My work as an ER physician routinely shows me not only the good that modern medications can bring, but also their potential to do harm. On one hand, drugs can ease pain, cure infections, prevent strokes, and save lives when used judiciously in the right circumstances. Bombarded with constant pharmaceutical marketing and a stream of medical TV dramas, it is easy to believe there is a safe, effective pill for each and every ill. Some believe we should use drugs to enhance health and athletic performance. Misguided expectations fuel the dark-side of medications: side effects and drug abuse.
There has been much publicity of celebrity sports figures using illegal performance-enhancing drugs such as steroids. Although these substances grab headlines, the more commonly used legal substances may be causing the most harm in our fellow athletes. Of these legal drugs, the most likely to inflict harm are the non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. It is so widely used by athletes that some call it “Vitamin I.” Ibuprofen is sold over-the-counter under the brand names Advil or Motrin. There are many other NSAIDs acting by the same general mechanisms and cause similar effects. These include naproxen (Aleve), Relafen, and indomethacin.
Many endurance athletes use NSAIDS routinely with both training and competition. There is a belief that use before, during, and after events will prevent and heal both pain and injuries. There is no evidence that NSAIDs do any of this. In fact, there is abundant evidence that NSAIDs have a large potential for harm.
NSAIDs interfere with the function of kidneys. Combined with the dehydration and stress of a long athletic event, kidney failure becomes a possibility. In the 2009 running of the Western States Endurance Run, a study found that over 1% of the 400 runners developed dangerous hyponatremia (very low blood sodium level) with rhabdomyolysis (a dangerously high level of muscle tissue breakdown which clogs the kidneys.) Three of the ill racers progressed to acute renal failure. Compared to the healthy participants, the ill runners tended to have been more likely to use NSAIDs during the race.
In a 2006 study of earlier runnings of the same race, the ibuprofen users showed signs of mild kidney impairment and low-level endotoxemia, a condition in which bacteria leak from the colon into the bloodstream. These findings were disturbing because most of the runners in that race were using ibuprofen both before and during the race. There were no benefits from self-inflicting this metabolic havoc: the study found that the runners using ibuprofen reported legs just as sore as those who were given a placebo.
Moreover, researchers have found in laboratory experiments on animal tissues that NSAIDs actually slowed the healing of injured muscles, tendons, ligaments, and bones. NSAIDs work by inhibiting the production of substances that are involved in pain but also in the creation of collagen. Collagen is the building block of most tissues. NSAIDs inhibit the healing of tissue and bone injuries including the micro-tears and other trauma to muscles and tissues that occur after any strenuous workout or race. It is a robust healing and remodeling process that allows muscles, tendons, and ligaments to strengthen in response to exercise.
Other potential adverse effects of NSAIDS:
- Headaches
- High blood pressure (occurs in up to 1 in 8 regular users)
- Heart failure in people with heart disease was increased 10-fold with regular use of non-aspirin NSAIDs
- Heart attacks and related heart events were found to be 1.5 times more common in users of high dose ibuprofen compared to those not using NSAIDs.
- Ulcers and gastritis: Studies show that over 50% of patients taking NSAIDs sustain damage to their small intestine. NSAID-associated upper gastrointestinal bleeding and perforation result in 103,000 hospitalizations and 16,500 deaths per year in the United States
The toxic effects of NSAIDS are worsened by certain medical conditions such as atherosclerosis, hypertension, renal failure, diabetes, advanced age, dehydration, stress, and inflammatory bowel disease (e.g.: Crohn’s disease or ulcerative colitis.) Also, there are many medications, which can dangerously interact with NSAIDs. If you have any medical conditions or are on any medications, it is especially important not to use NSAIDs unless there are no other options to relieve significant pain and inflammation and your doctor recommends them.
If NSAIDs Are So Bad For You, Why Does Everyone Use Them?
While a growing number of doctors and lay people are beginning to appreciate the true scope of the risks posed by NSAIDs, many of us still use them indiscriminately. The reasons for their ubiquitous use are many. First, old habits die slowly and athletes tend to be a superstitious bunch, associating a variety of quirky habits to success. Picture a tennis star “needing” to bounce the ball seven times before each serve. Or the ritualized antics of baseball pitchers and batters just before the ball is thrown to the plate. When we see successful athletes chronically use large amounts of “Vitamin I” it is hard not to wonder if, just maybe, they know something we don’t.
In fact, pill-popping partisans cite only remotely plausible mechanisms whereby NSAIDs could conceivably reduce muscle damage and aid healing. However, no study that has studied pain, injuries, or strength in actual whole animals or athletes has shown any functional benefits. To repeat: harm is the only verified effect of routine NSAID use in sports.
A cynical mind might implicate the marketing departments of deep-pocketed pharmaceutical companies with manipulating the perceptions of the public and of health professionals via placement of misleading ads in mainstream media and in professional journals.
Are There Rational, Safe Uses For NSAIDS in Sports?
In sports medicine, it is widely accepted that NSAIDs should be used only for short-term use, if at all, in the treatment of acute pain and inflammation during rehabilitation of an injury. In these cases, they should be used only as part of a comprehensive program to heal an injury in consultation with a sports medicine professional. Further, NSAID use should only be used in minimal dosages for minimal duration, usually a week or less, following injury when inflammation symptoms such as swelling and resting or night pain are present. Those with risk factors for or a history of side effects should not use them. These people, indeed all of us, would be safer using no drugs. For intolerable pain acetaminophen (Tylenol) is safer.
In a strongly worded 2009 editorial in British Journal of Sports Medicine, Stuart J. Warden states: “Ultimately, there is no indication or rationale for the current prophylactic use of NSAIDs by athletes, and such ritual use represents misuse of these potentially dangerous agents.”1
The achy legs and arms of the weekend warrior who has conquered a section of the Catamount Trail are best treated not with drugs but with rest, gentle stretching, massage, and plenty of sleep. Pain, a badge of courage, is nature’s way of saying let’s rest a bit while we heal the micro-injuries and become stronger than we were before. Your body is smarter than your brain; don’t blunt your body’s efforts to heal and get stronger. Just say no to NSAIDs.
1. Br J Sports Med 2009;43:548-549
This article was originally printed in the Catamount Trail Newsletter and was authored by Dr. George Terwilliger, an ER physician who lives in Brattleboro and is a lifelong Vermont resident. He is an avid backcountry skier and has skied many sections of the Catamount Trail.
