[Senate Hearing 115-218]
[From the U.S. Government Publishing Office]
S. Hrg. 115-218
CURRENT ISSUES IN AMERICAN SPORTS:
PROTECTING THE HEALTH AND SAFETY OF AMERICAN ATHLETES
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HEARING
before the
COMMITTEE ON COMMERCE,
SCIENCE, AND TRANSPORTATION
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
MAY 17, 2017
__________
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SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
JOHN THUNE, South Dakota, Chairman
ROGER F. WICKER, Mississippi BILL NELSON, Florida, Ranking
ROY BLUNT, Missouri MARIA CANTWELL, Washington
TED CRUZ, Texas AMY KLOBUCHAR, Minnesota
DEB FISCHER, Nebraska RICHARD BLUMENTHAL, Connecticut
JERRY MORAN, Kansas BRIAN SCHATZ, Hawaii
DAN SULLIVAN, Alaska EDWARD MARKEY, Massachusetts
DEAN HELLER, Nevada CORY BOOKER, New Jersey
JAMES INHOFE, Oklahoma TOM UDALL, New Mexico
MIKE LEE, Utah GARY PETERS, Michigan
RON JOHNSON, Wisconsin TAMMY BALDWIN, Wisconsin
SHELLEY MOORE CAPITO, West Virginia TAMMY DUCKWORTH, Illinois
CORY GARDNER, Colorado MAGGIE HASSAN, New Hampshire
TODD YOUNG, Indiana CATHERINE CORTEZ MASTO, Nevada
Nick Rossi, Staff Director
Adrian Arnakis, Deputy Staff Director
Jason Van Beek, General Counsel
Kim Lipsky, Democratic Staff Director
Chris Day, Democratic Deputy Staff Director
Renae Black, Senior Counsel
C O N T E N T S
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Page
Hearing held on May 17, 2017..................................... 1
Statement of Senator Thune....................................... 1
Statement of Senator Nelson...................................... 3
Prepared statement........................................... 4
Statement of Senator Sullivan.................................... 4
Prepared statement from Jake Wald, Business Development
Manager, Positive Coaching Alliance........................ 102
Statement of Senator Markey...................................... 5
Statement of Senator Moran....................................... 78
Statement of Senator Udall....................................... 82
Letter dated May 16, 2017 to Hon. John Thune and Hon. Bill
Nelson from Katherine Snedaker, LCSW, Executive Director,
PINK Concussions........................................... 94
Prepared statement from Katherine Starr, Founder,
Safe4Athletes.............................................. 95
Letter dated May 17, 2017 to Hon. John Thune and Hon. Bill
Nelson from David Goodfriend, Chairman, Sports Fans
Coalition.................................................. 97
Statement of Senator Blumenthal.................................. 84
Statement of Senator Cortez Masto................................ 85
Statement of Senator Hassan...................................... 87
Statement of Senator Young....................................... 89
Statement of Senator Moore Capito................................ 90
Witnesses
Jay C. Butler, MD, Chief Medical Officer, Alaska Department of
Health and Social Services and Director of Public Health; and
President, Association of State Territorial Health Officials
(ASTHO)........................................................ 6
Prepared statement........................................... 8
Maureen Deutscher, Family Representative, Prescription Opioid
Abuse Advisory Committee, South Dakota Department of Health.... 11
Prepared statement........................................... 14
Shellie Pfohl, Chief Executive Officer, United States Center for
Safe Sport..................................................... 16
Prepared statement........................................... 17
Scott R. Sailor, President, National Athletic Trainers'
Association.................................................... 51
Prepared statement........................................... 53
Robert A. Stern, Ph.D., Professor of Neurology, Neurosurgery, and
Anatomy, and Neurobiology; Director, Clinical Core, BU
Alzheimer's Disease and CTE Center, Boston University School of
Medicine....................................................... 57
Prepared statement........................................... 58
Lauryn Williams, Olympian and Proud TrueSport Ambassador, United
States Anti-Doping Agency...................................... 72
Prepared statement........................................... 74
CURRENT ISSUES IN AMERICAN SPORTS:
PROTECTING THE HEALTH AND SAFETY OF AMERICAN ATHLETES
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WEDNESDAY, MAY 17, 2017
U.S. Senate,
Committee on Commerce, Science, and Transportation,
Washington, DC.
The Committee met, pursuant to notice, at 10:02 a.m. in
room 253, Russell Senate Office Building, Hon. John Thune,
Chairman of the Committee, presiding.
Present: Senators Thune [presiding], Fischer, Moran,
Sullivan, Heller, Moore Capito, Gardner, Young, Nelson,
Cantwell, Klobuchar, Blumenthal, Markey, Booker, Udall,
Baldwin, Hassan, and Cortez Masto.
OPENING STATEMENT OF HON. JOHN THUNE,
U.S. SENATOR FROM SOUTH DAKOTA
The Chairman. Good morning and welcome to today's hearing.
It is no exaggeration to say that Americans love sports. We
love watching them, playing them, collecting sports
memorabilia, and even arguing about our favorite teams and
athletes.
Whether it is watching the Super Bowl with friends, joining
an office bracket pool for ``March Madness,'' or stretching out
for the Turkey Trot 5K races on Thanksgiving morning, and the
pickup football games later that afternoon, we love our sports.
Personally, I am a Dodgers and a Packers fan, and some of
my best moments have been spent competing in sports, or
cheering on my two daughters at their meets and games.
This Committee is committed to promoting American success
in international competition, ensuring exciting play in our
professional leagues, providing opportunity for our student
athletes, and maintaining a vibrant sports culture for the
benefit of all Americans. At the same time, protecting the
health and safety of American athletes of all levels--
professional, amateur, student, and youth--is a longstanding
priority of the Commerce Committee.
The issue of sexual abuse within the United States Olympic
movement has received considerable media attention in recent
months. The troubling nature of these reports triggered the
Committee's inquiry into the ability of the U.S. Olympic
Committee, and the U.S. National Governing Bodies for
individual sports, to conduct effective, timely, and impartial
investigations into allegations of abuse. I am glad that
Shellie Pfohl of the United States Center for SafeSport is here
today to discuss the Center's work to protect these athletes.
While I believe that nothing in the current law prevents
USOC and NGBs from taking immediate steps to remove a suspected
predator from being in contact with athletes, it is also clear
that certain stakeholders have, at times, sown confusion about
the legal requirements of the Ted Stevens Olympic and Amateur
Sports Act, and manufactured ambiguities behind which to hide.
I am pleased that Senator Feinstein and her colleagues on
the Senate Judiciary Committee have advanced legislation to
address this issue. I look forward to working with her to
strengthen her bill as it advances to the full Senate.
Specifically, any legislation to address this issue must
include unambiguous language clarifying that it is the
responsibility of our Olympic leaders to provide an environment
that is free from abuse.
In the same way Congress codified the United States Anti-
Doping Agency to combat the use of performance-enhancing drugs
in 2001, I believe we should authorize the U.S. Center for
SafeSport as an independent organization with the expertise to
investigate and adjudicate abuse allegations as they arise.
Speaking of anti-doping, I am pleased that we are joined
here today by Olympic medalist, and True Sport Ambassador,
Lauryn Williams, who will testify on behalf of USADA. The
Committee last reauthorized USADA in 2014, and since that time
has been active on a number of clean sport issues.
For instance, in 2016, following the revelation of an
elaborate doping program sponsored by the Russian Government,
the Committee conducted oversight of the World Anti-Doping
Agency's response, prompting the Agency to appoint a new
independent investigator and to expand the scope of its
investigation.
Following a reanalysis of samples collected during the 2008
Summer Olympic Games in Beijing, which revealed cheating in the
men's pole vault event, I wrote to the International Olympic
Committee to correct the final results of that competition and
to award the bronze medal to an American, Derek Miles, just
last month.
The issue of prescription opioids to treat sports injuries
is another growing concern, in particular because of the
addiction and overdose risks they carry. Though substance abuse
and misuse affects all demographics, athletes are a
particularly vulnerable population.
While the media has focused recent attention on the use of
prescription opioids in professional sports leagues, this issue
impacts all athletes, including at the high school and
collegiate levels.
While I wish she were here under different circumstances, I
am glad that we are joined by Maureen Deutscher, and her
husband Jeff, of Sioux Falls, South Dakota, who will testify
about their family tragedy involving the loss of their son,
Nick, to opioid painkillers. Maureen and Jeff, I am deeply
sorry for your loss, and thank you for your bravery in sharing
your story with us today.
Finally, the issue of concussions in sports is a
longstanding issue that this Committee has sought to address.
Concussions are common injuries among athletes participating in
contact sports, and are among the most complex injuries to
manage in sports medicine. The Committee has conducted
oversight of efforts to prevent and mitigate the occurrence of
concussions in sports, including game rule changes, coaching
and player education, guidelines, as well as the development of
brain injury and equipment research.
Dr. Jay Clarence Butler of the Alaska Department of Health
and Social Services; Mr. Scott Sailor, President of the
National Athletic Trainers' Association; and Dr. Robert Stern
of Boston University School of Medicine will be able to speak
to this issue, as well as many others, that affect our Nation's
athletes.
And so, I thank you all for being here today, and I look
forward to hearing your testimony, and the opportunity for you
to interact with members of this committee, and give us a
chance to ask questions.
With that, I will yield to the distinguished Senator from
Florida, the Ranking Member, Senator Nelson, for his opening
statement.
STATEMENT OF HON. BILL NELSON,
U.S. SENATOR FROM FLORIDA
Senator Nelson. Thank you, Mr. Chairman.
I think this is an opportunity, as the Chairman has said,
to start a conversation about what more can be done to protect
America's athletes. Obviously, we must protect the young
athletes, some of whom are children. They are starting early.
They are training for the Olympics.
Obviously, we were all shocked by the revelations of
widespread sexual abuse in USA Gymnastics, USA Taekwondo, and
other Olympic sports. Even more appalling was evidence that
responsible adults were indifferent and looked the other way.
When so many young victims can be horribly abused by adults for
so long without repercussions, it is a stain on America's proud
Olympics heritage.
So we in Congress need to respond to this travesty. I am,
along with many others, a sponsor of the bill that has been
introduced. This bill would require immediate reporting of
sexual abuse allegations, require National Governing Bodies to
adopt strict protocols and measures to protect children, and
make it easier for victims to come forward and report to the
authorities.
We also need, as the Chairman has already outlined very
well, to examine athletic doping at the international level.
There was a time when we thought of the Olympics, we thought
this is just above reproach. What now when we think of the
Olympics? You think of scandals that have been revealed
involving doping.
Over 100 Russian athletes were banned from the Olympic
Games in Rio de Janeiro. We should address attacks on clean,
drug-free sports, and protect athletes who do things the right
way.
The issue of head injuries is something that is becoming
alarming. Each one of us, more than likely, has had a fellow
athlete friend along the way that has had concussions. And now,
years later, we are seeing the manifestations of those
concussions.
Concussions and CTE are not limited to professional sports.
They affect children and can have devastating effects on their
still-developing young brains.
I want to recognize and commend Senator Udall, who is here
with us today, who has been such a champion and a leader on
this issue. His dedication to preventing concussions and youth
athletic safety is well known to everyone here. I want to thank
him, on behalf of the Committee, for raising awareness about
this very troubling issue.
Thank you, Mr. Chairman.
[The prepared statement of Senator Nelson follows:]
Prepared Statement of Hon. Bill Nelson, U.S. Senator from Florida
Thank you, Mr. Chairman, for holding this hearing. I'm pleased that
we'll be able to start a conversation about what more can be done to
protect America's athletes of all ages and at all levels.
For instance, we must protect our young athletes, many of whom are
children, training for Olympic sports. We were all shocked by the
revelations of widespread sexual abuse in USA Gymnastics, USA
Taekwondo, and other Olympic sports. Even more appalling was evidence
that responsible adults were indifferent and looked the other way. When
so many young victims can be horribly abused by adults for so long
without repercussions, it's a stain on America's proud Olympics
heritage.
Congress needs to respond to this national travesty. It's why I'm
proud to cosponsor the Protecting Young Victims from Sexual Abuse Act
of 2017. This bill would require immediate reporting of sexual-abuse
allegations, require national governing bodies to adopt strict
protocols and measures to protect children, and make it easier for
victims to come forward and report to the authorities.
We also need to examine athletic doping at the international level.
There are allegations that the Russian government runs a doping program
for the sole purpose of providing its athletes an unfair advantage.
Over 100 Russian athletes were banned from Olympic games in Rio. We
should address attacks on clean, drug-free sports and protect athletes
who do things the right way.
Finally, the issue of head injuries in sports is something that
only becomes more alarming as more research comes out. As we all know,
concussions and CTE are not limited to pro-sports. It's also about kids
and the devastating effects on their still-developing young brains. I
want to recognize Senator Udall, who's been such a champion and leader
on this issue. His dedication to preventing concussions and youth
athletic safety is well known to everyone here, and I want to thank him
for raising awareness about this very troubling issue.
The Chairman. Thank you, Senator Nelson.
I want to recognize, for an introduction of one of our
panelists today, Senator Sullivan to introduce Dr. Butler,
followed by Senator Markey for a short statement to introduce
Dr. Stern.
Senator Sullivan.
STATEMENT OF HON. DAN SULLIVAN,
U.S. SENATOR FROM ALASKA
Senator Sullivan. Thank you, Mr. Chairman.
Thank you and the Ranking Member for holding this important
hearing.
I do want to recognize Dr. Jay Butler, who came all the way
from the great State of Alaska to testify today. Dr. Butler
does great work in the State of Alaska and serves as the Chief
Medical Officer and Director in the state.
Although it is not an uplifting topic, Dr. Butler has
committed his time and effort across the state, really across
the country, to help stymie the opioid epidemic that is raging
through Alaska like it is in so many of the other states in the
United States.
His efforts have included education and awareness on the
dangers of opioid use especially for our young Alaskans; aiding
in the distribution of Naloxone to nonmedical personnel and
facilities; currently serving as the President of the
Association of State and Territorial Health Officials; and
representing the State of Alaska in his position of Director of
Public Health and Chief Medical Officer for the state.
I will not go through his extensive resume, but will just
mention briefly, Mr. Chairman, my experience with Dr. Butler.
We worked together last year when we put on a Wellness Summit
in the State that was focused on conquering the opioid crisis.
Dr. Butler was instrumental in the success of this Summit. Over
500 Alaskans, with several hundred more online, showed up at
this Summit.
He participated in planning on the steering committee. He
interviewed the United States Surgeon General for a fireside
chat and moderated the ending panel of this discussion and
Summit.
I just want to thank him for, again, traveling from Alaska,
all the work he is doing in our state, and participating on a
national level on this important issue that crosses partisan
lines. This is an issue that is impacting every single state in
our great Nation and Dr. Butler is a leader in this, not only
in Alaska, but in our country.
Thank you.
The Chairman. Thank you, Senator Sullivan. It is always
nice to have you here.
Senator Markey.
STATEMENT OF HON. EDWARD MARKEY,
U.S. SENATOR FROM MASSACHUSETTS
Senator Markey. Yes, thank you, Mr. Chairman.
Dr. Robert Stern, is a Professor at the Boston University
School of Medicine and is the Director of Clinical Research for
the BU Chronic Traumatic Encephalopathy Center. Also known as
CTE, it is a neurodegenerative disease often found in athletes.
While a lot of Dr. Stern's research focuses on repeated
brain trauma in athletes, I know him best through his work on
Alzheimer's disease as he is the Director of the Clinical Core
at the BU Alzheimer's Disease Center.
Throughout his career, he has won multiple national and
federally funded grants for his work. He has published more
than 250 journal articles, chapters, and abstracts in his
field. He is a Fellow of both the American Neuropsychiatric
Association and the American Academy of Neuropsychology.
I just wanted to thank you, doctor, for all of the work
which you have done on the brain. For helping to explain, not
only Alzheimer's and the pathways that are possible for finding
a cure, but also what you have done in becoming the center for
the study of the impact on the brain that contact in sports
has. You have become the national leader and I just wanted to
thank you for that.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Markey, and welcome, Dr.
Stern.
I want to just introduce again for the panel in terms of
the order of presentation. We will start on my left and your
right with Dr. Butler, who is the Chief Medical Officer, as was
pointed out by our colleague from Alaska, of the Alaska
Department of Health and Social Services.
Mrs. Maureen Deutscher, who is a Family Representative,
Prescription Opioid Abuse Advisory Committee on behalf of the
South Dakota Department of Health.
Ms. Shellie Pfohl, who is the Chief Executive Officer of
the United States Center for SafeSport.
Mr. Scott Sailor, President of the National Athletic
Trainers' Association.
Dr. Robert Stern, Professor of Neurology, Boston University
School of Medicine.
Ms. Lauryn Williams, we will save our speedster for last,
True Sport Ambassador, United States Anti-Doping Agency.
So if you would proceed in that order. Dr. Butler, if you
could, confine your oral remarks as closely to five minutes as
possible, it will maximize the opportunity that members of the
Committee will have to ask questions.
Thank you all for being here.
Dr. Butler.
STATEMENT OF JAY C. BUTLER, MD, CHIEF MEDICAL
OFFICER, ALASKA DEPARTMENT OF HEALTH AND SOCIAL
SERVICES AND DIRECTOR OF PUBLIC HEALTH; AND
PRESIDENT, ASSOCIATION OF STATE TERRITORIAL HEALTH OFFICIALS
(ASTHO)
Dr. Butler. Good morning, Chairman Thune, Ranking Member
Nelson, and members of the Committee.
It is an honor to be able to speak with you today.
In my role as Chief Medical Officer in Alaska, I oversee
State-related prevention, preparedness, and response
activities. During the past 3 months, in addition to the roles
that Senator Sullivan has described, I have also served as the
Incident Commander of Governor Bill Walker's opioid response.
In Alaska, we are responding to the opioid epidemic much as
we would to any other disaster, whether an earthquake or a
tsunami, using an incident command structure to coordinate
communication across State Government. This response is
addressing the three- to fourfold increase in opioid overdose
deaths that have occurred in Alaska over the past two decades,
which mirrors an increase that has occurred across our Nation.
The epidemic started somewhat silently, with gradual
increases in deaths caused by prescription painkillers as more
and more of these drugs were prescribed. The problem has been
compounded over the past decade by the increased availability
of heroin and more recently of illicitly-produced Fentanyls.
The majority of people who use heroin and Fentanyl report that
they first became addicted through use of prescription opioid
pain relievers.
I want to be clear at the outset of the discussion that the
health benefits of participation in sports and physical
activity are extensive and well-documented: reduced risk of
cardiovascular disease, obesity, diabetes, certain types of
cancer, also better musculoskeletal strength, and an improved
sense of well-being and connectedness to community.
Youth who participate in sports historically have been
shown to be less likely to use illicit drugs. Unfortunately,
athletes have not been immune to the devastating effects of the
opioid epidemic. Too often, sports-related injuries managed
with opioid pain relievers have been the beginning of a path to
addiction.
One coach expressed her frustration to me by describing
that she had seen too many times an injury leading to a
prescription for pills, leading to additional prescriptions for
pills, leading to use of a friend's pills, leading to use of
any pills that could be obtained by any means, and
unfortunately sometimes leading to use of heroin and overdose
deaths.
High profile stories of professional athletes who began
using prescription opioids for injury and then struggled with
addiction or died of overdose may grab the headlines, but we
need to recognize that the problem is occurring at all levels
of competition. One adult recreational softball league in
Alaska with roughly 750 participants has had five players die
of opioid overdose.
An epidemiological study of high school students in
Michigan found that boys who participated in organized sports
were more likely to be prescribed opioid painkillers than those
who did not. And as a result, participation in organized sports
actually increased the risk of subsequent opioid misuse. With
over 4 million youth sports and recreation-associated injuries
occurring each year in the U.S., there is a reason for concern.
What can be done? There are no easy answers and no magic
bullets. We need to be clear about that. But I would like to
highlight three areas of opportunity.
First, we can promote evidence-based pain management
strategies and more rational use of opioid pain relievers.
Opioids can be useful for the management of acute pain and many
people who receive these medications use them without problem.
However, opioids should not be the first line of treatment
following any sports injury. These medications are used best
when they are prescribed in the lowest effective dose and for
the shortest period possible, generally for less than 3 to 7
days.
Larger first time prescriptions have specifically been
associated with higher risk of long-term use and thus greater
risk of dependency and addiction.
A school nurse recently told me about a student who came
back to school after arthroscopic surgery for an athletic
injury. In line with school policy, he checked in with her and
turned his prescription medicines in. She was shocked to find
that he had a bottle of 120 Oxycodone containing pills.
Special care needs to be taken when prescribing these
medications to teens. Adolescence is a particularly high risk
period and use of opioids--even as prescribed by a healthcare
provider--by high school students has been linked to increased
likelihood of subsequent misuse.
Second, we can provide more information on the risks of
opioid pain relievers for both healthcare providers and the
public, including coaches and trainers.
In talking with teens, I frequently hear the sentiment that
if opioid pain relievers are really dangerous, then why do
doctors prescribe them? In talking to people in recovery, I
frequently hear, ``No one told me.'' And, ``If I had had any
idea how dangerous these drugs were, I never would have taken
them.''
We can do a better job not only describing the risk of
opioids, but also providing information on what can be done in
our communities to address the problem including promotion of
leftover drug return and disposal, and talking openly about the
recognition, and management of dependency, and addiction as a
health issue rather than as solely a criminal justice issue or
some type of moral failing.
There is a role for professional athletes, as well as
Olympians and other high profile athletes, to be able to serve
as spokespersons in promoting conversations to reduce the
stigma of addiction.
There is also a need for better continuing medical
education for all healthcare providers to improve their
knowledge and confidence in optimal pain management and the
basics of addiction medicine.
Finally, maybe at the risk of sounding corny, the effective
response to this epidemic will be a team sport. It will involve
coaches, parents, trainers, and the athletes themselves, as
well as organizations including professional, scholastic, and
amateur sports leagues, public health agencies, healthcare
providers, third party payers, the criminal justice system,
educators, businesses, and lawmakers as well.
Working together sports participation cannot only be made
safer, but I believe can also be part of how we reduce the
number of people who become newly dependent on opioids and
increase the number of Americans living in recovery.
Finally, I just want to conclude by pointing out that the
issue of opioid abuse is not just an isolated event and not
just an isolated topic as we talk about sports safety.
It is no accident that we have the broad range of topics
that we are discussing today. These topics are complementary
and not in competition.
Sexual assault is a trauma that ultimately can lead to
unhealthy coping mechanisms and increase the risk of self-
medication.
Traumatic brain injury is a brain process that can lead to
altered cognition as well as altered risk assessment, and can
also possibly create increased risk of abuse.
So the question is not to ask one another, ``What are you
doing to address these issues?'' But, what we can all do
together to solve all of them?
Thank you for your time.
