After Doctors Cut Their Opioids, Patients Turn to a Risky Treatment for Back Pain

Blackmail. More unintended consequences of our War on Drugs. https://khn.org/news/missed-visits-uncontrolled-pain-and-fraud-report-sa...

No one (who is well trained) uses depomedrol anymore for spine injections!!!! Hasn’t been used in years.

Not a well informed or useful article. Quoting the opinion of a single Kentucky physician is an absurdity. Chronic pan exists and it is no longer being treated effectively in this country.

For all those commenters who say how necessary opioids are for the management of low back pain, it is worth noting that not a single guideline on the treatment of low back pain recommends the use of opioids. This is because nobody has shown these medications are effective for this. Instead, it has been shown that exercise, physical therapy, cognitive behavioral therapy, and acupuncture are effective and as to medications, the most effective are the NSAIDs and the serotonin-norepinephrine reuptake inhibitors. For all those who disagree with this, if you've got research contradicting what the guidelines state, present it. And for anyone who believes that anecdotes are just as valuable as actual research, there are anecdotes about people being cured of cancer through prayer alone. But how many of you, if your were diagnosed with cancer, would seek care from a minister instead of an oncologist?

To in any way suggest that, as Dr. Kolodny does, this is in any way tied to the opioid crisis completely ignores history. I have been a pain management doctor for 30 years and even before I entered the field, doctors were doing all sorts of unnecessary procedures for back pain that had absolutely no science to support their use. Repeated studies have shown that people with back pain do as well with conservative treatment modalities as they do with more invasive ones without the significant risks many of the latter carry. Not a single professional guideline of which I am aware recommend the use of opioids for the management of chronic low back pain so the idea that doctors are doing these procedures because they are afraid of prescribing opioids is foolish. And by the way, there are no studies to support the use of epidural steroid injections. Although doctors like to pretend to patients that they need these because their pain is caused by inflammation, there is not one shred of evidence to prove this is true. But why base the practice of medicine on science when doctors can make far more money deceiving patients. I don't know of anything worse than patients suffering because of the greed of their physicians.

I think that in a significant way this article misses the point or is at best incomplete. Chronic back pain not due to malignancy and not due to an acute process such as a herniated intervertebral disc is frequently a disorder without an effective medical solution. Patients with this problem are very frustrated and go from care giver to care giver seeking a remedy that doesn't exist. Oral and parenteral non opiate medications are often tried without success and with their own complications, such as the kidney damage associated with non steroidal analgesics.Thoughtful interventional pain doctors see a lot of these patients and are frustrated by their own very limited remedies. Individual practitioners frequently pass them along to other caregivers. Chronic back pain is a disorder worthy of a new approach such as a multidisciplinary team that can invest time and knowledge into making a specific accurate diagnosis and formulating a treatment plan that can address the fixable and palliate what can't be fixed. Such a team might include physical therapy, psychiatry, anesthesiology, neurosurgery, neurology, palliative and rehabilitative medicine, and orthopedics. The story the author told was of exploitive doctors using inappropriate and dangerous medications and procedures for financial gain. She failed to explain the context and to differentiate between disorders such as acute and chronic pain syndromes with respect to outcome and complications.

"In West Virginia, the heart of the opioid epidemic" It's not a coincidence that the rise in opioid abuse and the great recession go hand in hand and with West Virginia being one of the poorer states the crisis has reached epidemic proportions. If an unskilled job in sanitation can support a middle class lifestyle the solution is clear. A living wage for all where one can raise a family with dignity and respect without the need of public assistance. It's that simple.

Medical Marijuana can be a very good thing. Just saying.

This article refers to injections "along the spine". The epidural space is inside the spinal [bony] column separated from the spinal [neural] cord by the dura. The phrase is ambiguous, and perhaps minimizes the technical skill of getting the injection in the right place.

