NYT strikes again

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Sensationalist, fear mongering, ill informed, click bait, trash.

Big paper like the NYT should have physician consultants on retainer to prevent themselves from looking like a BuzzFeed article.
 
If you elected not to click through to the link, here is the executive summary: Poor desperate souls. Their unlimited supply of completely harmless opioids has been cut off by cruel money-grubbing doctors, and now their only choice is dangerous, experimental, should-have-been-banned-years-ago ESIs
 
What the hell would they have us do for Chronic pain patients???

You know, bc opiates are evil, and injections are evil.

Pt and nsaids for everyone? No other options?

Ugh, these broad brush articles really piss me off
 
“The victims of our era of aggressive opioid prescribing are being exploited in some cases by interventional pain doctors, who will continue them on opioids in exchange for allowing them to perform expensive procedures that they don’t need,” said Dr. Kolodny, who is also executive director of Physicians for Responsible Opioid Prescribing. “These are not benign procedures. Patients can be harmed and are harmed.”
 
I think the most important part of this whole discussion is at the end.

"""
Dr. James Patrick Murphy, an anesthesiologist and addiction specialist in Kentucky, believes that recent studies showing the shots do not work better than physical therapy for many patients are reason enough not to use them on so many patients. He also thinks they cost too much.

“The physician fee is usually somewhere between $100 and $300,” Dr. Murphy said, “but the hospital fee for the procedure, the separate fee, can be anywhere from $1,000 to $5,000. That’s a lot of expense for somebody when you really can’t promise you’re going to cure them.”
"""

Unlike cardiac stenting, joint replacement, fusions, etc, the lack of face validity at your ability to "fix" something makes interventional pain interventions seem exploitative. Granted the data suggest the "fixes" may not be any better than the bandaids and may cause more harm, but gosh darn it does make sense to clean the pipes, replace the hinges, and spackle stuff together!

I do agree though, there are some bad apples out there with a pills for needles mentality, and if it isn't being dictated from the top, there are the patients who are "addicted" to a needle q2-6weeks when they really just need a PT or life coach qday.
 
Orin said:
I think the most important part of this whole discussion is at the end.

"""
Dr. James Patrick Murphy, an anesthesiologist and addiction specialist in Kentucky, believes that recent studies showing the shots do not work better than physical therapy for many patients are reason enough not to use them on so many patients. He also thinks they cost too much.

“The physician fee is usually somewhere between $100 and $300,” Dr. Murphy said, “but the hospital fee for the procedure, the separate fee, can be anywhere from $1,000 to $5,000. That’s a lot of expense for somebody when you really can’t promise you’re going to cure them.”
"""

Unlike cardiac stenting, joint replacement, fusions, etc, the lack of face validity at your ability to "fix" something makes interventional pain interventions seem exploitative. Granted the data suggest the "fixes" may not be any better than the bandaids and may cause more harm, but gosh darn it does make sense to clean the pipes, replace the hinges, and spackle stuff together!

I do agree though, there are some bad apples out there with a pills for needles mentality, and if it isn't being dictated from the top, there are the patients who are "addicted" to a needle q2-6weeks when they really just need a PT or life coach qday.
Click to expand...

The site-of-service differential roars thunderously..."Feed me!"
 
Orin said:
I think the most important part of this whole discussion is at the end.

"""
Dr. James Patrick Murphy, an anesthesiologist and addiction specialist in Kentucky, believes that recent studies showing the shots do not work better than physical therapy for many patients are reason enough not to use them on so many patients. He also thinks they cost too much.

“The physician fee is usually somewhere between $100 and $300,” Dr. Murphy said, “but the hospital fee for the procedure, the separate fee, can be anywhere from $1,000 to $5,000. That’s a lot of expense for somebody when you really can’t promise you’re going to cure them.”
"""

Unlike cardiac stenting, joint replacement, fusions, etc, the lack of face validity at your ability to "fix" something makes interventional pain interventions seem exploitative. Granted the data suggest the "fixes" may not be any better than the bandaids and may cause more harm, but gosh darn it does make sense to clean the pipes, replace the hinges, and spackle stuff together!

I do agree though, there are some bad apples out there with a pills for needles mentality, and if it isn't being dictated from the top, there are the patients who are "addicted" to a needle q2-6weeks when they really just need a PT or life coach qday.
Click to expand...
Absolutely no bias at all.
 
They rehash this article occasionally... it's always the same ideas from the same people.

For the life of me I can't imaging why a doctor would says something as hare-brained as:

"The use of injections has increased dramatically, yet the prevalence of back pain has remained relatively unchanged,” Dr. Rathmell said."

That's like saying "The use of blood pressure medicines has increased dramatically, yet the prevalence of hypertension has remained relatively unchanged."

