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Friday, February 15, 2013

Yahoo! Sports: Passan: Red Sox’s Use of Toradol Could Put Ex-Trainer At Odds With Law

“I had a Toradol shot almost every single game for the last 10 years of my career,” Schilling told Yahoo! Sports. “It was never administered by a doctor at home or on the road. I didn’t think it was wrong.”
Though Schilling said Reinold never injected him with Toradol – he declined to say who did – the right-hander said he saw Reinold inject other players.
“Absolutely he did,” Schilling said.
. . .
More than 300 Toradol shots over his career taught Schilling their vitality. He said he experimented with different times of injection before settling on the optimal one: 5:25 p.m., exactly 100 minutes before a 7:05 start. Even though it’s neither considered nor classified as a performance-enhancing drug, its ability to help pitchers perform isn’t in doubt. Schilling remembers one particular game, a 2002 Sunday getaway day in Milwaukee with the Arizona Diamondbacks.
“I slept on a pillow wrong,” he said. “I woke up at 5:30 [a.m.]. I couldn’t move my head. I went to the ballpark at 6:30 for a 1:30 [p.m.] game. Worked for four hours on it. I literally couldn’t move my head. I went to the bullpen and started throwing and I didn’t think there was any way I could pitch.
“Then the Toradol kicked in. I threw a one-hitter and struck out 17.”

Sounds somewhat performance enhancing, no?

The league’s 2012 investigation wasn’t its first into Reinold. In 2008, as he was rehabbing an injury that would end his career, Schilling said Reinold suggested he consider taking performance-enhancing drugs to recover. Schilling told manager Terry Francona and Epstein, who reported the story to MLB.
Though officials have tried to discredit Schilling’s story since he first told it last week, Schilling maintains he has no reason to fabricate the incident. Schilling said he didn’t tell investigators the entire truth because Beckett and others liked Reinold and, as a player on his way out of the game, he did not want to upset the clubhouse.
League officials including Dan Mullin, head of the league’s Department of Investigations, and Dan Halem, MLB’s general counsel, interviewed Schilling with union leader Michael Weiner present. During the interview, Schilling recanted his story and said he had taken Reinold’s suggestion that he use performance-enhancing drugs out of context.
“I gave Reinold a free pass,” Schilling said. “I didn’t want to disrupt them trying to win a championship.”

 

The Yankee Clapper Posted: February 15, 2013 at 11:12 PM | 16 comment(s) Login to Bookmark
  Tags: crazy clown town, curt schilling, peds, red sox

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   1. vortex of dissipation Posted: February 16, 2013 at 02:55 AM (#4370597)
Schilling remembers one particular game, a 2002 Sunday getaway day in Milwaukee with the Arizona Diamondbacks.

"I slept on a pillow wrong," he said. "I woke up at 5:30 [a.m.]. I couldn't move my head. I went to the ballpark at 6:30 for a 1:30 [p.m.] game. Worked for four hours on it. I literally couldn't move my head. I went to the bullpen and started throwing and I didn't think there was any way I could pitch.

"Then the Toradol kicked in. I threw a one-hitter and struck out 17."


Checks out in every detail.
   2. Jack Carter, calling Beleaguered Castle Posted: February 16, 2013 at 04:33 AM (#4370610)
Wow--isn't this Schillling just throwing a guy under the bus who helped him out?
   3. Matt Clement of Alexandria Posted: February 16, 2013 at 07:33 AM (#4370616)
I really wish the drug company had chosen a different name than "Toradol". If people were saying, "injectable advil" - which is basically all Toradol is - I think there would be a very different public reaction. I assume that's why the drug manufacturers gave it that name, though. You tell an athlete you can give them a shot of "Toradol" or a shot of advil, they'll pick the former. (You'll also probably see a more significant placebo effect - Schilling's 5:25 AM shot of Toradol is classic ballplayer placebo effect stuff. That's ritual, not chemistry.)

The Red Sox fired Reinold this year. He took over as head trainer after 2009. He basically held the job of Red Sox trainer through two of the worst injury-plagued seasons in club history (2010 and 2012), plus a season where the Sox took a big hit of injuries at the worst possible time down the stretch (2011). I'm surprised he wasn't fired a year ago.

