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Many needlessly getting steroid injections for back pain, bioethicist says

The quest for relief from pain has now resulted in the deaths of 19 people and a total of 247 confirmed infections of fungal meningitis from tainted steroid injections. Thousands more who got the injections, made by the New England Compounding Center in Massachusetts, are worried that they too may wind up sick or dead. 

The horrific outbreak has resulted in the outrage about a lack of oversight of the compounding pharmacy.

But, this tragedy has another aspect that is not getting sufficient attention. Why are so many Americans getting spinal injections?

Most people in the United States will experience low back pain at least once during their lives. Back pain is one of the most common reasons people go to the doctor or miss work. It has also spawned a lucrative industry of spinal injection treatments whose efficacy, safety and long-term utility are mixed.

Epidural steroid injections are a common treatment for many forms of low back pain such as bulging discs, sciatica and leg pain. Experts agree that injections should be a last resort after patients in pain have tried anti-inflammatory medications and physical therapy. Millions of Americans get shots but far too many as a first attempt at relief, rather than a last resort.

The use of spinal injections, which have been around for 50 years, has been growing rapidly with one study reporting a 629 percent increase in Medicare expenditures for epidural steroid injections over the last decade.

Back pain injections can cost as much as $600 per shot. Insurance will pay much of the cost and there are often a lot of shots given. Sadly, there are lots of programs all over America that advise you on the Internet and in newspaper ads to come in and get a shot for back pain before trying anything else – that’s just lousy medicine.

Do the shots work? Many patients who get them say they do. But  the evidence is not convincing that people do better with shots than pain relievers and anti-inflammatory drugs. One recent, blinded study, published in the British Medical Journal, showed that patients reported as much pain relief with saline placebo shots as those who got epidural steroid injections.

Another study, published in 2007 in the medical journal Spine, showed that shots are most useful for people with herniated disks and pain radiating into their legs or arms but fewer than half of the injections given are for these conditions.

The explosion in back pain injection treatment closely parallels the explosion of obesity in the United States. Not surprisingly, the treatments that have the best evidence of helping relieve back pain are losing weight, exercising more and maintaining better posture. We are becoming a society that relies on symptom relief for health issues, not fixing the underlying problem.

No one should have to fear getting a fungus that might kill them when they go to get treatment for their back pain. Our legislators and regulators have let us down when it comes to keeping an eye on mom and pop drug makers. But, too many of us are using spinal injections as the first response to back pain. And too many doctors and clinics are pushing that treatment as an easy fix. Nothing is easy when it comes to pain. Medicine needs to stop promoting quick and very lucrative fixes for back pain when for a lot of people who suffer an alteration in lifestyle should be what the doctor orders.

Arthur Caplan is the head of the Division of Medical Ethics at NYU Langone Medical Center.

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