Any idea why he went so anti-pain? Did his clinic serve a lot of opioid dependents? If so, I can forgive a dim view of the field, but he needs to understand that the experience of practicing interventional pain on the non-narcotic crowd is a very different experience.
 
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powermd said:
They rehash this article occasionally... it's always the same ideas from the same people.

For the life of me I can't imaging why a doctor would says something as hare-brained as:

"The use of injections has increased dramatically, yet the prevalence of back pain has remained relatively unchanged,” Dr. Rathmell said."

That's like saying "The use of blood pressure medicines has increased dramatically, yet the prevalence of hypertension has remained relatively unchanged."

Any idea why he went so anti-pain? Did his clinic serve a lot of opioid dependents? If so, I can forgive a dim view of the field, but he needs to understand that the experience of practicing interventional pain on the non-narcotic crowd is a very different experience.
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Everyone is after their own nut. He probably saw the declining reimbursement of interventions and switched gears to marijuana for cash, vitamin c infusions and testosterone therapy..
 
So glad I cancelled my NYT subscription.

I can’t take their far far left socialist take on every subject and I can’t stand the flagrant anti physician hit pieces they publish, without any reasonable editorial oversight.
 
bedrock said:
So glad I cancelled my NYT subscription.

I can’t take their far far left socialist take on every subject and I can’t stand the flagrant anti physician hit pieces they publish, without any reasonable editorial oversight.
Click to expand...
Same here. They make ZERO effort to try to understand and present all sides of a story. They just pick a side and ram it down the reader's throat.
 
propaganda from the NYT?!??!?! No way
 
Dr. Ice said:
Everyone is after their own nut. He probably saw the declining reimbursement of interventions and switched gears to marijuana for cash, vitamin c infusions and testosterone therapy..
Click to expand...

Rathmel is the former director of pain program at mass general and now chair of Brigham’s anesthesia Dept. I’m sure nyt picked the one quote ....
 
The pain physician-holding-patients-hostage-for-opioids is very real and existed in a clinic across town where I practiced. The expense issue is also real with some pain docs owning their own out of network surgery center, charging $2500 for each injection, then doing three of these in 3 weeks before the bill was sent out. This also happened in more than one place. These injections are treatments, not cures, and the pain docs pulling in 2 mill a year for these expensive bandaids are disgusting. There is indeed risk but is overstated by this article that seems to be unaware of the change in epidural steroids being used and the fact that price escalation by Pfizer is responsible for most of the increased revenues. But overall, the article makes some good points. Rathmell has always been on the conservative side and was briefly a member of SIS BOD. He is rock solid as a clinician and as a golden representative for anesthesiology.
 
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I'm sure all the folks quoted are great people or were at one time.

It seems the further up the ladder people go though, the further away they get from treating the patient and the more they focus on treating the sy$tem/society.

Suddenly then everything they had done to treat patients is suddenly heresy, but their careers/bank accounts are solid so time to see the light and be born again
 
Orin said:
I'm sure all the folks quoted are great people or were at one time.

It seems the further up the ladder people go though, the further away they get from treating the patient and the more they focus on treating the sy$tem/society.

Suddenly then everything they had done to treat patients is suddenly heresy, but their careers/bank accounts are solid so time to see the light and be born again
Click to expand...
Exactly
 
At least fewer people read the NY Times than watch Dr. Oz. So far no questions from patients but after that Oz show I was swamped with questions.
 
algosdoc said:
The pain physician-holding-patients-hostage-for-opioids is very real and existed in a clinic across town where I practiced. The expense issue is also real with some pain docs owning their own out of network surgery center, charging $2500 for each injection, then doing three of these in 3 weeks before the bill was sent out. This also happened in more than one place. These injections are treatments, not cures, and the pain docs pulling in 2 mill a year for these expensive bandaids are disgusting. There is indeed risk but is overstated by this article that seems to be unaware of the change in epidural steroids being used and the fact that price escalation by Pfizer is responsible for most of the increased revenues. But overall, the article makes some good points. Rathmell has always been on the conservative side and was briefly a member of SIS BOD. He is rock solid as a clinician and as a golden representative for anesthesiology.
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That may be the case but to do make a blanket statement against one procedure is dangerous.

If the article was about the pills for pokes scam, then sure go for it and stay on target.

If you want to talk about DepoMedrol and how it's dangerous, then go ahead but explain why, talk about particular vs non particulate. It's not that hard to understand for the common lay person.

The entire mentality of one size fits all is hurting the field and damaging patient expectations.
 
I believe there is indeed a place for epidural steroids but there is too much latitude for mercenary activity by doctors who are fleecing patients. There is indeed a quid pro quo occurring with pills for pokes. I am aware of many pain clinics doing exactly that or a de facto quid pro quo that has the PCP prescribing opioids sends patients to interventional pain as a demonstration the pills are actually needed.
 
