Opioids and Youth Athletes

Abstract

Context:

The ongoing opioid epidemic and associated adverse effects impart a large burden on our current healthcare system. The annual economic and noneconomic cost of opioid use disorder and fatal opioid overdose is currently estimated at $1 trillion.

Objective:

This review presents the prevalence, frequency of use, need, and effectiveness of opioid analgesia in the youth and adolescent athlete population. It identifies current indications for opioid versus nonopioid analgesic use in the setting of acute orthopaedic injuries, postoperative management, concussion, and chronic pain. Current knowledge of youth athlete opioid use, risks related to use, misuse, diversion, and addiction are reviewed.

Data Sources:

A PubMed, Medline, and Cochrane Library search was conducted in February 2023 to review opioid pain management strategies in the pediatric athlete population from 2000 to present.

Study Selection:

Searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by all authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies.

Study Design:

Narrative review.

Level of Evidence:

Level 3.

Data Extraction:

First author name, publication year, study design, study country, subject demographics, and data on the frequency, type, and duration of analgesic treatments for musculoskeletal injuries, postsurgical care, chronic pain disorders, and concussion were extracted.

Results:

Pediatric athletes comprise a high-risk population seeking analgesic relief for injury-related pain. Participation in high school sports is associated with increased risk of opioid use. An average of 28% to 46% of high school athletes have used opioids in their lifetime. Participation in ≥1 high school sport puts adolescents at 30% greater odds of future opioid misuse.

Conclusion:

The use of opioids in the pediatric athlete population is common and associated with both short- and long-term risks of misuse and addiction.

The opioid crisis was officially declared a United States (US) public health emergency in 2017. Although Americans comprise only 4.6% of the world’s population, they consume 80% of the global opioid supply, 99% of the world’s hydrocodone, and more than 66% of global illegal drug supply. ³⁷ The US took measures through state law to reduce the frequency of opioid prescriptions, monitor for misuse, and treat patients with opioid use disorder (OUD) as early as the 1990s, with limited effectiveness. More than 2 million Americans currently suffer from OUD. An average of 130 people die from an opioid overdose each day, totaling over 50,000 opioid-related deaths per year, with approximately 40% of annual deaths due to prescription opioids.^1,21,55 While overdose deaths peaked at over 80,000 in 2021, the total deaths attributed to prescription opioid use dropped to <20%.^21,55 Between 1999 and 2016, there were nearly 9000 reported pediatric deaths from prescription and illicit opioids, ²³ with approximately 88% (7921) among adolescents 15 to 19 years old and 6.7% (605) among children 0 to 4 years old. ²³ In ages 14 to 18 years, overdose mortality has continued to rise annually, with a 94% increase from 2019 to 2020 and a 20% increase from 2020 to 2021 (Figure 1). This is in large part due to the widespread prevalence of fentanyl availability, with 77% of adolescent overdose deaths involving fentanyl. ²² The majority of reported pediatric deaths from both prescription and illicit opioid use are in white males, with yearly increases reported in non-Hispanic Black children. ²³ In 2020, death from drug overdose and poisoning became the third leading cause of death in children and adolescents. ²⁴ The actual number of opioid related deaths in pediatric athletes is unknown.

Figure 1.

Drug overdose death rates. (Figure 4 in National Institutes of Health National Institute on Drug Abuse. ⁵⁵ Reproduced with permission).

To understand the opioid epidemic, one must understand the complexities of the pain experience. Pain has been referred to as the “fifth vital sign” and, whereas multiple strategies have attempted to objectively quantify pain, it is a perception that is subjective to each individual patient. Pain reduction and analgesia are motivating factors to seek and use opioids. ³⁶ Youth athletes are at higher risk to experience pain than their peers due to the frequency of injury occurrence. Approximately 8 million American high school students play sports annually. Of those, the Centers for Disease Control and Prevention (CDC) estimates that 2.6 million children suffer a sport-related injury annually, and that approximately 7% of these injuries require surgical treatment. ¹⁴ Injury-related pain causes both physical and psychological burdens. ⁴⁴ Adolescent athletes report greater pain levels and higher psychological stress when compared with their nonathlete counterparts. ⁷⁷ Youth athletes also may be at higher risk for injury than older athletes due to biomechanical stresses in the setting of skeletal immaturity.

