By Shayna Goldfarb, Professional Physical Therapy Certified Outreach Athletic Trainer at Mamaroneck High School, NY
This article was the 2023 NATA Award Winner, Best Original Research, Springfield College
Table of Contents
- Purpose of Study and What is Non-Steroidal Anti-Inflammatory Drug (NSAID)
- Introduction
- Study Conclusions Discussion (current study findings versus others)
Purpose of Study and What is Non-Steroidal Anti-Inflammatory Drug (NSAID)
Non-steroidal anti-inflammatory (NSAID) drugs are the most common over the counter (OTC) drug used among collegiate athletes.1 NSAIDs are OTC because they have a low addiction risk, however they are not without complications.2 NSAID misuse may lead to serious complications including, kidney, gastrointestinal, cardiovascular, and orthopaedic impairments.3 The purpose of this study was to examine the prevalence of NSAID use and NSAID education among athletes on a specific Division III college campus. A descriptive questionnaire was administered via Qualtrics to all varsity athletes on the DIII college campus. While 39% of athletes were taking NSAIDs, only 7% had a prescription. Among those athletes taking NSAIDS 65% were unaware of any side effects regarding NSAID usage and 25% based their usage off pain, disregarding the directions on the NSAID bottle. NSAID use was higher in season than out of season, possibly due to the higher physical demands faced by in-season athletes. In and out of season, the most common reasons for NSAID usage were for pain relief, soreness, and prevention. Interestingly, more athletes out of season took NSAIDs for recovery than in season. These findings show athletes may not be properly using NSAIDs, predisposing them to further illness and injury. Overall, the study showed that most athletes who take NSAIDs are not properly educated on appropriate NSAID dosage and are not educated on proper use. It is important to understand athlete behavior, as it can help the healthcare providers give their athletes the best possible care.
Introduction
The “win at all costs” mentality is sweeping the sports world.2 While coaches are winning titles, athletes are slowly hurting their bodies with non-steroidal anti-inflammatory over the counter drugs.2 47.1% of athletes agreed with the statement, “If injured, I would take painkilling drugs so that I could continue to play”.4 The most frequently used over the counter pain killers taken by athletes are NSAIDs, which are medications with analgesic (pain reliving), antipyretic (fever reducing), antithrombotic (blood thinning), and anti-inflammatory properties (Davis).3 NSAIDs are over the counter (OTC) drugs, meaning a prescription is not required to purchase them and are OTC because they are low risk for misuse.2 The abuse of NSAIDs however can lead to serious complications including, kidney, gastrointestinal, cardiovascular, and orthopaedic impairments.3 NSAIDs are one of the most common causes for hospitalization because of adverse drug reactions.3
The main reason for NSAID use among athletes is pain relief due to injury, injury prevention, soreness, recovery, tightness energy, cramping.1 While prophylactically consuming NSAIDs to prevent injury seems logical to athletes, it is contradicted in much of the literature.1 Frequent prophylactic NSAID use makes athletes more susceptible to the adverse drug reactions.3 NSAIDs reduce pain by masking it, which in the moment is great for the athlete because the pain is gone, however it can be damaging on the physiological level.3 In the human body pain is an indicator for tissue damage and is necessary for protection and avoidance of worsening injury.5 When the body is injured and pain is indicated, the inflammatory response takes action to start healing the damaged tissue.5 An athlete who is frequently taking NSAIDs to mask the pain allows tissue damage to initiate and progress.3
More than 80% of athletes self-prescribe, meaning there is no prescription needed because the drugs are OTC, and obtain the medication on their own.2 With such high percentages of athletes using NSAIDs, it is important for healthcare providers to be aware of what their respective athletes are taking to make sure dosing and usage is being done safely. Half of the athletes using NSAIDs are unaware of the consequences and do not follow the dosing instructions found on the medication label.2 As a large number of athletes use NSAIDs without professional healthcare instruction, the likelihood of misuse and abuse is increased.3 It is the responsibility of athletic trainers and team physicians to ensure athletes are properly educated to combat the possibility for abuse and misuse.3
There is extensive research on NSAID use among athletes which discusses frequency, duration, reasoning, and education, however, there has not been any research done for the small Division III college being investigated. Therefore, the purpose of the study was to examine the prevalence of NSAID use and athlete education of NSAIDs among athletes on a specific single Division III college campus. Hypotheses included, 1.) the number NSAID users will be high because of the desire to play after COVID, 2.) a high percentage of athletes will be aware of NSAID side effects because many student athletes are in a healthcare program
Methods
A validated questionnaire was used for the descriptive study. Institutional Review Board (IRB) approval was obtained.
