Nate Jackson played six seasons in the National Football League for the Denver Broncos. He is the author of "Slow Getting Up: A Story of NFL Survival from the Bottom of the Pile." Jackson's story was adapted for Deadspin in the piece, "My Injury File: How I Shot, Smoked, and Screwed My Way Through the NFL."

"My body was a mess. But what was the main culprit? The Toradol shots? All the anti-inflammatories and painkillers? My diet? Was it the creatine? Poor treatments of my chronic hamstring injury? Poor health care in general?... Was it fate? God? No… It was football. I played football for a living." 

Jackson’s memoir details the realities of pain and pain management in the NFL. Players feel immense pressure to return from injuries before they are fully healed, mainly due to a lack of job security. This leads to a cycle of re-injury that is perpetuated by the standard operating procedure of rehabilitation for injured players. Team doctors typically do not design treatment plans with a player’s long-term health interests in mind. Rather, the standard methods of injury treatment serve a single purpose: winning football games (see: profit). NFL players are being exploited by a system that does not care about their well-being outside of the game of football, and many players are forced to rely on painkillers in order to simply keep their jobs. The solution to this problem revolves entirely around making the general public aware of the problem’s existence.

"During my football career, I dislocated my shoulder multiple times, separated both shoulders, broke my tibia, broke a rib, broke my fingers, tore my medial collateral ligament in my right knee, tore my groin off the bone, tore my hamstring off the bone twice. I had bone chips in my elbow, bone chips in my ankle, concussions, sub-concussions, countless muscle strains, labral tears in either hip, cumulative trauma in the lower spine, sciatic nerve damage, achilles tendinitis, plantar fasciitis in both feet, blisters—oh the blisters! My neck is bad. My clavicles are misaligned. I probably have brain damage."

Injuries are an unfortunate but unchangeable aspect of playing football. The job description involves beastly men smashing into each other at high speeds and awkward angles. When an NFL player is injured, by the terms of their contract, they are required to follow a rehabilitation plan designed by team doctors and approved by upper-level management. NFL management – coaches, general managers, team presidents, etc. – are paid to win as many football games as possible. Employees, such as the players, become commodities whose sole purpose is to help the team win games.

This mentality is the crux of the problem at hand. There is no job security in the NFL, because most contracts are not guaranteed. Once a player’s injuries and pain compromise his ability to play, he becomes easily replaceable, and is quickly replaced. There is no shortage of healthy collegiate football players aiming to take the jobs of professionals upon graduation. This lack of job security leads nearly all NFL players to make health sacrifices in order to keep their jobs. The Washington Post, as part of a 2013 story on the culture of pain management in the NFL, surveyed over 500 former players. Almost 90 percent stated they played games while hurt, 56 percent “frequently.” Furthermore, nearly half of those retired players who took the field with injuries said they later regretted doing so, and 68 percent said they "did not feel like they had a choice as to whether to play hurt."

"I thought I needed to get on the field and prove myself a warrior if I had any chance of making the team."

The cycle begins with the first injury. An NFL player gets hurt – usually a minor injury, like a muscle strain or joint sprain – and receives rehabilitation. Then, due to pressure from a lack of job security, they return to action as soon as physically able, before the injury is fully-healed. And sometimes, everything is okay. But typically, the injury is aggravated, and becomes more serious. So, a more rigorous rehabilitation plan is put into effect. If the pain is severe, the player receives treatment to numb the pain. Once the pain is manageable, the player returns to action. But then, a new injury occurs. It’s a coincidence, right? How can separate injuries be connected?

"One injury leads to the next, to the next, to the next. The aggressive rehabilitation of one muscle neglects its opposite. The body is thrown out of balance… My story is not unique. Every other football-playing man deals with the same cycle of injury and rehab, separated by periods of relative health." 

The existence of this cycle alone does not constitute exploitation. NFL players are aware of the inherent dangers that come with playing football, especially when hurt. However, what many injured players are not aware of is that their recovery regiment – and especially the reliance on painkillers – can have serious long-term health consequences. Team doctors encourage the use of painkillers among injured players, but deliberately choose not to disclose the true effects of these dangerous drugs. And the use of painkillers is only one of the many facets of treatment plans that neglect the overall well-being of players. Injured players have no say in the day-to-day exercises and treatments which are a part of their recovery regiment, and team doctors mislead players into believing that this regiment is actually healing their injuries. In reality, these treatments are only simulating the healing of the injury, masking the pain and forcing players to return to the field.