Methods

A PubMed search in February 2023 was conducted from 2000 to the present of acute and chronic pain management strategies in pediatric and adolescent athletes with acute sports-related orthopaedic injuries, chronic postinjury pain, postoperative pain, and concussion for this narrative scoping review. Prescription and nonprescription opioid use behaviors were investigated. An additional search was conducted on the use of adjunct or alternative therapies for pain control in youth athletes. The searches were restricted to English language articles and human subjects. Initial reviews of titles and abstracts were performed by each of the authors and relevant full-text articles were selected. Priority was given to systematic and narrative reviews, meta-analyses, and prospective studies. The keyword search terms included opioids, opiates, acute pain, chronic pain, postoperative pain, nonsteroidal anti-inflammatory drugs (NSAIDS), misuse, opioid use disorder (OUD), concussion, pediatric and adolescent athletes, and alternative medical therapies. Age; number of subjects; and the type, efficacy, and indications for the analgesic agents studied were recorded. The PICO (population, intervention, comparison, and outcome) approach was used. The goals were to assess the use of various opioid analgesics in sports-related injuries as well as side-effects, short- and long-term risks of harm, and overall effects on clinical outcomes.

Results

Definition of Pain and Need for Analgesia

Pain, or nociception, is an unpleasant sensory and emotional nervous system response to avoid perceived or real harm and injury. ³ It is typically a self-limiting adaptive response and resolves quickly. Chronic pain is a more maladaptive response and refers to intractable pain that persists despite adequate attempts at treatment for >3 months. ⁶⁴ Biopsychosocial and neuropsychological factors affect everyone’s unique perceptions of pain. Chronic pain, hyperalgesia, negative behaviors, unplanned healthcare visits/hospitalizations, and fear of medical providers are all unwanted consequences of inadequately or inappropriately managed musculoskeletal (MSK) injury-related pain in the pediatric population.^44,74,86 Conversely, adequate pain control results in shorter hospital stays, early return of function, and faster mobilization postinjury. For this reason, the use of analgesics is a necessity. Opioid therapy is the traditional cornerstone for acute, procedural, and postoperative pain management as well as for chronic pain syndromes and conditions. ⁸⁸ Typical nonopioid analgesic medications used in pediatrics for MSK injuries include NSAIDs such as ibuprofen, naproxen, or ketorola, among others. Acetaminophen is also used frequently in this population (Figure 2). Use of these medications is defined as acute when limited to ≤1 month, subacute for 1 to 3 months, and chronic if ≥3 months. Alternatively, not all analgesic therapies involve use of medication. There is currently a wide variety of nonpharmacological treatment options available for patients of all ages. Unfortunately, many of them are considered as adjunctive, alternative, or complementary therapies rather than as a first-line choice for pain management.

Figure 2.

Revised 4-step analgesic ladder. (Figure 3 in Vargas-Schaffer et al. ⁷⁸ Reproduced with permission).

NSAID–nonsteroidal anti-inflammatory drug, TENS–transcutaneous electrical nerve stimulation.*Acute and chronic pain.