[The prepared statement of Dr. Butler follows:]
Prepared Statement of Jay C. Butler, MD, Chief Medical Officer, Alaska
Department of Health and Social Services, and Director of Public
Health; and President, Association of State Territorial Health
Officials (ASTHO)
Good morning Chairman Thune, Ranking Member Nelson, and Committee
members. Thank you for the invitation to speak to you this morning. My
name is Jay Butler, Chief Medical Officer for the Alaska Department of
Health and Social Services and Director of Public Health, and President
of the Association of State Territorial Health Officials (ASTHO). In my
role of Chief Medical Officer in Alaska, I oversee state health-related
prevention, preparedness, and response activities. I maintain board
certifications in internal medical, pediatrics, and infectious
diseases, and much of both my clinical and public health activities
have been focused on infectious diseases. While I am not a specialist
in addiction medicine, I have had firsthand experience with the
infectious complications of drug use, including endocarditis, skin and
soft tissue infections, and HIV and hepatitis C infections.
During the past 3 months, I have also served as incident commander
of Alaska Governor Bill Walker's opioid response activity. In Alaska,
we are managing the response to the opioid epidemic much as we would
the response to any disaster whether that is a pandemic of infectious
disease, a terror attack, an outbreak of wildfires, a major earthquake,
or a tsunami. In fact, the intensified, multiagency response started
with a disaster declaration by Governor Walker in February. Some have
criticized describing the increase in opioid misuse, addiction, and
overdose deaths as an ``epidemic'', and I admit that I generally avoid
using the term ``epidemic'' myself. However, when a single cause of
death increases three to four fold over a period of roughly 20 years,
as has occurred with opioid overdose deaths in our nation, even the
most rigorous definition of ``epidemic'' has been met.
The first 15 years of this epidemic appears to have been driven by
changes in clinical practices relating to pain management and a three-
fold increase in prescriptions for opioid pain relievers. The opioid
epidemic is like a tsunami in that most of us did not feel the seismic
shift in medical practice until the first wave of overdose deaths was
upon us. And like a tsunami, additional waves have come ashore--with
dramatic increases in heroin deaths over the past decade, driven by the
increased prevalence of opioid pain reliever dependence and addiction
and by the increased supply, and decreased price, of heroin. The
majority of persons who use heroin today report that their addiction
started with use of prescription opioid pain relievers. More recently,
a third wave of overdose deaths has been driven by an influx of
illicitly produced fentanyl and related synthetic opioids. These drugs
have spread throughout our nation--overdose deaths due to synthetic
opioids have even occurred in the most remote Alaska villages.
Why are we discussing drug misuse and addiction at a hearing on
sports safety? The health benefits of participation in sports and
physical activity are extensive and well-documented: reduced risk of
cardiovascular disease, obesity and diabetes, and certain types of
cancer, better musculoskeletal strength, and improved sense of well-
being and social connectedness, to name a few. Active people live
longer and have better quality of life. Youth who participate in sports
generally achieve greater academic success, have been less likely to
use drugs or suffer from depression, and are more likely to be
physically active adults.
Despite these benefits, athletes have not been immune to
devastating effects of the opioid epidemic. Too often, sports-related
injuries managed with opioid pain relievers have been the beginning of
a path to physical dependency and addiction. While these drugs can be
useful in management of pain in severe acute injuries, too often, they
are prescribed in large amounts that can lead to prolonged use, leading
to physical dependency and addiction, or to diversion and misuse of
unused pills. One coach described to me the too-familiar sequence of a
sports injury leading to prescribed pills, leading to more prescribed
pills, leading to a friend's pills, leading to any pills that can be
obtained, leading to heroin, and ultimately leading to addiction or
overdose death. High profile stories of professional athletes who begin
using prescription opioids for injury and then struggled with
addiction, or died of overdose, may grab headlines, but we need to
recognize that the problem of opioid misuse occurs at all levels of
competition.\1\ One adult recreational softball league in Alaska with
roughly 750 participants has had 5 players die of opioid overdose. An
epidemiological study of high school students in Michigan found that
boys who participated in organized sports were more likely to be
prescribed opioid painkillers.\2\ What was more disturbing was the
finding that participation in organized high school sports actually
increased the risk of subsequent opioid misuse. With over 4 million
youth sports- and recreation-related injuries occurring each year in
the U.S., there is reason for concern.\3\
So what can be done? There are no easy answers and there are no
magic bullets. Responding to the health challenges of all substance
misuse and addictions, including those that are part of the opioid
epidemic, requires a multifaceted and multisector approach as outlined
in the 2017 ASTHO President's Challenge on public health approaches to
preventing substance misuse and addictions.\4\ People are dying today;
therefore, let's start with what is immediately lifesaving for those
who are already living in addiction. We need to prevent drug overdose
deaths by increasing access to naloxone, an easy-to-administer
medication that can reverse the fatal respiratory depression that kills
in an overdose. We can reduce the risk of life-threatening infections
related to drug use by removing barriers to clean syringes and needles
and by promoting testing for HIV and hepatitis C infections. While
these measures can save lives, they do not solve the problem or treat
addictions. To increase the number of people living in recovery, we
need to fill the immense gap between the number of people in need of
treatment and the availability of services to manage drug withdrawal
and maintenance of recovery. We also need to reduce the stigma
associated with addictions and increase recognition of opioid addiction
as a chronic health condition involving the brain. Ultimately, we must
prevent substance misuse and addictions by reducing the flood of
prescription and illicit opioids into our communities and by improving
personal resiliency and community connectedness to reduce the need to
self-medicate.
I would like to highlight three specific areas of opportunity to
reduce the risk of opioid misuse and addiction among athletes at all
levels of competition:
First, we can promote evidence-based pain management strategies and
more rational use of opioid pain relievers. Opioids can be useful for
management of acute pain, and many people who receive these medications
use them without problem. However, it has become clear that opioids
should not be the first line of treatment following sports injury, and
that these medications are used best when prescribed at the lowest
effective dose for the short periods, generally less than 3-7 days, as
recommended in the Centers for Disease Control and Prevention's 2016
guideline on use of opioids for pain.\5\ While there are encouraging
data indicating that there has been some recent decline in total amount
of opioids that are prescribed, the number of pills dispensed is still
often too many.\6\ Larger first-time prescriptions of opioids have been
associated with higher risk of long-term use, and thus, greater risk of
dependency and even addiction.\7\ A school nurse recently told me of a
high school athlete who returned to school after arthroscopic surgery--
in keeping with school policy, he checked his prescription medications
in with the nurse, and she was surprised to see a bottle of 120 pills
containing hydrocodone. Special care needs to be taken when prescribing
these medications to teens: adolescence is a particularly high risk
period and use of opioids as prescribed by a health care provider by
high school students has been linked to increased likelihood of
subsequent misuse.8,9
Second, we can provide more information on the risks of opioid pain
relievers for both health care providers and the public, including
coaches, trainers, and athletes. In talking with teens, I frequently
hear the sentiment that if opioid pain relievers are prescribed by
doctors, they must be safe. We can do a better job in not only
describing the risks of opioids but also providing information on what
can be done in our communities, including promoting leftover drug
return and disposal and talking about the risks of dependency and
addiction. Professional athletes and major league sports can play an
important role as spokespersons and in promoting conversation to reduce
the stigma of addiction and to encourage positive community action. We
need to recognize that the goal of complete absence of pain may not be
realistic and pursuing that goal will come at the high price of higher
rates of addiction and death. There is also a need for better
continuing medical education for all health care providers to improve
their knowledge and confidence in optimal pain management and the
basics of addiction medicine.\10\
Finally, we need to recognize that we all have a part to play in
addressing the opioid epidemic. The problem cannot be solved by simply
placing blame or by pinning the responsibility to address this health
crisis on one sector. The response to the opioid crisis and prevention
of future drug addiction will require teamwork involving the combined
efforts of all Americans, including parents, coaches, trainers, and the
athletes themselves, as well as organizations such as professional,
scholastic, and amateur sports leagues, public health agencies, health
care providers, third party payers, the criminal justice system, social
service agencies, educators, businesses, and law makers. Working
together, sports participation cannot only be made safer, but can also
be part of how we reduce the number of people who become newly
dependent on opioids and increase the number of Americans successfully
living in recovery.
Endnotes
1. Wertheim LJ, Rodriguez K. Smack epidemic: how painkillers are
turning young athletes into heroin addicts. Sport Illustrated. June 22,
2015.
2. Veliz P, Epstein-Ngo QM, Meier E, Ross-Durow PL, McCabe SE, Boyd
CJ. Painfully obvious: a longitudinal examination of medical use and
misuse of opioid medication among adolescent sports participants. J
Adolesc Health 2014; 54:333-340.
3. Gotsch K, Annest JL, Holmgreen P, et al., Non-fatal sports and
recreation-related injuries treated in emergency departments--United
States, July 2000-June 2001. MMWR Morb Mortal Wkly Rep 2002;
51(33):736-740.
4. Association of State and Territorial Health Officials. 2017
President's Challenge: Public Health Approaches to Preventing Substance
Misuse and Addictions. http://www.astho.org/addictions/
5. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing
opioids for chronic pain--United States, 2016. MMWR Recomm Rep 2016;
65(RR-1):1-49.
6. Hill MV, McMahon ML, Stucke RS, Barth RJ. Wide variation and
excessive dosage of opioid prescriptions for common general surgical
procedures. Ann Surg 2017; 265(4):709-714.
7. Shah A, Hayes CJ, Martin BC. Characteristics of initial
prescription episodes and likelihood of long-term opioid use--United
States, 2006-2015. MMWR Morb Mortal Wkly Rep 2017; 66(10);265-269.
8. Miech R, Johnston L, O'Malley PM, Keyes KM, Heard K.
Prescription opioids in adolescence and future opioid misuse.
Pediatrics 2015; 136(5):e1-e9.
9. McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, Boyd CJ.
Trends in medical and nonmedical use of prescription opioids among U.S.
adolescents: 1976-2015. Pediatrics 2017; 139(4):e20162387.
10. Volkow ND, McLellan AT. Opioid abuse in chronic pain--
misconceptions and mitigation strategies. N Engl J Med 2016;
374(13):1253-1263.
The Chairman. Thank you, Dr. Butler.
Ms. Deutscher.
STATEMENT OF MAUREEN DEUTSCHER, FAMILY
REPRESENTATIVE, PRESCRIPTION OPIOID ABUSE ADVISORY COMMITTEE,
SOUTH DAKOTA DEPARTMENT OF HEALTH
Ms. Deutscher. Chairman Thune, Ranking Member Nelson, and
members of the Committee.
Thank you for the opportunity to provide testimony and our
insight regarding opioid use as it relates to the effect on our
young athletes in our home state of South Dakota and around the
country.
In our 30 years of marriage, my husband Jeff and I have
been blessed with three wonderful children: Jeremy, Nick, and
Annie. Today, we are here to tell you about our son Nick.
Kind, funny, happy, uplifting--these were some of the words
used in memory of Nick by friends and family following his
death on July 18, 2015. We would add smart, intuitive,
adventurous, frustrating, and amazing. Another recurring theme,
``Nick always had your back.'' He was a true and loyal friend.
We are just a regular Midwest family gathering for meals,
enjoying family vacations, and celebrating special occasions
together. Jeff and I have supported our children in their
education and activities as religious ed. leaders, room
parents, coaches, and club leaders.
Nick had positive role models in extended family, teachers,
and coaches. Our parenting style, as I would describe it, is
consequence when called for, praise, and always love, and we
all take care to be there for one another.
So what happened? What did we miss in protecting our son?
This has been our daily reflection for the past 21 months and
29 days. We would like to share with you some of Nick's journey
through the last 4 years of his life.
Nick excelled in academics and athletics. Nick had many and
varied friends. Nick was a bit of a risk taker, always up for
the challenge.
Nick's experience with opioids began shortly after his 18th
birthday in the fall of 2011 with his MCL/ACL injury; second
play of the second game senior year with his High School State
Champion football team. Then they prescribed Hydrocodone, and
Percocet or Oxycodone, through the partial tear, rehab, back in
play for the last game of the season, and subsequent surgery
for the full ACL tear.
As though it were yesterday, we recall driving to Walgreens
pharmacy directly from the game field for the first of a series
of prescriptions. I personally maintained possession and
control of Nick's opioid prescriptions for his welfare, but my
understanding of the risks associated with the medication did
not even scratch the surface.
An alarm went off in November when Nick indicated the
Hydrocodone was no longer sufficiently addressing his pain. We
shared this information with his orthopedic staff. We were told
they were not concerned with the progression, and Percocet was
prescribed over the phone and without further evaluation.
Following recovery and rehab from surgery through December
of that year, the prescriptions abruptly ceased. Beginning in
January, it became very clear that Nick was struggling. He
underwent counseling and through our physicians, alternative
medications were prescribed to help with the withdrawal
culminating in 30 days of residential treatment.
Still, Nick graduated with his class as a Regents Scholar.
No stranger to hard work, Nick made it through that very
frightening and challenging time, all while under the care of
excellent physicians, and all with the continued love and
support of his family, and the support of his high school
principal, coaches, and staff.
For the next 3 years, Nick attended college classes and
worked, but the disease had taken hold and did not retreat. As
he continued to struggle, protecting us, his family, as best he
could from the fear of what could happen to him and the
frustration at not being able to diminish the symptoms of
addiction. Still good, kind, and fun, Nick continued to share
with us his hope in recovery.
The symptoms of addiction can move a person in directions
they do not want to go and often do not comprehend. That
happened to Nick as he found himself faced with charges
stemming from substance use in 2014. Nick knew what to do, ask
for help.
We were blessed to have been able to support him through
his work with Tallgrass Recovery in Sioux Falls in two 30-day
stays between October 2014 and March 2015. Coming home in March
was a young man renewed in his recovery, attending meetings,
getting together with his sponsor, going to church, working,
and spending time at Tallgrass.
On May 20, 2015 we attended Nick's sentencing hearing for
the 2014 offences, and on June 3, Nick checked into the work
release program with Minnehaha County for just under four
months.
July 18 brought a visit by the sheriff's department at our
home at approximately 8:30 p.m. Nick had died in his sleep,
having returned to the work release facility after work at
approximately 3:30 that afternoon, spending time with others in
the program, and laying down for a nap.
Nick died an accidental death. Reports indicated
prescription medications in Nick's system, all but two
prescribed; one of which was Oxycodone at an elevated level.
Nick was 21.
From what we can discern through conversations with Nick's
friends and investigative findings, Nick likely relapsed due to
the stress of his situation. We believe the medications were
intended by Nick for use as a coping tool and to aid in sleep
at the corrections facility. But as all too many parents,
family members, and friends across the Nation are learning
every day, for some people, opioids have their own intentions.
We can no longer experience the joy of Nick's laughter,
awesome hugs, and genuine goodness. What we hope to accomplish
here is to reinforce the need for careful consideration of the
effects of opioid therapy in the management of injury as our
young athletes press forward to perform, to highlight the
responsibility of medical professionals in prescribing
practices relating to opioid pain medication, and to reinforce
the need for education of the public on the addiction risks
associated with the use of opioid therapy in sports injury
management.
In our experience with Nick, the addiction hit swiftly and
without retreat, reinforcing that addiction is a chronic
disease.
Over the past 21 months, we have had meetings and
conversations with county and State appointed, and elected
officials, members of the medical and legal communities, and
judicial systems, and agency directors in the very
misunderstood field of addiction and recovery.
Jeff and I have provided testimony at our State's
Legislative Study on Substance Abuse Prevention, and are
currently serving on the South Dakota Governor's Opioid Abuse
Advisory Committee.
Through all of the conversations and meetings, there are
key issues that rise to the top for Jeff and me. Number one,
the risks of addiction to opioid medications and the risk of
that leading to further addiction are seriously misunderstood
and understated.
And second, the prescription opioid issue begins with just
that, a prescription, calling for responsible prescribing
practices and distribution monitoring.
As parents, Jeff and I feel our most important role in life
is to protect our children; if only we had known then what we
know now.
In closing, we are grateful for the current work being done
to address the issues at hand. Now, we ask for your thoughtful
consideration of the information we have provided and
experience gained through our journey with our son, Nick.
Thank you.
[The prepared statement of Mrs. Deutscher follows:]
Prepared Statement of Maureen and Jeff Deutscher,
Sioux Falls, South Dakota
Ladies and Gentlemen,
Thank you for the opportunity to provide testimony and our insight
regarding Opioid use as it relates to the effect on our young athletes
in our home state of South Dakota and around the country.
In our 30 years of marriage, my husband Jeff and I have been
blessed with 3 wonderful children, Jeremy, Nick and Annie.
Today we are here to tell you about our son, Nick.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Kind, funny, happy, uplifting--these were some of the words used in
memory of Nick by friends and family following his death on July 18th
of 2015.
We would add smart, intuitive, adventurous, frustrating and
amazing! Another recurring theme, ``Nick always had your back'', a true
and loyal friend.
We're just a regular Midwest family gathering for meals, enjoying
family vacations and celebrating special occasions together. Jeff and I
have supported our children in their education and activities as
religious ed leaders, room parents, coaches and club leaders. Nick had
positive role models in extended family, teachers and coaches. Our
parenting style, as we would describe it, is consequence when called
for, praise and always love and we all take care to be there for one
another.
So what happened? What did we miss in protecting our son? This has
been our daily reflection for the past 21 months and 29 days.
We would like to share with you some of Nick's journey through the
last four years of his life.
Nick excelled in academics and athletics. Nick had many and varied
friends. Nick was a bit of a risk taker, always up for the challenge.
Nick's experience with Opioids began shortly after his 18th
Birthday in the fall of 2011 with his MCL/ACL injury--second play of
the second game Senior Year as a starter with his High School State
Champion football team. Then the prescribed Hydrocodone and Percocet
(Oxycodone)--through the partial tear, rehab, back in play for the last
game of the season and subsequent surgery for the full ACL tear.
As though it were yesterday, we recall driving to Walgreen's
pharmacy directly from the game field for the first of a series of
prescriptions. I personally maintained possession and control of Nick's
Opioid prescriptions for Nick's welfare, but my understanding of the
risks associated with the medication did not even scratch the surface.
An alarm went off in November when Nick indicated the Hydrocodone
was no longer sufficiently addressing his pain. We shared this
information with his orthopedic staff, were told they were not
concerned with the progression and Percocet was prescribed over the
phone without further evaluation.
Following recovery and rehab from surgery through December of that
year, the prescriptions abruptly ceased.
Beginning in January, it became very clear that Nick was
struggling. He underwent counseling and through our physicians,
alternative medications were prescribed to help with the withdrawal
culminating with 30 days of residential treatment. Still, Nick
graduated with his class as a Regents Scholar. No stranger to hard
work, Nick made it through that very frightening and challenging time,
all while under the care of excellent physicians and all with the
continued love and support of his family and the support of his high
school's principal, coaches and staff.
For the next 3 years Nick attended college classes and worked, but
the disease had taken hold and did not retreat as he continued to
struggle, protecting us, his family, as best he could from the fear of
what could happen to him and the frustration at not being able to
diminish the symptoms of Addiction.
Still good, kind and fun Nick continued to share with us his hope
in recovery.
The symptoms of Addiction can move a person in directions they do
not want to go and often do not comprehend. That happened to Nick as he
found himself faced with charges stemming from substance use in 2014.
Nick knew what to do, ask for help. We were blessed to have been able
to support him through his work with Tallgrass Recovery in Sioux Falls
in two 30 day stays between October 2014 and March 2015. Coming home in
March was a young man renewed in his recovery, attending meetings,
getting together with his sponsor, going to church, working and
spending time at Tallgrass.
On May 20th of 2015 we attended Nick's sentencing hearing for the
2014 offences and on June 3rd Nick checked into the work release
program with Minnehaha County for just under four months.
July 18th brought a visit by the Sheriff's Department at our home
at approximately 8:30 p.m. Nick had died in his sleep, having returned
to the work release facility after work at approximately 3:30 that
afternoon, spending time with others in the program and laying down for
a nap. Nick died an accidental death. Reports indicated prescription
medications in Nick's system, all but two prescribed--one of which was
Oxycodone, at an elevated level.
Nick was 21.
From what we can discern through conversations with Nick's friends
and investigative findings, Nick likely relapsed due to the stress of
his situation. We believe the medications were intended by Nick for use
as a coping tool and to aid in sleep at the corrections facility. But
as all too many parents, family members and friends across the Nation
are learning every day, for some people, Opioids have their own
intentions.
We can no longer experience the joy of Nick's laughter, awesome
hugs and genuine goodness. What we hope to accomplish here is to
reinforce the need for careful consideration of the effects of Opioid
therapy in the management of injury as our young athletes press forward
to perform, to highlight the responsibility of Medical Professionals in
prescribing practices relating to Opioid pain medication and to
reinforce the need for education of the public on the Addiction risks
associated with the use of Opioid therapy in sports injury management.
In our experience with Nick, the Addiction hit swiftly and without
retreat, reinforcing that Addiction is a Chronic Disease.
Over the past 21 months we have had meetings and conversations with
county and state appointed and elected officials, members of the
medical and legal communities and judicial systems and agency directors
in the very misunderstood field of Addiction and Recovery.
Jeff and I have provided testimony at our state's Legislative Study
on Substance Abuse Prevention and are currently serving on the SD
Governor's Opioid Abuse Advisory Committee.
Through all of the conversations and meetings there are key issues
that rise to the top for Jeff and me:
1. The risks of Addiction to Opioid medications and the risk of that
leading to further addiction(s) are seriously misunderstood and
understated.
2. The prescription Opioid issue begins with just that--a
prescription--calling for responsible prescribing practices and
distribution monitoring.
As parents, Jeff and I feel our most important role in life is to
protect our children . . . if only we had known then what we know now.
. . .
In closing, we are grateful for the current work being done to
address the issues at hand. Now, we ask for your thoughtful
consideration of the information we have provided, experience gained
through our journey with our son, Nick.
The Chairman. Thank you, Ms. Deutscher.
Ms. Pfohl.
STATEMENT OF SHELLIE PFOHL, CHIEF EXECUTIVE OFFICER, UNITED
STATES CENTER FOR SAFESPORT
Ms. Pfohl. Thank you, Chairman Thune, Ranking Member
Nelson, and members of the Committee.
Mr. Chairman, I am Shellie Pfohl, CEO of the United States
Center for SafeSport, a national, nonprofit headquartered in
Denver, Colorado. Our organization exists to protect athletes
from all forms of abuse. We serve sports' participants from the
local recreation leagues to the professional ranks.
The ongoing national discourse around sports has focused
largely on two issues, concussions and doping, which remain
important topics today.
I thank you, Mr. Chairman, Ranking Member Nelson, and your
staffs for adding our voice to the conversation. By bringing
attention to emotional, physical, and sexual abuse prevention
in sports, you are advancing SafeSport's call to action, which
is to champion respect and end abuse.
Forty-five million youth in the U.S. play sports, as well
as scores of adults at the collegiate, professional, and
recreational level. Athletics offer unparalleled opportunities
for personal growth and developing character, all while
advancing health and fitness.
A study of 400 female executives found that more than 90
percent participated in sports at sometime in their life. I can
honestly say I would not be who I am today without sports.
We never want to see those benefits that I just mentioned
undermined by abuse. Sadly, it exists in society as it does in
sports, whether it is an athlete bullying another athlete, or a
coach exploiting his or her power to sexually assault a player.
While we do not have statistics specific to sports, we know
that in the U.S., one in five youth are bullied, and one in ten
will be sexually abused before the age of 18.
Fancy slogans are not enough to prevent abuse. We know that
best practices and prevention include policies, tools, and
training that are embedded in an organization's culture. While
we are working to get data on how well sports organizations are
doing at preventing abuse, we know anecdotally that much more
needs to be done.