Biohazard685 said:
That may be the case but to do make a blanket statement against one procedure is dangerous.

If the article was about the pills for pokes scam, then sure go for it and stay on target.

If you want to talk about DepoMedrol and how it's dangerous, then go ahead but explain why, talk about particular vs non particulate. It's not that hard to understand for the common lay person.

The entire mentality of one size fits all is hurting the field and damaging patient expectations.
Click to expand...

Yes, this.

Explain particulate vs non particulate, transforaminal vs interlams, etc. any lay person can understand “ injecting A steroid with large particles can lead to complications, especially when done from a side approach, patients should speak to their doctor about pro/con of diff steroid and diff epidural approaches to minimize risk”
 
Add transient paralysis to your list of rare complications from dexamethasone epidural steroid injections:
PM R. 2018 May;10(5):544-547. doi: 10.1016/j.pmrj.2017.10.003. Epub 2017 Oct 24.
Transient Hypokalemic Quadriplegia After a Lumbar Transforaminal Epidural DexamethasoneInjection: A Case Report.
Tahmasbi Sohi M1, Sullivan WJ2, Anderson DJM3.
Author information

Abstract
A 30-year-old man with no significant medical history presented with hypokalemic quadriplegia 4 hours after he received a lumbar transforaminal epidural steroid injection (ESI) containing dexamethasone and lidocaine. A comprehensive workup ruled out acquired and hereditary causes of hypokalemic paralysis. Symptoms gradually resolved within hours after potassium restoration with no residual neurologic deficits. Paralysis after transforaminal ESI is uncommon but has been associated with particulate steroids that can coalesce into aggregates and occlude vessels. To our knowledge, there have been no case reports of paralysis after ESI with dexamethasone, a nonparticulate steroid. This transient paralysis is possibly caused by the effects of glucocorticoids on Na-K channels and insulin resistance resulting in hyperglycemia and subsequent hypokalemia. We reviewed the differential diagnosis of transient paralysis after epidural steroidinjection in this report.

LEVEL OF EVIDENCE:
IV.
 
Then there is this: if it is true, and given Pfizer wants Depomedrol banned for epidural use, and Kenalog (and generics) clearly state "Not for epidural use", then why not use non-particulates for every epidural injection?
PM R. 2017 May;9(5):502-512. doi: 10.1016/j.pmrj.2016.11.008. Epub 2016 Nov 30.
Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections.
Mehta P1, Syrop I2, Singh JR3, Kirschner J4.
Author information

Abstract
OBJECTIVE:
To systematically analyze published studies in regard to the comparative efficacy of particulate versus nonparticulate corticosteroids for cervical and lumbosacral epidural steroid injections (ESI) in reducing pain and improving function. TYPE: Systematic review.

LITERATURE SURVEY:
MEDLINE (Ovid), EMBASE, and Cochrane databases were searched from the period of 1950 to December 2015.

METHODOLOGY:
Criteria for inclusion in this review were (1) randomized controlled trials and (2) retrospective studies that compared particulate versus nonparticulate medication in fluoroscopically guided injections via a transforaminal (TF) or interlaminar (IL) approach. Each study was assigned a level of evidence (I-V) based on criteria for therapeutic studies. A grade of recommendation (A, B, C, or I) was assigned to each statement. Categorical analysis of the data was reported when available, with success defined by the minimal clinically important difference for appendicular radicular pain-a reduction of at least 2 on the visual analog scale. When data were available, additional categorical analysis included the proportion of individuals with a reduction in pain of at least 50%, 70%, or 75%. Follow-up was included at all reported intervals from 2 weeks to 6 months.

SYNTHESIS:
Three cervical ESI and 6 lumbar ESI studies were found to be suitable for review. Of the 3 cervical ESI studies, 2 were retrospective studies with grade III level of evidence and 1 was a randomized controlled trial with grade II evidence. Of 4 lumbar ESI studies that used a TF approach, the 2 randomized double-blinded controlled trials were grade I evidence and 2 retrospective studies were grade II and III level of evidence. One randomized controlled trial using the lumbar IL approach was level II evidence. One retrospective cohort study using the lumbar TF, IL and caudal approach was level III evidence.

CONCLUSIONS:
There is no statistically significant difference in terms of pain reduction or improved functional outcome between particulate and nonparticulate preparations in cervical ESI and, therefore, the authors recommend using nonparticulate steroid when performing cervical TFESI (Grade of Recommendation: B). In patients with lumbar radiculopathy due to stenosis or disk herniation, TFESI using particulate versus non-particulate is equivocal in reducing pain (Grade of Recommendation: B) and improving function (Grade of Recommendation: C) and therefore the authors recommend the use of nonparticulate steroids for lumbar TFESI in patients with lumbar radicular pain (Grade of Recommendation: B). There is insufficient information to make a recommendation of one steroid preparation over the other in lumbar ILESI (Grade of Recommendation: I). Given the lack of strong data favoring the efficacy of one steroid preparation over the other, and the potential risk of catastrophic complications, all of which have been reported with particulate steroids, nonparticulate steroids should be considered as first line agents when performing ESIs.

