Wednesday, 15 Aug 2018

You are here

Opioid Aversion is Augmenting Spinal Steroid Injections

As physicians turn away from opioids, are they resorting to options that may also be unsafe?

The New York Times reports that some physicians are using the anti-inflammatory drug, Depo-Medrol, for intraspinal injections to manage painful spinal and perispinal disorders.

Five years ago the Food and Drug Administration was requested by the manufacturer Pfizer to ban the use of depomedrol injections owing to reports of blindness, stroke, paralysis and death.  Pfizer offered that Depomedrol  “...must not be used by the intrathecal, epidural, intravenous or any other unspecified routes.” 

After an internal review, the FDA declined to issue a ban but toughened the label warning. Other countries (Australia, Brazil, Canada, France, Italy, New Zealand and Switzerland) have followed these same warnings. 

In the face of a worrisome opioid epidemice there are concerns about the growing off-label use of spinal injections to manage spinal pain.  The NYT reports that "weekend classes to train physicians in the procedure are flourishing" and that they are "transforming pain clinics into drill mills.”

Adding to the problem, the House of Representatives approved an increase in Medicare reimbursement for the procedure.

The number of Medicare providers giving steroid injections along the spine, including Depo-Medrol and other similar drugs, had increased 13 percent in 2016 from 2012. The number of Medicare beneficiaries receiving these injections is up 7.5 percent. The Department of Veterans Affairs reported a 17 percent increase in the injections from 2015 to 2017. Moreover, total sales of Depo-Medrol grew 35 percent to $185 million from $133 million from 2015 to 2017. 

Pain specialists show claim that the pressure to avoid opioids is prompting many doctors to refer patients to pain intervention specialists who promote the shots.  The temptation is that these injections are easier to administer and result in higher reimbursements, compared to other pain management alternative.

A freedom of information act review of FDA records on Depomedrol between 2004 - 2016 shows 2,442 serious problems, including reports of 154 deaths.

Pfizer notes that the product’s warning label states: “Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke.”

Pfizer says it is unable to track how much off-label Depo-Medrol is used, nor can it stop the off-label shots.

 

 

 

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

Company Payments to Rheumatologists, Specialists Linked to Increased ACTH Prescriptions

Despite its exorbitant price tag and paucity of supportive clinical evidence, ACTH (corticotropin) sales have increased in the United States. A recent JAMA article examined its use by specialists and found that those who prescribe ACTH (including rheumatologists, nephrologists, neurologists) received corticotropin-related payments from the products sole manufacturer, Mallinckrod.

Veterans Administration Shuns Marijuana as an Option

Cannabis therapy is legal in 30 states in the US, and soon to be legal in Canada and Great Britian, but the US Veterans Administration continues to reject medical marijuana as a therapeutic option - even in states where it is approved.

Predictors of Methotrexate Non-Response

New research from a UK study suggests that nonresponse to oral or subcutaneous MTX was seen in 43% and is predicted by seronegativity, higher disease activity measures and higher anxiety scores.

Best of 2017: New EULAR Guidelines on Behçet's

At the EULAR 2016 meeting, new EULAR recommendations for the management of Behçet's disease (BD) were presented. These were developed by a multidisciplinary expert committee that reviewed the evidence from the medical literature and developed final set of 9 recommendations:

EULAR 2018 - Day 3 Report

Day 3 highlights include Behcet’s responds to apremilast and that biologics do not differentially affect TKR/THR post-operative infection rates. Be sure to check out today's podcast as well.