There is all this negative spin around the individual who quarterback Tom Brady uses . Apparently the Quarterback understands that a shot is not a cure all even if the NFL swears that the team doctor is God. So lets make fun of Tom Brady because he wants the best medical care he can get, which means a holistic approach. As usual the medical profession is a dollar short a day late and could care less about patients. Its all about making the money off the suffering of the Citizens of this country . Cure for cancer, dementia,back problems not when there is so much money to be made off of the medical issues. Most people go into the hospital and their lives are forever changed and not all for the better

What did they think would happen? Chronic pain, particularly back pain, can make life unbearable. I have had several episodes over the years which have made even small movements out of a single “comfortable” position send me into paralyzing pain, unable to walk, stand, or sit, depending on the injury. The only thing I wanted was relief...immediately. Not reprogramming of my subconscious, not acupuncture, not radio frequency ablation...and Yoga? Are you kidding me? Not for a pinched nerve caused by a herniated disc. Since back surgery several years ago, I have managed to stay relatively pain free and have not needed opioids again. But I wouldn’t hesitate to take them again if I had a recurrence. Unfortunately, the knee jerk reaction to the opioid crisis will certainly make relief much harder to get should I ever have the need again.

This is really crazy. There is no reason that those with severe chronic pain should not receive opioids. Punishing sick people because of the occurrences of opioid abuse makes no sense. Morphine is often used in end of life care. Do the dying have to suffer more too? This is throwing the baby out with the bathwater.

Isn’t it adorable how innocent these pushers pretend that they have been throughout this whole mess? There are actual drug dealers that express more concern over the lives of their addict customers than many of the medical professionals involved. Interesting how different people act when their word is the thing that gives them credibility.

I have a good friend about 60 years old .He has had a few back surgeries ,a lung transplant and recently recovering from cancer.Recently his pain doctor cut his prescription in half telling him there are new rules.Now my friend stays in bed until midday at least since he has too much pain and not enough medication.He is afraid to switch doctors since the one he has might drop him and the unknown may not be better.I have never seen my friend intoxicated from taking his pills but now he is being punished without recourse.He probably won't go on the black market due to cost but he is contemplating suicide .Why?

After reading this article, I don’t know what to think. Sciatica from L4/L5 and S1 areas of the spine caused me excruciating pain. I wanted no part of surgery so the surgeon referred me to a pain doctor. My first words to him were: “Don’t even talk to me about opioids because I won’t take them.” So I took ibuprofen, 800 mg/3Xday, for months. When my primary care physician became alarmed at the amount of ibuprofen, I went back to the pain doc for epidural shots. Over a period of 8 months I had 3 or 4 shots; I’ve had none since Oct. 2017. I have no explanation, but I get by with 1 or 2 ibuprofens a *week.* After this article, I doubt I’ll go back for more shots. I was terrified of them to begin with, and I’m still terrified of them. BTW, my doc was a specialist, not someone who took a couple of weekend courses.

I injured my neck severely a few years ago. Bad enough that I couldn’t even sit at a desk for more than 15 minutes. After months of doctors refusing to manage my pain appropriately, I finally just paid for a steroid injection myself. It was a lifesaver. I feel like regulatory authorities are slowly closing off all avenues of relief form serious spine issues, no opioids, and now potentially no steroid injections? What are we supposed to do? Megadoses of ibuprofen (which are arguably more, not less, dangerous than opioids) and months off work? Meditation? Nonpharmacologic pain relief modalities are an absolute joke when you’ve got bills to pay.

Can't help wondering how much special interest pressure determines Medicare rate of payment. Hospice is one example. Theoretically, it's for those with less than six months to live, but this is not enforced. For about 5K per month, it's a daily visit for a half hour, and maybe a bath every few days. There is an eagerness to sign up the elderly, and no price competition. For some reason, a simpler form of aortic valve repair that is done with no anesthesia or chest opening and heart bypass is fully paid for, while for a sub-catagory that is a fraction of the time as it is like a stent, is not approved, even if the patient would sign a waver since the mortality is somewhat higher. I'm sure the interest groups, thoracic surgeons v. interventionists is ongoing under the the radar. Right now for me, the simper TAVR would cost me 90Gs while the more expensive open heart route is fully paid by medicare. Having insurers with a profit motive rather than civil servants just could have value, as is the case with ACA in contrast to the push for Medicare for All

Perhaps our puritanical and sadistic approach to pain-relieving drugs will eventually result in people having to treat their pain with alcohol, if that's the only drug left they can readily obtain.

