Tom Nalen understands the NFL grind. While anchoring the Broncos' offensive line for the better part of 14 seasons, Nalen got the glory of putting on the jersey every Sunday, as well as the obligations that come the other six days of the week.
Because he knows how exhausting life in the league is, he's not surprised by the outbreak of Adderall use in the NFL over the past few years.
Nalen, who played center, said he never used the drug, and it wasn't common when he played from 1994 to 2007. But based on what he has heard, he understands why football players are tempted to try it.
"I can see the benefits, because sometimes you don't feel like playing football," Nalen said. "It heightens your awareness and gets you ready to play a football game if you're not feeling good or you're tired."
Adderall, a brand-name amphetamine most commonly prescribed for attention deficit hyperactivity disorder, can increase focus and provide a jolt of energy. Because of those advantages, it's banned under the NFL's drug policy for those who don't obtain a therapeutic-use exemption. Broncos linebacker Wesley Woodyard said he knows of many players who have exemptions to use Adderall.
In 2012, the NFL handed out suspensions to 19 players for a violation of the league's substance-abuse policy; in eight of those, the player was linked to Adderall or publicly blamed it for a failed test.
That number was more than double from 2011, when seven players had drug-related suspensions, one of which was linked to Adderall. One suspended player has been linked to Adderall in 2013: Seahawks defensive end Bruce Irvin.
Adderall is known as a popular study drug among college students, and that trend has leaked into the realm of professional sports. It is classified by the NFL as a performance-enhancing drug and as a drug of abuse. Discipline depends on which policy a player is being tested under. Adderall also is banned by Major League Baseball, the NBA, Major League Soccer, the NCAA and the U.S. Anti-Doping Agency, which regulates Olympic sports.
The national prevalence of ADHD in adults is about 4 percent, according to the National Institute of Mental Health. The number of exemptions granted by the NFL is confidential, but MLB granted 116 exemptions in the 2012 season, meaning about 9 percent of baseball had the exemption.
University of Colorado director of sports medicine Eric McCarty said he's not surprised to see the trend in the NFL.
"It's rising in society, particularly in high school and college students," McCarty said. "It doesn't surprise me if there is a fair amount (of use in the NFL). Probably, they feel like it helps to stay focused and helps with tasks involved in studying."
But the issue is complicated by the nuances of the NFL's drug policy, which doesn't allow the league to specify which substance caused a player to fail a test. Because of that, many think Adderall is being used as a coverup for performance-enhancing drugs or other substances that carry a larger stigma.
Although he's not able to discuss specific cases, Adolpho Birch, NFL senior vice president of labor law and policy, said the league saw an uptick in positive amphetamine tests during the 2012 season.
The test doesn't distinguish between Adderall and other amphetamines. The NFL would like to be able to publicly announce the causes of failed tests but hasn't gained that concession from the players association.
"We're hopeful that we will be able to get to a point that we are able to do that, because we do feel that it has an educational and awareness effect," Birch said.
NFL grants exemptions
Players who have legitimate cause to use Adderall can gain a therapeutic-use exemption from the NFL. The league always has granted exemptions, but Birch said the policy used to allow a player to obtain one after a failed test. Within the past five years, the rule changed to require players to obtain an exemption before using Adderall.
Getting an exemption isn't as simple as getting a prescription. According to Denver-area adult ADHD specialist Dr. William Dodson, a doctor must provide an exhaustive evaluation, which then goes to the league, where it is reviewed by one or more independent specialists. It also requires a doctor who treated the player in adolescence to confirm his childhood history. The league pays for the process.
"It's a very rigorous process because we're concerned about the competitive implications of the issue, we're concerned about the health effects, and we're concerned about the message to young athletes," Birch said.
Dodson said players who need the drug don't gain any advantage from taking it; it simply brings their focus even with the rest of the players. He said few of the football players he has treated use it when they play. Most of them use it for studying playbooks and game film.
Awareness an issue
But many of last year's suspended players claimed they didn't realize the drug was banned, and the NFL wants to eliminate that excuse. Several Broncos players have noticed an increased effort to make sure all players are aware of the policy.
"I get an e-mail probably once a week or so (from the NFL) of a new drug or a new supplement that's banned," Woodyard said. "You've just got to stay on top of it. There's a lot of stuff we really don't know about, but that's why you've got to use your resources."
Broncos rookie wide receiver Tavarres King said he had teammates at Georgia who were prescribed Adderall, though he didn't know of any issues with misuse. NFL rookies are required to attend meetings that explain the drug policy.
"The biggest thing they talk about in meetings is to know what's going in your body," King said. "If somebody's doing that, they know what they're doing."
Birch said the NFL's message is clear: Before you use any drug, get it cleared with a team physician.
"The key to understanding is to make sure people know they've got to get these things checked out and approved," Birch said. "That's a message we have to say constantly. There's not much more that we can do, but you do have to be consistent with messaging."
Adderall restrictions in various sports
Adderall is most commonly prescribed for attention deficit hyperactivity disorder but is sometimes used as a performance enhancer by athletes. Here's a look at requirements of different leagues and sports governing bodies for the use of Adderall:
NFL: A doctor must fill out an exhaustive diagnostic form documenting the presence of lifelong impairments, and childhood history must be confirmed by a physician who treated the player as a child. The form goes to an NFL administrator, who sends it to an independent expert in ADHD. Everyone must agree the case is legitimate before the player can get a exemption. The exemption must be renewed every year.
MLB: A player must be diagnosed with ADD or ADHD by an MLB-certified clinician using a specific diagnostic interview. If the player hasn't been diagnosed by an MLB-certified clinician, the case is referred to the MLB's Expert Panel on ADD/ADHD, which can then request additional information or tests before issuing an exemption.
NBA: Players can apply for an exemption with the medical director of the league's anti-drug program.
NHL: A player must apply to the league's Program Committee, which will review the application and decide whether to grant an exemption. This process must be repeated yearly.
NCAA: The student-athlete can show proof of an earlier ADHD diagnosis and course of treatment, or undergo an assessment through the university in order to get an exemption. The paperwork must be maintained by the athletic administration to show in the case of a positive test.
USADA/Olympic sports: The athlete's physician must fill out a sport-specific application and provide supporting documentation of ADD or ADHD. Those are submitted to organizers of the event the athlete is preparing for.