Ask any parent of a child playing sports these three simple
questions. Did you or your child receive training on how to
prevent abuse? Do you know what the sport organization's policy
on adult to youth interaction is? Would you know who to turn to
if you were concerned about an abuse situation involving your
child? My guess is they would answer no to at least one of
those questions, which is simply unacceptable.
Our goal is to establish a national SafeSport standard that
organizations can use as a measuring stick of their own
policies. SafeSport best practices, resources, and training
tools will then help these organizations to get to where they
need to be.
SafeSport sought the counsel of many organizations in
establishing the SafeSport Code that I refer to in my written
testimony. From that interaction with other professionals,
including those from youth-serving organizations, we understand
that simply conducting criminal background checks is not
enough.
Awareness and training are at the heart of a good
prevention effort and are essential to our work. To date, more
than 300,000 coaches affiliated with the U.S. Olympic and
Paralympic movements receive SafeSport training.
We must now work to expand that education beyond coaches to
include parents and athletes, and at all levels of competition
beyond the Olympics.
In addition to our education and outreach efforts,
SafeSport is the independent response and resolution office for
the U.S. Olympic and Paralympic movements including the 47
National Governing Bodies that represent each of the sports.
Reports can be made multiple ways including anonymously and
are handled by our team of highly qualified investigators.
Reports of sexual misconduct fall within the exclusive
authority of SafeSport. If a report is substantiated, SafeSport
will determine appropriate resolution, which could include a
lifetime ban that would apply across any U.S. Olympic
organization.
Sports are in my DNA. Every person here has a sports
experience, either your own or through a family member
underscoring the magnitude of this challenge. We have a lot of
work to do. Your efforts to prioritize the health and safety of
U.S. athletes goes a long way toward making our SafeSport Call
to Action to champion respect and end abuse a reality.
Thank you and I look forward to your questions.
[The prepared statement of Ms. Pfohl follows:]
Prepared Statement of Shellie Pfohl, Chief Executive Officer,
U.S. Center for SafeSport
I. Introduction
The U.S. Center for SafeSport congratulates and thanks the Senate
Commerce, Science and Transportation Committee for holding this hearing
to address the issue of ``Current Issues in American Sports: Protecting
the Health and Safety of American Athletes.'' A special thank you to
Chairman John Thune for inviting SafeSport to testify.
The written testimony herein highlights the efforts of SafeSport to
foster a national sports culture built on respect and free from abuse.
SafeSport is the first of its kind: a national nonprofit dedicated to
preserving the safety and well-being of athletes by preventing
emotional, physical and sexual abuse in sports. This includes bullying,
harassment, hazing and all other forms of misconduct and abuse.
II. State of Play of Abuse with Athletes
The national discourse in the sports world to date has focused on
two serious issues: concussions and doping. But there is another that
demands our attention. Today, we need to discuss how to recognize,
reduce and respond to emotional, physical and sexual abuse of athletes,
regardless of age or competitive level.
Three out of four American families with school-aged children have
at least one playing an organized sport--that is over 45 million youth.
All deserve to reap the benefits of participating in sports, including
fitness, fun, social connections, character development and more.
But sports do not happen in a vacuum, they occur in communities
across the country where statistics suggest one in five youth are
bullied,\1\ and one in ten will be sexually abused \2\ before the age
of 18. These are startling numbers and while we do not know what the
data looks like among athletes specifically, we know that abuse is
happening and that more must be done.
---------------------------------------------------------------------------
\1\ Stopbullying.gov
\2\ Townsend/Rheingold Study (2013)
---------------------------------------------------------------------------
Sports afford participants a unique ability to learn respect,
perseverance and teamwork while building self-esteem, confidence and
social skills. Sports are more than a game or competition, sports build
character. The sports community must at its core champion respect and
protect all athletes from any form of abuse.
That is why ask for your support in authorizing the U.S. Center for
SafeSport in S. 534 ``Protecting Young Victims from Sexual Abuse Act of
2017.''
III. Who We Are
Originally created by the United States Olympic Committee,
SafeSport is now an independent 501(c)(3) nonprofit headquartered in
Denver, Colorado. The organization is governed by a nine-member board
of independent directors, including subject-matter experts in the areas
of abuse prevention and response, ethics compliance and sports
administration. It's supported financially through the USOC, NGBs and
charitable donations.
IV. What We Do
SafeSport is committed to creating and maintaining a culture where
all persons who participate in sports programs and activities can work
and learn together in an atmosphere free of all forms of emotional,
physical and sexual misconduct. SafeSport believes when athletes are
safe, they can achieve their full potential.
Prevention is at the heart of SafeSport's mission. SafeSport serves
sports organizations across the Nation by providing educational
resources that instill positive behavior, build character and develop
strong communities. Its programs help to reinforce respect, safety and
health in sports. SafeSport is working to help equip these sports
organizations and, in turn, millions of athletes, parents and coaches,
with tools to address issues of abuse before they occur.
For athletes at every level--from amateur to elite, community-based
to professional--SafeSport's approach to prevent emotional, physical
and sexual abuse is designed to create a greater positive impact than
any single sports organization can achieve alone.
Additionally, the USOC retained SafeSport to investigate all cases
of sexual misconduct or abuse for its 47 National Governing Bodies
(NGBs).
SafeSport's prevention efforts take shape in the form of two
offices within the organization.
Education and Outreach Office
The Education and Outreach Office administers programming to
promote respect and prevent abuse; raise awareness of issues; and
develops and distributes educational materials and resources. It serves
all sports organizations, athletes, parents and coaches.
SafeSport's current training has been taught to more than 300,000
coaches in the United States.
SafeSport is working on a resource guide that organizations can use
to evaluate their own policies, procedures, tools and training.
SafeSport's goal is to ensure that every sports organization in the
United States has access to the right kinds of policies and procedures,
tools and training materials to keep their athletes safe, regardless of
geography, socioeconomic status or competition level.
While SafeSport addresses the well-being of all athletes, its top
priority is on its most vulnerable participants, children. And while
best practices and training are essential, awareness of these issues is
an important first step, an additional accent on the importance of this
hearing. Our awareness campaigns will be supported by ``SafeSport
Champions'', a program that will draw on the popularity of certain
athletes and coaches to bring attention to these important issues.
The Response and Resolution Office
The Response and Resolution Office investigates and resolves
reports of sexual misconduct for the U.S. Olympic and Paralympic
Movements. Its neutral and independent investigators and arbitrators
review reports, and gather and analyze data, to improve awareness and
prevention programs. Currently, SafeSport has 35 active cases in 14
different sports.
SafeSport's reporting process is available to anyone wanting to
report abuse within the Olympic and Paralympic NGBs. SafeSport
immediately reports allegations of child abuse to the appropriate law
enforcement agency. If a covered individual violates the SafeSport
Code,\3\ that person can be sanctioned, up to and including a lifetime
ban enforced across the Olympic and Paralympic Movements.
---------------------------------------------------------------------------
\3\ SafeSport Code full copy in Appendix
---------------------------------------------------------------------------
Three policies govern the resolution process for the U.S. Olympic
and Paralympic Movement's 47 sport's National Governing Bodies:
SafeSport Code for the U.S. Olympic and Paralympic
Movement--The Code applies to all Covered Individuals and
identifies and defines prohibited conduct.
SafeSport Practices and Procedures for the U.S. Olympic and
Paralympic Movement--These Procedures set forth the informal
and formal resolution process the Office uses to resolve
possible violations of the Code within the Office's authority.
Supplementary Rules for U.S. Olympic and Paralympic Movement
SafeSport Arbitrations--The Rules govern the arbitration
process (when applicable).
Below is a graphic that illustrates how the Response & Resolution
Office works to investigate and resolve possible violations of the
SafeSport Code. This chart is not meant to represent every aspect of
the process.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Appendix can be found at https://safesport.org/files/index/tag/
policies-procedures
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you, Ms. Pfohl.
Mr. Sailor.
STATEMENT OF SCOTT R. SAILOR, PRESIDENT,
NATIONAL ATHLETIC TRAINERS' ASSOCIATION
Mr. Sailor. Chairman Thune, Ranking Member Nelson, and
members of the Senate Committee on Commerce, Science, and
Transportation.
Thank you for the opportunity to participate in today's
hearing.
My name is Scott Sailor, and I am Chair of the Department
of Kinesiology, and Professor of the Athletic Training Program
at California State University Fresno. I am also proud to be
the President of the National Athletic Trainers' Association.
NATA is a professional organization serving more than 46,000
Certified Athletic Trainers, students of athletic training, and
other healthcare professionals.
Protecting the health and safety of athletes is exactly
what members of NATA have been doing since the organization was
founded in 1950. The mission of NATA is to represent, engage,
and foster the continued growth and development of the athletic
training profession and athletic trainers as unique healthcare
providers.
Athletic trainers are healthcare professionals who
collaborate with physicians to provide preventative services,
emergency care, clinical diagnosis, therapeutic intervention,
and rehabilitation of injuries. They are required to graduate
from an accredited baccalaureate or master's degree program. An
academic curriculum and clinical training follow the medical
model. Athletic trainers are licensed and otherwise regulated
in 49 States and the District of Columbia.
NATA has long been a leader in bringing a voice to the many
health and safety issues facing athletes. We actively provide
our expertise and specific recommendations to policymakers at
the local, State, and Federal levels.
NATA believes Congress should fully invest in efforts to
track youth sports injuries and fatalities. It is only with a
comprehensive system for collecting and analyzing this data
that we will be able to understand the scope of the problem and
the best methods for addressing it.
Based upon current published studies and available data, we
know America faces challenges balancing an active and healthy
sports culture while protecting the safety of the youth
athlete.
I would like to give you a few of the current statistics on
athletic involvement and injuries in the United States.
There are 420,000 college-level athletes who experience
209,000 injuries per year. At the secondary school level, there
are 7.6 million athletes who have 1.4 million injuries per
year. The 46.5 million children playing team sports in our
country have 1.35 million injuries per year. In 2013, there
were 124 million emergency room visits by children 19 years of
age and younger for injuries related to sport.
These injury statistics are compelling, but to athletic
trainers, the most compelling fact is that the secondary school
athletic population leads the Nation in athletic-related
deaths.
Between 2008 and 2015, there were more than 300 sports-
related fatalities among young athletes. Let me underscore that
fact. In a 7-year period, we lost over 300 children who were
merely playing sports. As a Nation, we must do a better job of
protecting our youth athletes.
However, only an estimated 42 percent of high schools
employee a full-time athletic trainer. We need to improve
access to athletic trainers in secondary schools and youth
sports organizations.
We have a responsibility here to our athletes to provide
appropriate medical care. The investment in proper safety
measures and adequate medical supervision such as a full time
athletic trainer is not costly when compared to the death or a
catastrophic injury of a young athlete.
In 2010, NATA founded the Youth Sports Safety Alliance,
YSSA, which is now comprised of nearly 290 organizations. The
members of YSSA range from parent advocate groups, research
institutions, professional associations, healthcare
organizations, and youth sports leagues. NATA and YSSA are
working to promote and preserve sports, but we must also ensure
that sports are played safely. When injuries occur, we must be
adequately prepared to respond.
In 2013, NATA also sponsored the Safe Sports School Award,
a program designed to establish a standard for secondary school
athlete safety and recognize those athletic programs that excel
in taking all the necessary steps to ensure athlete safety. To
date, there have been more than 1,100 schools that have
received the Award.
NATA partners with the American Medical Society for Sports
Medicine, and the Korey Stringer Institute in organizing
Collaborative Solutions for Safety in Sports. This is an annual
event among youth sports safety leaders from every state who
come together to discuss appropriate sports medicine policy.
Finally, over the past several years, NATA has partnered
with the NFL Foundation, Gatorade, and the Professional
Football Athletic Trainers Society to fund multimillion dollar
efforts to place athletic trainers in underserved high schools.
With the knowledge and understanding of the physical and
mental benefits of being physically active, NATA has taken a
leadership role within a number of national coalitions involved
in promoting physical activity issues.
This week, NATA members were here on Capitol Hill urging
members of Congress to support the Personal Health Investment
Today Act or the PHIT Act. This legislation provides an
incentive for adults and their children to get fit, which will
help prevent healthcare costs related to preventable chronic
diseases.
I would like to thank Chairman Thune for being the lead
sponsor of the bill in the Senate and to thank Senators Wicker,
Moore Capito, and Baldwin for being cosponsors.
Athletic trainers are uniquely positioned to help with the
prevention of opioid abuse and successful rehabilitation from
injury among student athletes.
NATA supports proposals to increase access to and training
in administrating Naloxone.
NATA also supports the Student and Student Athlete Opioid
Misuse Prevention Act introduced by New Hampshire Senator
Shaheen. This bill authorizes new Federal grant funding to
support programs for students and student athletes as well as
training for teachers, administrators, and athletic trainers.
As a leading organization representing athletic trainers,
NATA fully supports Chairman Thune's and Senator Klobuchar's
Sports Medicine Licensure Clarity Act. I would like to thank
Senators Wicker and Moore Capito for being cosponsors of the
bill.
The Sports Medicine Licensure Clarity Act clarifies medical
liability rules for athletic trainers, and other medical
professionals, to ensure they are properly covered by their
liability insurance when traveling with athletic teams in
another state. This legislation also has the support of sports
leagues and professional medical associations. This week, most
senate offices were visited by athletic trainers requesting
support for this legislation.
I want to join my fellow athletic trainers, and the more
than 46,000 members of the NATA, in urging Members of the
Senate, including the members of this committee, to cosponsor
the Sports Medicine Licensure Clarity Act.
Thank you for this opportunity to present the views of the
National Athletic Trainers' Association and I welcome your
questions.
[The prepared statement of Mr. Sailor follows:]
Prepared Statement of Scott R. Sailor, President,
National Athletic Trainers' Association
On behalf of the National Athletic Trainers' Association (NATA), I
am pleased to have the opportunity to provide testimony to the United
States Senate Commerce, Science, and Transportation Committee on the
important topic of protecting the health and safety of American
athletes. My name is Scott R. Sailor and I am the President of NATA and
Chair of the Department of Kinesiology and Program Director for the
Athletic Training Program at Fresno State University.
NATA is a professional organization serving more than 46,000
certified athletic trainers, students of athletic training, and other
health care professionals. Protecting the health and safety of athletes
is exactly what NATA members have been doing since the organization was
founded in 1950.
Background on the Athletic Training Profession
The mission of NATA is to represent, engage, and foster the
continued growth and development of the athletic training profession
and athletic trainers as unique health care providers. Athletic
trainers are health care professionals who collaborate with physicians
to provide preventative services, emergency care, clinical diagnosis,
therapeutic intervention, and rehabilitation of injuries. As part of
the health care team, services provided by athletic trainers include
injury and illness prevention, wellness promotion and education,
emergent care, examination and clinical diagnosis, and therapeutic
intervention.
Athletic trainers provide urgent and acute care of injuries; they
specialize in preventing, diagnosing, and treating muscle and bone
injuries. Athletic trainers are included under the allied health
professions category as defined by the U.S. Department of Health and
Human Services and are assigned National Provider Identifier numbers.
In addition to employment by sports and athletic organizations,
athletic trainers are employed by hospitals, clinics, occupational
health departments, wellness facilities, the United States military,
and numerous other health care settings.
Athletic trainers are highly qualified, multi-skilled health care
professionals. To provide appropriate care for patients, athletic
trainers receive training in prevention, recognition, and treatment of
critical situations. They must graduate from an accredited
baccalaureate or master's program and it is required that athletic
trainers' academic curriculum and clinical training follow the medical
model. Leaders of key athletic training organizations, including NATA,
have jointly decided to change the athletic training degree level to be
a master's; this change is in process and will become effective by
2022. Currently, 70 percent of athletic trainers already have advanced
degrees beyond a bachelor's degree. Athletic trainers are licensed or
otherwise regulated in 49 states and the District of Columbia.
Using a medical-based education model, athletic trainers serve as
allied health professionals with an emphasis on clinical reasoning
skills. The curriculum of an accredited athletic training program must
include a comprehensive basic and applied science background and uses a
competency based approach in both the classroom and clinical settings.
Athletic training education programs are accredited by the
Commission on Accreditation of Athletic Training Education (CAATE),
which is recognized by the Council for Higher Education Accreditation.
The CAATE sets forth rigorous standards for the preparation of athletic
training graduates that are science-based and didactic. CAATE also
administers post-professional athletic training residency programs.
Upon completion of an accredited athletic training program,
athletic trainers are required to pass a comprehensive examination
administered by the Board of Certification, Inc. (BOC). The BOC
certification program ensures that individuals have the knowledge and
skills necessary to perform the tasks critical to safe and competent
practice as an athletic trainer. Athletic trainers who pass the BOC's
examination are awarded the ATC credential.
Athlete Health and Safety Issues
NATA has long been a leader in bringing a voice to the many health
and safety issues facing athletes. We are actively engaged in providing
our expertise and specific recommendations to policymakers at the
local, state, and Federal levels.
As a health professional organization, we pride ourselves on
staying informed of the latest research findings and reports related to
athlete safety. The athletic trainers involved in conducting research
and analyzing sports injuries are doing outstanding work. However, NATA
urges Congress to fully invest in efforts to track youth sports
injuries and fatalities. It is only with a comprehensive system for
collecting and analyzing this data that we will be able to understand
the scope of the problem and the best methods for addressing it.
Based upon current studies and reports, the following statistics
provide the best snapshot of the relationship between athletic
participation and sports-related injuries in the Unites States:
420,000 college-level athletes experience 209 million
injuries per year;
7.6 million secondary school athletes experience 1.4 million
injuries per year;
46.5 million children playing team sports experience 1.35
million injuries per year;
62 percent of injuries occur during practice; and
1.6 to 3.8 million sports-related concussions occur every
year.
In 2013, there were 1.24 million emergency room visits by children
19 years of age and under for injuries related to sports; that is 3,397
visits per day, 141 per hour, and 1 every 25 seconds.
These injury statistics are compelling, but to athletic trainers,
the most concerning fact is that the secondary school athletic
population leads the Nation in athletic-related deaths. Between 2008
and 2015, there have been more than 300 sports-related fatalities among
young athletes. Let me underscore this fact; in a seven-year period, we
lost over 300 children who were merely playing sports. As a nation, we
must do a better job in protecting youth athletes.
Athletic trainers are experts in creating and applying strategies
to prevent and reduce the many different causes of sudden death in
athletic participation. The underlying causes of sudden death in
athletics might include asthma, catastrophic brain injuries, cervical
spine injuries, diabetes, exertional heat stroke, and sudden cardiac
arrest, which is the leading cause of death in young athletes.
NATA supports proposals to ensure that every high school with an
athletics department has a full-time athletic trainer on staff to
monitor the health of student athletes. However, only an estimated 42
percent of high schools employ a full-time athletic trainer. We must
improve access to athletic trainers in secondary schools and youth-
sports organizations.
The investment in proper safety measures and providing adequate
medical supervision, such as a full-time athletic trainer, for sports
practices and games is not costly when compared to the loss of a young
life to injury that may have been prevented or properly treated.
NATA further advocates for the implementation of emergency action
plans for all sporting events and venues. These plans, developed in
conjunction with a health care team, ensure a plan of action is in
place in case of injury, whether minor or catastrophic.
NATA's Leadership on Youth Athlete Safety Issues
In 2010, NATA founded the Youth Sports Safety Alliance (YSSA),
which is now comprised of nearly 290 organizations. The members of YSSA
range from parent advocate groups, research institutions, professional
associations, health care organizations, and youth sports leagues.
Organized sports bring enormous health benefits to children, but
certain factors may cause them to ignore pain and injuries, which could
result in lifelong injuries or even death. NATA is working to preserve
amateur and professional sports, but we must also ensure that sports
are played safely and that when injuries occur, we are adequately
prepared to respond.
NATA has worked on a number of other partnerships and initiatives
to bring attention to youth athlete safety issues at a local, state,
and national level including the following:
NATA Safe Sports School Award: Since 2013, NATA has
sponsored the Safe Sports School Award, a program designed to
establish a standard for secondary school athlete safety and
recognize those athletic programs that excel in taking all the
necessary steps to ensure athlete safety. To date, there have
been more than 1,100 schools that have received the award.
At Your Own Risk Campaign: NATA has developed a public
awareness campaign, At Your Own Risk, aimed specifically at
educating parents, student athletes, school administrators,
legislators, and employers on the role of athletic trainers as
experts in prevention and safety in work, life, and sport.
Annual Youth Sports Safety Leaders Event: NATA partners with
the American Medical Society for Sports Medicine, the Korey
Stringer Institute, and the National Football League (NFL) in
organizing ``Collaborative Solutions for Safety in Sports,'' an
annual event among youth sports safety leaders from every state
to discuss emergency action planning and coaching education in
secondary schools.
Athletic Trainers in Underserved High Schools: Over the past
several years, NATA has partnered with the NFL Foundation,
Gatorade, and the Professional Football Athletic Trainers
Society to fund multimillion dollar efforts to place athletic
trainers in underserved high schools.
Publications on Best Practices: NATA continues to publish
resources on best practices related to preventing sudden death
in secondary school athletics, concussion, heat
acclimatization, emergency action plans, lightning safety, and
other emerging athlete safety issues.
Promoting Physical Activity
Athletic trainers more than any other health profession understand
the physical and mental health benefits of an active lifestyle. While
NATA has been engaged in raising awareness of youth athlete safety
issues, we have remained just as steadfast in our efforts to promote
the benefits of physical activity and sports. NATA has had both of
these issues at the top of its Federal legislative agenda for many
years.
The Centers for Disease Control and Prevention's National
Prevention Strategy ``outlines the importance of preventive care and
recognizes that active living is important to reducing the burden of
disease and death.'' According to the U.S. Department of Health and
Humans Services' 2008 Physical Activity Guidelines, ``adults who are
physically active are healthier and less likely to develop many chronic
diseases than adults who are not active--regardless of their gender or
ethnicity.''
Further statistics show that participation in sport helps children
develop and improve cognitive skills. Physical activity in general is
associated with improved academic achievement, including grades and
standardized tests scores. Such activity can affect attitudes and
academic behavior, including enhanced concentration and attention and
improved classroom behavior. Physical activity and sports in particular
can positively affect aspects of personal development among young
people, such as self-esteem, goal setting, and leadership. Moreover,
high school athletes are more likely than non-athletes to graduate from
high school, attend college, and receive a degree.
On Tuesday, May 16, 2017, NATA members were on Capitol Hill, urging
Members of Congress to support the Personal Health Investment Today Act
or the PHIT Act. This legislation provides an incentive for adults and
their children to get fit, which will help prevent health care costs
related to preventable chronic diseases. I would like to thank Chairman
Thune for being the lead sponsor of the bill in the Senate and to thank
Senators Wicker, Capito, and Baldwin for being cosponsors. I would
encourage the other members of the Senate Commerce Committee to
cosponsor the PHIT Act.
Also, NATA has taken a leadership role within a number of national
coalitions involved in promoting physical activity issues. NATA's
Director of Government Affairs, Amy Callender, represents us on the
Board of Directors of the National Physical Activity Plan Alliance and
she is the President of the Board of Directors of the National
Coalition to Promote Physical Activity.
