Since the fungal meningitis outbreak began on Sept. 21, 2012, 36 people have died and 510 meningitis cases have been detected. The multistate meningitis outbreak has been linked to contaminated steroid injections, distributed by the New England Compounding Center, given mostly to patients with chronic neck or back pain, and a few with joint pain. Many people are demanding better oversight of drug manufacturers -- including compounders, who have been working under the radar. But few people are asking an even more important question.
Why were these patients getting questionable -- and mostly unnecessary -- steroid injections in the first place?
Many people are surprised that there is no good scientific evidence that steroid injections help reduce back pain.[1] In fact, research has shown that over the long term, steroid injections do not lead to less pain, better quality of life, or better functioning.[2],[3] Yet steroid injections for back pain in the Medicare population increased by 271 percent between 1994 and 2001, according to a 2009 study.[4] During that same period, the inflation-adjusted amount spent on these injections increased from $24 million to more than $175 million.[5] In short, the amounts of money spent on back pain injections keeps rising -- even though patients are no better off, and in some cases are made worse and sickened by this treatment
But the problem is much larger than just steroid injections. Why do doctors continue to order tests and procedures that are not supported by scientific evidence and could harm patients? Why do patients agree to tests and procedures that have no proven benefit?
I can list many reasons. Problems like chronic back pain are so difficult to treat that physicians and patients resort to procedures that have no proven benefit, hoping that it might work for this one patient. Many patients expect a quick fix for intractable chronic problems like back pain. That won't happen.
Chronic disease often requires a team approach in which physicians, physical therapists, psychologists, pharmacists and other health professionals work together to help patients manage, rather than cure, the illness or its symptoms. As a result of a wide range of medical breakthroughs over the past 50 years, more and more diseases require this kind of ongoing management, including diabetes, heart failure, HIV -- and now back pain.
But doctors feel pressure from patients to do something -- and pressure from their practices to do something that can be reimbursed. Few doctors have the time or skills to explain the uncertainties and risks that can come with procedures and tests, or that that a "promising" new technology isn't backed by good science and could backfire. Giving a patient a steroid injection can be far more immediately gratifying. And it's certainly more remunerative, considering that health insurance companies offer better reimbursement for "procedures" (however spurious) than for intensive, ongoing chronic disease management. But at what risk and at what cost?
What's missing is an emphasis on communicating realistic expectations and on taking the long-term view -- in medical training, in insurance reimbursements, and in day-to-day health-care delivery. Much harm could be avoided if patients and their physicians could have open and frank conversations about the potential harms of medical procedures and tests, especially when scientific evidence is murky or entirely lacking.
I became a physician because I wanted to make people feel better -- but I have learned that tests and iffy procedures are not what accomplish that goal. Some of my most grateful patients are the ones who hear me say, "There is really no evidence that shows this procedure or test will benefit you. Let's think this through together so we can make sure you understand the pros and cons, and I understand what your goals are." While this takes time, it helps me stay true to one of medicine's guiding principles: "to do good or to do no harm." The health-care system and physicians must acknowledge the harm that results from unnecessary procedures and tests, so we can do more good for our patients. Having an in-depth discussion may be harder than grabbing at a quick fix -- but it will have better results for us all.
Namratha Kandula, M.D., MPH, a Public Voices Fellow with the Op-Ed Project, is an Assistant Professor of Medicine at Northwestern University.
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References:
[1] Deyo RA, Mirza SK, Turner JA, Martin BI. "Overtreating chronic back pain: time to back off?" J Am Board Fam Med. 2009 Jan-Feb;22(1):62-8.
[2] Fukusaki M, Kobayashi I, Hara T, Sumikawa K: "Symptoms of spinal stenosis do not improve after epidural steroid injection." Clin J Pain 1998, 14(2):148-151.
[3] Manchikanti L, Boswell MV, Datta S, Fellows B, Abdi S, Singh V, Benyamin RM, Falco FJ, Helm S, Hayek SM, et al.: "Comprehensive review of therapeutic interventions in managing chronic spinal pain." Pain Physician 2009, 12(4):E123-E198.
[4] Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, Sullivan SD. "Expenditures and health status among adults with back and neck problems." JAMA. 2008 Feb 13;299(6):656-64.
[5] Friedly J, Chan L, Deyo R: "Increases in lumbosacral injections in the Medicare population: 1994 to 2001." Spine 2007, 32(16):1754-1760.