Participants
Participants were DIII collegiate athletes at a small private college in New England. Athletes were listed on the varsity roster of the DIII school. A total of 101 student athletes attempted to complete the questionnaire. 98 athletes completed the questionnaire. 3 student athletes were not able to complete the questionnaire because they had never taken NSAIDs. Of the 98 participants, 62 were male and 33 were female. The average age of participants was 19 years old.
Instrumentation
The researcher used an anonymous questionnaire to gather information about NSAID use among student athletes. In the survey participants provided demographic information, behaviors, and knowledge relating to NSAIDs. During the creation of the survey Davis 1 determined face validity was achieved through discussion with sports medicine professionals familiar with college athletes and NSAIDs.1 Content validity was achieved though refined pilot testing of the questions.1
The survey included questions regarding demographic information, history of use, sports related use, NSAID behavior and general information, including side effect education. Demographic questions included age, gender, primary sport, and year of eligibility. History of use asked about first NSAID use and frequency of taking NSAIDs. Sport-related use included questions regarding if the use of NSAIDs was due to sports, if the athletes received prescription NSAIDs, and how often NSAIDs were taken in season versus out of season. Behavioral questions included reasons for NSAID use in and out of season and who the athlete received NSAIDs from, and NSAID dosing. General information questions included awareness of side effects.
Procedures
IRB approval was first obtained for this study. The contact information of the assistant athlete director was obtained. An email went out to the assistant athletic director, Kevin Wood to obtain permission to contact all varsity athletes. Participant email addresses were obtained from publicly accessible website rosters and the Pride Net database. A recruitment email was sent out to all varsity athletes. The email contained the purpose of the study, information about recruitment, and a link to the consent form and the questionnaire. The email instructed the athletes to clink the link (Qualtrics, Provo, UT) and fill out the questionnaire. The survey was to be done by the athlete on their own time. The names of the athlete were not asked, and the survey responses were kept anonymous.
Statistical Analysis
Descriptive statistics were used to calculate the means for the demographic information including, age, gender, year of eligibility and sports team. Means, standard deviations, and percentages were calculated based on the survey questions. Data was analyzed using Excel.
Results
When asked what specific NSAIDs the participants had taken, 89 had taken Ibuprofen. Out of 88 participants who responded regarding Naproxen, 42 had taken it and 46 had not. 87 participants responded about taking Acetylsalicylic Acid and combination drug. 53 participants had taken Acetylsalicylic Acid and 34 had not. 26 participants had taken a combination drug and 61 had not. In general, out of 68 participants, 7 took NSAIDs frequently, 21 took them regularly, and 40 took them infrequently. In the week prior to completing the survey, out of 86 participants, 34 used NSAIDs and 52 did not. In general, out of 86 participants, 7 participants used NSAIDs prescribed by a healthcare provider. Figure 1 depicts why athletes, in and out of season, took NSAIDs.