Definition of Opioids and Mechanism of Action

An opioid is a compound that binds to opiate receptors. Opiate refers to natural opioid alkaloids derived from the opium poppy (eg, morphine and codeine). Opioids are often subdivided into semi-synthetic and synthetic substances. Semi-synthetic drugs are synthesized from naturally occurring opiates, such as heroin from morphine and oxycodone from thebaine. Synthetic substances are man-made compounds and include drugs like methadone, fentanyl, and propoxyphene (Table 1). Opioids bind to opioid receptor proteins located in both the central (CNS) and peripheral (PNS) nervous systems. Endogenous endorphins can also bind to opioid receptors to modulate pain and other body functions. At the CNS level, opioids produce analgesia, but they can also induce effects such as miosis, somnolence, respiratory depression, and mood changes (euphoria and dysphoria). At the PNS level, they can induce pruritus and reduce peristalsis (constipation) (Table 2). Opioid antagonists disable opioid receptors by occupying their binding sites and preventing their activation by other compounds. Opioids come in a variety of formulary, dosages, and routes of administration. Opioids such as codeine, oxycodone, tramadol, fentanyl, methadone, dextromethorphan, meperidine, and buprenorphine are commonly used in oral forms although many exist in intravenous, intramuscular, intranasal, or transdermal forms as well. In the emergency department (ED) setting, morphine, hydromorphone, and fentanyl are popular choices for pain control after acute orthopaedic injuries. ⁴⁴ Administration of combination products containing opioids with non-narcotic analgesics like acetaminophen and NSAIDs are also common practice. Methadone as medication to treat OUD and opioid withdrawal is used infrequently in youth athletes.

Table 1.

Types of opioids and their sources

Type of opioid	Source	Examples
Natural (opiate)	Alkaloids and derivatives from the opium poppy plant	Opium, morphine, codeine
Semi-synthetic	Created from natural opiates that undergo chemical processing	hydrocodone, hydromorphone, oxycodone, oxymorphone, buprenorphine, heroin
Fully synthetic	Chemically man-made to mimic effects of opiates	Fentanyl, methadone, meperidine, tramadol

Table 2.

Signs and symptoms of opioid overdose; think BLUE

B: Breathing - shallow, erratic, labored, choking, gurgling, snoring or absent breath sounds with apnea

L: Lips and fingertips are blue due to hypoxia; skin cold or clammy

U: Unresponsive to verbal or physical stimulation or unconscious. Profound slowing, disorientation, dizziness and/or obtundation present

E: Eyes (pupils) are pinpoint from opioid-induced constriction

Adolescents are at a critical point in neurocognitive development and are particularly sensitive to the effects of opioid medication. Opioid exposure has been demonstrated to alter their reward, tolerance, and withdrawal pathways. ⁸⁷ Physical dependence and tolerance to opioids can occur with both short-term and long-term use. The adverse effects of opioid use, misuse, and diversion can lead to serious, often preventable, harm, including death in children and adults. It also poses a great burden on the healthcare system due to increased ED visits, hospitalizations, and greater healthcare expenditure. There is a profound lack of research on efficacy of opioids and nonopioids for analgesia in pediatric athletes. The paucity of literature has prevented the development of any significant consensus-based or evidence-based guidelines for pain management in the setting of nonoperative and operative sport-related injuries.

Pain Management in Athletes

A systemic review of pain in elite athletes concluded that use of pain-reliever medication, particularly NSAIDs, is widespread and common. ³⁰ Pressure for athletes to return to play quickly leads to overuse of pain medication, thus increasing the risk of adverse events. Athletes are also more likely to use analgesics in high doses, via multiple routes of administration, for chronic pain prophylaxis, and to take multiple concurrent types of pain medications.^30,84 Typical pain treatments in athletes include oral, injectable, and transdermal NSAIDS, acetaminophen, anesthetics, antidepressants, anxiolytics, anticonvulsants, muscle relaxants, opioids, and cannabinoids. Many pain drugs and substances such as opioids and cannabinoids are listed on the World Anti-Doping Agency (WADA) List of Prohibited Substances and Methods. There are punitive measures in place for athletes identified as competing while using a banned substance at the youth elite, high school, collegiate and elite/professional levels of sport. ³⁵ As previously mentioned, there are numerous alternative and integrative pain therapies (Table 3), which include, but are not limited to, acupuncture, dry needling, guided imagery, yoga, hypnosis, biofeedback, chiropractic treatments, physical therapy, relaxation, herbal remedies, and massage. Medical devices such as transcutaneous electrical nerve stimulation (TENS), extracorporeal shockwave (ECSW), and therapeutic ultrasound are also beneficial but tend to be costly and time-consuming to use. Cold therapies such as topical ice, coolant sprays, ice baths, ice massage, ice whirlpool, and cryotherapy provide good pain relief and are popular with athletes. Benefits of cold therapy include lowering of skin temperature, which reduces nerve activity and decreases tissue inflammation. Adverse side effects include frostbite and tissue damage. ¹⁷

Table 3.