"What's that, Nate? You want to rest it? Wait until it feels better before you start working it?...You don't know anything about the human body, do you? We have to speed up the healing process! Your body's natural reaction to the injury is incorrect. We can't trust it, Nate. We need to manipulate the body's natural healing process, send shocks to it, changes of temperature, strain it to the point of exhaustion, stretch it to the point of snapping, blast it with powerful anti-inflammatories and painkillers, then shock/temperature change again, strain/stretch again, pills again, and repeat. That's how you heal the human body, Nate." 

The expectation that injured players will use specific painkillers is perhaps the most exploitive aspect of this process. The Post’s 2013 survey of retired players found “one in four said he felt pressure from team doctors to take medication he was uncomfortable with.”  These medications fall under two categories: the pill and the needle. First, let’s examine the pill: opioids. A 2011 study by researchers at Washington University in St. Louis included a survey of 644 retired NFL players on their use of synthetic opium pills (such as Vicodin and OxyContin). Over half of the surveyed players used opioid painkillers at some point during their careers. Of those, 71 percent admitted misusing the drug, and 15 percent stated that they still relied on opioids to manage their pain at the time of the survey, often many years, even decades after retirement. Opioids can be incredibly dangerous and addictive, especially when relied upon for extended periods of time.

According to The Post, they are responsible for more American deaths every year than all illegal “street” drugs – such as cocaine, heroin, and meth – combined. And NFL doctors prescribe them for players with reluctance similar to candy prescriptions on Halloween. But is it a treat, or a trick? These are statements from three different anonymous participants in the Washington University study, according to ESPN's Outside the Lines.

• "All players had to do was ask the team doctor and they would give medicines"

• "After games they would dump three or four Percocets in my hands"

• "We didn't know what we were taking – they just gave it to us"

The needle is relied upon even more so than the pill in today’s NFL, and may have more serious side effects.  The Post’s survey found that roughly 70 percent of players who retired after 2000 used the anti-inflammatory drug Toradol during their careers. Near the end of his career, like many players caught in the cycle, Nate Jackson relied upon weekly Toradol shots.

"Thus began my long relationship with the needle-as-savior approach to injury treatment… Toradol for the next week's game, and all subsequent games... Every game a needle."

Toradol was developed for short-term use by patients after surgery. It is used by NFL players because it is an effective painkiller. Toradol use has many health consequences, which is why it has been banned by many European countries, even for post-operation purposes. But NFL players, until recently, have been largely unaware of the dangers posed by reliance on the drug. It is not a narcotic, and therefore not chemically addictive, but it is still habit forming. And the NFL has been aware of this since as early as 2002, when, according to The Post, a “study of the drug’s usage in the NFL found several teams reporting a ‘psychological addiction’ to game-day injections.”

Twelve years later, NFL doctors continue to prescribe Toradol for nearly all players who request it, many of whom do not see it as the dangerous drug it is, but instead, as “armor.” But psychological addiction is only one of the many side effects involved. Anti-inflammatory use can cause kidney failure and gastrointestinal bleeding. Seattle Seahawks’ player Michael Robinson spent weeks in the hospital in 2013 after his kidneys began to shut down due to use of the anti-inflammatory drug Indocin. He took it exactly as it was prescribed.

"Hello again, Mr. Needle, how well you mask my pain. But will I pay for this quick fix some other lonely day?"

Furthermore, recent research indicates that because anti-inflammatories like Toradol function as an anticoagulant, they “could exacerbate the effects of concussions.” As part of a lawsuit, settled in 2013, in which retired players accused the NFL of misleading them regarding the dangers of concussions, 11 players claimed “their team doctors repeatedly treated them with Toradol without properly advising them of the dangers.” But the dangers of painkiller reliance in the NFL do not stop with these side effects alone. The most common consequence resulting from painkiller use involves re-injury.

By numbing the pain of injuries in order to play – and keep their jobs – players are putting themselves at increased risk for further injury. Pain is the brain’s way of alerting the body of damage, but when players take painkillers, they lose the ability to sense re-injury during a game. So injuries become worse, and more painkillers are required to return to action, and on and on the cycle continues until the player can play no more.

"What do you call a football player who's not playing football? You don't."