In terms of dosage, out of 86 participants, 58 participants followed the directions when dosing, 22 dose based off pain, 5 dose based off healthcare provider suggestion and 1 based on activity load. 73 participants typically dosed 2 pills, 12 dosed 4 pills, and 1 dosed more than 6 pills. Out of 85 participants, 20 were aware of side effects, and 65 were not. The listed side effects were “ulcers & GI issues, kidney issues, blood thinning, harmful to stomach lining, indigestion, dizziness & drowsiness”. Only 2 out of 85 participants experienced side effects from NSAIDs, consisting of dizziness, drowsiness, feeling sick and short of breath. Regarding additional side effects, 21 have had a stress fracture in the past 10 years while 21 did not and 6 participants suffered from gastrointestinal complications, 3 with peptic ulcers and 3 with gastroesophageal reflux disease.
Discussion
The purpose of the study was to investigate the amount of NSAID use in Division III collegiate athletes. Out of 101 participating athletes, 98 reported taking NSAIDs. According to Davis1 50% of athletes take NSAIDs throughout the duration of their collegiate career in and out of season.1 Tricker et al.,4 found that 47.1% of athletes agreed with the statement, “if injured, I would take painkilling drugs so that I could continue to play”. In a time where winning is everything in sports, NSAID use is an important issue. NSAIDs are the most abused drug, and because it is not a banned substance by the National Collegiate Athletic Association (NCAA) there is no regulation on how much an athlete can take.2 NSAIDs are not regulated because they have a low risk of addiction, however NSAIDs are responsible for the most hospitalizations of any drug.2,3 Irresponsible prolonged NSAID use may result in complications including kidney, gastrointestinal, cardiovascular, and orthopaedic impairments.3 6 athletes reported gastrointestinal complications, 3 had peptic ulcers and 3 had gastroesophageal reflux disease (GERD). However, since 76% of participants were unaware of NSAID side effects, gastrointestinal complications may not have been registered as an NSAID side effects in the participants minds.
NSAID use without prescription
Davis1 investigated the prevalence and education of NSAID use among Division I collegiate athletes and found that 33% of athlete were currently taking NSAIDs. The current study provided similar findings with 39% of athletes currently using NSAIDs. Although in the current study only 7% of athletes reported prescription NSAID use while 12.5% were reported in Davis’1. In a similar study of 209 athletes representing Sri Lankan national teams, 60.8% of participants reported self-medicating in the past 3 months.6 This suggests that most athletes take NSAIDs without prescriptions from a health care professional. In the current study and in Davis1 however had more than 50% of athletes self-prescribing and purchasing their own NSAIDs.
NSAID use in season versus off season
Like Davis1 our study found a larger percentage of high use of NSAIDs when athletes were in season and lower percentage of high use when they were out of season. Christopher et al.,7 found that in-season 11% of females and 7% of males used NSAIDs frequently as compared to out of season use which was 4% of females and 0 males. Response rates for higher NSAID usage in season supports our hypothesis that due to increased rigors of in season training and competition, in season NSAID use was higher than off season.
Athletes in the current study and Davis1 reported the most common use for NSAIDs both in and out of season were for pain relief, soreness, and prevention. This supports the notion that NSAID use is higher in season due to the increased physical demands of in season competition. Fernando et al.,6 found that 44.5% of athletes reported taking NSAIDs for musculoskeletal pain as well. In the current study, both in and out of season more athletes used NSAIDs for tightness than recovery, this trend stands with Davis’1 study for athletes out of season. However, in season Davis1 reported more athletes using NSAIDs for recovery than tightness. In the current study, out of season athletes used NSAIDs for recovery, which might support the fact that athletes are predisposed to self-prescribe NSAIDs outside of their intended use.
