By Alan Dymock From Rugby World

After our 2017 feature Playing Through The Pain, we return to the subject of chronic pain management in rugby. Now we ask: could there be new ways of approaching the issue?

PAIN WILL forever be a part of collision sport. We accept this now. But at some point, in another part of the world, some ask about the cost.

“We’ve done a lot of work and engaged with our former athletes and you almost have a direct correlation between (long-term) painkiller usage and things like depression and issues with mental health,” says George Atallah, of the NFL Players Association. “There is no doubt about that. And I think once we found a direct correlation between those things, that’s what triggered us to look at ways to prevent.

“You can clearly load up on a bunch of painkillers and play, or you might have to take them to get out of bed after you’ve had a collision. But what is the impact on your long-term mental health (if you do it repeatedly)?

“It is still a concern; it’s not fixed yet.”

The above is about American Football, not rugby, and looks more at long-term opioid use well beyond acute injury – in this part of the world we may be more familiar with opioids like codeine or tramadol which are not recommended for long-term, chronic pain management.

But there are a few reasons why we start there. Bear with us.

Facing the pain: The risks facing NFL stars are well documented (Getty Images)

In 2017, Rugby World took a long look at the culture of painkiller use in our Playing Through The Pain feature. In the years since, the topic has washed in and out of public discourse. We have heard some former rugby internationals detail their broken histories of injuries and their relationships with pills and pain. They want to talk about their futures too.

So three years on, we had to come back to the topic. Not because of any sense of things worsening or to raise panic but to take a different view.

If we accept that pain is a given, that team medics should have players’ best interests at heart and that brave athletes must make peace with the aches of oncoming years, could we approach chronic pain management differently?

Which can mean looking at other sports, other treatments, other mindsets. And being wary of what athletes in rugby and other comparable competitions are exploring to alleviate their pain.

That brings us back to the NFL and quickly on to the discussion about using cannabis-based products.

The US sport does not adhere to the World Anti-Doping Agency’s code, while rugby does, but chat of weed is spreading. In March, a collective bargaining agreement for the NFL was reached that relaxed their rules on testing for cannabis.

Atallah, assistant executive director of external affairs, explains that in late 2017, the NFLPA set up a committee to look at cannabis but also opioid use, as part of a “wide-ranging look at pain management”. He says they also looked at training methodology, recovery methodology, nutrition. Then in January 2018, cannabidiol (CBD, a product that can be produced without the psychoactive compound tetrahydrocannabinol (THC), the part of cannabis that creates the ‘high’), was removed from WADA’s banned list, and it became possible for rugby players to use CBD products, including CBD oil.

Talking point: CBD products are focus of a national discussion (Getty)

The NFLPA formed their own task force, Atallah says, because so many people around their sport had competing interests. Politics is never far away, particularly with the issue of legalisation and varied approaches to cannabis across states and nations. But he adds, “We certainly talk to other sports and sports unions (about this issue). I think what I’m primarily trying to convey is that the athletes are the ones who are advocating to protect themselves. And the leagues don’t really push the envelope on this issue in a comprehensive way.

“I think we (collision sports) should all be learning from each other, yes.”

Again, the laws on what substances are prohibited in rugby and Football are very different, but in this instance it is being recommended that dialogues stretch across sports.

Glenn Healy, a former National Hockey League goaltender and current NHL Alumni Association president, would appreciate that.

“If someone’s got a better mousetrap than I do, please share it with me,” he says.

“We want to make tomorrow better than today for a whole bunch of players and making tomorrow better might mean something like more sleep, less anxiety, less depression, more functional integration with your world.

“I’m just looking for where I don’t have to come up with the answer to this question: ‘How did we get here with this player?’ How did it get to this?

“So your rugby player that was probably revered around the world, how do we get there with him? I don’t want to have another call from a wife or a kid saying, ‘I want my husband back’ or ‘I want my dad back’, because things are not going the way they should be going.”

Exploring new avenues: The physical NHL (Getty Images)

Healy says that when it was announced that the NHLAA would partner with the Canopy Growth cannabis company in Canada, to look for alternative treatments, he expected a backlash from some disgusted members. But he claims all he heard were thanks “for going to the corners on this”.

This is another point where rugby players may be interested. Because the use of CBD is a hot topic in the sport. In August, researchers at Liverpool John Moores University found that more than 25% of 517 union and league players surveyed use or have used CBD oil (despite warnings not to – but more on that in our companion piece).

