Toradol was good for him. From the complaint:

In Pittsburgh, syringes full of Toradol were lined up in the locker room labelled with the player's number. Mr. Sadowski was never told of the side effects of any of these drugs. In fact, he was told by a number of trainers that Toradol was good for his long-term health — it cleaned out his organs.

Former offensive tackle Jerry Wunsch alleges that in 2003, Seattle Seahawks head coach Mike Holmgren pressured him into taking painkillers before a game.

Coach Holmgren asked Mr. Wunsch if he could play, to which Mr. Wunsch replied "I do not think so." Coach Holmgren then called for Sam Ramsden, the Seahawks' trainer, and asked "what can we do to help Mr. Wunsch play today."

Wunsch was allegedly given Vicodin and a shot of Toradol before kickoff, and another dose of Vicodin at halftime after "the medications wore off and he told anyone who would listen that he could not play anymore." Wunsch claims he received Toradol before every game and occasionally during practice, and now has a damaged kidney among other internal problems, for which he has no family medical history.

Steven Silverman, the lead plaintiffs' attorney who headed a similar 2014 lawsuit that was dismissed, believes the class action could have more than 5,000 former players by the end of the summer.

"Take it out of the context of sports, and the employment workplace conduct," Silverman says. "It really is mind blowing what's being reported to us."

Up until at least 2012, some NFL doctors had few reservations about administering Toradol. Dr. Bertram Zarins, team doctor of the Patriots from 1982 to 2007, tells SB Nation that he would prescribe Toradol before kickoffs even if players weren't injured, as a prophylactic to the pain they hadn't yet experienced.

"In the beginning we would give it to people who had injuries," Zarins says. "And then sort of over time people say, 'Well, you know, I don't have pain now but a couple hours from now I'm going to be getting hit and I'm going to be having pain, so I'll take it now before I get the pain.'"

Photo illustration: Brittany Holloway-Brown (Michael Bezjian/WireImage)

Zarins says he learned about Toradol roughly 10 years after he entered the NFL from other team doctors at the NFL Draft Combine. According to Zarins, doctors didn't proliferate it as much as the players themselves, however. He recalls that players would tell each other how effective it was, and so more and more players would request it from their medical staffs.

According to Zarins, the Pats weren't nearly the biggest purveyors of Toradol. When free agents from other teams were signed, presumably healthy, they'd ask him for shots. Those incoming players described Toradol lines as deep as 30 men on their former teams, according to Zarins, which is about twice as long as he says the Patriots' Toradol line ever got.

But if Zarins was relatively cautious towards Toradol, he still admittedly stretched the guidelines of its use, even against what was written on the black box label — "If we took it literally we would not prescribe anything," he says.

"Like in any medication I give or prescribe, or anything we do, we look at the risks versus the benefits, and so somebody says they have pain and they want a medication for it, there's no contraindication, you might give it."

Risks and benefits — those two words are the crux of the medical profession in a lot of ways. Doctors must determine whether a patient will be helped more than he is harmed in the course of any medical action. How that risk-benefit analysis is conducted varies from doctor to doctor.

"Everyone kind of stretches the indication to suit their needs, and I think the black box warning is saying, 'Here you stop,'" Berman says. "‘This you can't do.' Because I think there's enough data to say, if you have chronic kidney disease, you should not be taking this stuff."

NFL team doctors usually maintain private practices, as well, and may agree with Berman on the limits of Toradol when they're sitting in their personal offices. The guidelines they use in their clinics, Silverman alleges, are much different than in NFL locker rooms.

"These doctors are telling us, 'If we don't give it, somebody else will,' and they're under a lot of pressure from the clubs to keep these guys on the field," Silverman says. "They really don't answer to, technically, their patients, who are the players. They really are agents of the clubs."

In 2012, the NFL Physicians Society published a paper with the findings of a task force it commissioned on Toradol. It recommended that Toradol not be used prophylactically, and be given only to players on the injury report. The paper's primary concern was the increased risk of internal bleeding from a contact sport. St. Louis Rams doctor Matthew Matava headed the task force, and virtually eliminated Toradol from his locker room. Only in instances of severe pain will the team use it.