That said, Schilling coming out with this now, changing his story once again, smacks of kicking a guy while he's down, when there's no institution that can defend him. I like these two sentences:
Though officials have tried to discredit Schilling’s story since he first told it last week, Schilling maintains he has no reason to fabricate the incident. Schilling said he didn’t tell investigators the entire truth because Beckett and others liked Reinold and, as a player on his way out of the game, he did not want to upset the clubhouse.
Yes, they "tried to discredit" the story by noting the acknowledged fact that Schilling told a completely different story to MLB's investigators. Schilling may well be telling the truth. I certainly have no reason to trust that any athletic trainer isn't dispensing banned substances. But the fact that he's now changed his story twice since the original incident makes it a little hard to believe Schilling.
   4. Matt Clement of Alexandria Posted: February 16, 2013 at 07:38 AM (#4370617)
Even though it’s neither considered nor classified as a performance-enhancing drug, its ability to help pitchers perform isn’t in doubt
Just like all other NSAIDs. There are tons of drugs that can enhance your athletic performance and aren't ever listed among banned PEDs. If you want to call Toradol a PED, then so is aspirin. (Which, based on the literal meaning of "PED", is certainly the case.)
   5. Pasta-diving Jeter (jmac66) Posted: February 16, 2013 at 11:12 AM (#4370637)
I really wish the drug company had chosen a different name than "Toradol". If people were saying, "injectable advil" - which is basically all Toradol is - I think there would be a very different public reaction

wow..MCOA, you couldn't possibly be more wrong (and, yes, I can speak with authority on this subject, since I'm a Professor of Pharmacology--you could look it up). What you wrote is functionally equivalent to saying "heroin is just an injectable form of Demerol". After all, pharmacologically, they work the same way--they're mu opioid receptor antagonists. Ketorolac (the generic name for Toradol) and ibuprofen are both cyclooxygenase inhibitors...BUT--ketorolac has a longer t 1/2, a lower IC50, a lower Kd--it is a MUCH stronger drug.

To quote from the text "The Pharmacological Basis of Therapeutics" (generically known as "Goodman and Gilman", or simply "The Bible")

"The use of ketorolac is limited to <5 days for acute pain requiring opioid-level analgesia and can be administered intramuscularly, intravenously, or orally.....It is widely used in postoperative patients, but it should not be used for routine analgesia...

The black box warning for ketorolac stresses the possibility of serious adverse GI, renal, bleeding, and hypersensitivity reactions from the use of this potent NSAID analgesic."

if the Bosox docs/trainers really were using this routinely, that's bordering on medical malpractice.
   6. Matt Clement of Alexandria Posted: February 16, 2013 at 11:26 AM (#4370642)
I'm open to being educated here - I am not a health professional or scientist, my information comes from speaking to a couple of physicians. All of them considered Toradol to be a strong but perfectly normal NSAID. You are suggesting that it isn't, but can you explain why?
"The use of ketorolac is limited to 5 days for acute pain requiring opioid-level analgesia and can be administered intramuscularly, intravenously, or orally.....It is widely used in postoperative patients, but it should not be used for routine analgesia...

The black box warning for ketorolac stresses the possibility of serious adverse GI, renal, bleeding, and hypersensitivity reactions from the use of this potent NSAID analgesic."
All of the warnings there are your traditional advil overdose warnings. There is only one story of an alleged adverse reaction to Toradol among ballplayers (Buchholz's esophagitis) and that's a relatively rare side effect that easily could have any number of other causes. The issue with Toradol use doesn't seem to be its side effects. It's that it's a strong NSAID.

The reason that strength differences matter so much for opioids has to do with issues of dependence and resistance. Those issues don't apply for NSAIDs, as I understand it.

So what is it about the strength of Toradol that makes its usage so problematic?
   7. Pasta-diving Jeter (jmac66) Posted: February 16, 2013 at 11:35 AM (#4370643)
All of them considered Toradol to be a strong but perfectly normal NSAID.


but NOT to be used routinely--it's intended for acute post-operative pain

The reason that strength differences matter so much for opioids has to do with issues of dependence and resistance. Those issues don't apply for NSAIDs, as I understand it.

not resistance (or tolerance, as it is actually called), but addiction to opioids is largely based on the extent to which they cross the blood-brain barrier.

The "strength" of COX inhibitors does make a difference. The GI bleed and ulceration is due to the inhibition of COX 1 in the stomach and gut. The prostaglandins produced by COX 1 serve as cytoprotectants in 2 ways:

1. they inhibit gastric acid secretion from the parietal cells

2. they increase the production of mucous.

Toradol is going to give a much more long-lasting inhibition of COX1.

I suppose I could say that getting jabbed in the butt with Toradol is the equivalent of taking four 250mg advils, 6 times a day

   8. Matt Clement of Alexandria Posted: February 16, 2013 at 11:40 AM (#4370645)
The "strength" of COX inhibitors does make a difference. The GI bleed and ulceration is due to the inhibition of COX 1 in the stomach and gut. The prostaglandins produced by COX 1 serve as cytoprotectants in 2 ways:
So, the strength of Toradol matters because it increases the risk of renal / GI side effects. I get that. But there haven't been any reports of players suffering from bad renal / GI problems as a result of Toradol use. (Other than Buchholz, and his case is a weird one.) If that is happening, then obviously malpractice is going on.