"Pfizer was worried about liability from the off-label use" they have to look out for their shareholders first and foremost. Patients are obviously secondary even if "giving steroid shots close to the spine could cause rare but catastrophic injuries or death." Who knew "weekend classes aren’t sufficient training" for injecting someone anywhere near their spinal cord that could cause paralysis or death! I have avoided - refused, actually - opioid pain killers to bear the frequently unbearable pain from a spinal cord injury five years ago. I continue to seek pain relief and my spine surgeon keeps saying the best thing to do is remain active (painful to do) and strengthen the core (also painful). He said the pain will be there always, unfortunately. Fortunately I am one of the four out of five users of a TENS device that is placed on the calf just below the knee that has worked for me so far. It has certainly turned down the volume on the never ending and varying pain I'm in - skeptical as I was that zapping my upper calf wouldn't just ADD to my pain. https://www.consumerreports.org/conditions-treatments/quell-wearable-mig... Too many gimmicks out there and getting injected by someone who took a weekend class seems a bit reckless and dangerous to me.

This is an extreme case and I have sympathy for the subject - but the larger point that opioids (in small, appropriate quantities) are now vastly under-prescribed is both true and relevant to many Americans who are not addicted but do have sporadic need for the pain relief these drugs bring. We have wildly overcorrected and forced many to live with debilitating pain, find other means of "numbing" a pain, or exacerbate the black / gray market for these drugs.

I am very perturbed by the gross generalizations and inaccurate information in this article. There are several different medical specialties who perform epidural and transforaminal injections. Anetheisologists, rehab, and radiologists are some of the medical specialties. Why that is IMPORTANT is that each specialty does not perform the procedure the same way. Radiologists use flouroscopy (live x-ray) to guide the needle into the proper space. They will frequently inject a small amount of contrast visible on xray to confirm that the thecal sac is not punctured so steroid is not inadvertently injected into the wrong space. Radiologists do not routinely write opioid prescriptions. The ones I know refuse to do so when asked by patients. There is no quid pro quo of procedures for prescription. Patients come back because they feel the procedure benefited them.

Has anyone researched radio frequency ablation? I have had my spinal nerve, L5-S1, numbed by radio waves and it has helped without opioids. The ablations leave no side effects. I also walk my dog one to two hours nightly which helps my back muscles along with gentle back stretching.

I am a primary care doctor (MD) and I happen to have an interest in an obscure drug called LDN .Website is www.lowdosenaltrexone.org. It works for over 100 physical and mental conditions and in particular it works for autoimmune diseases and chronic pain. it is an opiate antagonist so it cannot be used with opiates. We make natural opiates as we sleep and if one adds LDN it triples the production of natural opiates for the next day! I have over 50 patients with Fibromyalgia alone . An American lady with advanced MS came to Ireland. I put her on LDN , Six months later she sold her wheelchair and went back to work in America. I am amazed that so few physicians know about it. It has minimal side effects and it costs in the region of a dollar a day. Research reports are at www.ldnscience.org. There are over 60 research projects active at present including several top American universities.

We need to make stem cell treatments legal and affordable.

Banning opioids is dumb. They are very effective medicines. As usual, the government is attacking the symptoms, and not the disease. Opioid misuse is a symptom of a society that has abandoned its working poor and working classes. Do more to improve their lives and the opioid misuse will wither away. Of course, that would involve making changes to the system that has created these problems, and those who are doing well under that system don't care at all about the lives of the people it leaves behind.

Important article. I'd suggest digging deeper into the medical literature. See Chou et al in Spine 2009, 34: 1078-1093. These injections are not superior to placebo injections. Please write about that. Thanks!