Multidisciplinary pain management treatment in acute and chronic pain

Pharmacologic treatments	Opioids Nonopioids
Interventions and procedures	Injections Regional anesthesia Spinal cord stimulators
Rehabilitation services	Physical therapy Occupational therapy Aquatic therapy
Nonpharmacologic treatments	Biochemical - herbal supplements, diets, cold therapy Mind-body - yoga, hypnosis, biofeedback, imagery, music therapy Body-based - chiropractic, massage, osteopathic Bioenergetic - acupuncture Complementary - cognitive behavioral therapy, biofeedback, mindfulness

Table 4.

Emergency response to opioid overdose

1. Try to wake the person up

2. Call 911

3. Administer naloxone (intranasal) if available

4. Check for breathing and pulse

5. Begin CPR if no breathing or pulse

6. Stay with person until help comes

CPR, cardiopulmonary resuscitation.

Prescription Use of Opioids

MSK Injuries and Pain Management

One study comparing the effects of various analgesics medications in pediatric patients with acute fractures found that patients who were given ibuprofen had statistically significant improvements in pain scores compared with those given acetaminophen or codeine. However, when comparing pain scores across patients with soft tissue injuries, there were no differences among the 3 medications. ¹³ Although their analgesic potency is well proven, historical concern exists that frequent use of ibuprofen or NSAIDs after acute orthopaedic injuries may have an adverse effect on time of bone healing, thus resulting in delayed return to play. This has been discounted in recent studies and critical reviews, leaving clinicians puzzled over the potential safety issues.^16,62 A reasonable conclusion is to avoid using NSAIDS in high-risk patients and limit postinjury long-term use whenever possible.^16,62 One recent narrative review of acute pain management in pediatric athletes found that enteral opioids were not more effective than ibuprofen for pain relief and had a higher side-effect profile, concluding that opioids should not be used in the management of acute nonsurgical MSK injuries. ⁴⁴ The pain from most sports-related injuries can be managed adequately with short-term non-narcotic medications. Patients should be instructed to read all labels carefully and take only the recommended dose at the prescribed frequency. There is an increased risk of adverse or dangerous side-effects, even with over-the-counter (OTC) analgesics, if taken inappropriately. Parents or guardians should control the dispensing of pain medications for youth athletes, and they should be kept in a safe location that is not easy to access. Unused medications, particularly narcotics, should be disposed of immediately upon cessation of use. Any local hospital or pharmacy should have information on drop off locations or home disposal kits. It is important to note that both narcotic and non-narcotic pain medications do not help heal athletic injuries. Furthermore, there are significant risks associated with using pain medications to mask sport-related pain. Masking pain can lead to prolonged recovery or an increase in the severity of an injury if an athlete cannot judge when to stop training or competing. Chronic use with the intention to mask injury pain can lead to misuse and enables the athlete to avoid taking the necessary steps to recover.