NSAID use damage to body/ mask the pain
Prophylactic NSAID use may be damaging on the body.5 Injury is an indication to the inflammatory response to act and begin the healing process.5 Constantly taking NSAIDs and masking the pain allows tissue damage to initiate and progress.5 While prophylactic use seems logical to athletes, it is contraindicated in the literature and there is no evidence of prophylactic use on reducing muscle pain and inflammation.1 Warden et al.,3 found 50% of high school football athletes use NSAIDs prophylactically with no regards for the instructions, or side effects. Many of the athletes in the current study as well as Davis1 reported high use of NSAIDs for the duration of the entire sports season, thus putting them at risk of experiencing an adverse event. The current study found 65% of athletes were unaware of side effects related to NSAID use, which is a lower percentage than the 79% of athletes in Davis’1 study who were unaware of side effects. This data further supports the hypothesis that in the DIII school focusing on spirit, mind, and body with a large percent of students in the healthcare field, more athletes would be aware of side effects. Additionally, more athletes in the current study dosed based off directions and less on pain compared to the results of Davis.1
NSAID use and impact on stress factors and side effects
One question the survey investigated was the relationship between stress fractures and prolonged NSAID use. Hughes et al.,8 investigated stress fractures with prolonged NSAID use. Stress fractures were most common during periods of increased repetitive loading.8 The mechanically stimulated bone formation improves the fatigue life of bone. Due to the anti-prostaglandin activity of NSAIDs, increased physical activity may predispose a bone to a stress fracture. The current study found 19 participants reported stress fractures in the past 10 years. Of the previously mentioned participants, 52% reported taking NSAIDs regularly/frequently in season. However, not enough information was gathered to determine whether the NSAID use had a direct impact on stress fractures.
The current study found out of the 85 participants, 20 were aware of side effects, and 65 were not. Our study appeared to have better outcomes with this question when compared with other studies done on similar populations. Half of the athletes reported by Fernando et al.,6 and O’Connor et al.,2 were unaware of possible side effects. Davis1 found 83% and 76% of males and females respectively were unaware of any side effects as well. In terms of dosage, the current study found only 25% of athletes dose based off pain and 67% followed the directions on the label. O’Connor et al.,2 found 43.9% of athletes dosed more than the daily recommendation. Davis1 reported 42% following directions and 28% dosing based off pain. These findings support the hypothesis that in the DIII school with a large percentage of athletes studying to become healthcare professionals, drug education would be increased along with better direction following. However, until all athletes are aware of side effects and proper dosing, self-prescribed NSAIDs will be a risk factor.
Limitations
Our study was not without limitations. As mentioned above, failing to gather when the stress fracture occurred as well as specific NSAID usage in the past 10 years limited the ability to determine a relationship between stress fractures and NSAIDs. Another limitation of the study was regarding the survey question asking about eligibility. The question was an open response and needed to be more specific as some answers pertained to what year the athlete was in, and some were how many the athlete had left. This limited the current study from using eligibility as a possible factor for comparison. Lastly, a major limiting factor of the study was not making every question in the survey mandatory. Many participants skipped questions throughout the survey which disrupted the data collection and analysis as not every question had the same number of respondents.
Future Research
More research can be done to further investigate NSAID usage among collegiate student athletes. Future research would include surveying athletes before and after taking NSAIDs to understand why they are taking them and determine the perceived result for the athlete. This research should also include current injuries as this might be a factor as to why an athlete would have an increased NSAID intake. Future research may also wish to include further investigation on the specific prescription drugs used by the athletes. Additionally, concomitant use of two or more OTC medications could be investigated. Omeragic et al.,9 found 40% of athletes using two or more drugs, the current study only evaluated the use of OTC drugs individually. Males and females respond to pain differently, this was not considered in the current study. Females have a greater pain incidence in comparison to males and have a greater response to painful stimuli and overall pain reporting.3 Looking into gender differences in pain perception and the usage of NSAID may better help clinicians monitor and evaluate their patients.3 NSAID use is highest while athletes are in season. Further investigation should be completed to evaluate whether athletes take more NSAIDs pre or post games and practices. These results could show how NSAIDs relate to perceived performance. NSAID perception may also be studies using a pain scale survey before and after use to see how it affected athlete’s pain. Additionally, adding questions on NSAID usage and possible side effects might be added into the history portion of pre-participation exam screenings. Knowing about athlete NSAID use can help the healthcare provider understand the athletes better and provide the best possible care. Lastly, it would be interesting to investigate how a pre-season educational program provided to athletes on NSAID education including side effects, dosage, appropriate use, recommendations for use, and contraindications for use, would affect their usage throughout the duration of the following season.