The temperance movement against opioids shows little concern for medical ethics, and the article shows some of the damage. The DEA has the power to shut down a doctor's practice for even a suspicion, a career ending move for most doctors. I've been on opioids for years, low dose mind you when I need them, which I do from time to time because a crushed disc allows my spine to pinch the nerve going down the front of my left thigh. Anti-inflammatory like Depo-Medrol would probably make my wound worse if it shrank my disc, a frightening prospect that could cripple me like my wound did for two months. I crawled everywhere because a hematoma to lodged in my spine, adding insult to injury. The left side of my disc is permanently one-third the size of the right. It's engineering on a medical scale, and I don't want surgery that my back and family doctor said will probably cause other problems, anyway. I'm 66, and like many geezers, am getting high blood pressure. Thousands and perhaps millions of chronic pain sufferers will die prematurely from heart attack and stroke caused by high blood pressure that pain exacerbates if the craze against pain medicine that's been used for thousands of years continues.

from a retired medical attorney: This week three friends told me about their new "pain doctors" who are doing injections "to help diagnose the cause of their pain" and figure out non-opioid treaments, e.g., "nerve ablation." I told each one to stop. Then gave each with no history of heart disease five 60 mg Arcoxia (VIOXX replacements) to take over five days . . .to see if their pain is OA. All three got complete pain relief by day three, but one said it messed with her anti-depressants. Imagine my horror when each said they were going back to their pain docs. I asked "Why?" You now have a diagnosis for all of your pain--OA. Steroid injections cannot block that pain. All three said they "really like their pain doctor" so I went straight to "STOP." Think. Nice docs can maim or kill with these injections--that can never be effective controlling severe OA pain. They all agreed to report this drug trial for OA pain relief to their primary care MD. FDA and primary care physicians know that Pfizer's Celebrex for severe OA only works for some patients. Many for whom Celebrex does not work got complete OA pain relief with VIOXX. It is time for FDA to act on an "expedited approval" of Arcoxia 30/60/90 mg doses like I have gotten for 13 years from London. So that my friends can stop their suffering and get this drug through their local pharmacies and physicians. We have finished the drug trial for three-of-7M patients here in FL. They suffer until FDA acts.

After building lower back pain for 30 years. I couldn’t walk, sleep, or sit for long. Lying on my stomach on my office floor was the only physical relief available. That & too many OTC pain meds. PT a year earlier had left no lasting results. Desperate I elected to try injections w/a scan revealing a herniated disk: cause unknown. After two separate injection treatments, one opioid pill that made the pain better, only to return with greater intensity. My experience anyway. The pain returned. I met w/the hyper scheduled injection doctor at his thriving practice. He couldn’t explain how or why the injections worked, or why not for me. Maybe a third procedure? In from the side, more expensive and more painful, w/the increased risk of arthritis that’s associated with all this. Coverage was checked and he sighed, “You’ll have to wait six months...” I just looked at him. Finally he wrote a name out. “Call them they’re the best.” Now years later w/long periods of no discernible pain, it’s inconceivable to me that proper PT, real PT, was the last resort short of fusing my disks. No one’s saying PT works for all. Yet done well it can be the lower risk, longer lasting way for many to deal with some chronic physical pains, and it has great side effects. It takes committed work from the patient and smart guidance and support from the providers, but it should be widely available. It’s worth it, and should be suggested at the first sign of a chronic problem. The earlier the better.

The best approach to chronic pain. back or otherwise, is PT and/or acupuncture.

For decades New Yorkers had the benefit of the late John Sarno M.D. at NYU's Rusk Institute. He taught thousands of chronic pain patients (like me) to cure our pain not by surgery, injections or physical therapy but by re-programming our subconscious to stop the pain. Repressed emotion causes the pain- stuffed feelings- and the subconscious runs amok. I was about half disabled for seven years from back pain, dragging one leg, until Dr. Sarno taught me his method. You can learn the method from his best seller books "Healing Back Pain" and "The Mind-Body Prescription."

What the public needs to know is that epidural injections can be done in a safe manner by physicians who are fellowship trained and who know the difference between a particulate and non-particulate steroids. Depomedrol is a particulate steroid and can be used safely when performing an intralaminar epidural approach. It is not safe in a transforaminal epidural approach due to the rare complication of the particle being injected into a blood vessel. This is why interventional pain physicians have switched to using non-particulate steroids when performing a transforaminal epidural. Epidural injections are just one part of the treatment plan which usually includes physical therapy, medications and psychology. Epidurals are excellent in treating acute pain from a disc herniation and until you suffer from this condition it is easy to say that they don't work. With regards to physicians exchanging pain medication for injections this is highly unethical and those providers should be held accountable.