Postoperative Analgesia

In the US, approximately 80% of pediatric and adult patients undergoing surgery report experiencing moderate or severe postoperative pain.^60,65 Untreated postoperative pain is associated with an increased risk for chronic pain. Therefore, it is necessary for surgeons to have an algorithmic pain management treatment protocol. A wide variation in orthopaedic surgeons’ prescribing habits currently exists regarding the amount and duration of postoperative opioid medications.^41,45,68 Implementation of multidisciplinary, evidence-based postoperative pathways reduces total costs and lengths of stay, and improves pain control while seeing less postoperative opioid use. ⁵⁹ There is a growing body of literature demonstrating that postoperative pain in children and adolescents treated surgically for orthopaedic injuries can be controlled successfully with nonopioid analgesics with minimal need to utilize opioids. ⁴⁷ For example, numerous authors have determined that most children being treated surgically for supracondylar humerus fractures do not require postoperative narcotics because acetaminophen and ibuprofen provided satisfactory pain control.^47,72 A 2021 study reviewing children aged 17 years and younger who were treated postoperatively for fractures showed that most patients were overprescribed unnecessary narcotics. In the studied cohort, 92% of subjects were prescribed opioids. Of those prescribed narcotics, 97% of them used <8 analgesic doses postdischarge, which corresponded to approximately 22% of the total prescriptions being used. ⁴⁰ Furthermore, opioid refills in postoperative orthopaedic patients are rare, occurring approximately 2% of the time, and are more common in patients who required high-dose opioids while inpatient or who underwent nonfracture surgery. ⁴⁰ A 2017 systematic review concluded that current practice for postoperative opioid prescriptions in adolescents is based primarily on adult dosing. ¹⁵ Typical postoperative use of prescribed opioids ranges from 30% to 40% in both the pediatric and adult population.^41,75 Tepolt ⁷⁵ demonstrated in an adolescent and young adult population (n = 100) undergoing knee arthroscopy and related surgery that approximately 50% kept unused pills in their possession postoperatively, 11% never used opioids, and only 1% requested a refill. Nerve blocks, injection of local anesthetics, and use of intravenous acetaminophen and ketorolac are common intra- and perioperative orthopaedic analgesic practices and are associated positively with decreased postoperative opioid use and decreased overall pain.^41,47,75

Many orthopaedic surgeons have moved toward more judicious use of postoperative opioids in their pediatric patients with excellent results. Both overprescribing and failure to support safe disposal of unused medications have contributed to, if not directly caused, much of the opioid epidemic seen in orthopaedics. A multimodal approach that combines various analgesics consistently decreases the number of opioids consumed by synergistic blockage of multiple pain generators in the nociceptive pathway.^39,54 It is unclear if the anti-inflammatory effects of NSAIDs, mediated via the conversion of arachidonic acid to prostaglandins, is related to the prevention of pain receptor sensitization. A meta-analysis of 17 randomized controlled trials on 400 adult lumbar spine surgery postoperative patients found that patients who received opioid monotherapy had higher pain scores and consumed more opioids than those who received combination NSAIDS and opioid therapy. ³⁸ In children, oral gabapentin use in the first 2 postoperative days after spinal fusion for scoliosis significantly decreased the amount of morphine required for adequate analgesia. ⁶⁷ In general, high postoperative levels of pain in pediatric orthopaedic patients are uncommon and should raise suspicion for complications such as acute compartment syndrome or infection. ⁵⁶ Consensus is lacking for appropriate dosing and duration of treatment with opioids for the postsurgical youth, adolescent, and young adult patient population. Future development of guidelines for multimodal pain management strategies and opioid alternative approaches are essential.

Concussion and Pain Management

Concussive injuries are seen frequently among athletes, with estimates ranging from 3.6% to 7.0% among children aged 3 to 17 years with higher percentages (6.5%-18.3%) among adolescents aged 13 to 17 years. ²⁷ Studies have also demonstrated increased ED visits over the last decade for recreational concussions and sport-related concussions (SRCs) ranging from increases of 57% to >200% in the 8- to 19-year-old age-group. Headaches are reported in up to 86% of concussion patients, whereas neck pain occurs less often.^26,29 It is crucial for primary care, sports medicine, and ER providers to accurately recognize and manage concussions. There are currently no medications that are specific to treat concussion and therefore none are required nor expected to aid in recovery. ²⁹ Guidelines from the CDC suggest that postconcussive symptoms such as headaches or neck pain can be managed with nonopioid analgesic medications such as NSAIDs and acetaminophen. ⁴⁶ Primary care physicians are more likely to prescribe melatonin and amitriptyline.^43,71 Frequent or chronic use of NSAIDS and acetaminophen can cause medication overuse headaches and is discouraged. ³² Avoidance of unnecessary opioid prescriptions is imperative as concussions are strongly associated with an increased risk of illicit substance use. A study on over 7000 US high school students found higher prevalence of prescription opioid misuse among students diagnosed with ≥1 concussions over the past 12 months compared with peers without a history of concussion (9.9% versus 5.5%; P < 0.01). ⁷⁶ Another study sampling 8th to 12th graders found adolescents who had ≥1 previous concussion had increased odds of engaging in risky behaviors, including binge drinking, use of cigarettes, marijuana, and other illicit drugs. ⁸¹ These odds further increased among the cohort of adolescents who had ≥1 diagnosed concussion, even when controlling for sensation-seeking behaviors among the 12th grade subjects. ⁸¹ There is strong evidence that postconcussive syndrome and prolonged concussion recovery merits a multidisciplinary treatment approach with both pharmacologic and nonpharmacologic interventions prescribed, while avoiding opioid use for pain control. ²⁹