The Opioid and Prescription Drug Epidemic
The widespread availability and abuse of prescription opioids and
heroin has been recognized as a public health crisis by both lawmakers
and the public.
In 2016, an estimated one in five patients with non-cancer pain or
pain-related diagnoses was prescribed an opioid. In many cases,
addiction to prescription opioids can lead to abuse of less expensive
heroin. In 2014, there were 18,893 overdose deaths related to
prescription pain relievers and 10,574 overdose deaths related to
heroin.
Athletic trainers can play an important role in promoting safe
opioid use and preventing opioid abuse. Sports injuries may result in a
student being prescribed an opioid pain medication, putting student
athletes at a higher risk for abusing those medications. Athletic
trainers are uniquely positioned to help with the prevention of opioid
abuse and successful rehabilitation from injury amongst student
athletes.
If a student athlete is prescribed an opioid, the athletic trainer
at his or her school should be informed so they can assist with
monitoring the student's usage and recovery progress. Opioid overdoses
can be reversed when the lifesaving drug naloxone is promptly
administered. NATA supports proposals to increase access to and
training in administering naloxone, including amongst athletic
trainers.
In October 2015, the Obama Administration encouraged federal,
state, local, and private sector entities to address the prescription
drug abuse and heroin epidemic. NATA was invited to participate in this
effort and we shared educational materials on opioid misuse prevention
with our entire membership.
We were strong advocates for the passage of the Comprehensive
Addiction and Recovery Act or CARA. Also, NATA has provided comments
and recommendations on National Pain Strategy and we were represented
at the recently held ``Implementation of the National Pain Strategy
Listening Session'' hosted by the Office of the Assistant Secretary for
Health.
NATA also supports S. 786, the Student and Student Athlete Opioid
Misuse Prevention Act, introduced by New Hampshire Senator Jeanne
Shaheen. The bill is focused on preventing opioid abuse amongst
students, and particularly amongst student athletes. The bill
authorizes new Federal grant funding to support programs for students
and student athletes, as well as training for teachers, administrators,
and athletic trainers.
Other Federal Legislative and Regulatory Policy Issues
As the leading organization representing athletic trainers, NATA
fully supports Chairman Thune's Sports Medicine Licensure Clarity Act.
I would also like to thank Senators Klobuchar, Wicker, and Capito for
being original cosponsors of the bill.
The Sports Medicine Licensure Clarity Act clarifies medical
liability rules for athletic trainers and other medical professionals
to ensure they are properly covered by their liability insurance while
traveling with athletic teams in another state.
The legislation has the support of the Academy of Orthopedic
Surgeons, the American Medical Society for Sports Medicine, the
American Academy of Neurology, and numerous other physician and sports
medicine organizations. Additionally, the United States Olympic and
Paralympic Committee, the National Collegiate Athletic Association, and
every major American professional sports league have endorsed the bill.
The House version of the bill, H.R. 302, passed on January 9, 2017
and awaits action by the Unites States Senate. This week, most Senate
offices were visited by athletic trainers requesting support for this
legislation. I want to join my fellow athletic trainers and the more
than 46,000 members of NATA in urging members of the United States
Senate, including the members of this Committee, to cosponsor the
Sports Medicine Licensure Clarity Act.
Thank you for this opportunity to present the views of the National
Athletic Trainers' Association and I welcome your questions.
The Chairman. Thank you, Mr. Sailor.
Dr. Stern.
STATEMENT OF ROBERT A. STERN, Ph.D., PROFESSOR
OF NEUROLOGY, NEUROSURGERY, AND ANATOMY,
AND NEUROBIOLOGY; DIRECTOR, CLINICAL CORE,
BU ALZHEIMER'S DISEASE AND CTE CENTER,
BOSTON UNIVERSITY SCHOOL OF MEDICINE
Dr. Stern. Good morning, Mr. Chairman, Ranking Member
Nelson, and distinguished members of the Committee.
It is a great honor to appear before you today.
My name is Dr. Robert Stern. I am a Professor of Neurology,
and Neurosurgery, and Anatomy, and Neurobiology at Boston
University School of Medicine. I am also the Director of the
Clinical Core of the BU Alzheimer's Disease and CTE Center.
For the past 30 years, I have been conducting clinical
neuroscience research, primarily focused on issues pertaining
to neurodegenerative diseases such as Alzheimer's. Since 2008,
my research has focused on the long-term consequences of
repetitive brain trauma in athletes including Chronic Traumatic
Encephalopathy or CTE.
CTE is a neurodegenerative disease that can lead to
dramatic changes in mood, behavior, movement, and cognition
eventually leading to dementia. It is similar to Alzheimer's
disease, but it is a unique disease easily distinguished from
Alzheimer's and other diseases through postmortem
neuropathological examination.
We have actually known about CTE for almost 100 years. It
was originally called ``punch drunk'' or dementia pugilistica
in the early 1900s when it was believed to occur only in
boxers.
However, CTE has now been found in people who never boxed
from ages 16 to 98, including former youth, college, and
professional contact sport athletes such as football, hockey,
soccer, and rugby players. At this time, CTE can only be
diagnosed after death through postmortem neuropathological
examination.
It is very important to understand that concussion and CTE
are very distinct. A concussion is an acute brain injury which,
if managed appropriately, results in transient symptoms without
long-term consequences.
CTE, on the other hand, is a neurodegenerative disease that
appears to begin earlier in life when repetitive brain trauma
starts to trigger a cascade of events leading to progressive
destruction of the brain tissue. The symptoms often begin years
or decades after the brain trauma, after the cessation of the
athletic activity and continue to worsen as the individual
ages.
There have been numerous cases of advanced stage CTE
diagnosed postmortem in former athletes who had no symptoms of
concussion, no history of concussion, but who had extensive
exposure to what is referred to as sub-concussive trauma.
Several important questions about CTE remain unanswered
such as, how common is CTE? Why does one person get it and
another person does not? How can CTE be differentiated during
life from other diseases and conditions with similar symptoms?
To answer these and other questions the ability to diagnose CTE
while someone is living is the critical next step.
Our group at Boston University, and other scientists from
around the country and abroad, are actively conducting research
to develop methods to accurately diagnose CTE during life. I am
honored to be the lead investigator of a seven-year
longitudinal multicenter investigation funded by the National
Institute of Neurological Disorders and Stroke that brings
together a network of approximately 50 scientists from ten
major research institutions across the country.
The study referred to as the Diagnose CTE Research Project
is aimed at developing methods of diagnosing CTE during life.
In total, hundreds of former professional football players,
former college football players, and healthy controls will
undergo extensive testing over a three-day period at one of
four sites around the country, and then return 3 years later
for a follow-up evaluation. We are well underway, and yet, this
is just one study. So much more research is needed.
In closing, it is imperative that we do everything we can
as a Nation to continue to reap the profound benefits of
American sports and athletic participation, while also assuring
that we protect the health and safety of former, current, and
future American athletes. That is a difficult balance and
requires a combination of unbiased scientific information and
common sense.
I want to thank the Committee for your interest in
addressing this important issue, and for your continued
commitment toward protecting the health and safety of all
athletes.
I also want to express my gratitude toward the Senate for
approving the Fiscal Year 2017 Appropriations bill that was
recently signed into law with a $2 billion increase for the
National Institutes of Health including an additional $400
million in funding of Alzheimer's disease research. I urge you
to continue and to expand upon that type of support.
Thank you.
[The prepared statement of Dr. Stern follows:]
Prepared Statement of Robert A. Stern, Ph.D., Professor of Neurology,
Neurosurgery, and Anatomy & Neurobiology; Director, Clinical Core, BU
Alzheimer's Disease and CTE Center, Boston University School of
Medicine
Introduction
Mr. Chairman, Ranking Member Nelson, and distinguished Members of
the Committee, it is a great honor to appear before you today for this
hearing on ``Current Issues in American Sports: Protecting the Health
and Safety of American Athletes.'' I am a Professor of Neurology,
Neurosurgery, and Anatomy & Neurobiology at Boston University School of
Medicine. I am also the Director of the Clinical Core of the Boston
University (BU) Alzheimer's Disease and CTE Center, one of 29
Alzheimer's research centers funded by the National Institute on Aging.
For the past 30 years, I have been conducting clinical neuroscience
research, primarily focused on the cognitive, mood, and behavioral
changes of aging, in general, and in neurodegenerative diseases, in
particular. I have been on the faculties of the University of North
Carolina School of Medicine, Brown Medical School, and, for the past 13
years, BU School of Medicine. In my role in the BU Alzheimer's Disease
and CTE Center, I oversee all clinical research pertaining to
Alzheimer's disease (AD), including studies aimed at the diagnosis,
genetics, prevention, and treatment of this devastating cause of
dementia.
Chronic Traumatic Encephalopathy (CTE)
You may be asking, ``Why is an Alzheimer's disease specialist
testifying at a hearing on Protecting the Health and Safety of American
Athletes?'' The answer is, in short, that repetitive hits to the head,
such as those incurred through American tackle football and other
contact sports, can have long-term negative consequences to brain
health, including the development of another neurodegenerative disease,
chronic traumatic encephalopathy or CTE. In 2008, I co-founded the BU
Center for the Study of Traumatic Encephalopathy (now referred to as
the BU CTE Center) with Dr. Ann McKee, Dr. Robert Cantu, and Mr.
Christopher Nowinski.\1\ Since that time, my research has focused on
the long-term consequences of repetitive brain trauma in athletes,
including CTE, a progressive neurodegenerative disease that can lead to
dramatic changes in mood, behavior, and cognition, eventually leading
to dementia. It is similar to Alzheimer's disease, but it is a unique
disease, easily distinguished from AD and other diseases through post-
mortem neuropathological examination (McKee et al., 2013; 2016). CTE
has been found in individuals from ages 16-98, including youth,
college, and professional contact sport athletes (e.g., football,
hockey, soccer, and rugby players, as well as boxers), military service
members exposed to blast trauma and other brain injuries, and others
with a history of repetitive brain trauma, such as a physically abused
woman, developmentally disabled head bangers, and seizure disorder
patients. (See Table 1)
---------------------------------------------------------------------------
\1\ Christopher Nowinski will formally receive his Ph.D. in
Behavioral Neurosciences from Boston University School of Medicine on
the day following this Hearing (May 18, 2017).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
CTE has been known to affect boxers since the 1920s (previously
referred to as ``punch drunk'' or dementia pugilistica). The post-
mortem neuropathological characteristics were first clearly described
in the 1970s by Corsellis et al., (1973). In 2002, CTE was diagnosed
neuropathologically in a former professional football player for the
first time (i.e., Mike Webster of the Pittsburgh Steelers). That case
and subsequent discoveries of CTE in other deceased former NFL players
led to growing media attention on CTE. Until recently, I have stated
publicly that the scientific knowledge of CTE is in its infancy.
However, due to important new scientific discoveries about CTE, along
with an exponential increase in the number of publications in medical/
scientific journals focusing on CTE (See Figure 1), I am led to think
that we are now in the ``toddlerhood'' of our scientific knowledge
about this disease.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
CTE Neuropathology
What is currently known about CTE is based primarily on post-mortem
examinations of brain tissue, and interviews from the family members of
the deceased athletes. My colleague, Dr. Ann McKee, and her team have
examined more brains of individuals with a history of repetitive brain
trauma than any group in the world. What these studies have shown is
that, in some individuals, repetitive brain trauma triggers a cascade
of events in the brain leading to progressive destruction of the brain
tissue. The hallmark feature of CTE is the build-up of an abnormal form
of a protein called tau (See Figure 2; based on the work of Dr. McKee).
The tau protein becomes hyperphosphorylated (referred to as p-tau) and,
rather than serve its vital role in the structure and function of brain
cells, it becomes toxic, eventually destroying the cells. In 2015, the
National Institute of Neurological Disorders and Stroke (NINDS) and the
National Institute of Biomedical Imaging and Bioengineering (NIBIB)
convened a consensus conference panel of seven independent
neuropathologists with specific expertise in neurodegenerative
tauopathies (McKee et al., 2016). The group of experts agreed that CTE
is a unique disease, only seen in individuals with a history of
repetitive brain trauma. Further, they agreed that the pathognomonic
lesion of CTE (i.e., the changes in the brain that are uniquely found
in CTE and can be used to diagnose it) is an irregular deposition of p-
tau around small blood vessels at the depths of the cortical sulci
(i.e., the valleys of the cerebral cortex). This pattern of p-tau was
agreed to be distinct from any other neurodegenerative tauopathy,
including Alzheimer's disease and frontotemporal lobar degeneration. As
the disease advances, the disease spreads to other areas of the brain,
leading to progressive destruction of brain tissue (i.e., atrophy). The
changes in the brain from CTE can begin years, or even decades, after
the last brain trauma or end of athletic involvement.
CTE is not prolonged post-concussion syndrome, nor is it the
cumulative effect of concussions or mild traumatic brain injuries.
Rather, CTE is not a ``brain injury,'' per se; CTE is a
neurodegenerative disease that appears to begin earlier in life, at the
time of exposure to repetitive head impacts, but the symptoms often
begin years or decades after the brain trauma and continue to worsen as
the individual ages. Importantly, there have been numerous cases of
neuropathologically-confirmed later stage CTE without any history of
symptomatic concussions, but with extensive exposure to
``subconcussive'' trauma (see below).
The Clinical Features of CTE
Depending upon the areas of the brain destroyed by the disease, CTE
can lead to a variety of changes in cognitive, behavioral, mood, and
often motor functioning (See Table 1). As cognitive impairment worsens,
the individual typically demonstrates progressive dementia, i.e.,
memory and other cognitive dysfunction severe enough to impair
independence in activities of living. Although the cognitive changes in
CTE are very similar to those in Alzheimer's disease, many individuals
with CTE develop the significant changes in mood and behavior
relatively early in life (Stern, et al., 2013). This can lead to
significant distress for the individual with CTE as well as their
family, friends, and other loved ones. These mood and behavioral
impairments associated with CTE are often misdiagnosed and attributed
to routine psychiatric disorders, stress, substance abuse, or pre-
existing personality traits. Although there can be many potential
underlying causes for changes in mood and behavior in individuals in
their 20s-50s, it is also known that the areas of the brain damaged in
CTE could lead to these problems, including depression, impulsivity,
emotional liability, irritability, and behavioral dyscontrol. Based on
reviews of the published case reports and other literature, along with
our own research of the reported clinical features of CTE in
neuropathologically-confirmed cases (Stern et al., 2013), our group
published provisional Research Diagnostic Criteria for the clinical
presentation of CTE, referred to as Traumatic Encephalopathy Syndrome
or TES (Montenigro et al., 2014). An important aspect of these proposed
diagnostic criteria is the use of objective biological tests (i.e.,
biomarkers), when they are available and validated, to indicate that
CTE is the underlying disease for the clinical presentation. This
diagnostic approach is similar to that currently accepted in the
research community for the clinical diagnosis of Alzheimer's disease,
including Mild Cognitive Impairment (MCI) due to Alzheimer's disease
and dementia due to Alzheimer's disease.
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Although there are have been tremendous gains in our understanding
of CTE during the last decade, there remain many important questions
(see Table 2). Most of these questions cannot easily be answered until
CTE can be diagnosed during life. However, we cannot wait until CTE can
be diagnosed during life to begin to examine the short-term and long-
term neurological consequences of repetitive head impacts in athletes.
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Concussions are the Tip of the Iceberg: Importance of Subconcussive
Trauma
The Centers for Disease Control and Prevention (CDC) estimates as
many as 3.8 million concussions occur in the U.S. each year through
sports and recreational activities. It is clear that a single sports-
related concussion can result in significant physical, emotional, and
cognitive symptoms and signs. Although the majority of concussions
resolve within a few weeks, 10-30 percent result in prolonged recovery
(i.e., post-concussion syndrome). However, at some point, a single
concussion is likely to completely resolve and result in no long-term
consequences. It is likely that concussions are only the ``tip of the
iceberg,'' when it comes to long-term neurological problems, in
general, and CTE, in particular. What is significantly more common than
symptomatic concussions are ``subconcussive'' hits. This subconcussive
trauma is believed to occur when there is impact to the brain with
adequate force to have an effect on neuronal functioning, but without
immediate symptoms and signs of concussion. Some sports (e.g., American
tackle football) and positions (e.g., lineman) are very prone to these
impacts. The most common method used to quantify the number of these
subconcussive impacts involves helmets outfitted with accelerometers,
devices that measure the linear, lateral, and rotational forces of
impacts. Numerous studies have been published over the past 10 years,
primarily in tackle football at the high school and college level. For
example, a study by Broglio and colleagues (2011) found that high
school football players received, on average, 652 hits to the head in
excess of 15g of force in a single season. One player received 2,235
hits. The average number of hits in college players is even greater.
There is now growing evidence that even after one season, repetitive
subconcussive trauma can lead to cognitive, physiological, and
structural changes to the brain (e.g., Abbas et al., 2015; Davenport et
al., 2014, 2016; Helmer et al., 2014; McAllister et al., 2012;
Breedlove et al., 2012; Poole et al., 2015; Kawata et al., 2017). One
recent study of youth (8-12 year olds) tackle football by researchers
at Wake Forest University (Bahrami et al., 2016) had rather striking
results. In this study, the players underwent a special type of MRI
scan, referred to as diffusion tensor imaging (DTI), prior to the
season, and then again following the football season. The players wore
helmets with accelerometers during the course of the season. Without
including any players with symptomatic, diagnosed concussions, the
researchers found that players who experienced greater cumulative head
impact exposure (i.e., more hits above a g-force threshold across the
season) had more changes in the integrity of the white matter of the
brain. Research studies such as these provide strong support that there
are short-term neurological consequences of repetitive subconcussive
trauma.
Cumulative Head Impact Exposure
One thing we do know about CTE is that every case of post-mortem
diagnosed CTE has had one thing in common: a history of repetitive
brain trauma (Bieniek et al., 2015). This means that the repetitive
brain trauma is a necessary factor in developing this disease. However,
it is not a sufficient factor. That is, not everyone who hits their
head repeatedly will develop this progressive brain disease. There are
additional, as yet unknown, variables that lead to CTE, such as genetic
susceptibility or specific aspects of the exposure to the brain trauma
(e.g., severity and type of trauma, amount of rest between hits, total
duration of exposure to trauma, cumulative number of head impacts, age
of first exposure). An important next step in CTE research is to
examine the specific aspects of head impact exposure, vis-a-vis risk
for later life neurological changes.
Similar to measuring and modeling ``exposure'' to toxins in the
environment or in the workplace, our group has been employing the
approaches and techniques used in Exposure Science to guide our
examination of exposure to head impacts through tackle football. We
recently published a study evaluating the relationship between the
estimated cumulative number of head impacts received playing amateur
football and later life mood, behavioral, and cognitive functioning
(Montenigro et al., 2016). In this study, we developed the cumulative
head impact index (CHII), using a sample of 93 former high school and
college American football players, with an average age of 47. The CHII
was calculated from an algorithm based on the number of seasons played,
position(s) played, levels played (youth, high school, college), and
estimated head impact frequencies from published helmet accelerometer
studies. The total number of hits was not meant to reflect merely the
number of ``concussions,'' but, rather, all impacts above a minimum
force, including those referred to as subconcussive hits. The average
number of total impacts estimated to have been received by participants
in our study was 7,742, a number that is consistent with the range of
cumulative impacts expected for former high school and college football
players based on previous published helmet accelerometer studies. We
found a strong, dose-response relationship between the estimated total
number of head impacts experienced through youth, high school, and
college football and the risk of developing clinically-meaningful
cognitive, mood, and behavioral impairments later in life. Figures 3
and 4 depict the dose-response relationships between the CHII and
later-life depression and cognitive impairment, respectively. In
layman's terms, the more hits to the head a football player received in
his career, the more likely he was to have impaired cognitive
functioning, as well as depression, apathy, and behavioral regulation
difficulties.
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We have also found significant relationships between greater
lifetime exposure to head impacts in football (using the CHII metric)
and objective biomarkers of possible overall neurodegeneration in
former NFL players between the ages of 40-69 years. For example, in one
study (Alosco et al., 2016), the greater the exposure level (i.e., the
amount of estimated head impacts), the higher the amount of total tau
protein in blood, as determined by a state-of-the-art blood test using
ultrasensitive single-molecule array (Simoa) assays (p = 0.014; see
Figure 5). Other studies from our group have found significant
relationships between the estimated overall exposure to head impacts
and the amount of atrophy of specific areas of the brain (using
magnetic resonance imaging [MRI]), as well as alterations in brain
chemistry (using magnetic resonance spectroscopy [MRS]). The
relationship between the total years playing football and the severity
of postmortem tau pathology in CTE has also been reported (Cherry et
al., 2016).
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Age of First Exposure to Tackle Football
The brain undergoes significant maturation and development during
childhood, with several brain structures and functions reaching their
peaks or plateaus of development during the period leading up to age 12
(see Table 3). Our group conducted a study to investigate whether or
not there is a relationship between experiencing repeated hits to the
head during this critical period of brain development and cognitive
difficulties later in life (Stamm et al., 2015). Participants in this
study were former NFL players ages 41-65 who were part of my NIH-funded
DETECT study at Boston University. The former players were divided into
two groups: those who began playing tackle football before age 12 and
those who began at age 12 or older. We examined their performance on
tests of memory and mental flexibility. We found that even after
accounting for the total number of years they played football, those
who began playing before age 12 performed significantly worse on all
tests we measured. This suggests that being hit in the head repeatedly
through tackle football during a critical time of brain development is
associated with later-life cognitive difficulties. In a subsequent
similar study (Stamm et al., 2015) of the same sample of former NFL
players, conducted in collaboration with my colleagues, Drs. Martha
Shenton and Inga Koerte at Brigham and Women's Hospital in Boston, we
examined the relationship between the age of first exposure to tackle
football and the structural integrity of the corpus callosum, the large
white matter fiber tracts connecting the two hemispheres of the brain.
The former players underwent MRI scans with diffusion tensor imaging
(DTI) which showed that subjects who began playing football before age
12 were found to have significantly altered integrity of the anterior
portions of the corpus callosum at middle-age, compared to those who
began playing football at age 12 or older.
The participants in these studies were all former NFL players,
which limits the ability to apply these findings to other groups of
athletes. However, in another investigation from our group, we studied
former football players who only played up through high school or
college, and we found that those who began playing tackle football
before age 12 had significantly greater impairments in mood and
behavior as adults, compared with those who began playing at age 12 or
older. More research is needed to study this question in athletes who
played other sports, and female athletes, as females generally reach
milestones of brain development earlier than males.