Summary
In summary, the goal of the current study was to investigate NSAID usage and education among the athletes in the DIII college. There was a high prevalence of NSAID usage, specifically self-purchasing, and prescribing. Additionally, a general lack of knowledge about NSAID regarding their intended use, proper dosage, and side effects. Since many athletes lack the proper education on NSAID usage, an education program could be implemented to all student athletes during pre-season. The focus of the program should be on intended usage, safe dosing, adverse reactions, and immediate and long-term side effects. Understanding athlete NSAID usage is important in providing the best overall healthcare and will give the healthcare provider the ability to individualize patient treatment based on their needs.
About the Author
Shayna Goldfarb, Professional Physical Therapy Certified Outreach Athletic Trainer
Shayna graduated from Springfield College athletic training program in 2022. She is from New Rochelle, NY and conducted this research study as part of her senior capstone project. Shayna joined Professional Physical Therapy in 2023 as a certified outreach Athletic Trainer at Mamaroneck High School, NY.
“Investigation of Non-Steroidal Anti-Inflammatory Drug Prevalence and Education in DIII College Athletes”
Key take home message: non-steroidal anti-inflammatory drugs (NSAID) are a great tool for recovery and injury management for athletes. Being an easily obtainable over-the-counter medication, NSAIDs have become abused, and athletes have little knowledge of proper dosage or long-term side effects. No athletic trainer can prevent all injuries, but it is our job to educate our athletes. This investigation raised awareness for the need to implement an NSAID education program.
References
- Davis, Brian Robert. Non-Steroidal Anti-Inflammatory Drug Use in Collegiate Athletes.
- O’Connor, S., McCaffrey, N., Whyte, E., Moran, K., & Lacey, P. Nonsteroidal anti-inflammatory drug use, knowledge, and behaviors around their use and misuse in Irish collegiate student-athletes. Physician & Sportsmedicine 2018 Dec 6; 47(3), 318-322.
- Warden S. Prophylactic use of NSAIDs by Athletes: A Risk/Benefit Assessment. The Physician and Sportsmedicine. 2010;38(1):132-138. DOI:10.3810/psm.2010.04.1770 (football state)
- Tricker, R. Painkilling drugs in collegiate athletics: knowledge, attitudes, and use of Journal Of Drug Education 2000; 30(3). doi: 10.2190/N1K3-V8BK-90GH-TTHU
- Cialella, K., & Harper, W. V. The perceptions of NSAID use among one Midwestern DIII Athletic Department. J Sport Behavior 2017; 40(1), 25. (prolonged effect)
- Fernando A, Bandara L, Bandara H, Pilapitiya S and Silva A. A descriptive study of self- medication practices among Sri Lankan national level athletes. BMC Res Notes. 2017;10(257)2-12. Doi: 10.1186/s13104-017-2579-8
- Christopher, S., Tadlock, B. A., Veroneau, B. J., Harnish, C., Perera, N. K. P., Knab, A. M., & Bullock, G. S. Epidemiological profile of pain and non-steroid anti-inflammatory drug use in collegiate athletes in the United States. BMC Musculoskeletal Disord. 2020 Aug 19; 21(1), 1-9.
- Hughes J, McKinnon C, Taylor K, Kardouni J, Bulathsinhala L, Guerrire K, Popp M, Proctor S, & Matheny R. Nonsteroidal Anti-Inflammatory Drug Prescription are Associated with Increased Stress Fracture Diagnosis in the US Army Population. ASBMR. 2018;34(3):429-436. Doi:10.1002/jbmr.3616
- Omeragic E, Marjanovic A, Djedjibegovic J, Turalic A, Dedic M, Niksic H, Lugusic A, Sober M. Prevalence of use of permitted pharmacological substances for recovery among athletes. Pharmacia. 2021;68(1): 35–42. doi.org/10.3897/pharmacy
Figure 1. Reasons for NSAID Use