Chronic Pain

Chronic pain in pediatric patients is commonly caused by headaches, abdominal pain, and MSK pain. ⁴² Although most chronic pain in adolescents is not traditionally attributed to athletic injuries, there is evidence that increasing numbers of youth athletes are being affected by chronic pain. ⁷⁰ Myofascial pain syndrome, juvenile fibromyalgia, amplified pain syndrome, and, in rare cases, complex regional pain syndrome can occur in adolescent athletes. An acute or overuse MSK injury, overtraining, and burnout can precede the development of chronic pain, ⁷⁰ A post-MSK injury progression to a chronic pain state or syndrome is presumed to be multifactorial. Therefore, it is important to assess other medical and psychiatric contributing factors to chronic pain in athletes, as well as to comprehensively address reasons for slow resolution of pain related to athletic injuries.

There is limited evidence for improvement in postinjury pain from opioids when compared with other analgesics after the acute pain phase.^18,25,69 Therefore, when acute pain relating to a sports injury progresses to subacute or chronic, use of a multimodal pain plan is essential, with emphasis on avoidance of opioids for pain control. Delayed recovery and progression to chronic pain from a sports injury is correlated to emotional stress, anxiety, and pain-related fear. ² Injuries can also lead to social isolation and disruption of daily activities. Utilization of mindfulness activities, physical therapy, and cognitive behavioral therapy can serve as valuable adjunctive treatment modalities if a patient is not recovering as expected. Opioids are the principal treatments for certain chronic, advanced, or progressive pediatric diseases such as sickle cell disease pain crises, cancer, palliative, or end-of-life care. In these cases, the undertreatment of pain is of greater concern than opioid overuse, misuse, or addiction.^18,69

Nonprescription use of Opioids

Misuse and Nonmedical Use of Prescription Drugs in At-Risk Youth Athletes

Children and adolescents are a vulnerable population. Involvement in contact, collision, and highly strenuous youth sports comprise a pediatric subpopulation that is at even higher risk for early opioid exposure due to increased frequency of injury occurrence, subsequent pain, and the need for analgesia. General involvement in high school sports correlates with increased use and misuse of opioids while in college.^79,80 Furthermore, early exposure to prescription opioid medications is associated with future opioid misuse.^11,51