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Diagnosing CTE During Life
Our group at BU and other scientists from around the country and
abroad are conducting research to develop methods of accurately
diagnosing CTE during life. Fortunately, because CTE is similar to
Alzheimer's disease and other neurodegenerative disorders, we can
exploit the incredible discoveries and advances in diagnostic tests
developed for these other disorders in recent years to accelerate our
ability to diagnose CTE during life. Once we can accurately diagnose
CTE, we will be able to more clearly address the important questions
listed above in Table 2. We will be able to differentiate between CTE
and other causes of cognitive and behavioral change, including
Alzheimer's disease, Frontotemporal Dementia, PTSD, persistent symptoms
from previous repetitive or single concussions, ``routine'' depression
and aggressive behavior, and others. We will be able to measure more
clearly the true incidence and prevalence of the disease. We will be
able to determine more accurately the risk factors (including genetic
and exposure variables) for developing CTE. Perhaps most importantly,
we will be able to begin clinical trials for the treatment and
prevention of CTE, as new anti-tau compounds (as well as other disease
modifying treatments) move through the pharmaceutical development
pipeline. And, similar to Alzheimer's disease and other
neurodegenerative diseases, the earlier a disease modifying treatment
can be initiated, the more likely it will be successful in slowing the
progression of symptoms. That is, once a disease has resulted in too
much destruction of brain tissue, it may be too late to intervene
successfully (i.e., the destroyed tissue cannot be regenerated).
Therefore, early detection of the disease, before symptoms manifest,
can potentially prevent the symptoms from ever appearing. However, it
is likely that not all CTE will be able to be prevented and, therefore,
there will always be need for successful methods of treating and
slowing the progression of symptoms.
Development of Biomarkers for CTE Diagnosis
In 2011, I was fortunate to receive a grant co-funded by the
National Institute of Neurologic Diseases and Stroke, the National
Institute of Aging, and the National Institute of Childhood Health and
Development (Grants #s R01NS078337 and R56NS078337) for a study
referred to as, ``Diagnosing and Evaluating Traumatic Encephalopathy
using Clinical Tests'' (DETECT). The goals of the DETECT study (which
was the first grant ever funded by NIH to study CTE) were to examine
the later-life clinical presentation of former NFL players at high risk
for CTE, and to begin to develop in vivo biomarkers for CTE. The DETECT
study concluded in 2015 and involved a total of 96 symptomatic former
NFL players and 28 same-age asymptomatic controls without head trauma
history. All research participants underwent extensive brain scans,
lumbar punctures (to measure proteins in cerebrospinal fluid),
electrophysiological studies, blood tests (e.g., for genetic studies
and novel potential biomarkers), and in-depth neurological,
neuropsychological, and psychiatric evaluations. In addition, Dr.
Martha Shenton of the Brigham and Women's Hospital and I received
Department of Defense funding for a related study to examine a
promising new Positron Emission Tomography (PET) ligand (developed and
owned by Avid Radiopharmaceuticals) that is designed to attach to
abnormal forms of tau protein, such as those found in CTE. I also
received a separate grant from Avid Radiopharmaceuticals to examine
that same PET scan, in conjunction with colleagues from Banner
Alzheimer's Institute and Mayo Clinic Arizona. Results from the DETECT
study have been very promising, resulting in preliminary support for
potential blood biomarkers of CTE (e.g., Alosco et al., 2017; Stern et
al., 2016; See Figure 6), as well as a variety of potential MRI and MRS
biomarkers (e.g., Koerte et al., 2016). In addition, preliminary
analyses of the tau PET data are encouraging.
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The DETECT study was just the first step. Much more research is
needed, including studies with longitudinal designs and much larger and
more diverse samples, the inclusion of newer techniques and
technologies, as well as post-mortem validation of the findings during
life.
DIAGNOSE CTE Research Project
In December 2015, I, along with three co-principal investigators
(Jeffrey Cummings, M.D., from the Cleveland Clinic; Eric Reiman, M.D.,
from Banner Alzheimer's Institute; Martha Shenton, Ph.D., from Brigham
& Women's Hospital), were honored to receive a $16 million
collaborative research grant funded by the National Institute of
Neurological Disorders & Stroke (U01NS093334), entitled, ``Chronic
Traumatic Encephalopathy: Detection, Diagnosis, Course, and Risk
Factors.'' The goals of the project are summarized in Table 4.
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To study the clinical presentation, diagnostic criteria,
biomarkers, and risk factors of CTE requires expertise across many
disciplines, including neurology, neuropsychology, psychiatry,
neuroimaging, molecular medicine, neuropathology, exposure science,
genetics, biostatistics, bioinformatics, engineering, and others. This
project brings together a network of approximately 50 scientists from
10 major research institutions from across the country, including
Banner Alzheimer's Institute in Arizona, BU Schools of Medicine and
Public Health, Brigham and Women's Hospital (Harvard Medical School),
Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Mayo
Clinic Arizona, New York University (NYU) Langone Medical Center and
NYU School of Medicine, VA Puget Sound, University of Washington,
Molecular NeuroImaging (New Haven, CT), and the Neuroinformatics
Research Group and Central Neuroimaging Data Archive (CNDA) at
Washington University School of Medicine (in St. Louis).
This 7-year, longitudinal, multicenter investigation, referred to
as the Diagnostics, Imaging, And Genetics Network for the Objective
Study & Evaluation of Chronic Traumatic Encephalopathy (DIAGNOSE CTE)
Research Project, is well underway. In total, we will examine 240
former professional football players, former college football players,
and healthy controls (without history of contact sports of brain
trauma), between the ages of 45-74. Participants will undergo extensive
testing over a three-day period at one of four sites (see Table 5), and
then return three years later for a follow-up evaluation. Examinations
include: Advanced MRI and MRS imaging; two brain PET scans to measure
abnormal tau and amyloid protein deposits, respectively; lumbar
punctures, to measure proteins and other substances in cerebrospinal
fluid; blood and saliva collection, to measure proteins and other
compounds using state-of-the-art analyses; extensive
neuropsychological, neuropsychiatric, neurological, and motor
examinations; and genetic testing, as part of risk factor analyses. We
are fortunate to have an External Advisory Board made up of Key Opinion
Leaders, including David Knopman, M.D., External Advisory Board Chair
(Professor of Neurology, Mayo Clinic), Col. Dallas Hack, M.D. (Ret.)
(Medical Leader, One Mind), Brian Hainline, M.D. (Chief Medical
Officer, National Collegiate Athletic Association), Mike Haynes (Member
of Pro Football Hall of Fame, President and founder, Mike Haynes &
Assoc.), Thomas McAllister, M.D. (Chair, Department of Psychiatry,
Albert Eugene Stern Professor of Clinical Psychiatry; Indiana
University School of Medicine), Arthur Toga, M.D. (Provost Professor;
Director of the Institute for Neuroimaging and Informatics, University
of Southern California), and Michael Weiner, M.D. (Professor of
Medicine, Radiology, Psychiatry, and Neurology, University of
California San Francisco). We are confident that based on the results
of this study, along with scientific advances in the diagnosis of other
neurodegenerative diseases, CTE will be able to be accurately diagnosed
during life within the next 5-10 years.
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Concussions, Repetitive Subconcussive Head Impacts, and CTE
Over the past 10 years, there have been tremendous strides made in
sports concussion awareness, prevention, detection, and management.
These gains have resulted in improved public health and have likely
saved the lives of many American athletes. Continued efforts must be
made to better detect concussion using objective tests, to reduce risk
for concussion, and to educate players, parents, coaches, medical
staff, and the public as a whole, about the concussions. However, I am
concerned that there is confusion regarding the difference between
concussion and CTE. A concussion is an acute brain injury, which, if
managed appropriately, results in transient symptoms, without long-term
consequences. CTE, on the other hand, is a neurodegenerative disease
that has only been diagnosed in individuals with a history of
repetitive head impacts. As stated above, the disease appears to begin
at the time of exposure to those repetitive impacts but often does not
result in any symptoms until years or decades following the cessation
of the exposure (i.e., ending involvement in the sport). It also
appears that it is the overall exposure to repetitive head impacts
(including the much more common subconcussive trauma) that results in
later life neurological disorders, including CTE. In short, concussion
and CTE are very distinct, and yet, there seems to be widespread
confusion about this. My hope is that the national discussion about
brain trauma in football and other contact sports can shift from a
focus primarily on ``concussion'' to the much more common and,
potentially more problematic, subconcussive trauma. In other words, the
big hits and symptomatic concussions can be easily observed, counted,
and, with appropriate societal effort, reduced. However, the
repetitive, subconcussive hits are currently viewed as fundamental to
certain sports (e.g., routine plays in American tackle football,
heading in soccer), but may have a greater negative overall impact on
public health.
Tackle Football History
American tackle football began in the late 19th century. It was
originally played without any protective headgear and then thin leather
helmets were worn. However, it was not until the 1950s and 1960s that
hard plastic helmets with facemasks were used. The helmets were
developed to prevent skull fractures (which they did and continue to do
extremely well), but they also allowed individuals to hit their head
repeatedly against their opponent without feeling pain, thus possibly
creating a sense of invincibility and also portraying minimal safety
concerns. In the 1960s and early 1970s, children started to play
organized American tackle football when Pop Warner youth football
became popular nationally. From a public health perspective, the first
individuals who played youth football are currently in their late 50s
and 60s, and the first individuals who played college football with
hard plastic helmets and facemasks are currently in their mid-70s.
Aside from boxing, there does not seem to be any other activity that
human beings have been involved with that includes exposure to
hundreds, thousands, or even tens of thousands of head impacts.
Although boxing has been around for hundreds of years, it was not until
the mid-20th century that it involved extensive exposure to repetitive
head impacts. It was at that time that the padded glove was used
routinely (initially meant as a means of protecting the hands from
injury, but also resulted in increased numbers of blows to the head).
Therefore, it is only in the past 55-65 years that large numbers of
human beings have been exposed to repetitive head impacts. While the
epidemiology of CTE is unknown, it is possible that millions of living
older adults are currently at high risk for CTE or other long-term
neurological conditions due to their history of exposure to repetitive
head impacts.
Decision-Making Regarding Participation in Tackle Football
With increased knowledge of the potential short-term and long-term
risks of repetitive head impacts and other injuries incurred through
tackle football, adult athletes should be able to make informed
decisions about participating. However, the issue of youth
participation is quite different because children's brains are not yet
fully developed, especially the frontal lobes, the parts of the brain
responsible for complex thought, planning, judgement, abstract
thinking, and decision-making. As such, children and adolescents are
not able to weigh the long-term risks and benefits of playing tackle
football (Bachynsky, 2016). Parents and other adults involved in the
decision-making process and in setting policies often search for
guidance from professional organizations, such as groups of medical and
scientific experts. One such organization is the American Academy of
Pediatrics (AAP) and its Council on Sports Medicine and Fitness which,
after reviewing the literature regarding tackling and football-related
injuries (including concussions, subconcussive trauma, and CTE),
published a Policy Statement, as part of the AAP ``Organizational
Principles to Guide and Define the Child Health Care System and/or
Improve the Health of all Children.'' (Council on Sports Medicine and
Fitness, 2015). At the end of their review, they provided the following
summary (with italics added for emphasis):
Removing tackling from football altogether would likely lead to
a decrease in the incidence of overall injuries, severe
injuries, catastrophic injuries, and concussions. The American
Academy of Pediatrics recognizes, however, that the removal of
tackling from football would lead to a fundamental change in
the way the game is played. Participants in football must
decide whether the potential health risks of sustaining these
injuries are outweighed by the recreational benefits associated
with proper tackling. (Council on Sports Medicine and Fitness,
2015; p. e1426)
It is my opinion that if making a fundamental change to the way a
game is played would likely decrease injuries, severe injuries,
catastrophic injuries, and brain injuries (i.e., concussions), then
perhaps there should be a recommendation that such a fundamental change
should be made. And, similar to Bachynsky (2016), in his editorial in
the New England Journal of Medicine critiquing the AAP Policy
Statement, I strongly believe that youth are not capable of making
their own decisions about participation in a game with these known
short-term and long-term risks. Therefore, parents, guardians, school
officials, leagues, coaches, state Departments of Health, and other key
decision-makers, require ongoing, up-to-date scientific/medical
information and guidance, not merely from the media or from groups with
potential financial conflicts of interest or other biases.
Consensus Statements developed at conferences sponsored and
organized by institutions with financial conflicts of interest (e.g.,
Federation Internationale de Football Association [FIFA], Federation
for Equestrian Sports [FEI], International Olympic Committee [IOC],
International Ice Hockey Federation [IIHF]), and written by experts in
concussion and brain injury, rather than in neurodegenerative diseases,
may not necessarily result in accurate summaries and recommendations
regarding the relationship between repetitive head impacts and CTE. One
example of a Consensus Statement published by a less biased group of
clinicians and scientists (including several with expertise in
neurodegenerative diseases and neuroscience) is the ``Expert Consensus
Document'' resulting from a one-day meeting convened by Safe Kids
Worldwide, the Alzheimer's Drug Discovery Foundation, and the Andrews
Institute for Orthopedics and Sports Medicine (Carmen et al., 2015).
Based on their review of the literature pertaining to CTE, they
concluded that CTE is a ``disease associated exclusively with
repetitive head trauma,'' that ``. . . long sporting careers are not
required for CTE development, and that youth athletes represent an at-
risk population.'' (p. 233)
Continued discussion and collaboration amongst expert scientists
and clinicians about the current state of scientific knowledge
regarding short-term and long-term consequences of repetitive head
impacts in contact sports is critically needed. Governmental
organizations (e.g., NIH, Department of Defense, Centers of Disease
Control and Prevention, Department of Veteran's Affairs) which serve as
the primary funders of biomedical research can and should take the
lead, by convening expert panels to help guide future scientific
discovery in this area, as well as to provide the public with accurate,
unbiased, state-of-the science summaries and recommendations aimed at
issues pertinent to improving public health.
Increased Funding for CTE Research
In order to tackle the complex issue of CTE, we must continue to
expand upon current approaches to conducting research in
neurodegenerative disease. We must continue to break down the
traditional silos of individual research labs, research institutions,
and disciplines, and begin to conduct multidisciplinary, collaborative,
and translational research, bringing together the very best scientists,
novel methodologies, and state-of-the-art technology. Most importantly,
we cannot forget that our research must focus on reducing individual
human suffering and improving public health. Alas, this requires
tremendous financial support. There is the possibility that millions of
Americans are at risk for developing CTE and other long-term
neurological complications from exposure to repetitive head impacts in
the sports they participated in during youth, high school, and college,
over the past six decades. However, there remain critical questions in
need of answers and gaps in our scientific knowledge are in need of
filling. We must do everything we can to continue to reap the profound
benefits of American sports while also assuring that we protect the
health and safety of former, current, and future American athletes.
Summary
In summary, many of our most cherished American sports, such as
tackle football, soccer, and hockey, involve repetitive blows to the
head, often resulting in changes to brain structure and function, even
after just one season of play. This exposure to repetitive head impacts
(often without any experience of symptomatic concussions) potentially
leads to a degenerative brain disease with later life impairments in
behavior, mood, and cognition, as well as the development of dementia
and lack of independent functioning. Therefore, it is imperative that
we: (1) determine who may be at increased risk for CTE and other long-
term consequences of the repetitive head impacts experienced by
athletes at all ages; (2) develop methods of accurately diagnosing CTE
during life (perhaps even before symptoms); and (3) create and test
methods of slowing the progression of the disease, treating its
symptoms, and even preventing the onset of symptoms altogether. I want
to close by thanking the Committee for your interest in addressing this
important issue and for your continued commitment toward protecting the
health and safety of all athletes.
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The Chairman. Thank you, Dr. Stern.
Ms. Williams.
STATEMENT OF LAURYN WILLIAMS, OLYMPIAN
AND PROUD TRUESPORT AMBASSADOR,
UNITED STATES ANTI-DOPING AGENCY
Ms. Williams. Mr. Chairman, Ranking Member Nelson, members
of the Committee.
Good morning. My name is Lauryn Williams. I am a four-time
Olympian, a three-time Olympic medalist, and a proud United
States Anti-Doping Agency TrueSport Ambassador.
I want to thank this Committee for its interest in clean
sport and for the opportunity to appear before you today to
discuss how we can better protect the rights of athletes around
the world.
When I started running at 9 years old, I never imagined I
would one day be competing in the Olympic Games, much less to
compete four times. Yet, I obtained the unobtainable. I became
the first American woman to win medals in both the Summer and
Winter Olympics. I was naturally fast from the start, but
innate talent was not always enough.
The cost of Olympic achievement is high. Opportunities
cost. The pursuit of an Olympic dream costs money, time,
experiences, and your social life among other things. But these
expenditures are not always a sacrifice, but a choice.
The thing is while we choose to chase the extraordinary
moments, we do so believing the basic idea that every athlete
deserves to compete on a level playing field. Sadly, that
notion is under attack and with it, the very credibility of the
Olympic Games.
Why? Because of the use of performance enhancing drugs.
Shortcuts are being taken for personal gain. Podium moments are
being stolen. And perhaps most disheartening, this kind of
abuse continues ad nauseam because sports leaders around the
world cannot find the will, or courage, to properly protect
athletes.
Chairman Thune, members of the Committee, I encourage you
to imagine dedicating your entire life to the mission of
representing your country and achieving your best performance.
To give your blood--literally give your blood--sweat, and
tears, only to have your dreams stolen by someone willing to
cheat. Someone willing to corrupt themselves and the sport you
love for a hollow victory. It is devastating. And when this
happens, clean athletes look to sport leaders who are supposed
to be our advocates, but we seldom get worthwhile responses.
When doping goes unpunished, clean athletes are left
wondering, what would my life look like if I had actually
competed on a level playing field? Am I owed a moment on the
podium? Should I have trained for another Olympics? Did I miss
sponsorships and endorsements that only come with an Olympic
medal? The unanswered questions degrade the experience
significantly.
Of course, there is individual suffering when clean
athletes lose their moments to cheaters, but it corrupts the
experience for others. Fans, spectators, sponsors, and society
as a whole are left asking, ``Why play if the game is rigged
and if the destination has become more important than the
journey?''
I am not the first athlete to say this on Capitol Hill. In
February, the House Energy and Commerce Subcommittee on
Oversight and Investigations heard Adam Nelson, the American
shot putter who, 9 years after the 2004 Summer Olympics,
received his gold medal in an airport food court; really, a
food court. And they heard from Michael Phelps, the most
decorated Olympian in history, who despite his own
unprecedented success, still questions whether he truly ever
competed on a level playing field while on the international
stage.
The reason that athletes like Adam, Michael, and myself
speak on issues like this is because we know that here in the
United States, we are being held to the highest standard there
is.
However, while American athletes are asked to report their
whereabouts 24 hours a day, 7 days a week so that drug testers
can knock on our door unannounced to request we pee in a cup,
or give blood, many athletes from other parts of the world are
not.
The simple truth is, not all elite athletes worldwide are
being held to the same standard we are and it is a frustrating
reality.
I was tested 66 times during my athletic career. That is 66
different times that a doping control officer tapped me on the
shoulder after a competition, or showed up at my home at 6
a.m., waking me and my family to take my blood, watch me pee in
a cup no matter what time of the month it was. That is 66 times
I bore the burden of having to prove I was competing clean,
that I was doing it the right way.
Yet somehow, and this is important, of the 11,470 athletes
who competed in Rio de Janeiro last summer, a staggering 4,125
of those athletes have no record of testing in the 12 months
prior to the Olympic Games. That is unacceptable!
So, I am here today to ask you this, how many more? How
many more Olympic Games are we going to allow to be corrupted
by performance enhancing drugs? How many more podium moments
need to be stolen? How many more dreams crushed? What kind of
message are we sending to the next generation of competitors?
As athletes, we have a responsibility to require that our
voices are heard and that we have an opportunity to be engaged
in the conversation that directly affects us.
Mr. Chairman, I encourage our Government, and governments
from around the world, to exercise your influence for this
important cause.
We are just 266 days away from the Winter Games in
PyeongChang. The clock is ticking. The time is now.
Thank you for your time.
[The prepared statement of Ms. Williams follows:]
Prepared Statement of Lauryn Williams, Olympian and Proud TrueSport
Ambassador, United States Anti-Doping Agency
Mr. Chairman, members of the Committee, good morning. My name is
Lauryn Williams; I am a four-time Olympian, three-time Olympic medalist
and a proud United States Anti-Doping Agency TrueSport Ambassador. I
want to thank this Committee for its interest in clean sport and for
the opportunity to appear before you today to discuss how we can better
protect the rights of athletes around the world.
When I started running at 9 years old I never imagined I would one
day be competing in the Olympic Games, much less four times. Yet, I
obtained the unobtainable, and I became the first American woman to win
medals in both the summer and winter Olympics. I was naturally fast
from the start, but innate talent isn't always enough.
The cost of these achievements is high. Opportunities cost. The
pursuit of an Olympic dream cost time, money, experiences, social life,
but the cost of these things are not a sacrifice but a choice.
But the thing is: while we choose to chase the extraordinary
moments, we do so believing the basic idea that every athlete deserves
to compete on a level playing field. But sadly, that notion is under
attack . . . and with it, the very credibility of the Olympic Games.
Why?
Because of performance-enhancing drug use.
Shortcuts are being taken for personal gain. Podium moments are
being stolen. And perhaps most disheartening, this kind of abuse
continues ad nauseam because sport leaders around the world cannot find
the will, or courage, to properly protect athletes.
Mr. Chairman I encourage you to imagine an entire life dedicated to
the mission of representing your country and achieving your best
performance. To give your blood, literally give your blood, sweat and
tears, only to have your dreams stolen by someone willing to cheat.
Someone willing to corrupt themselves and the sport you love for a
hollow victory. It's devastating. And when this happens, clean athletes
look to the sport leaders who are supposed to be our advocates . . .
but we seldom get a worthwhile response.
When doping goes unpunished, clean athletes are left wondering:
What would my life look like if I had actually competed on a level
playing field? Am I owed a moment on the podium? Should I have trained
for another Olympics? Did I miss sponsorships or endorsements that only
come with an Olympic medal? The unanswered questions degrade the
experience significantly.
There is individual suffering when clean athletes lose their moment
to cheaters, but it corrupts the experience for everyone. Fans,
spectators, sponsors, and society as a whole are left asking ``Why play
if the game is rigged? . . . If the destination has become more
important than the journey?''
I'm not the first athlete to say this on Capitol Hill. In February,
the House Energy and Commerce Subcommittee on Oversight and
Investigations heard from Adam Nelson, the American shot putter who,
nine years after the 2004 Summer Olympics, received his gold medal in
an airport food court. And they heard from Michael Phelps, the most
decorated Olympian in history, who despite his own unprecedented
success, still questions whether he ever truly competed on a level
playing field while on the international stage.
The reason that athletes like Adam, Michael, and myself speak on
these issues is because we know that here in the United States, we are
being held to the highest standard there is.
However, while American athletes are asked to report their
whereabouts 24 hours a day, seven days a week so that drug testers can
knock on our door unannounced to request we pee in a cup, or give
blood, many athletes from other parts of the world are not. The simple
truth is, not all elite-level athletes worldwide are being held to the
same standard as we are and it is frustrating reality.
I was tested 66 times during my athletic career. That's 66
different times a doping control officer tapped me on a shoulder after
a competition, or showed up at six a.m. to take blood or watch me pee
in to cup. That's 66 times that I bore the burden of having to prove I
was competing clean--that I was doing it the right way. Yet, somehow--
and this is important . . . Of the 11,470 athletes who competed in Rio
de Janeiro last summer, a staggering 4,125 of those athletes had no
record of testing in the 12-months prior to the Games. That's
unacceptable!
So, I'm here today to ask you this:
How many more?
How many more Olympic Games are we going to allow to be
corrupted by performance-enhancing drug use?
How many more podium moments need to be stolen?