The problem of the NFL’s exploitive culture of pain management is a complex one, and, as of yet, there have been no legitimate attempts to solve it. There have been proposals, sure, but they tend to demonstrate a quick-fix mentality, which is the exact mentality at the core of the issue. Some of these include reforms to the process by which players are prescribed painkillers, which is an attempt to limit the side effects. But the cycle continues. Other proposals involve increasing a player’s options when it comes to managing pain. As nationwide public sentiment regarding medical marijuana use shifts toward legalization, many retired players, including Nate Jackson, are speaking out in favor of allowing players to use marijuana in order to deal with the cycle.

"How to manage the pain? It's an important question that all players must answer for themselves, and everyone has a different approach? I found marijuana worked best for me. I developed no physical dependence on it, as many of my friends did with pain pills, and it never interfered with my work."

Players absolutely should be allowed to use marijuana to manage their pain. Reform to the prescription process absolutely should take place. But these proposed attempts at solving the problem do not address the crux of the problem itself: the cycle. In order to truly solve this problem and end the exploitation of players, the system must be overhauled, and the entire approach to injury treatment must be rethought and considered with players’ long-term health at the forefront. Thankfully, there is a precedent for changing the culture of the NFL concerning the treatment of players as commodities. For decades, the NFL misled players regarding the dangers of concussions. But in the past few years, a three-pronged approach has forced the league to reform its concussion policy.

Studies by medical professionals proved what should have been common sense all along – that concussions are dangerous and potentially debilitating. The media then reported the information found in these studies to the public through a variety of channels. Then the public did the rest, pressuring the NFL to make the necessary changes simply because they were aware of the problem’s existence and the exploitation taking place. These same three processes are essential in order to change the culture of pain management which leads so many players into a cycle of pain and pain management that often lasts beyond retirement. There have been too few medical studies and media reports involving the dangers of this cycle. The Washington Post's and Outside the Lines' 2013 stories have been the only mainstream media reports to gain significant traction on this isssue, and they don't go far enough in demonstrating the exploitave nature of the NFL's process of injury treatment.

The handful of studies and reports that have been presented only seem to focus on the prevalence of painkiller use among players. They need to instead focus on the root cause of players’ reliance on painkillers – the overwhelming pressure to play while injured. They need to expose the exploitation that is taking place. Only then will the public become fully aware of the true problem at hand, and only then will the NFL be forced to make the necessary systemic changes:

•    Focusing treatment plans on healing injuries by giving players the option to rest
•    Guaranteeing contracts, providing job security and lessening the pressure to play injured
•    Drastically reducing the prescriptions of painkillers, providing them only post-surgery
•    Allowing players the option to have personal doctors control their treatment
•    Eliminating the contractual requirement for players to sign treatment waivers
•    Giving players the full knowledge of the side effects involved with their treatment

Some will dispute the arguments made in this piece and consider the proposed changes above as nothing more than a pipe-dream. This is worth evaluating. An initial counter-argument to the declaration that NFL management largely does not care about the long-term health of its players would involve statements from coaches which indicate otherwise. The head coach of the Seattle Seahawks, Pete Carroll, for instance, stated, “We care about these guys tremendously,” in reference to Michael Robinson’s near-kidney failure caused by team-prescribed painkillers.

Carroll is an undeniably nice fellow, and who does, in fact, appear to care about the overall well-being of his players, both during and after their careers. However, the Seahawks still cut Robinson and voided his contract after his hospitalization. Business is business, so it seems. Another counter-argument would be that not all NFL teams so willingly prescribe painkillers to any players with pain. The St. Louis Rams, for example, do not offer their players Toradol injections. However, 28 of the NFL’s 30 teams still do.

A final counter-argument, and perhaps the most persuasive, would be that professional athletes should be responsible enough to weigh the dangers involved with their pain management regiment against their desire to continue to play professional sports. However, what if players simply aren’t made aware of the dangers?

“Do you consider yourself fit to play football?” “Yes.”
“Then sign here. And have a good off-season, Nate.”
I was signing an affirmation of health. Next to that piece of paper was a file as large as a dictionary that contained my injury history. Every injury I ever had was described somewhere in that file. But I never saw it. It wasn't my property.
Had I owned that file, that information, I would have had a better idea of what was happening to me.

The NFL’s culture of exploitation can only survive if the public remains in the dark to its existence. It is the duty of researchers to conduct studies on the dangers of the pain management cycle and publish their findings in reputable professional outlets, such as the Journal of Sport and Social Issues. Only then will the media have the support necessary to fully expose the league’s exploitive tendencies to the masses. As Francis Bacon so famously said, “knowledge is power.”

Reach staff writer Ryan Bouziane here