Opioid misuse refers to using opioid drugs in a manner or dose that was not intended by a prescriber. The National Survey on Drug Use and Health (NSDUH) reports 1.6% or 396,000 adolescents, aged 12 to 17 years, misused opioids in 2020, with almost all misuse being related to prescription pain relievers and not heroin.^4,50 Common examples of misuse include inappropriate drug dosing or frequency, and the mixing of analgesics with other substances such as alcohol, stimulants, cannabinoids, or other narcotics. Misuse also encompasses self-administered analgesics that are obtained from nonprescription sources through diversion or illicit sources. Nonmedical use of prescription drugs (NUPD) describes the use of prescription medications solely for the experience of feeling euphoria or dissociation. Studies show that approximately 20% of young people aged 12 to 17 years have used prescription drugs for nonmedical purposes and 0.6% suffer from some form of OUD. ²⁵ NUPD use, particularly opioids, is more common in adolescent and young adult athletes than their nonathlete peers. The typical reasons for misusing opioids following high school were to treat pain (self-treaters), but also to “relax, relieve tension, feel good, or get high” (sensation seekers). ⁵³ One theory to explain the relatively high rates of nonmedical opioid misuse is that the initial experience of pain relief in the opioid naive adolescent is pleasurable and subsequently sought after. ⁴⁸ Future opioid misuse risk factors include chronic pain in adolescence, ²⁵ being prescribed opioids, ²⁰ any healthcare exposure, ²⁰ electronic vaping, cigarette use, and use of other substances.^4,9,34 A systematic review of opioid use prevalence in high school athletes from 2009 to 2013 found rates of lifetime opioid use ranging from 28.4% to 46.4%. ¹⁹ Interestingly, the increase in opioid misuse was higher among young adults who initially reported little-to-no history of drug use and indicated strong disapproval of recreational marijuana use. Male gender and participation in high contact/collision sports increased the risk of NUPD. ⁸⁰ Opioid misuse is often an antecedent to more serious illicit drug use as previous studies concluded that approximately 80% of heroin users started out by using, then abusing, narcotic painkillers. The CDC reported that heroin use has more than doubled among 18- to 25-year-olds in the last decade, with a significant percentage of those identifying as current or former student-athletes. ¹⁰

How do Youth and Adolescent Athletes Obtain Opioids?

Exposure to opioids may come from a variety of places, including personal prescriptions, family member household supplies, peer usage, and street drugs. ⁸ Most student-athletes obtain opioid pills through prescriptions from EDs, immediate or primary care clinics, and/or postoperative settings. Common pain complaints resulting in opioid prescriptions include headaches, abdominal pain, and MSK pain. It is estimated that approximately 2.7 million ED visits are made annually for sports-related injuries among patients aged 5 to 24 years in the US. ⁶⁶ Most of these visits (66.5%) are among children between 10 and 19 years of age. In these data evaluating ED visits for sports injuries from 2011 to 2016, 63.9% of patients were administered or prescribed analgesic medication, with opioids accounting for 22.5% and nonopioid analgesics accounting for 41.4%. ⁶⁶ By age 18 years, approximately 20% of US children have received an opioid prescription from a healthcare provider.^49,52 There is little consistency in the rates and percentages of opioids prescribed in any healthcare setting. Medical professionals should use good judgment and carefully weigh the benefits of using prescription opioids for pain management in adolescent athletes against the future risks. Leftover and unused pills are often kept and are therefore freely available for “self-prescribed” use at the athlete’s discretion. ⁵³ Intentional or unintentional household availability of opioids makes diversion and access easier for children and adolescents and is a widespread contributing factor to the current epidemic. ²⁵

Risk of Opioid-Related Harms in Young Athletes

In contrast to opioid misuse, OUD involves significant impairment and distress in a person’s life due to opioid use. Based on the NSDUH in 2020, about 19% of adolescents (ages 12-17 years) who misused opioids already suffered from OUD, ⁷³ and many more have a greater lifetime risk of developing OUD. ⁵⁸ Risk factors for developing OUD in a vulnerable adolescent include perceived availability of opioids, antisocial traits, and parental history of substance misuse.^57,58 Navigating OUD is daunting, but there are effective evidence-based treatment options available including methadone, buprenorphine, and naltrexone. Unfortunately, a large systematic review found that adolescents are less likely to access these treatments than adults. ⁶¹

A diagnosis of OUD is associated with stigma in society as well as the medical community. Stigma from OUD can cause patients to marginalize themselves from the healthcare system and avoid seeking treatment for substance use, delay care for other illnesses, and conceal drug use.^5,6,28,31 Youth athletes with OUD need a support system for improved outcomes. Coaches, parents, caregivers, family, and team members can provide essential support during and after treatment. All persons who work with athletes should be educated about opioids, set aside personal biases, and cultivate a compassionate awareness of the risks of OUD.