How many more dreams crushed?
What kind of message are we sending to the next generation of
competitors?
As athletes, we have a responsibility to require that our voices
heard and that we have an opportunity to be engaged in a conversation
that directly affects us. Mr. Chairman I encourage our government, and
governments from around the world, to exercise your influence for this
important cause.
We are just 266 days away from the Winter Games in PyeongChang . .
. The clock is ticking . . . The time is now.
The Chairman. Thank you, Ms. Williams.
I will start with asking questions and we will do five
minute rounds with members of the Committee.
Ms. Deutscher, I want to begin again by thanking you and
your husband for being here and express our sympathy to you for
your family's loss.
Just looking back on that tragic experience, do you have
recommendations for other parents whose children face sports
injuries? And then maybe as a follow-up, are there warning
signs that you can share with other parents who are in similar
situations?
Ms. Deutscher. Education to me is key for the parent.
When it happened with Nick when he said, ``This Hydrocodone
is not cutting it,'' we should have just said stop. That would
be the advice that I would give to other parents. If it does
not seem right, it is probably not right.
The thing is we had excellent physicians. We had a great
athletic trainer who was working with Nick at OI. It just seems
like education and awareness of this issue is just so key.
The warning sign for Nick was when he said he needed
additional. I told Jeff, ``He has his hand out for this
Hydrocodone.'' So that is a big red flag. But he was still
going to school. He was training. He was rehabbing to get back
for the last game of the season.
I just think education and awareness and follow your
instincts, but it was 2011 and there was not the highlight on
it that there is now.
I do have to say, though, that addiction hits so swiftly. I
mean, it just kind of happened before our eyes. We all wanted
Nick to play football, everybody from the coaches, to the other
parents, to us. So education, awareness, and do not be afraid
to raise your hand and say stop. Then once the addiction does
kick in, it is just a sad, long journey.
Thank you.
The Chairman. Thank you.
Ms. Williams, Derek Miles who, as you know, is the
Associate Coach at the University of South Dakota recently
received a bronze medal for his performance at the 2008 Olympic
Games in Beijing. He received this medal more than eight years
after the actual games because the athlete that actually stood
on the podium in Beijing tested positive for a banned
substance. You mentioned this in your testimony and referred to
it.
How many other American athletes like Derek, do you think,
are still waiting to receive the Olympic medal they rightfully
earned? What can be done to ensure that that long awaited and
deserved medal gets there sooner rather than later?
Ms. Williams. I believe there are many other athletes that
are entitled to a medal that they did not receive, a moment
that has been stolen from them.
The thing that we need to do, one of the most important
right now, is to store samples a lot longer. So right now, they
are storing samples for 10 years, which is how Adam Nelson, 9
years after his medal, was able to find out that the person had
used performance enhancing drugs.
The longer we can store these samples, the better our
technology is getting, and we can look back and say, ``Now we
have new technology and we can know what you were using at this
time.'' And we can restore those opportunities.
But what we need to be doing too is to stop that from
happening and get the technology now, so that if we are getting
positive tests, we do not give medals to people who did not
rightfully earn them.
The Chairman. Yes, getting your Olympic medal at a food
court seems a little anticlimactic.
Ms. Williams. Very anticlimactic.
The Chairman. Mr. Sailor, in your written testimony, you
state that, and I quote, ``Underlying causes of sudden death in
athletics might include asthma, catastrophic brain injury,
cervical spine injuries, diabetes, exertional heat stroke, and
sudden cardiac arrest,'' to quote from your statement.
Given the diverse range of underlying causes that young
athletes may experience, is it reasonable to single out contact
football as the most problematic sport in need of fundamental
change?
Mr. Sailor. Well, as athletic trainers, we recognize that
the number one cause of death in athletes is cardiac. The other
issues that are killing our athletes today are related heat
stress, heat illness, as well as issues that deal with
concussion, of course.
The important thing that we need to recognize is that the
response to those crisis situations within the first few
minutes dictates in a large part to their outcome. It is
important that we have individuals there and a plan in place to
care for those athletes when those situations exist.
These are not strictly limited to the sport of football, of
course. We see concussion, we see heat, and we see cardiac in
many of our sports and it is important for us to be prepared
for those.
The Chairman. Do you think accessibility and influence of
athletic trainers in youth sports is a more appropriate
solution than fundamentally altering sports like football, for
example?
Mr. Sailor. I certainly believe in a comprehensive aspect
of addressing these issues.
I advocate for athletic trainers because I believe that it
is important for an individual, an adult, to be present that is
taking into consideration the safety as well as the preparation
for catastrophic injury at that site.
Often, we have other adults, but their primary charge is
things like coaching, and strategy, and things like that. We
need someone that is there, a trained professional, that looks
at things like creation of an emergency action plan and access
to the appropriate medical care. How do we access facilities in
the case of a catastrophic injury? That is what an athletic
trainer does by nature.
The Chairman. Thank you.
I will yield to Senator Nelson.
Senator Nelson. I will be quick so that we can get onto our
members' questions.
First of all, I want to say to Ms. Williams. Amen. Thank
you. You did it the right way and others cheated, and you still
got the medals, so, amen.
I want to say to Mrs. Deutscher, I do not understand how
you survived. What I do not understand is when your son was
asking for some more Oxycontin, what was it that you said you
ought to stop right there?
Ms. Deutscher. As I said, everybody wanted Nick to play
football and Nick wanted to play football. I mean, he loved
being part of the team. He loved everything about that sport.
We should have said stop, reevaluate. Is this worth it? He
was getting football letters and he was looking forward to
maybe playing college ball. So had we known then what we know
now, I would have said stop. We need to decide if this is
worthwhile or right. And unfortunately, we did not.
Senator Nelson. To all the panel, the Chairman and I were
discussing that we could have a separate hearing on each one of
the topics that each of you have brought up.
Dr. Stern, I got the impression that you said a person
could not have any concussions and still get to CTE. What is it
about that? If you have many concussions, is that a cause of
ultimately becoming CTE?
Dr. Stern. Yes, to both of those.
Concussion is a form of a mild traumatic brain injury.
There is no real hard and fast line between what is a
concussion and what is not a concussion. Right now, I think
there are 140 or more published definitions of concussion.
Actually, the one published by the NATA is one of my favorites.
But it is all based on having symptoms, having an individual
report symptoms, or signs of the injury.
That does not mean that there are no problems to the brain,
and those brain cells, and the brain tissue. If the injury did
not either result in the type of problem that leads to the
symptoms, or very commonly, the person does not report the
symptoms for a whole range of reasons.
But what our research, and that of many others, is now
showing is that these sub-concussive hits--the ones that happen
in every play, in every game, in every practice of many sports,
but especially tackle football--do have consequences, short
term and long term.
There is now growing evidence that even after just one
season of football, tackle football in high school, let us say,
there are structural changes to the brain, physiological
changes to the brain, changes to blood-based biomarkers, and
changes to thinking and memory without any symptomatic
concussions. And those changes are directly associated with the
number of hits the person gets to the head as measured by
accelerometers in the helmets.
Senator Nelson. So would that apply to soccer and headers
as well?
Dr. Stern. It would. And that is, to me, a very scary next
part of the journey that now there is growing evidence that
heading in soccer, not the concussions in soccer, but heading
does seem to lead to changes over just one season, but also
after a lifetime of heading.
In fact, there is now, just recently, several cases of
postmortem confirmed CTE in individuals who were demented at
the end of their lifetime who never had histories of
concussion, or maybe just one concussion, through professional
and semi-professional football. But they had a huge amount of
heading through their career suggesting, again, that the
exposure to these repetitive hits, whether or not they lead to
the symptoms of concussion, seem to be raising the risk for
these later life complications.
Senator Nelson. Are you following our former military
members and the traumatic brain injury there, and seeing if
that produces CTE?
Dr. Stern. Our group has sadly found CTE postmortem in
former military service members who were exposed to blast
trauma and other brain trauma. It is a very complex issue, and
it is a very, very important one, and one that the Department
of Veterans Affairs and the Department of Defense is taking
very seriously.
The symptoms of PTSD, the long-term problems of traumatic
brain injury, the difficulties that we now see in the
tremendous increase in suicide in our veterans, all of those
seem to overlap with the symptoms of CTE. We are seeing that,
indeed, CTE may be playing a very important role in the
development of these cognitive, and behavioral, and mood
changes later in life in our military service members.
Senator Nelson. Thank you.
We could spend a whole day just on that subject.
The Chairman. We could. No question about it. Thank you,
Senator Nelson.
Senator Moran.
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Mr. Chairman, thank you.
Thank you and the Ranking Member for hosting this hearing.
Dr. Stern, thank you for those comments. I chair the
Appropriations Subcommittee. I am on the Veterans Committee
related to veterans, and you have given me some ideas of things
that I need to personally pursue with the Department of
Veterans Affairs. Thank you.
Mrs. Deutscher, at least in Kansas that is how we pronounce
your name, thank you very much for you being here. What you
described was very compelling to me because what you described
in your family's situation, who you are, and the way you
conduct your lives, and the way your family operates is the way
that I recognize the way so many Kansans live their lives. We
do not expect bad things to happen. I am very sorry.
I chair the Subcommittee that has responsibility here in
the Commerce Committee over amateur and professional sports,
and I will address most of my questions to Ms. Pfohl.
Senator Thune and I wrote the CEO of the United States
Olympics Committee about 2 months ago raising questions about
sexual activity, abuse, and harassment within the Olympic
Games.
I think kind of a take away from the response that we
received is that your organization was coming into play. That
the solution to this challenge is going to lie with you. I
would ask you if that is the way you see it, the relationship
between the United States Olympic Committee and SafeSport.
What is that relationship and who has responsibility for
these issues?
Ms. Pfohl. Thank you, Senator Moran.
To quote Dr. Butler, I think, it is going to take all of
us, first and foremost.
We, like USADA, the U.S. Anti-Doping Association, we were
formed first, if you will, within the U.S. Olympic Committee.
We would not exist without the support of the U.S. Olympic
Committee, financial and otherwise. But we are an independent
501(c)(3) nonprofit organization charged with this issue.
That said, all of the 47 NGBs, the National Governing
Bodies of the Olympic sports, all have SafeSport
responsibilities. They all have their SafeSport programs by
which they are tasked with implementing training, with making
sure all of their coaches and covered individuals, as we call
them, are certified related to SafeSport. So implementing and
creating a culture that prevents abuse is really important.
We are absolutely working in partnership with the USOC and
the National Governing Bodies. We are independent in terms of
our investigations. USOC has retained us, if you will, to
investigate all areas of sexual abuse. So any report of sexual
misconduct or abuse, we investigate those reports.
Senator Moran. Let me ask, then. If you are the
investigative arm, who is the enforcing arm?
Ms. Pfohl. The sanctions, if we have a finding from a
report--a case, if you will--that finding goes to the National
Governing Body. Not only must they enforce--and which could be
anything up to and including a lifetime ban--not only must that
NGB enforce that sanction, but it must be enforced across the
Olympic and Paralympic movements.
Senator Moran. So when you say they must enforce, what is
it that requires them to do so? Maybe your report is ignored or
just taken as a recommendation. Who determines what the
consequence is?
Ms. Pfohl. The USOC has mandated, if you will, that the
NGBs adhere to not only the SafeSport code and part of the
SafeSport code is that the sanctions must be enforced. So in
that case, we hand down the sanction and the USOC and the NGBs
themselves make sure that it is enforced.
Senator Moran. Ms. Williams, is that any different than the
way that the Anti-Doping Agency works?
Ms. Williams. It is similar. Well, USADA has the ability to
hand the sanction down. Then the actual enforcement goes up to
the World Anti-Doping Agency and then the enforcement happens
there.
Senator Moran. Thank you.
And Ms. Pfohl, it seems to me, and this may be a false
impression, but your organization was slow to come into
existence. My impression is, it is related to fundraising, the
ability to have the necessary resources to do the work that you
are setting out to do.
Can you assure us that the dollars, the resources are now
available?
Ms. Pfohl. Senator, thank you.
I think that is a reason that it has taken a while for the
Center to be up and running. We opened our doors in early
March. I will tell you that we have funding from the USOC, from
NGBs, and from other charitable organizations.
I would ask the Committee's support and the Senate support
in authorizing, as Chairman Thune stated at the beginning of
his remarks. Authorizing the Center in legislation would go a
long way to establishing our credibility, our place, if you
will, in terms of addressing all of these SafeSport issues.
So make no mistake. We have a ways to go. We need more
funding, and part of my job is to go out and raise private
sector dollars, foundations, corporations, and individuals in
addition.
Senator Moran. No one that you know of would object to
legislation that the Chairman was describing?
Ms. Pfohl. Not that I know of.
Senator Moran. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Moran.
That was a good exchange and discussion there because we
need to figure out how to formalize that role and ensure there
is enforceability there associated with it. Thank you.
Senator Markey.
Senator Markey. Thank you, Mr. Chairman, very much.
The cover story this week in Sports Illustrated is Nick
Buoniconti. He is a great football player, a hall of fame
football player. Essentially what it says is that his brain has
atrophied to a point where he cannot tie his tie or his shoes.
Unfortunately, that is the story that is all too common to
former athletes.
Dr. Stern, if you could, would you talk a little bit about
the warnings that you are giving to the country, especially to
those who have young athletes in their families about injuries
that can occur? Not just in football, but in hockey, and
soccer, and in any sport where concussions are possible.
What is the core message you are sending to athletes,
especially to their parents?
Dr. Stern. Thank you, Senator Markey.
It is a complex message. It is one that is hard to always
get across because there are many different forces out there
that move the message in different ways.
One important part of the message is that concussion is
just the tip of the iceberg. We have heard so much about
concussion. There has been concussion-this, concussion-that and
thank goodness because there have been so many important
changes in the way concussion is being dealt with, and is being
detected and managed thanks to NATA and others. The problems
associated with concussion are indeed, I think, moving in the
right direction.
But for me what people need to understand is when they read
stories about Nick Buoniconti and others, those were not
necessarily caused by concussions. They were caused by the
cumulative amount of the hits they received to the head from
youth, to high school, to college, to the pros.
One part of the message is just because your child plays
football does not mean they are going to develop this bad
disease and they are going to have suicidal ideation. We cannot
have a kneejerk response.
We have to have appropriate scientific understanding. We
have to have advances in our scientific knowledge that can be
given to informed parents, and informed leaders, and informed
policymakers.
But as we are gathering that scientific information, people
also have to make decisions based on common sense. In other
words, our brains are pretty darn important. They control who
we are, what we are, how we move. They control our athleticism.
They control our passion to participate. They do everything and
they are precious.
One of the things that we are focusing on is what happens
during that time in childhood when the brain is going through
unbelievable growth and maturation. It is the period before age
12 with all kinds of changes and developmental milestones are
occurring.
If we then say it is OK to put our kids in fields and say,
``Go at it. Hit your head. Move that brain around over and over
and over again,'' during those times of potential
neurodevelopmental vulnerability, then we may need to question
that decision.
Senator Markey. So what percentage of your research is
funded by the Federal Government, doctor?
Dr. Stern. I would say around 90 percent of my current
research is funded by the Federal Government.
Senator Markey. So if the NIH budget was cut by 18 percent,
which is the proposal for the next fiscal year, how would that
impact?
Dr. Stern. It would be devastating, not just to me
personally, and to the research that we are doing, and to our
future research. It would be devastating to science as we know
it. It would get rid of an entire generation of future
scientists across all areas.
I can speak to the neurodegenerative diseases and brain
research in particular. We cannot move forward even with the
current budgets at the rate that is required to make important
discoveries to alleviate the pain and suffering from all of
these brain diseases.
Senator Markey. Senator Udall is doing great work on this
issue.
My question, is there a relationship between the research
you are now doing on brain injury and your Alzheimer's
research? Can one inform the other in terms of perhaps trying
to find the clues that can give hope to families?
Dr. Stern. Tremendously. That is, in fact, why I got
involved and interested in CTE work in the first place because
as an Alzheimer's researcher, I realized that this is a very
similar disease. As we learn more about it, the more we
understand. Yes, indeed.
What we are gaining in our understanding of CTE is directly
informing what we know about Alzheimer's disease and other
related disorders. What we learn about Alzheimer's disease is
now helping us move forward rather quickly in our understanding
of CTE. They are very intertwined.
Senator Markey. How much more transparency would you like
to see in terms of all the information about brain injury being
put out into the public just so that there can be a full
understanding of this problem?
Dr. Stern. Unfortunately, there are so many organizations
out there and statements that are made that are filled with
conflicts of interest; organizations that are funded, directly
or indirectly, from professional sports leagues around the
world. Those conflicts lead to, I think, either a
misunderstanding or a misrepresentation of what the science
tells us.
Most importantly, scientists need to be transparent
themselves. We need to share data. We need to break down silos.
We need to explain our findings in ways that are meaningful,
appropriate, and not beyond what the science says.
Senator Markey. I think the brain health of this generation
of young athletes is going to depend upon the transparency of
this generation of leaders who control the information that can
help to inform parents in making the correct decision.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Markey.
Senator Udall.
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Chairman Thune, thank you so much.
You and I have been talking for a long time about doing a
hearing like this. So we really appreciate you doing it.
I also just want to thank Senator Nelson for all of his
kind comments and also Senator Markey.
The issue here, and I want to emphasize, I do not think,
Dr. Stern, you got a chance to say this specifically. I am just
going to read it from your testimony and ask you to talk about
it a little bit more.
You said, ``It is only in the past 55 or 60 years that
large numbers of human beings have been exposed to repetitive
head impacts.'' So we are talking about constant impacts to the
head.
``While the epidemiology of CTE is unknown, it is possible
that millions,'' millions we are talking about, ``living older
adults are currently at high risk for CTE or other long term
neurological conditions due to their history of exposure to
repetitive head impacts.''
This is something we need to realize in terms of human
history. Talk a little bit about human history and repetitive
head impacts and where we are, because I think that is where we
get to millions of people.
People, I think, would be surprised and kind of shocked to
know we are talking here about millions of people with CTE,
especially if they have seen the sports figures, and seen the
deterioration, and the kinds of things that happened to them.
Please, go ahead and put that in a little bit of context there.
Dr. Stern. To preface it, I am not an anthropologist. I am
not an epidemiologist. But I am someone who speaks a lot with
those experts and look at what the history tells us.
Boxing has been around for a thousand-plus years and boxers
only started putting these heavy padded gloves on in the mid
part of the last century in order to protect their hands from
being broken. But that also led to increased hits to the face,
to the head, and changed perhaps the numbers of those types of
hits that boxers get, but more importantly for this country,
our national pastime of American football.
It was not until the mid-1950s that hard plastic
encasements, these big helmets, started to be used in American
football, plus the big facemasks. Even though, yes, we have
been playing football since the 1800s, it was not until then
that leather helmets were used to start maybe preventing skull
fractures. And then the big helmets were there to do a great
job to prevent skull fractures and death. They have done an
amazing job at doing that.
But in the mid-1950s, to late 1950s, to early 1960s, there
was this beginning of a sense of invincibility because it did
not hurt to hit your head, and the way the game was changed
included lots of these hits, the line of scrimmage and
elsewhere. Not the big hits, not the spearing, not the use of
the helmet as a weapon. Those are important, but I am talking
about just routine hits.
Then it was not until the 1960s and early 1970s that Pop
Warner football began to be a national pastime. Our youth, our
children 6 years old and older, were going into fields wearing
these helmets and facemasks, and again hitting their heads
repeatedly.
That is where the concept of we do not know where we are
yet with a little bit of fear, or perhaps a lot of fear. That
is the only type of experience that humans have been involved
with that really include repetitive hits to the head with the
brain moving back and forth in millions of people just in our
country alone.
Those people who started playing high school and college
football in the 1950s and 1960s, the people who started playing
youth football in the late 1960s and 1970s. Well, they are in
their late fifties to seventies right now. That is the age that
we see the clinical manifestation of many neurodegenerative
diseases and other diseases of aging. And so, that is when we
also see a lot of the incidents of CTE.
With all of those millions of people who have had that type
of exposure to those hits for the first time in history, I do
fear that--based on the knowledge of what we understand of the
risk for CTE and other neurological problems later in life--we
are going to see a very shocking number of people over the next
few decades.
Senator Udall. Yes. I really appreciate that testimony and
I want to be clear that I think sports are good for young
people. I think exercise is good.
I think what you are emphasizing, though, is you are
talking about repetitive hits to the head when you have
protective equipment that can make it feel like it does not
hurt and it is okay. What you are telling us is that we need to
recognize that this could have a big impact. We may be on the
tip of the iceberg as to what we start seeing in the future.
I thank you for all your work, and thank you for being
here, and being so frank about this. Appreciate it.
The Chairman. Thank you, Senator Udall.
Senator Blumenthal.
STATEMENT OF HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thank you, Mr. Chairman.
Thank you for having this hearing which could extend for
several days, the topics are so varied and important.
As a father of four children, who all play sports, I know
that we cannot protect our children from all sports injuries,
but at least we can protect them from some if we are attentive
and respectful of science. I want to talk about two areas where
I think we have been somewhat less than respectful.
One is the NHL in denying concussion science, and I intend
to reintroduce legislation that would, in effect, create very
strong incentives for improvements in this area. And the other
relates to sexual assault, particularly in gymnastics that we
were hearing recently in the Judiciary Committee, and I am
going to ask some questions, if I have time, about that as
well.
Let me begin with you, Dr. Stern, if I may.
Last year, an NHL executive made headlines while testifying
at a hearing exactly like this one, it should not have been
earth shattering news, but it was. For the first time, the NHL
admitted that there is, in fact, a link between head trauma and
CTE, and you know how debilitating and disruptive that disease
is.
But reports surfaced last year, revealing e-mails from
league officials recognizing the danger of concussions, but
also demonstrating a very dismissive attitude in addressing
them.
And so I wrote to the NHL Commissioner and in response, he
flat out dismissed any connection between head trauma and
concussions and CTE. In my letter to him, I cited research done
at Boston University.
Beyond the resistance, there are now troubling reports that
the NHL is trying even to intimidate scientists using tactics
employed in other industries. Without making unfair
comparisons, the tobacco industry is one of them.
Let me ask you, does it trouble you that leading officials
with such power and sway in this sport and in important
positions of responsibility actually deny the science of CTE
and have no apparent willingness to learn more? And have you
experienced this kind of intimidation yourself, Dr. Stern?
Dr. Stern. It does not surprise me because we are talking
about businesses that have billions of dollars on the line. And
that if some aspect of the way that their sport is played is
going to have to change, and therefore they may lose viewers or
support from advertising, that is a big deal. I understand
that. But I think that everyone needs to put athletes first.
What the NHL did and the Commissioner's statements have
done is indeed sad. I do not agree with them. I find them kind
of antiquated and perhaps they should take the lead of what the
NFL has recently done and accepted the link.
Senator Blumenthal. In my opening, I may have confused the
NFL with the NHL. It was the NFL that acknowledged the
connection.
Dr. Stern. That is right. It was the NFL that finally
acknowledged the association between getting your head hit and
CTE later in life after years and years and years of dismissing
it. The NHL continues to say, ``Oh, no. There is no
association,'' contradicting the science.
I cannot go on too much about it because, in fact, you
raised the issue of their attempt to get in the way of science.