All of the reporting has instead been about the performance enhancing or injury-masking effects of Toradol. Which are not significantly different from, as you say, taking a lot of advil.
   9. Pasta-diving Jeter (jmac66) Posted: February 16, 2013 at 11:45 AM (#4370648)
I should add that we don't know what dose they were injecting. Conceivably, I suppose, they could have been using a much lower dose that that used for acute post-operative pain (I doubt it, though). And the placebo effect that you mentioned could very well be operative here. For all we know, they were shooting up Schilling with saline and telling him it was Toradol.
   10. Chip Posted: February 16, 2013 at 11:47 AM (#4370649)
but NOT to be used routinely


This is also true of corticosteroids, isn't it? But pro sports teams, and especially baseball teams, appear to ignore the warnings when it comes to cortisone shots, too.
   11. Pasta-diving Jeter (jmac66) Posted: February 16, 2013 at 11:52 AM (#4370650)
This is also true of corticosteroids, isn't it? But pro sports teams, and especially baseball teams, appear to ignore the warnings when it comes to cortisone shots, too.

of course--it's all based on the same mentality-- GET THEM BACK ON THE FIELD!!!

but players are complicit in this--they want back on the field as well

BTW, Toradol misuse is far more common in the NFL
   12. Matt Clement of Alexandria Posted: February 16, 2013 at 12:21 PM (#4370664)
Conceivably, I suppose, they could have been using a much lower dose that that used for acute post-operative pain (I doubt it, though).
Another second-hand note from a physician - post-operative pain is one of a bunch of common uses for Toradol in the hospital. It's also used for any reasonably young, healthy patient (someone unlikely to have underlying GI/renal issues or other issues that could be exacerbated by a high dose of advil) with significant pain from inflammation - say a young woman with a UTI that moved up to her kidney, or a guy with a bad skin infection. It's a normal thing.

It is true that NSAIDs and corticosteroids are used by professional athletes at rates that go well beyond how they're used in hospitals. This is a worthwhile problem to consider that can cause athletes real problems later in life. It's also a problem that doctors who see pro athletes are usually working for the team and not the athlete, which produces some dangerous incentives.

But Toradol use at these rates is not new or special. It's just another NSAID that ballplayers are using a lot of, as they do with corticosteroids. There are no reports of athletes with renal problems from overdosing on Toradol. The brouhaha is about pain management / performance enhancement, and on that level it's nothing new at all.
   13. Matt Clement of Alexandria Posted: February 16, 2013 at 12:23 PM (#4370666)
And the placebo effect that you mentioned could very well be operative here.
Another note from a doctor. She likes to tell patients, "For your pain, I'm going to give you an injection. It's a drug called Toradol." Anecdotally, this has much better effects than giving similar doses of other NSAIDs. The name and the fact that it's injectable make a big difference.

I think an analogous kind of effect is driving the Toradol hysteria in the media.

(Also, on esophagitis in a 20-something athlete, she thinks drinking is a more likely cause than Toradol/advil side effects.)
   14. Mayor Blomberg Posted: February 16, 2013 at 08:19 PM (#4370845)
re 13: and the fried chicken, don''t forget the fried chicken!
   15. Jim Wisinski Posted: February 16, 2013 at 10:52 PM (#4370871)
Also, on esophagitis in a 20-something athlete, she thinks drinking is a more likely cause than Toradol/advil side effects


Drinking increases the risk of damage from the use of pain relievers, especially high doses of them (and vice versa). Your wife (if I recall correctly from the other thread who you're getting this info from) may well be right that drinking had something to do with Buchholz's problems but if he was frequently getting Toradol injections then that was likely a major contributing factor. Plus the damage from high doses of pain relievers/the combo of them and drinking isn't necessarily immediate and obvious, it can easily be causing damage that will show up later in life but isn't affecting the player right now. There's also the problem of the players being properly informed about the risks involved with what they're being given; I'm sure your wife lets her patients know what she's giving them and the dangers of doing stuff like drinking heavily while on it, plus she is going to try to avoid using it on someone that is going to be at an increased risk for bad side effects. Can we honestly say that we believe team doctors and trainers are fully informing the players of the dangers of the medication in general and especially when combined with alcohol? And are they refusing to provide the injections to players they know drink a lot or have other risk factors? I highly doubt it and that's a big problem.

   16. Jim Wisinski Posted: February 16, 2013 at 11:00 PM (#4370876)
Matt, I should add that neither I nor I think most of the people here are saying that Toradol is this new horrible thing that eclipses the other questionable practices that get players back on the field and performing well. There are definitely worse things being done (like frequent cortisone shots) but Toradol is in the news right now and to many of us is something that we didn't know anything about before. I don't see any actual hysteria in the media over this (feel free to link any examples of hysteria that you have come across, I don't read a whole lot of news), it's just being discussed. There's push back against the suggestion that it's just injectable Advil when the high dosage and frequency with which some players are receiving it makes it much more serious than that.

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