The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review.

OBJECTIVES: To determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas. DATA SOURCES: A PubMed, Medline (EBSCO), and Cochrane library search (January 1971-December 2005), as well as additional references found from the initial search. STUDY SELECTION: There were no studies that specifically addressed the objectives outlined. Eleven randomized controlled trials, 1 prospective controlled trial, and 2 prospective cohort studies were identified that included a protocol involving repeat epidural injections for radicular pain secondary to herniated nucleus pulposus or spinal stenosis. One qualitative survey was also identified. Five review articles were also included that discussed this topic. DATA EXTRACTION: Data were extracted from clinical trials if they included the following: (1) protocols in clinical trials on ESIs that included repeat injections and the response required to trigger these injections, (2) any evidence given for establishing these protocols, and (3) similar studies that included only 1 injection. Specific mention of repeat ESIs and partial response that was mentioned in review articles was also included. DATA SYNTHESIS: There is limited evidence to suggest guidelines for frequency and timing of ESIs or to help to define what constitutes the appropriate partial response to trigger a repeat injection. No study has specifically evaluated these objectives. Methodologically limited research suggests that repeat injections may improve outcomes, but the evidence is insufficient to make any conclusions. CONCLUSIONS: There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design.

Trends in medical use and abuse of sustained-release opioid analgesics: a revisit.

OBJECTIVE: Previous literature suggests that increases in the medical use of opioids over the early 1990s did not contribute to increased morbidity secondary to opioid abuse. Our objective was to evaluate the period 1997-2001 to analyze trends in medical use and medical abuse of three classes of opioid analgesics that are commonly used in sustained-release formulations: fentanyl, morphine, and oxycodone. DESIGN AND SETTING: A retrospective analysis of the Drug Abuse Warning Network (DAWN) database and the Automation of Reports and Consolidated Orders System (ARCOS) database for the years 1997-2001 was used for this study. RESULTS: The analysis of the DAWN database showed that there was an 83.5% increase in all opioid analgesic mentions from 1997 to 2001. Mentions involving any fentanyl compound increased 249.8%, any morphine compound increased 161.8%, and any oxycodone-containing compound increased 267.3%. Mentions of each of these three classes of opioids remained less than 2% of all total drug mentions per year for each year studied. Medical use of the selected opioid classes, as reported in the ARCOS database and measured by grams distributed, all increased substantially (fentanyl 151.2%, morphine 48.8%, oxycodone 347.9%). CONCLUSION: Using this method of analysis, the rates of drug abuse, and resultant morbidity secondary to the use of opioid analgesics, remain low in spite of the increase in medical use of these substances.