In fact, my colleague and I at the University were subpoenaed
by the NHL for a great deal of information that went way beyond
any reasonable request within how science is conducted. And, in
fact, the court denied their request.
So I cannot really get into it because there is this
ongoing case.
Senator Blumenthal. Thank you.
Let me ask you, Ms. Pfohl. Recently, the Judiciary
Committee had hearings on sexual abuse in gymnastics
particularly the youngest of participants in this sport.
Statistics from SafeSport indicate that one in ten youth who
participate in organized sports will be victims of sexual
abuse. And I think you would agree with me that number is
clearly unacceptable.
The United State Olympic Committee bylaws require National
Governing Bodies to comply with SafeSport policies in order to
remain in good standing.
How can those policies be better enforced?
Ms. Pfohl. Thank you, Senator Blumenthal.
Just a quick note on the one in ten that will be sexually
abused, that is actually in the general population.
One of the problems is we do not know the true prevalence
within the sports community. That is one of the reasons we
exist is to gather that data, to have that data, to follow the
trends, and to help our prevention efforts. That is what needs
to happen.
So your support, certainly, of the U.S. Center for
SafeSport and hopefully being authorized perhaps in S. 534, the
Protecting Young Victims from Sexual Abuse Act of 2017, would
go a long way in helping us to develop policies. We already
have the SafeSport code that has been taken up by the USOC and
all the NGB's. But our work goes far beyond the Olympics
movement.
Senator Blumenthal. Would you support young athletes having
the right to win cases in court as opposed to arbitration?
Ms. Pfohl. In terms of what is currently in the S. 534, we
are certainly favorable to the bill overall and have been
providing that technical assistance. So we support the rights
of athletes. Period.
Senator Blumenthal. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Blumenthal.
Senator Cortez Masto.
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Thank you.
And like my colleagues, thank you, Chairman Thune for
bringing this topic forward, these many topics. And I agree,
they could all be a separate hearing. And every single one of
the areas, I have worked in and will continue to work in and to
address.
And so, let me just say, first of all, Mrs. Deutscher,
thank you so much. I was the Attorney General of Nevada for 8
years and this was an issue. I chaired a working group on
substance abuse and opioid abuse, and then followed by heroin
abuse is a problem; not just in Nevada, but across the country.
And you coming forward, telling your story, you will make a
difference and save a life. I want you to know that. So thank
you to both of you for being here.
Dr. Stern, I have a quick question for you. From your
knowledge, are the medical resources and research into CTE and
other long term brain concerns equally distributed between
males and females? And what would you say their allocation
percentage is by gender?
Dr. Stern. That is one of the most important issues that
needs to be dealt with.
CTE as a neurodegenerative disease diagnosed only after
death at this point has been found almost exclusively in males
to date. There have been a small number of women, not athletes.
Sadly, it includes a woman who was domestically abused and had
her head hit repeatedly.
This goes along with my testimony earlier about what is
going to happen in the future. I think women have been involved
now with sports at the level where their heads are being hit to
such a degree and for over a greater period of time, again,
over the last 50 years or so.
So, for example, soccer or the original football, women
now, at least in this country, are at the age now where they
started back in the 1970s playing at an early age, and playing
in club sports, and playing around the year, and doing a lot of
heading, and having a lot of concussions. So I think now as
that generation gets older, sadly, we will probably be seeing
more of this disease.
However, just because we have not seen the disease in women
that does not mean that the rest of the resources being focused
on brain diseases, brain conditions associated with athletic
involvement should be focused on men. We need to put a lot of
effort.
In fact, I am hoping to be starting a few different studies
coming up where we are actively going to be following women to
be able to look at the effects of various sports, various
aspects of the sport, and the head trauma in terms of later
life problems.
It is a very big deal.
Senator Cortez Masto. It is. And I thank you for saying
that because in my own family, I have a niece who played soccer
through high school and college. There are concerns because
they have had injuries in soccer just as they do in football
and other sports.
And then, as you well know, in Nevada, and you have said it
in your testimony, the Cleveland Clinic, the Lou Ruvo Center
for Brain Health in Las Vegas is a leader in this research,
particularly when it comes to the brain health of boxers and
MMA fighters, and we know a lot of women now are partaking in
those sports. And so I am glad to see that we are actually
going to be looking at women's brain health as well.
With respect to boxers and MMA fighters, do you feel that
there is enough being done at the State level to ensure that
standardized safety precautions are adapted to protect boxers
in every state?
Nevada has just recently adopted a requirement to our
athletic commission ensuring that the brain health of our
fighters is tested and we are making sure that is being
checked.
Do you think enough is being done across the country and in
other states?
Dr. Stern. I am not aware enough to be able to answer it
about all states. I do know that Nevada is a real leader.
Thanks to the partnership between the State, and the City of
Las Vegas, and the commission with the Cleveland Clinic Lou
Ruvo Center, there has been a tremendous gain, including great
research being done, to look at what is really important.
When it comes to boxing and MMA, to me I always just have
to stop and say, what could be done at the State level? What
kind of rules and changes could be done when you have sports
that are geared toward inducing brain damage?
If in boxing, a knockout is a way to win, a knockout is
brain damage. And I may be saying things a little bit too
indelicately, but one has to question how can we really make
those activities safe in terms of brain health?
Senator Cortez Masto. Thank you. Thank you very much for
all of you being here today. Appreciate the testimonies.
The Chairman. Thank you, Senator Cortez Masto.
Next up is Senator Hassan.
STATEMENT OF HON. MAGGIE HASSAN,
U.S. SENATOR FROM NEW HAMPSHIRE
Senator Hassan. Thank you very much, Mr. Chair.
And thank you to all the witnesses for being here today,
especially I would like to extend my thanks to Mrs. Deutscher
and Mr. Deutscher for meeting with me earlier today, and for
being here, and for sharing and honoring your son's life and
story by being here.
I want to focus a little bit on the issue of athletes and
addiction to help address the increased level of risk of opioid
addiction that student athletes experience.
Earlier this year, I co-sponsored the Student and Student
Athlete Opioid Misuse Prevention Act. This bill is being led by
my friend and colleague, Senator Shaheen, and it would
authorize the Substance Abuse and Mental Health Services
Administration, or SAMHSA, and the U.S. Department of Education
to grant money to help efforts to educate students and
communities about opioid use, abuse, and addiction.
In New Hampshire, SAMHSA grants have been an integral part
of funding in our State's substance misuse and prevention
efforts. So this is really a question to the whole panel.
Do you agree that further resources and dedicated funding
would help in the work you and others are doing to meet the
tough challenges associated with opioid addiction?
Dr. Butler. Thank you, Senator, for that question and do
not mind if I go first.
Senator Hassan. Yes.
Dr. Butler. I just want to agree with Dr. Stern's comments
earlier about the importance of support to the NIH to address
new knowledge. And that applies also in terms of our
understanding of pain and also the understanding of addiction.
NIH Director, Francis Collins, has observed that it is
amazing when we have millennia of writing about pain as a
cardinal sign of inflammation that we know so little about it.
But I also want to point out the critical importance of
education and using the knowledge that we already have much of
which is implemented through agencies such as the Centers for
Disease Control and Prevention, and also SAMHSA.
So it is, I think, not an either-or when we look at new
knowledge versus reacting and acting on the information that we
already have, but it really is going to require both to address
these issues.
Senator Hassan. Thank you.
Another component of the bill is to provide funding to
train State and local officials, and coaches, and trainers
among others to recognize and address substance misuse among
students.
Would this be helpful in your view and especially maybe Mr.
Sailor, you would like to comment on that?
Mr. Sailor. Yes. The National Athletic Trainers'
Association is in full support of this bill and we appreciate
that.
Senator Hassan. Thank you. And also to Ms. Williams and Mr.
Sailor, although we are starting to have a greater
understanding of substance abuse disorders, there is, as we all
know, still a lot of stigma attached.
One of the reasons I am so grateful to Mrs. Deutscher and
her family is because when people stand up and talk about their
experiences, and help us to understand the disease, that really
makes a difference. In my experience in New Hampshire that has
been the thing that has really helped us begin to change the
conversation.
But I suspect that it may be especially true for athletes
who may suffer consequences of being sidelined if they admit to
an addiction to opioids, or even to acknowledge the injury that
underlies their use of prescription pain medications.
In your experience, does this stigma and maybe the fear of
being sidelined prevent student athletes or professional
athletes from acknowledging a dependency on opioids?
Ms. Williams. I definitely think that the stigma is a
problem and something that we need to address.
I think the way that we address it is by outreach,
educating from the grassroots level all the way up into the
professional level. Starting the conversation before it becomes
a problem for people that are not using opioids, getting that
conversation going, having it frequently instead of just,
``There is this thing we probably should not talk about.'' Or,
``I think my friend or struggling, but I am not sure exactly
what I should do about it.''
Before it becomes a problem, we need to implement that as a
standard thing that we are doing on a regular basis and that
the conversation is being had.
Senator Hassan. Thank you.
Mr. Sailor. As an athletic trainer, we believe in a
comprehensive healthcare system for our athletes. And that
includes having access to resources that we can help obtain for
them when they are in need of things like addiction treatment
and things like that.
Senator Hassan. Thank you. Thank you all very much for
being here.
I will echo what the other Senators have said. We could
have a hearing on each of the issues that you all have spoken
about and I know we will look forward to continuing to work
with you help make athletics safer.
The Chairman. Thank you, Senator Hassan.
Senator Young.
STATEMENT OF HON. TODD YOUNG,
U.S. SENATOR FROM INDIANA
Senator Young. Thank you, Chairman Thune.
I want to thank you for holding this hearing on protecting
the health and safety of American athletes. I want to thank all
our panelists for being here today.
It is a timely hearing given the scrutiny the USOC has
received thanks, in large part, to the ``Indianapolis Star.''
So I want to commend them on their investigative reporting.
I am proud to have worked with many of my colleagues in the
Senate to address this issue and I look forward to working with
you, Mr. Chairman, as we continue to find ways to address this
very real problem.
Ms. Pfohl, I would like to ask you a question about the
independence of SafeSport from USOC. The USOC initially created
SafeSport and provided its initial seed funding.
I think this was certainly a recognition by USOC that they
finally needed to act in an aggressive manner to address the
serious problem that has been lurking within its ranks for
years. They ought to be applauded for implementing this
initiative. I have concerns about, as I stated, with
independence, specifically personnel and staffing issues.
What is your policy on hiring individuals directly from
USOC and National Governing Bodies into SafeSport? Do you have
any reservations about SafeSport's independence, if your
organization simply hires individuals from USOC and NGBs?
Ms. Pfohl. Thank you, Senator. Yes.
I have no issues or concerns related to our independence.
Our board, we have a nine person board of independent
directors. We have independent investigators, and outside
counsel, and arbitrators that meet a high bar of independence.
So we really look for those conflicts.
I will tell you that we have brought two people from the
USOC as employees. These are, at least one of them is a subject
matter expert in this space, not only in terms of SafeSport, in
terms of the abuse issues, but in terms of how the Olympic and
Paralympic movements are structured, which is hugely helpful to
us.
And again, following in the footsteps of USADA, they too
were born within the USOC. They had staff members that came
over to USADA. I do not think anyone can question their
independence. And so, we have followed that framework.
Senator Young. So these independent investigators who
presumably produce reports and various findings to inform your
future work, are these reports made available to members of the
public or would they be made available to Congress, because I
presume they touch on staffing issues, correct?
Ms. Pfohl. If we have the actual reports from victims, if
you will, cases that come in, is that what you are speaking to,
sir?
Senator Young. Yes, and also the performance of former
employees of the National Governing Bodies, and USOC, if they
are consistently subpar, suboptimal, or conflicted, which you
have emphasized they are not. That would be a finding that
would be of interest to this committee, I know.
Ms. Pfohl. Our jurisdiction lies in addressing sexual
misconduct and abuse within the Olympic and Paralympic
movements.
So we would take in reports. If we have a finding against
an employee of an NGB, or the USOC, or a coach, or anything, or
anyone that is a covered individual that sanction is then
handed down, if you will. And it must be enforced across the
Olympic and Paralympic movements.
Senator Young. With your permission, I may have a follow-up
question or two.
Ms. Pfohl. Absolutely.
Senator Young. I will submit it by writing. If you would
offer me the courtesy of a response, I would be grateful for
that.
Ms. Pfohl. Absolutely, sir.
Senator Young. Because I want to turn to another matter. I
know that reporting incidents of abuse is critical to starting
the investigation process. Unfortunately, our staff discovered
a problem here.
On SafeSport.org, the website, there is a link entitled
``Report.'' Unfortunately, that link is broken and takes
visitors to a ``Page Not Found'' website.
Moreover, if someone were to try and find more information
on reporting confidentiality--those concerns as referenced in
your materials to the USOC Athlete Ombudsman at www.AthleteOm
budsman.org--that website does not work either.
I know this is likely a surprise for you. What I am seeking
from you is some assurance that you will resolve this matter
expeditiously, and maybe the courtesy of informing our staff
this week about its status. Because one could see why you could
infer from this a lack of seriousness taken toward this issue,
which I have not heard from your testimony so far, by the way.
I have heard seriousness.
Can I get your commitment to report back about this or am I
missing something perhaps?
Ms. Pfohl. Absolutely, Senator.
Senator Young. All right.
Ms. Pfohl. I will check into it and get back to you.
Senator Young. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Young.
Senator Moore Capito.
STATEMENT OF HON. SHELLEY MOORE CAPITO,
U.S. SENATOR FROM WEST VIRGINIA
Senator Moore Capito. Thank you, Chairman Thune.
And thank all of you for being here today.
I come from the State of West Virginia. We have,
unfortunately, some of the largest and greatest statistics of
overdose from and deaths caused by drug addiction and drug
overdose. We have a lot of good things going on in terms of the
sports area. Our WVU Sports Medicine Center is, I think, on the
cutting edge of some of the research that is being done.
I would like to speak just personally to Mrs. Deutscher,
and thank you for coming, and telling your story. I think it is
so important that we hear from you because it is a hesitating
thing for, I think, parents and grandparents to talk about. So
I read your testimony. I am sorry I was not here to hear you
give it.
We are trying to work with families on certain things sort
of outside the athletic. Well, actually, one of them was an
athlete and she had described herself in the hospital as an
addict, and said she had been in and out of recovery.
Unbeknownst to the discharging physician, who did not read all
through the chart, they discharged her with 56 Oxycodone, which
she melted 8 and put into her PICC line, and did not wake up
the next day. So we are trying to fix those kinds of things so
that that situation cannot happen again.
But one of the things I am curious to know, tracing back
and looking at what happened with your son, we are trying to
get to this partial fill or acute pain issue. If you have a
wisdom tooth, if you have an acute athletic injury that you do
not need 2 weeks of pain medicine; maybe 48 hours or 72 hours.
Was that ever offered to your son, a short term sort of
treatment or short term prescription option for him?
Ms. Deutscher. The initial prescription, I believe, was
shorter term. I do not have that record. I did get his pharmacy
records for the balance of the prescriptions. But that would
have been offered when he first had his injury. It was a Friday
night and so he got in to get evaluated.
Then the other in a series of prescriptions started a
little bit later in the season when he was rehabbing to get
back into the game and those prescriptions, if memory serves me
correctly, were 40, 50 tablets.
Senator Moore Capito. Were there ever any diversionary
other pain methods to deal with the pain offered to him?
Ms. Deutscher. Well, by Jeff and I, the Tylenol.
Senator Moore Capito. Right.
Ms. Deutscher. But no, there was not that discussion. It
went to Hydrocodone and to Percocet.
Senator Moore Capito. Right away.
Well, that is something else I have been working on with
Senator Warren from Massachusetts to look at the partial fill.
And also an acute pain issue that I am working with Senator
Gillibrand on to try to eliminate that lengthy prescription
that it becomes quite a temptation in a lot of cases.
I wanted to ask Ms. Williams. Actually, I am the
appropriator for the General Government, which also covers the
U.S. Anti-Doping Agency and because of that, I got to meet
Michael Phelps and I get to meet you. So that is good.
It was interesting to me. We do appropriate that as a
member of the Anti-Doping Association of the United States and
then also try to help the worldwide organization for the elite
athletes that are competing on the stage, such as you.
But it was interesting what he said to me. I mean, think of
how many races he has been in and how many international races.
He said, ``I do not think I have ever had a clean race.'' He
was not talking about him. He was talking about everybody else
in the pool and he still won all the gold medals and you did
too, the medals.
So I am thinking to myself, ``What kind of pressure is that
at the elite level?'' Because of what the other countries are
doing.
Ms. Williams. I think there is a good amount of pressure
for athletes and I think that is why outreach is so important,
like I said, educating athletes from the grassroots level.
Also, the World Anti-Doping Agency does a good bit of
outreach trying to cross cultures because there are different
things that different cultures are dealing with as it pertains
to win-at-all-costs and all these sorts of things.
Being able to create examples, so for example, I did not
use any supplements for my whole career; not only did I not use
performance enhancing drugs, but I did not use vitamins or
protein powder. I go out and tell people as much as possible
that I made it to four Olympic Games without any of those
things, no multivitamin or whatever the case may be.
I think really being able to explain to athletes from the
grassroots level all the way up to the professional level that
it is not worth it, that the medal, that one moment on the
podium is not going to be rewarding enough. You are not going
to feel satisfied because you did this thing that was wrong in
order to get to that point.
And really being able to convey that and articulate that in
a way that is going to hit home so that they are not encouraged
to want to try and reach this next level or win at all costs is
really going to be the important thing.
Senator Moore Capito. That is an excellent point and thank
you for being that advocate.
I actually had the opportunity to meet Simone Biles just a
few weeks ago. She is working and outreaching to young people
to inspire them on different levels, clean living, and staying
away from substances.
So it is so important the work that you are doing and I
appreciate you all working with the next group of stellar
athletes. Thank you.
Ms. Williams. Thank you.
Senator Moore Capito. Thank you very much.
Senator Young. Mr. Chairman, could I just note that my
colleague is dropping a lot of impressive names here
gratuitously.
Senator Moore Capito. You wonder why they all come to see
me.
The Chairman. And they are out there dropping her name.
[Laughter.]
The Chairman. Well, thank you, Senator Capito.
I think Senator Sullivan is on his way back and would like
to ask a question or two, so let me keep it going here for just
a minute.
Ms. Pfohl, as the former Executive Director of the
President's Council on Fitness, Sports, and Nutrition and we
have talked a lot about the challenges that we face, the
problems, and things that we need to address in the world of
competitive sports.
Just as a question, do you believe we ought to be
discouraging participation in certain sports? I mean, are there
positive benefits to playing sports including contact sports
that we ought to be talking about as well?
Ms. Pfohl. Thank you, Chairman Thune.
But obviously, I believe in sports and all that comes from
it. Not only the health and fitness benefits, but certainly the
emotional benefits that come from it, the teamwork that you
learn, the perseverance, the dedication; all of those kinds of
character building things that are learned with and through
sports. I am not just talking competitive sports, but just
recreational, getting out there and having fun, I believe, are
so important.
I think all the issues, the safety issues that have been
talked about on this panel, are also critical so that we can
save sport not only for our generation, but for every
generation to come. So it is absolutely critical.
And Go Packers, by the way.
The Chairman. Very good. I like you more already.
Is your focus just Olympic athletes, or does your work go
beyond elite level sports participants? Is your focus solely on
children or does your work go beyond youth in terms of the
things that you are undertaking there?
Ms. Pfohl. Thank you for that question, Chairman Thune.
It absolutely goes beyond children. We address athletes at
every age and at every level. So again, really from the
recreation leagues, if you will, for folks that are just going
out and having fun whether that is children or adults, all the
way up to the Olympic and professional ranks. So all of the
above in terms of our education and outreach, and the training,
and awareness that we want to get out for sports organizations,
parents, and athletes all across the Nation.
The Chairman. Well, and we appreciate everything that
SafeSport is doing to stand up best practices to prevent abuse
within the Olympic movement.
As we examine legislative proposals in this area, and you
heard some of my colleagues speak to that earlier today, we
have to consider how best to craft policies governing one-on-
one contact between athletes and coaches. We definitely want to
avoid situations that put young athletes at risk of abuse. At
the same time, we want to avoid overbroad policies that
unnecessarily strain the athlete-coach relationship.
So the question is, do you support a blanket rule against
one-on-one contact or does a risk-based standard like the
standard the Centers for Disease Control and Prevention
advocates make more sense?
Ms. Pfohl. Thank you again, Chairman Thune.
We really follow the CDC, the Centers for Disease Control's
standards and guidelines in this space. We recognize and agree
with the Centers for Disease Control that limiting those one-
on-one interactions between adults and children, and making
sure that there are two adults present as often as possible is
the absolute right thing to do.
We also agree with their risk-based guidelines, as you
indicated. It basically says that maybe one size does not fit
all. So many sports organizations are so diverse that there may
be multiple options for achieving safety.
Their standards or their guidelines certainly are those
that we have made part of our best practices.
The Chairman. Just out of curiosity and other members of
the panel, do you share that view? Does anybody else want to
comment on that? Do you agree with that as articulated by Ms.
Pfohl? OK.
Senator Sullivan is coming in the door.
Senator Udall had asked that we include in the record three
items that he wanted included. So we will do that without
objection.
[The information referred to follows:]
PINK Concussions
May 16, 2017
Hon. John Thune,
Chairman,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.
Hon. Bill Nelson,
Ranking Member,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.
Dear Chairman Thune and Ranking Member Nelson:
Please allow this letter to be included in the official record for
the hearing ``Current Issues in American Sports: Protecting the Health
and Safety of American Athletes'' taking place on May 17, 2017, on the
topic concussions in female athletes.
My name is Katherine Price Snedaker, and I am LCSW and the
Executive Director of PINK Concussions, a non-profit which focuses on
female brain injury from sports, domestic violence, accidents and
military service.
I would like to share with you some very important information
about female brain injury which is not reaching our women athletes and
their coaches. Research in the early 2000s showed that female brain
injuries including concussions, were not the same as brain injuries in
males. Yet today, almost 20 years later, most woman and doctors are
still unaware of the biological differences in brain injury.
THE FACT is that, in multiple research studies dating back to the
early 2000s, women have been shown to:
Sustain more concussions at a higher rate than males in
sports with similar rules
Report a higher number, and more severe, symptoms than males
Have longer recovery periods than males
THE CHALLENGE is since women and girls are rarely educated about
female brain injury, many of these women are not prepared to cope with
more severe symptoms and often have unrealistic expectations of
recovery time of a few days or weeks when faced with months or years of
Post Concussion Syndrome.
And despite the established facts of female brain injury, the
sport, academic, military, and medical communities do not have any
female-specific medical guidelines, return to school/play/work/duty
protocols or education resources designed for women.
1. What are the differences between males and females in terms of
concussion frequency, severity, symptoms, outcomes, etc.?
Scientific research has shown that female and male brains
differ in more than 100 ways in structure, activity, chemistry,
and blood flow, and so it is logical that damage to the brain
would also manifest differently in women and men.
However, brain injury research including sport concussion
research has long been viewed through a masculine perspective
partly due to the findings that TBI in general occurs about
twice as often in males as it does in females (Rao & Lyketsos,
2000). The riskiest sports for concussion often have being
male-dominated (i.e., collision/contact sports such as ice
hockey, boxing/combat sports, football, rugby).