"They really don't answer to, technically, their patients, who are the players. They really are agents of the clubs." – Steven Silverman

Matava expects the team to maintain those practices in Los Angeles (he remained in St. Louis and is now a consultant).

"We've found no ill effect from player performance, or player pain or anything like that," Matava says. "It's a cultural change more than anything else. The players just realized they're not going to be getting this drug in a prophylactic capacity and we point out the reasons as far as that."

The task force's paper did not lead to any regulation, however — "The NFL is not in the healthcare business," Matava says — allowing doctors leeway to administer Toradol as Zarins did. According to Matava, one informal survey done the year after the paper was published indicated that NFL use of Toradol had dropped, but there hasn't been follow up. Eugene Monroe's story in the Players' Tribune suggests that it is still a fixture in locker rooms. "Before kickoff on game day, in NFL locker rooms all over the country, players wait in line to drop their pants. We call it the T Train." Recently, Lions linebacker DeAndre Levy and former wide receiver Calvin Johnson echoed Monroe's concerns.

"I try to stay away from them," Levy told the Detroit Free Press. "It's too easy to prescribe. Painkillers. Toradol. It's just putting a Band-Aid on something, but we're potentially developing a bigger issue for players when they're done."

Johnson told ESPN that painkillers were a reason he retired.

"If you were hurting, then you could get ‘em," Johnson said. "I mean, if you needed Vicodin, call out, 'My ankle hurt.'"

On matters of player health, the NFL has often struggled against the tide, from opioid addiction, to retiree insurance, to head trauma. To Chris Kemoeatu, the task force was too little a full 20 years after teams began using Toradol. The league can be patient, because it doesn't have as much to lose as anyone else.

"I remember being in the training room yelling and watching the TV," Rhett says. "They put [Priest Holmes] in the game and I remember saying, 'NOOOOOOOO.'"

Rhett laughs: "I knew it was over for me for the Ravens."

Photo illustration: Brittany Holloway-Brown (Rick Stewart/Getty Images)

Holmes haunted Rhett during the 1999 season, Rhett's second-to-last in the NFL. Rhett was the Ravens' workhorse into the second half of the season, but he was nearing the end of a punishing seven-year career, and Holmes, an eventual three-time All-Pro, was waiting.

"Boy, he had fresh legs," Rhett says. "If he even touched the football field he's gonna dominate because this is the time of the year when most players are tired."

The Ravens had a policy that whichever player was in the game, stayed in the game.

"The pressure on you to perform, that backup, they get in there man, and you might not ever see it," Rhett says, "you might not ever get back in there again, you know?"

The threat of losing a starting job compounds even bigger sources of pressures. To make the NFL requires singular focus from a young age. Chris and Ma’ake Kemoeatu, and many other players, never entertained other careers.

"As soon as I knew this is a talent that I would be able to take advantage of, to go to college and make a career out of it, that was all I was focused on," Ma'ake says. "There was no backup plan."

Professional football players could be forgiven for overlooking certain realities — that the average career length is still shrinking, now just 2.66 years — for Sunday stardom and a paycheck that represents nearly a decade of effort. Prestige is fleeting, so they do what they can to keep playing.

"If my shoulder is bothering me, they'll give me a shot," Ma'ake says. "I go, 'What is that?' 'Oh, it's Toradol.' So I know that's what it is and it gets me on the field."

Zarins says Patriots players had to sign consent forms saying that the doctor had discussed the risks of Toradol and alternative treatments. That's more precaution than Rhett's doctors seemed to take. Rhett says that he never once signed a consent form, and that there's no chance he ever signed one without knowing what it said.

"'I can give you a shot, I can give you a shot make you feel good,'" Rhett says. "These guys are NFL doctors, these guys are the best in the business. You're not even in a position to question them, to ask them what drug this is. You didn't go to school for medicine."