LEVEL OF EVIDENCE:
III.
 
because there will be those doctors whose "clinical experience" state that particulate steroids work better than nonparticulates...
 
pastafan said:
At least fewer people read the NY Times than watch Dr. Oz. So far no questions from patients but after that Oz show I was swamped with questions.
Click to expand...
A patient brought in the NYT article yesterday and said, "hopefully you didn't use depomedrol on me". I told him I've been using only dex for about 4 years for epidurals. We're about to try facet injections and he correctly pointed out the article implies danger with "spine injections".

I encouraged him to keep reading and asking good questions. I really like it when pts do this so I can put it all out there: the risks, benefits and balance.
 
hyperalgesia said:
A patient brought in the NYT article yesterday and said, "hopefully you didn't use depomedrol on me". I told him I've been using only dex for about 4 years for epidurals. We're about to try facet injections and he correctly pointed out the article implies danger with "spine injections".

I encouraged him to keep reading and asking good questions. I really like it when pts do this so I can put it all out there: the risks, benefits and balance.
Click to expand...

Are you using dex for lumbar interlaminars as well?
 
hyperalgesia said:
Yes. The only time I use kenalog/depo is for SIJ, hips and other peripheral joints.
Click to expand...

Wow interesting I’ve always use particulates for my interlaminar injections. You find dex has good results with it?
 
paindoc007 said:
Wow interesting I’ve always use particulates for my interlaminar injections. You find dex has good results with it?
Click to expand...
Apparently it doesn’t matter. Clinical experience doesn’t matter
 
paindoc007 said:
Wow interesting I’ve always use particulates for my interlaminar injections. You find dex has good results with it?
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I haven't noticed any difference. I know lots of guys that use particulates - the complication rate from particulates (because they are particulates) is probably minuscule.
 
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Ducttape said:
Not if you can’t back it up with some unbiased study.

Otherwise we’d still be doing blind epidurals with cocaine and weekly leech treatment.
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You’re probably right. Although let’s use some hypotheticals. How many injections are done a day? 30k? 50k? Let’s say 5-10k. That’s approximately 2 million/year. How many complications are reported per year? Let’s say 500. The risk is pretty minuscule. What are the statistics for any elective procedure done in any field of medicine? I would guess probably similar or even worse. The article cited about comparing particulate vs non particulate steroids is level 3 evidence. Interestingly one of the co-authors was one of my co-fellows who I respect very much.

All this being said..I’m moving further and further away from steroids and closer to regen and stim...

Happy trails to all
 
one of the recent articles stated 9 million epidurals done a year for pain, and a rate of 1500 serious complications and 150 deaths.... so yes, the rate is very low, and, regardless of what you naysayers state, a lot lower than complications of death from prescription opioids. even avowed opioid-taper-hater Kertesz admits that there are a minimum of at least 9000 deaths (fudged from 14000) from opioids per year.

fact is, they are pinpointing confounding depomedrol and epidurals. I don't see any evidence to suggest that non-particulate steroids are any less dangerous.
 
Ducttape said:
one of the recent articles stated 9 million epidurals done a year for pain, and a rate of 1500 serious complications and 150 deaths.... so yes, the rate is very low, and, regardless of what you naysayers state, a lot lower than complications of death from prescription opioids. even avowed opioid-taper-hater Kertesz admits that there are a minimum of at least 9000 deaths (fudged from 14000) from opioids per year.

fact is, they are pinpointing confounding depomedrol and epidurals. I don't see any evidence to suggest that non-particulate steroids are any less dangerous.
Click to expand...

I wonder how many of the deaths were sedation related?
 
“We believe this is a question of medical practice and defer to clinicians and pain experts who utilize these medicines in their practices for the treatment of pain conditions,” Mr. Biegi said.

Dr. Laxmaiah Manchikanti thinks that’s as it should be. Chief executive of the American Society of Interventional Pain Physicians, Dr. Manchikanti does not use Depo-Medrol in his own practice but believes it is safe for the lower spinal area.

----
What does Manchikanti use then? Dex for all?

Over the last year I've gone Dex for all epidurals except Lumbar interlaminars. I did not know that Depo was considered "banned" for all epidurals. I was under the assumption that Kenalog was Blackbox for epidurals.

We may see more cases of Dex related issues with its increased use now but are people trending towards Dex for all ESIs now?
 
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