Opioid Antagonists and Their Role in Pediatrics

Naloxone acts as a rapid opioid reversal agent that is safe and effective. Given the high risk of mortality, it is critical to make sure that Naloxone is available to anyone at risk of opioid overdose. Efforts to distribute Naloxone and to educate on proper use have been proven to reduce deaths from opioid overdose.^12,83 Naloxone prescribing by healthcare providers is low, with fewer than one-half of patients presenting to the ED with opioid overdose being prescribed Naloxone upon discharge. ⁸⁵ The reason for this underutilization is multifactorial. Barriers to prescribing Naloxone at the time of hospital discharge are cited as time constraints, patient education, provider training, and concern for increased high-risk behaviors. ⁶³ However, recent data show increased Naloxone access and distribution were correlated with a decrease in lifetime heroin and injection drug use among adolescents. ⁷ In an effort to make Naloxone readily available to the general public, on March 29, 2023 the US Food and Drug Administration approved it as an over-the-counter treatment. Given the minimal risk and great life-saving benefit, coprescribing Naloxone should be considered when prescribing opioids to any adolescent patient.

Conclusion

The incidence or prevalence of persistent pain in the pediatric athletic population is largely unknown, particularly with how this relates to physiologic dysfunction or exercise performance later in life. Furthermore, the efficacy of analgesics and the effects on injury recovery or outcomes are inadequately studied in the athletic population to date, thus resulting in the inability to create evidence-based guidelines for pain management. ³⁰ Best practice recommendations for student-athletes include the following: discourage playing through pain, use all pain medications judiciously, avoid unsupervised access to painkillers, find a safe storage space for all medications, and dispose of unused drugs immediately upon cessation of use. Adequate pain control, particularly postoperatively, correlates directly with patient satisfaction as well as decreasing the risk of chronic pain syndromes. So, although it is extremely challenging to eliminate opioid use entirely, a multimodal approach to pain control seems the most effective strategy to reduce opioid use in all settings, while maintaining improved function and good quality of life. Integration of a treatment team (including psychologists, child life specialists, and/or therapists) can help provide age-appropriate education and behavioral pain management. There is promising evidence that intensive interdisciplinary pain treatment programs and extensive use of nonpharmacologic therapies are the most effective strategies to treat chronic pain.

The risk of future opioid misuse in adolescents after short-term prescription pain treatments is significant and concerning. Community outreach, prescriber, athlete, parent, and coach education is needed to increase awareness of the warning signs of use, misuse, or addiction and to help address the ongoing opioid epidemic. Open communication is a key component. Creating safe spaces to talk about concerns at home, in school, in the athletic setting, in the community, and in the medical home is vital.

Healthcare providers are the primary gatekeepers to opioid prescriptions and are responsible for opioid stewardship. Incorporation of risk assessment into prescribing practices, utilization of opioid contracts, limitations on the number and quantity of opioid prescriptions, and provisions for disposal of unused medications are essential. Furthermore, some parents and athletes may opt to restrict pain management options to nonopioid treatments; therefore, both patient counseling and shared decision making with families is essential.^33,82 Some pain management strategies for the general population do exist, but there are few for the youth and elite sporting population and virtually none for athletes with a disability. Shared resources will strengthen the care of injured athletes. Better pain control after sports injuries will provide reassurance, speed return to active sport, and benefit performance while minimizing the short- and long-term risks of medication use in the pediatric athlete population.

Limitations

The paucity of data available, specifically in the youth athlete population, with regard to persistent and severe pain management is the primary limitation of this review. Another limitation is that the methodology used in studies varies widely and makes comparisons between studies challenging. No prospective studies on opioid use in youth athletes exist to date, and therefore it was not possible to perform a systematic review or a meta-analysis.

Future Areas of Research

The identification of the gaps in knowledge in the management of pain in athletes provides a unified direction for future research into non-narcotic and multimodal pain management strategies. The impact of cannabis or cannabinoids on pain management and athletic performance is an area of growing interest. More research is also needed around psychologically informed physiotherapy. Specifically, an assessment of the efficacy of cognitive-behavior therapies in improving specific injury outcomes is worthy of future investigation in athletes. Prospective studies that investigate the prevalence of opioid use, misuse, and abuse in athletes and the driving forces behind opioid-seeking behavior is of great public interest given the growing pediatric opioid epidemic.