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11 Articles in Volume 14, Issue #4
Recognizing and Treating Concussions Related to Sports Injuries
CDC Initiative: Concussion in Sports and Play
Pain Management After ACL Surgery
Risk Assessment in the Digital Age: Developing Meaningful Screening Tools for Opioid Prescribers
Testosterone Replacement: Essential in Pain Management
Why Is There Hydromorphone In My Patient’s Urine?
Benzodiazepines in Pain Practice: Necessary But Troubling
Commentary: Risk Assessment in the Digital Age
Zohydro Debate: Drug Hysteria or True Concern
Benefit of Long-acting Versus Short-acting Opioids?
Epidural Steroid Injections, Coping Skills, Medical Marijuana

Epidural Steroid Injections, Coping Skills, Medical Marijuana

Letter to the Editor May 2014

Epidural Steroid Injections

Thank you for your review of issues with epidural steroid injection (ESI) in Practical Pain Management.1 I am pleased that you included Nancy Epstein’s article.2 It is a great review and is freely available on line, which is helpful for any students reviewing the issue.

I am an orthopedic spine surgeon retired from active practice but still busy teaching. After the debacle in 2012 with infections from tainted medications, I became irate. Here in Michigan, there were many cases and many dire results. Infections do happen with any procedure, but it is essential for every person performing a procedure to perform in a sterile manner and use appropriate medications. Nobody seemed to be monitoring the manufacturer in Massachusetts.

For years, I used triamcinolone for steroid injection. It mixed without precipitating with local anesthetics and allowed for easier diffusion of medication. I was surprised it is “off label.” A decade ago, I was upset when my hospital pharmacy switched manufactures for this medication to an unknown manufacturer. As a surgeon, I found Depo-Medrol (methylprednisolone acetate) imbedded in dura and nerve roots, as well as in a median nerve after someone had injected directly into the carpal canal.

Complications from repeated dosages of ESI are many. We all know results of long-term oral use of steroids. I had a case of a middle-aged woman who developed a rare fungal lung infection that resolved following long-term treatment, but she had concurrently developed significant osteonecrosis of one of her hips. Her pain doctor had used at least 80 mg of Depo-Medrol every few weeks for intractable back pain that was not associated with a discernible surgical lesion. Recently, Mandel and others published a retrospective review suggesting an association with but one epidural steroid with increase risk of vertebral compression fracture.3

I volunteered to lecture at the American Osteopathic Academy of Orthopedics meeting last October because I had the time to research and was impassioned. At that time, concerns were surfacing about the compounding problems, and later complications related to technique and cortisone itself came to prominence. Most of the young doctors to whom I lectured were surgeons. A few performed procedures with injections as part of their treatment protocol, but most referred to pain management specialists. Some important points that I shared with them are that risks of a treatment, even if they are rare, need to be shared with patients and that repeating a procedure often is probably not worthwhile if it does not show signs of being helpful. Knowledge is essential to informed decision making.

On the plus side, technique has improved. No injection should be done without fluoroscopy. Placement of needle into foramen should be located away from artery, particularly in the neck. Many of the journals of pain management have discussed these topics well. Of equal interest is the possibility of using newer drugs to block cytokines in the area of disc disease. Physicians in training or working day to day need be aware of drugs that are specific to pain generators and that are less noxious than some of the available therapies; pharmacists need be aware of the techniques of injection to understand drug distribution; and proceduralists need to be aware of the risks of problems from medications.

I applaud you for your issue discussing some of the aspects of ESI. It is good to see those involved in education working to improve the quality of medical care.

Richard A. Scott, DO, Harbor Springs, Michigan

Dear Dr. Scott:

Thank you for your letter. Of note, the Food and Drug Administration (FDA) issued a warning that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.4 The injections were given to treat neck and back pain, and radiating pain in the arms and legs. As noted in your letter, according to the FDA, “the effectiveness and safety of epidural administration of corticosteroids have not been established,” and FDA has not approved corticosteroids for this use. 

The FDA is recommending that patients discuss the benefits and risks of epidural corticosteroid injections with their health care professionals, along with the benefits and risks associated with other possible treatments.

Nikki Kean, Managing Editor

Patient Coping Skills

I cannot get over the article from Ted Jones about the “The 5 Skills Every Chronic Patient Needs.”5

Talk about “right on!” It is so easy to forget that 3 legs hold a chair and we as doctors often only think of treatment as 2-legged.

I love his holistic treatment regimen. This article only reaffirms what I have been preaching my chronic pain patients.

Dr. Jones simplifies this very complex behavioral issue and I have sent the article to all of my psychologists and counselors to discuss these skills with every pain patient I send.

Thank you very very much.

Roland Chalifoux Jr., DO, McMechen, West Virginia

Medical Marijuana

I read with interest your article in the April 2014 issue of Practical Pain Management by DeGeorge and Dawson.6 The authors implied that, by analysis of urine drug testing, people with chronic pain who tested positive for the presence of cannabinoid metabolites and who were prescribed hydrocodone have fewer positives for prescribed hydrocodone than do hydrocodone users who testing negative for these metabolites.

The authors suggest that marijuana use leads to non-compliance with prescribed opioid therapy, somehow this being a “bad thing.” The authors do not address the equally likely conclusion that cannabinoid-induced analgesia is so effective for chronic pain management that fewer opioids are needed for pain relief. Indeed, as discussed in our textbook, cannabinoids provide excellent analgesia; this is probably the major therapeutic benefit of the alkaloids in this plant.7 The analgesia provided by cannabinoid agonists may reduce or eliminate the need for more potent, and perhaps more impairing, opioid analgesics. This would seem to account for a lower use of prescribed opioids.

The major problem with the use of cannabinoids for analgesia lies not in drug efficacy but in the use of raw plant material as a source of the effective alkaloids, primarily THC [tetrahydrocannabinol] and cannabadiol. To explain what I mean, I present what might seem to be a rather ridiculous example.

I spent 25 years as an operating room anesthesiologist. Routinely, the night before surgery I would telephone my next-day patients, explain anesthesia, and ask for questions. Knowing a patient might experience post-operative pain, I might suggest that they go out and find some opium poppies and bring them to the hospital so they can suck on the poppies to obtain morphine for analgesia.

How ridiculous! But is it really any different than asking a patient to grow a plant, harvest the leaves, dry them, and roll them into a cigarette to obtain analgesia. This is exactly what we are doing today with marijuana. Is it really any less stupid than sucking on opium poppies to obtain needed morphine? As discussed by Russo:

“Sativex, a cannabinoid derived oromucosal spray containing equal proportions of THC …. and cannabadiol was approved in Canada in 2005 for treatment of central neuropathic pain in multiple sclerosis, and in 2007 for intractable cancer pain. Numerous randomized clinical trials have demonstrated safety and efficacy for Sativex in central and peripheral neuropathic pain, rheumatoid arthritis and cancer pain.”8

Many other authors have confirmed such analgesic efficacy.9-12 With such confirmation of the analgesic effects of cannabinoids, is it not time to advocate for abandonment of the smoking of crude marijuana and adoption of refined therapeutic products such as Sativex? Further, in the United States, the government should be urged to introduce Sativex as a clinical agent, together with aggressive study of the analgesic potential and safety of cannabadiol and other cannabinoid partial agonists. I would hope that Practical Pain Management, its editors, and authors/consultants might support such a move.

Robert Julien, MD, PhD, Lake Oswego, Oregon

Last updated on: May 19, 2015
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