It is spoken about as a godsend. Yet as Dr Mark Ware, chief medical officer at Canopy Growth, says: “Unfortunately for CBD in particular there is nothing (by way of extensive research) on human pain and CBD. It’s astonishing that we don’t have data on that.

Read next: THE PROBLEMS WITH CBD OIL EXPLAINED

“With THC: different story. There’s way more information on neuropathic pain, spasticity, nausea, anxiety – there’s a ton of stuff. Some of it’s small and it’s not super strong but at least there’s data, there are trials that suggest THC is a pretty good analgesic in chronic pain management.

“But with CBD the jury’s still out.”

It’s perhaps not what some will want to hear. But in a sea of anecdotes, the scientists will want more. And it’s understandable why.

Information about the risks of CBD use are out there – as with the Liverpool John Moores report. But the same study highlights that professional athletes are seeking out the products.

Ware describes this as being athlete-driven, adding that something similar is being observed in clinics, with chronic pain sufferers who “will use and say ‘I don’t care if there’s no evidence, I’m trying it if it’s working for me’.”

Ware wants to see more regulations around CBD products across the board. So people know what they’re getting. Then he would like quality observational studies on why people are using the product and what they get from it. And he wants frank conversations with active players about this.

The biggest hurdle to progress in research here, he says, is the hard-wired notion of ‘the spirit of sport’.

“They (governing bodies) don’t want elite athletes to be seen as cannabis users,” Ware says. “And so we’re right back at that stigma again. The pro athlete who’s using cannabis to recover is not a pothead, junkie or druggie. They are a highly-functioning, highly-qualified individual who’s trying to perform and has found a way to do that.

“That conversation needs to happen in order for us to crack that stigma and stop looking at the ‘spirit of sport’, like somehow these athletes are lesser humans because they’re using. It’s okay for us to inject them with steroids and lidocaine and get them back on the field, but God forbid they should take a kind of gummy after a game. To me that’s the breaking point.”

Decision makers: World Anti-Doping Agency (Getty Images)

As of January 2021, WADA will have a new code, with a new approach to cannabis use.

The new rule says that the period of ineligibility will be reduced to a flat three months for any athlete that can prove the substance was taken out of competition and was unrelated to sport performance. The athlete can then reduce the period of ineligibility down to one month if they satisfactorily complete a substance of abuse treatment programme, approved by the relevant anti-doping organisation.

In addition, if an athlete can establish that in-competition use of the drug was unrelated to sport performance, then the violation will not be considered intentional, which means a two-year ban will be handed out.

However, the approach to cannabis use around the world is evolving and WADA must be mindful of that. And as the number of known, naturally-occurring cannabinoids grows, and more companies look to develop products, WADA must be quick to react.

Yet when asked if they would ever relax their approach for the sake of more research into pain relief, WADA’s science director Dr Olivier Rabin tells Rugby World: “Not so much, and there are good scientific reasons supporting the current approach.

“There’s a wealth of research in the field. Several research institutes in the world, like the National Institute of Drug Abuse in the US, and many other organisations that look at this from a social or societal standpoint, rather than from the sport perspective.

“So some evidence on substances we are dealing with are usually fairly well-known. It’s more a matter of what rules we want to implement, and how the science really applies to the particular field of anti-doping.

“There are many sectors of research where, despite the limited resources we have, we are very active in. But with this one in particular, we think there is some good research out there and this is typically an area where we rely more on others’ research and apply the outcomes to a very, very specific question that relates to anti-doping.”

Of course that doesn’t mean we cannot continue to change the conversation about how we face pain.

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IN 2019, former Newcastle, Yorkshire and London Welsh back-row Ed Williamson told Martha Kelner of Sky News all about his troubles with opioid addiction as a player.

Today, he lives in France and throws himself into art. He has had a catalogue of surgeries, and while he still has an emergency box of ‘odds and sods’ painkillers left over from so many scrapes with the scalpel, he has tried other methods of gaining relief.

“I was always really tight and around the time around my neck operation last year, in the nine months leading up to that I couldn’t turn my neck to the left, past a couple of degrees,” he says. “My traps were ridiculously tense.

“I smoked a bit of weed and over the next hour they eased off just enough for me to relax, breath a little bit. It was enough just to be a little bit less tense in my neck and my head.

“It might have been just a nice, temporary release of the tensions and pain that I had. Which I would have got with the painkillers. But then the problem I had with the painkillers was also getting a lot of residual effects.”

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