It is critical to recognize multiple research studies have
found in sports with similar rules between females and males,
in particular soccer, basketball and baseball/softball, the
rates of concussion are actually higher in women (Gessel,
Fields, Collins, Dick, & Comstock, 2007; Hootman, Dick, & Agel,
2007; A E Lincoln et al., 2012).
In the 2012 American Medical Society for Sports Medicine
Position Statement: Concussion in Sport research showed that in
sports with similar rules female athletes sustain more
concussions than their male counterparts. In addition, female
athletes experience or report a higher number and severity of
symptoms as well as a longer duration of recovery than male
athletes in several studies.
2. What are the proposed reasons for these differences?
Female athletes may be at a greater risk for concussion due to
which phase of their monthly hormones at the time of injury, an
increase in angular acceleration at the neck, AND/or neck
strength-to-head size ratios.
3. What can be the clinical implications of #pinkTBI?
While research shows females may have different injury rates,
symptoms, and rates of recovery, the medical community does not
yet have any female-specific guidelines, protocols, care plans
or education resources for women with brain injury including
concussions.
Since more men than women have brain injury, a woman, her
support system and the people around her will most likely know
more men than women who have had concussions therefore
typically judge her symptom pattern and length of recovery by
the male experience. The patient may doubt herself when the
speed of her recovery or the severity of her symptoms do not
match the more familiar and more publicized male experience.
Family members, school staff or employers judge her experience
to be abnormal, malingering or perceive that there maybe other
non-brain injury issues at play.
Without proper education of patient, family and community supports,
women and girls with brain injury including concussion, can experience
an additional lack of support, doubt, isolation and anxiety beyond that
which comes with brain injury.
Thank you for your interest in PINK Concussions. Please let me know
if you have any additional questions.
Sincerely,
Katherine Snedaker,
LCSW Executive Director,
PINK Concussions.
______
Prepared Statement of Katherine Starr, Founder, Safe4Athletes
Over 44 million young Americans participate in sport on a daily
basis; the United States Olympic Committee (USOC) members account for
approximately 3 million athlete members across the Olympic sports
family. The other 41+ million child athletes are members of various
non-governmental organizations; the AAU, YMCA, Little League, Pop
Warner, and several independent sports leagues, that don't fall
directly under the jurisdiction of the USOC or any other oversight
body. Each of these organizations set their own policies for their
respective communities with very few having any policies that address,
or even mention, the issue of coach-athlete abuse.
One of the most comprehensive studies of sexual abuse in sport was
done in Canada, with a survey of that country's Olympic athletes,
concerning their experiences in sport. In the study, 22 percent of the
athletes responding reported that they had engaged in sexual
intercourse with an authority figure in sport. Nearly 9 percent of
respondents reported experiencing a forcible sexual encounter. This
study is consistent with Safe4Athletes most recent survey that found
over 25 percent of the athletes that responded stated they experienced
some sort of sexual harassment over multiple seasons.
Coaches spend more time every day with their athletes than teachers
do. Coaches, unlike child health care workers, travel with their
athletes. Teachers and child health care workers are held to stringent
standards--as they should be--in regard to their behavior around
children. Many schools require that doors be kept open when teachers
counsel students, and mandate that parents be present for medical
examinations. Any suspicion of abuse is required by law to be reported.
Yet there are no guidelines or laws that dictate appropriate behavior
when it comes to coaches and athletes in non-school sports.
Requiring background checks for coaches will deter the convicted
pedophiles that we know about but will do nothing for the ``predator
amongst us'' who has not yet been caught. A background check is the
first line of defense, once the sports programs are active and if the
organization does not have a meaningful reporting and investigative
practice process identified and utilizes experts who understands the
complexities of any form of athlete-abuse that occurring on the field,
in the gym or at the pool.
This limitation is further exploited in our courts by the national
governing sports bodies that consistently defer blame back to the local
clubs. While giving the local sports club limited power and full
responsibility, for a multitude of reasons including claiming no
responsibility for the hiring choice, not being present to see the
wrong doing, or simply passing on any responsibility by not receiving
any complaint that requires investigation.
Many of these national organizations, have comprehensive rules that
dictate the uniform policy, presence or absence of make-up/jewelry,
grade point averages, practice times but fail completely to mandate
local policies that for hiring standards, reporting requirements,
investigation process into inappropriate coach-athlete behavior, and a
clear structure (that is athlete focused) to deter such behavior from
thriving in the sports environment.
The newly implemented `Center for Safe Sport' addresses some of
these issues for their approximately 3 million membered community by
creating a uniform and centralized system to investigate and
adjudicated coach-athlete sexual abuse across their sport families.
Other concerns remain in the sport organizations themselves as member
clubs are not required to have clear policies at the local level but
refer to the national governing bodies for their direction. While the
Center for Safe Sport has a set a standard, and created some uniformity
in USA sport, it has failed to reach the other 41+ million athletes
that are presently outside of their jurisdiction.
This leaves local clubs at the direction of their national
governing body and often they are not permitted to set their policies
regarding abuse in sport issues, often they are pressured into only
following the limited policies set at their respective national
governing sport bodies. Often when incidents occur the National
organizations pass the blame back to the local level to absolve
themselves of any responsibility whatsoever.
In general, these national organizations lack knowledge in coach-
athlete sexual abuse investigation. As a result, the predator coach can
easily take advantage and manipulate the sports clubs and their
leadership and of special concern, such coaches are allowed to leave
their current position prior to their behavior being questioned. This
is a direct result of the flaws in governance and leadership of the
youth serving organization. There is a lack of will to implement and
mandate stronger policy and in many cases NO policies exist at all.
Without empowering the local clubs and mandating policies to
prevent sexual abuse and all forms of abuse in sport, the issue will
continue to harm our youth. The abuse that occurs at a young age has
the ability to negatively impact a young person for life, denying the
child-athlete the opportunity to know the positive benefits of sport
that we all believe are going to make the individual a better person
all around.
In closing, the need for oversight to protect all athletes, across
all sports and all sport organizations must be put in place. This
system needs to start at the local level with sports clubs adopting
policies, committing to the creation of a safe environment that puts
the athlete first. The policies need to be designed to provide clubs
with a system that explicitly creates a positive environment free of
sexual abuse, bullying and harassment.
If we believe in and support the child-athlete anything less is
unthinkable.
______
Sports Fans Coalition
May 17, 2017
Hon. John Thune,
Chairman,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.
Hon. Bill Nelson,
Ranking Member,
Committee on Commerce, Science, and Transportation,
United States Senate,
Washington, DC.
Dear Chairman Thune and Ranking Member Nelson,
Sports Fans Coalition (``SFC'') is the largest fan advocacy group
in the U.S. devoted to representing the interest of sports fans
wherever public policy impacts the games. We were founded in 2009 and
today have members in all 50 states. SFC is best known for successfully
petitioning the Federal Communications Commission to end the decades-
old Sports Blackout Rule, which the Commission unanimously voted to
eliminate in 2014. The NFL subsequently suspended its local blackout
policy. We continue to advocate for public policy that maximizes fans'
access to games, grants fans and other members of the public a fair
return on any public resources devoted to sports facilities, and
upholds fair play both on and off the field.
SFC thanks you for holding today's hearing titled, ``Current Issues
in American Sports: Protecting the Health and Safety of American
Athletes.'' Fans believe that we can preserve the essence of our great
sports without unfairly compromising the health and safety of athletes.
SFC has called on the NFL, NHL, and other leagues to fully disclose
what they know about the risk of concussions posed by their sports so
that players and coaches can make informed decisions. Moreover, we
believe that Members of Congress currently investigating league
practices regarding concussions should not accept campaign
contributions from league Political Action Committees or team owners
while such investigations are pending. Tens of thousands of fans sent
that very message to Members of the House Energy and Commerce Committee
through a campaign organized by SFC and we urge Members of your
committee to heed that call. Fans want fair play, and that begins with
leagues telling the public the truth.
Our members do not want to see the rules of play altered to such a
degree that the sports themselves become unrecognizable from their
traditional origins. No one wants to see the NFL turn into a flag
football league. SFC believes, however, that just as football leagues
at all levels altered helmets to include facemasks, then created a new
rule that no player shall ``twist, turn or pull the facemask of an
opponent in any direction'' (NFL Rulebook at Rule 12, Sec. 2, Art. 5),
leagues can and should develop practices that reasonably protect
players. At the very least, we should have full disclosure of leagues'
knowledge on issues of player safety.
Thank you again for your attention to these issues.
Sincerely,
David Goodfriend,
Chairman.
The Chairman. I would say to all of you thank you for being
here. Thanks so much for your thoughtful input and suggestions
in response to our questions. These are all important issues;
in many cases life and death issues. Certainly when it comes to
safety, it is really critical that we get this right. So we
welcome your continued input.
I just want to indicate to you that there are members of
this committee who will have questions that they would like to
submit for the record, and if you could get those back to us as
soon as possible. We normally keep the record open for a couple
of weeks to allow your responses. So if you could get those
back to us as quickly as possible, we would appreciate it.
With that, I will yield to my colleague from Alaska,
Senator Sullivan. I think he is going to take us out.
But let me again just thank you for being here today. I
cannot tell you how much we appreciate your participation.
Senator Sullivan.
Senator Sullivan [presiding]. Thank you, Mr. Chairman.
I want to thank you again for calling this hearing. It is a
really important issue that is impacting the entire country. So
thank you for your leadership on that.
I want to thank the panel. Again, I am sorry. I had to step
out. I have my freshman duties where I have to preside over the
Senate. If you are a senior esteemed Senator like Chairman
Thune, you do not have those duties, but I had those for the
last hour. So it was not my lack of interest. I was over with
another gavel on the Senate floor.
I do want to thank the panel again. I have been keeping
tabs from my staff on the questions and I read the testimony.
Let me just start. Dr. Butler, I want to start with you.
Thanks again for coming and thanks again for all that you are
doing. You may have seen, you were quoted in the Alaska
Dispatch News this morning, front page, above the fold
headline, ``Anchorage is seeing a dramatic surge in heroin
overdoses.''
Let me ask a little parochial question, but still important
because I think it can shed light on what is going on in the
country. What do you think is behind that surge in our biggest
city back home?
As I mentioned, we held this Wellness Summit last August in
the Matsu Valley. One of the reasons I hosted that was a kind
of a warning signal in some ways to our state that this is
happening in a lot of places. We are not in the dire straits of
some lower 48 communities yet, and hopefully never, but this
could be coming.
Unfortunately, I fear that since we held that Summit, we
have been focused on this issue a lot in the Congress, but I
think in Alaska, it is getting worse. I think throughout the
country it is getting worse.
Do you mind addressing the headline today in the paper, the
dramatic surge of heroin overdoses in Anchorage? And then if
you want to address whether you think it is getting worse in
Alaska or not. And then if any of the panelists want to just
talk about it relating to the Nation, because it does look like
we are not winning this battle right now, at least in my view.
Dr. Butler. Senator Sullivan, I think Alaska really
reflects what is happening nationally.
What we have seen in Alaska is that while we have had some
leveling of the number of overdoses due to prescription
opioids, there has been an additive effect of an increasing
number of overdoses due to heroin and also the synthetic
Fentanyl-related compounds.
There has even been some decline in opioid prescribing. So
I think it is important to point out that we may be beginning
to bend that trend, but we are nowhere near where we need to
be.
We have heard a number of stories this morning of where
large amounts of opioids have been prescribed and have led to
problems or that problems with misuse have gone under-
recognized. And I think a lot of that is driven by a lack of
awareness among the healthcare provider community and even
among the public in terms of the risks associated with these
drugs.
Specifically, what is happening in Anchorage, I think,
highlights a number of issues. At this point, we do not know if
the increase in overdoses is being accompanied by an increase
in overdose deaths. It is possible that we are actually seeing
more people survive to interact with the EMS system because we
have been very aggressive in getting Naloxone kits out into the
community, distributing over 5,000 of those kits over the past
3 months.
It also highlights the importance of the interagency
communication between public health and law enforcement so that
we are sharing data and able to discuss exactly what we are
each seeing from our own perspectives.
For example, it is not clear whether or not this may be a
batch of some substance that is much more powerful than the
heroin that has been on the street in the past, or is it an
influx of primarily people who have reduced tolerance? We do
not know that degree of detail yet. But that is where working
together and having our incident command response really has
helped to be able to facilitate those communications.
We learned a bit of this during an outbreak of ``Spice''
overdoses of the synthetic cannabinoid a couple of years ago
where it actually took several weeks to be able to recognize
the problem and connect those dots.
In this case, we actually were aware of the increase late
last week and we were able to start having those conversations
as soon as we recognized it.
The final comment I was going to make is that while it is
important to address the challenge of illicit opioids, we have
to recognize that part of the reason heroin found such a ready
market when it came in, in larger quantities and at much lower
prices.
Starting about a decade ago, we had a much larger
proportion of our population that had physical dependency or
addiction to opioids. And that the way we oftentimes use
opioids with good intent and good intention therapeutically
oftentimes can be a set up for physical dependency.
Withdrawal can be awful even if it is not the more chronic
condition of addiction, people will oftentimes turn to whatever
they can turn to, to be able to avoid the rigors of dope
sickness.
Senator Sullivan. Anyone else on the panel want to comment
on what they see nationally as a trend and the reasons for it?
I do want to comment. Mrs. Deutscher, I was here for your
testimony and I really just appreciate it. I know that that
could not have been easy for you to testify before this
committee and recall some things that are obviously incredibly
heart wrenching for you personally and your family.
But unfortunately as I have dug into this issue, the story
that you told about your son, it is not an uncommon story in
terms of an athlete who has a bright future, a high school
star, and then there is an injury, and then this happens. Have
we learned enough from that? It is a very common story that we
are hearing.
How you talked about how you did not understand fully the
risk. Do you think there is more that needs to be done? Do you
think that people are recognizing that?
And again, I just want to commend you for being here today.
I am sure it is not easy.
Ms. Deutscher. Thank you.
I do not think there is enough being done. I think funding
is a huge issue to get the awareness out, to get into the high
schools, to get it to the coaches, to get it out to the general
public of opioids just in general, but also as it relates to
our athletes.
We had great coaches. Jeff and I are very involved. We had
a great athletic trainer. We had great physicians. But as I
have told in a couple of deliveries that we made to within our
state, it was ignorance that was part of Nick's death. We just
did not know.
And so, I think that is so crucial.
Senator Sullivan. Thank you.
Are there any other thoughts on the broader trends on the
opioid issue throughout the country and what direction you see
it going in?
Ms. Williams. This is not my area of expertise, but I would
like to add something, Senator.
I have lost three of my classmates. I am of the graduating
class of 1988 in my small town in Pennsylvania to heroin
overdose. I think the thing that is really important here, I
have said it multiple times, is outreach and communication.
What are we not communicating to people? This is getting to a
point where there is someone that is more charismatic or there
is something that is happening.
These were not the bad kids. These were not the ones that
were headed to nowhere. These were bright students. These were
people who had transitioned well from high school into college,
and gone on to professional careers that we have now lost to
heroin.
What is being said? What environment is being created
outside of the opioid use? What is the gateway that people are
entering into the heroin use? What can we do, like you said, to
be having constant communication, constant outreach?
I remember as I was growing up as a child there was
D.A.R.E. There was PAL. There were all kinds of songs, and
raps, and things about not using drugs. It seems like we saw
something that was working and we got away from it.
So now it appears there occasionally, but we are not
starting at the grassroots level saying this is really
important. These are the reasons that you should stay away from
drugs. At some point, the bad guys entered and they are doing
something that is convincing really good people to go down a
really bad path.
Senator Sullivan. Well, I think that is a really important
point. We are certainly trying to do that in Alaska.
Dr. Butler, you may have seen the head of the FBI in the
state and I have sent that FBI video. Some of you may have seen
it, ``Chasing the Dragon,'' which is very graphic, scaring the
young children into, ``This could happen to you,'' trying to
get it into all the high schools just to wake all these young
men and women up. But you are certainly correct about the point
of how some of the best and brightest in the country are
getting addicted.
Let me finish with one final question. And again, I want to
thank everybody for your patience and testimony today. On
another issue, and Dr. Butler, you mentioned how some of these
things are related, and I certainly have seen that as well.
On the issue of the sexual assaults and abuse of our
athletes, do we have enough safeguards, do you think, in place?
With regard to our young men and women who are, again,
America's finest and some of the most disciplined with regard
to some of the reports that has obviously alarmed a lot of us.
I am just wondering for the expertise here at the panel, if you
believe that we do have enough safeguards?
Congress always tries to act. Maybe it is an appropriate
role. But what do you think the role that we should be doing
and the role that you should be doing?
Ms. Pfohl. I would be happy to start. Thank you, Senator
Sullivan.
I think the answer is no. We do not have enough safeguards.
That is the reason the U.S. Center for SafeSport has been
created and the reason we exist, and the reason we need to
exist.
I think you asked what the Senate can do. I will say again,
I think having an authorization, again, following in the
footsteps of USADA, but being authorized in legislation.
Certainly, we would not turn down an appropriation, but being
authorized in legislation goes a long way into establishing the
credibility, the need for these safeguards as you have said.
It is our absolute goal, our mission to not only address
the abuse and weed out the bad actors, but to really get
upstream on prevention. To make sure that we are educating all
parents and youth sport organizers, if you will, the athletes
themselves on how to identify grooming behaviors, for example,
when we are talking about youth. What does that look like?
And so, all of the education, the outreach, the training
that needs to take place that is not currently taking place,
that is why we are here. We are absolutely committed to
creating change. Again, our motto is champion respect and end
abuse. That is our call to action.
Senator Sullivan. Thank you. Anyone else on that question?
Ms. Williams. I would also say no, that the safeguards that
we have in place are not enough. What we need in place is
uniform, baseline education across all the different levels of
sports from, like I said, the grassroots level, youth, moving
up into the elite ranks.
There needs to be something for when a coach, when a person
that is going to be of authority that is going to be dealing
with an athlete on a regular basis. Once they enter into this
field, what are the baseline requirements to make sure that you
are going to do what is in the athlete's best interest?
Right now, there is no uniformity across all these
different levels, different organizations that exist. You can
just wake up one morning and say, ``I am going to go coach
people and I am going to go coach kids.'' You are there and you
are coaching. Everyone is like, ``Oh, he is nice.'' And then
you are bringing kids home and it just degrades from there.
Senator Sullivan. Yes.
Ms. Williams. So baseline education and baseline points of
entry. There are requirements that make sure that we do have
proper safeguards. Those are the things that need to be put in
order.
Senator Sullivan. Thank you.
Before we conclude, I would ask unanimous consent to
include in the record letters from stakeholders providing
additional perspectives on today's hearing including the Sports
Fans Coalition* and the Positive Coaching Alliance.
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\*\ This letter can be found on page 97 of this hearing.
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Without objection, so ordered.
[The information referred to follows:]
Prepared Statement of Jake Wald, Business Development Manager,
Positive Coaching Alliance
Mr. Chairman, Mr. Ranking Member, and Members of the Committee. My
name is Jake Wald, and I appreciate this opportunity to submit
testimony on behalf of the Positive Coaching Alliance (PCA) for the
Committee's hearing entitled ``Current Issues in American Sports:
Protecting the Health and Safety of American Athletes.'' We appreciate
the Committee focusing attention on the issues facing athletes, both on
and off the field.
PCA is a non-profit, educational organization that provides
resources for students, parents, coaches, and leaders with the aim of
improving the culture around youth sports. Operating under the motto
``Better Athletes, Better People,'' PCA works to ensure that all youth
and high school athletes have positive and character-building sports
experiences.
We pursue this goal by working directly with youth and high school
sports leaders, coaches, athletes, parents, and officials through
partnerships with schools and youth sports organizations nationwide.
These partnerships consist of live workshops, online courses, books,
and more--all geared toward changing the culture of youth sports. Since
its inception, PCA has reached more than 8.6 million young people;
partnered with roughly 3,500 schools and youth sports organizations;
and delivered hundreds of thousands of online courses.
I joined PCA in 2012, and I am responsible for the development and
establishment of new PCA chapters, to add to the 17 we already have in
major cities including Chicago, New York, Houston, Los Angeles, and
Tampa Bay. I came to PCA after being fortunate enough to have a career
first as a student-athlete at George Washington University (GWU) and
then as a professional athlete in the San Francisco Giants and Arizona
Diamondbacks organizations. Upon my retirement, I returned to college
baseball as a coach, first at my alma mater, GWU, and then at
Georgetown University. These experiences informed my decision to get
involved with PCA, and provided me with the insight to speak firsthand
about the issues facing youth athletes today.
As the Committee begins exploring factors impacting athlete safety,
we urge the Committee to assess the culture of youth sports as an
integral factor affecting young athletes. Last Congress, the House
Energy and Commerce Subcommittee on Oversight and Investigations
convened a hearing to evaluate concussions in youth sports. At that
hearing, members noted that improving the safety of sports is not
merely about science; it is also about culture.
We strongly agree with the notion that that culture plays a
critical role in improving awareness, attention, and care for youth
athletes, and we are concerned that today's win-at-all-costs culture
incentivizes and normalizes damaging behaviors--including use of
performance enhancing drugs, opioid abuse, and overuse injuries spurred
by premature sport specialization. In fact, each year, the current win-
at-all-costs culture drives millions of kids out of sports for good.
Not only does this deprive them of the well-researched benefits of
participating in organized athletics, but their negative experiences
may have further effects throughout their lives.
PCA leads the charge for youth sports organizations to overcome
these cultural challenges and help millions of kids reach their
potential. Young people can only reap the full benefits of competing in
organized sports if the adult leaders, coaches, and parents behave as
character educators, intent on teaching life lessons--including healthy
competitiveness--through sports. With a winning combination of
truthful, specific praise; constructive criticism; and positive
motivation, athletic performance improves, and so do the chances that
kids stay involved and learn all the valuable life lessons that
organized competition can teach. As such, we appreciate and are pleased
to see that the Committee has an established interest in evaluating all
factors that impact athlete safety, beyond just the physical.
PCA is concerned with the decline in participation in youth sports,
which reduces the number of American youths who can benefit from the
experiences and life lessons a positive experience in sports can
provide. While there are a number of factors contributing to this
trend; it can be in part attributed to the tremendous negativity that
pervades youth sports today and the pressure placed on young athletes
to succeed at any cost. We appreciate and are pleased to see that the
Committee has an interest in evaluating factors that impact athlete
safety, and we urge you to continue to bring attention to the issue of
sports culture--particularly in the context of its role in the
development of our Nation's youth.
Thank you again for this opportunity. We would be happy to discuss
this and other issues related to youth sports with you at your
convenience.
The hearing record will remain open for two weeks. During
this time, senators are asked to submit any questions for the
record for our witnesses. Upon receipt, the witnesses are
requested to submit their written answers to the Committee as
soon as possible.
I want to, again, thank the witnesses for appearing today.
These are very important issues. You can see there is a lot of
bipartisan interest and, I think, motivation to address these
in a bipartisan way. We are going to continue to engage with
you and others to make sure we address some of these in the
best way possible.
This hearing is now adjourned.
[Whereupon, at 12:20 p.m., the hearing was adjourned.]
[all]