Yoga and pilates may or may not be helpful for chronic back pain. It depends on the specific causes and the location of the problem. Getting an accurate diagnosis is important - in my case an MRI. There are a variety of surgical interventions, some more radical than others. I've had two TLIFs. If surgery is an option, it should probably be considered sooner rather than later. Fortunately for me, I never developed a taste for opioats.

Think of the long term benefits for health and the reduction of pain if gym and yoga and pilates studios had reduced membership fees with your health care benefits. Think about equal access for all income levels to these studios or gyms. Why do we have to wait until we are 65 to get Silver Sneakers gym club benefits.

Physical therapy, done well, can substantially improve or cure chronic back pain in many patients. However, the physical therapist must be good and the patient must be willing to do the exercises at least once daily at home. However, many insurance companies are unwilling to pay for enough sessions, and many patients are unwilling to really work at the exercises. Instead, most patients are shunted into chronic opioids, epidural steroids, or back surgery, any of which can hurt more than help. My herniated disc pain resolved with the physical therapy I wish more patients could receive.

This may be a good spot to tell the story of the myriad of patients who are on opioid pain management and don't abuse the drugs. Those who can no longer receive pain relief will turn to anything to help. Living in pain, is not living at all! I know, I am one of those patients who has used medications, never going up in dose, for years. Without these drugs I am not sure what quality of life I would have. We are in a crisis on both sides of the coin. Those who abuse drugs for the high, and those who are facing a life of pain because our government has seen fit to interfere with the doctor patient relationship.

Having 30+ years in the trenchs and weekly or twice weekly visits from pharm reps, I would bet that the scenario goes something like this. "Doc, there have been many complaints about Depo-Medrol. Use it off label at your own risk. (wink wink nod nod). By the way, 500 bucks for five minutes of work should not be a motivator. (wink wink, nod nod)." This might sound unreal, but I bet most honest physicians would agree with me.

Deep thoughts: No incidence of spinal injury with non particulate steroids (dexamethasone) to date in the medical literature. Most academic pain physicians know this and exclusively use non particulate steroid for safety reasons. Depo-Medrol is a particulate steroid which has been implicated in complications due to the transforaminal epidural approach. The complications include spinal cord injury due to particulate steroid blocking smaller arteries that supply blood to the spinal cord. There are few efficacy differences between particulate and non particulate steroid (meaning they work about the same for pain control). I exclusively use dexamethasone for any injection, including spinal, as particulate steroid carries an unnecessary embolic risk. Chronic pain is a biopsychosocial condition requiring a multimodal approach that focuses on movement therapy of some sort and psychological therapy. A drug/injection approach to pain works for acute pain (biomedical model), but has poor efficacy for chronic pain. Evidence based medicine is supporting the biopsychosocial approach to effectively treat chronic pain. There is another story here, the difference between the biomedical model and the biopsychosocial approach to chronic pain.

Unless and until good quality research shows these injections to be safe and effective, these treatments should not be allowed. To my knowledge, there are no quality studies that demonstrate that using these injections adds value to the treatment of patients who are on pain medicine for back pain, and the requirement that patients accept injections as a condition for continuing to receive their oral pain medications could be construed as unethical or a conflict of interest.

My back pain went away when I started a yoga practice and added Alexander Technique for better posture. In a Pharmacy book used by aspiring doctors and nurses I looked up whether side effects were properly addressed in books that are used in schools. The index said it was on page 1, 2, and 3. Indeed, the first three pages of the book said over and over again that ALL medicines have side effects. And yet, the very first thing doctors and nurses do to "help" patients is propose medicine. They hardly ever spent time on finding the cause (like too much sitting, unhealthy diet, or other bad habits). If it hurts, stop! You very well may be doing it wrong.

The injections to the spine are billed at $1000-2000, which is also a major factor in its increased utilization and an incentive to repeat injections even if the first one fails, which it is likely to do.