NFL players are not comfortable with their doctors. A 2013 NFLPA survey found that roughly nine in 10 players didn't trust their team's medical staff, with 78 percent rating their distrust a "5," the highest score they could give.

Getting a second opinion can create problems, too. Rhett recalls seeing another team's physician, Dr. Robert Anderson of the Panthers, because he didn't trust the Browns' treatment plan for his Lisfranc injury. Rhett was happy with Anderson, who operated on the injury, but he says the Browns weren't.

Chris and Ma’ake didn't think they needed to see other doctors. They had been in football’s care from high school through their final days as pros.

"The doctor comes in and says, 'Errict, hey man, I didn't know that we weren't supposed to do the surgery, I didn't know you were just here on a second opinion,'" Rhett recalls. "‘I thought that we were here to take care of you. The Cleveland Browns just cussed us out.'"

Chris and Ma'ake didn't think they needed to see other doctors. They had been in football's care from high school through their final days as pros.

"When you go to the NFL, you trust the team, you trust the doctors," Ma'ake says. "Football is a team sport where you have to trust the 11 guys next to you, which is what we did down to the whole --"

Chris adds to the thought: "— Down to getting your driver's license —"

"— Down to getting your driver's license! You trust people to help you."

Rhett says the Browns held a grudge after he saw Dr. Anderson. He believes — "absolutely" — that his decision to get a second opinion led to his release in 2000.

"Before you know it, these doctors are saying stuff like, 'Hey Errict, we would like to have you -- let's try to get you on the field today,'" Rhett says. "And when they get you on tape performing, they can release you and base it on skill. Unlike if you were already playing and you were hurt, and you weren't healthy and they would have to pay you a salary for the year."

Chris Kemoeatu didn't question his doctors when they told him that the protein leak they found in his kidney during his rookie physical wasn't a problem. They reminded him of it every year, he says, but told him, "It's fine. It's good to go."

"If you do get sick, the doctor is where you work at, you have to go see him anyway," Chris says. "When you walk in they can ask you, 'You want to practice today?'

"Then they'll give you a shot."

"The thing that disturbs me, is the use of Toradol as a phrophylactic against pain," Robert Greenhouse says. "Pain is a good thing. It tells you that there's something wrong. And if you mask that pain, you allow yourself to worsen the injury."

NFL players, coaches, medical staff and executives make decisions on a risk-benefit spectrum. There's a measurable benefit to keeping the best players on the field against the risk of health problems that may only possibly become real in the indeterminate future.

Joe Muchowski remembers visiting his sister in Canada and seeing his son-in-law suddenly bend over, unable to straighten up. They went to a local clinic where Muchowski's son-in-law got a shot of Toradol.

"And half an hour later he was standing straight," Muchowski says. "And he came to me and he embraced me and he said, 'I've got to thank you for this.' I should have realized then that it was open for abuse, because he had no pain at all."

There are as many opinions about its risks as there are vested interests. Its long-term risk profile in a healthy body is somewhere between zero and silent scourge, but where exactly we may never know because sometimes science is inexact.

Two things we know for certain about Toradol: 1) It's a tremendous piece of chemistry, and 2) There are as many opinions about its risks as there are vested interests. Its long-term risk profile in a healthy body is somewhere between zero and silent scourge, but where exactly we may never know because sometimes science is inexact.

"It's very rare that you can say, 'this is safe, this is unsafe,'" Dr. Berman says. "I used to run a lot, and I would not take this drug for myself in order to get me to run. But if my livelihood was dependent on it, I would certainly consider it, because again, risk-benefit. If there's $20 million on the table, that's something to consider."

The NFL could rein in a controversial medication, follow through on its promise to study concussions and educate players so that they can make an informed risk-benefit analysis about their futures. Doing so would mean confronting football's inherent violence now, not later. Instead of being proactive about player health, it feels like the NFL is numbing the problem.

"It's just a dream and we're going to pursue it with everything we got," Chris Kemoeatu says, reflecting on his younger self. "We're going to make it just because—"

He pauses.

"I don't know."

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