1011
ORIGINAL ARTICLE
The Relationship Between Repeated Epidural Steroid
Injections and Subsequent Opioid Use and Lumbar Surgery
Janna Friedly, MD, Isuta Nishio, MD, PhD, Michael J. Bishop, MD, Charles Maynard, PhD
ABSTRACT. Friedly J, Nishio I, Bishop MJ, Maynard C.
The relationship between repeated epidural steroid injections
and subsequent opioid use and lumbar surgery. Arch Phys Med
Rehabil 2008;89:1011-5.
Objectives: To evaluate whether the use of epidural steroid
injections (ESIs) is associated with decreased subsequent opi-
oid use in patients in the Department of Veteran’s Affairs (VA)
and to determine whether treatment with multiple injections are
associated with decreased opioid use and lumbar surgery after
ESIs.
Design: VA patients undergoing ESIs during the study pe-
riod for specific low back pain (LBP) diagnoses were identi-
fied, and lumbar surgery and opioid use were examined for 6
months before and after ESI.
Setting: National VA administrative data.
Participants: U.S. veterans (retrospective data analysis).
Interventions: Not applicable.
Main Outcome Measures: Opioid use and lumbar surgery
after ESIs.
Results: During the 2-year study period, 13,741 different
VA patients underwent an ESI for LBP. The majority of
patients were using opioids before their ESIs (64%), as were
the majority after their ESIs (67%). Of patients not on opioids
before the ESIs, 38% were prescribed opioids afterward,
whereas only 16% of people on opioids before the ESIs
stopped using opioids afterward. Patients who received more
than 3 injections were more likely than patients receiving fewer
injections to start taking opioids after ESIs (19% vs 13%,
P⬍.001) and to undergo lumbar surgery after ESIs (8.7% vs
6.3%, P⫽.003).
Conclusions: Opioid use did not decrease in the 6 months
after ESIs. In this population, patients who received multiple
injections were more likely to start taking opioids and to
undergo lumbar surgery within the 6 months after treatment
with ESIs. These findings are concerning because our data
suggest that ESIs are not reducing opioid use in this VA
population.
Key Words: Injections, epidural; Low back pain; Rehabil-
itation; Spinal stenosis.
From the Departments of Rehabilitation Medicine and Comparative Effectiveness,
Costs and Outcomes Research Center, Harborview Medical Center (Friedly), VA
Puget Sound Health Care System Epidemiologic Research Information Center and
Department of Health Services (Maynard), and Department of Anesthesiology, Uni-
versity of Washington, Seattle, WA; and Department of Anesthesiology (Nishio,
Bishop). Puget Sound VA Health Care System, Seattle, WA (Nishio, Bishop).
Supported by the National Institutes of Health, Rehabilitation Medicine Scientist
K12 Program (grant no. 2K12HD001097-11) and the Office of Research and Devel-
opment, Puget Sound VA Health Care System, Seattle, WA.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Janna Friedly, MD, Dept of Rehabilitation Medicine and Center
for Cost and Outcomes Research, University of Washington, Harborview Medical
Center, Box 358740, 325 Ninth Ave, Seattle, WA 98127, e-mail: friedlyj@
u.washington.edu.
0003-9993/08/8906-00601$34.00/0
doi:10.1016/j.apmr.2007.10.037
© 2008 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
HE TREATMENT OF LOW back pain (LBP) is contro-
T versial, as evidenced by wide variability in the treatment
1
modalities used. Opioid use for non– cancer-related chronic
pain is a controversial treatment. Opioid use has been criticized
for the potential for a variety of side effects, dependence, and
addiction as well as for a lack of efficacy in various chronic
pain syndromes.2 However, opioid use for spine pain is partic-
ularly common, with 1 prior study3 of veterans in an orthopedic
spine clinic showing that a majority of patients (66%) are using
opioids for the treatment of spine pain. Lumbar surgery is
another controversial invasive treatment for LBP syndromes
with questionable effectiveness and substantial cost.4-7
Epidural steroid injections (ESIs) have become increasingly
popular as an alternative to lumbar surgery or opioid use when
more conservative measures fail to adequately relieve the
symptoms of LBP and/or radicular pain. Given the magnitude
of the epidemic of LBP within the United States and the
extraordinary health care costs associated with its treatment,8,9
many have examined the use of ESIs as potentially a more
effective, less invasive, safer, and less costly alternative to
either lumbar surgery or opioids for spine pain syndromes.10-19
The current literature20 reports success rates of 18% to 90%
for ESIs. Few studies have been randomized controlled trials;
all studies have suffered from methodologic limitations, and
treatment effects have often been small and short term.19,21-26
There is also considerable uncertainty as to the optimal number
of injections to perform and the frequency with which to
perform injections, particularly for chronic LBP disorders.
However, even with the uncertainty in terms of the optimal use
of these injections, this procedure has developed widespread
acceptance and is often used as a treatment for LBP disor-
ders.1,27
Much of the variability in results stems from the methodol-
ogy of the studies, including the outcome measures that are
used. One outcome measure is the use of opioid medications
for the treatment of pain. If ESIs are effective in terms of pain
reduction, one would expect that opioid use would decrease in
the months after ESI use. Few studies have specifically mea-
sured opioid use as an outcome measure, and those that have
typically have found no change in opioid use after the ESIs.19
Another commonly measured outcome with mixed results in
clinical studies of ESIs is subsequent lumbar surgery.13,21,28,29
Although ESIs are sometimes used as a presurgical diagnostic
tool to determine the location of the pain generator, more often
they are used in an attempt to avoid surgery. However, as the
rates of ESI use have been increasing over time so have the
surgical rates for the treatment of degenerative spine prob-
lems.7 Medicare claims data also suggest an increase in the
percentage of people receiving both ESIs as well as surgery.30
In this study, we examined both opioid use and lumbar
surgery rates after ESIs in the Department of Veterans
Affairs (VA) population. We specifically hypothesized that
Arch Phys Med Rehabil Vol 89, June 2008
1012 EPIDURAL STEROID INJECTIONS ON OPIOID USE AND LUMBAR SURGERY, Friedly
opioid use would decrease after ESIs in patients with LBP.
We also hypothesized that patients receiving repeat injec-
tions would be more likely to decrease opioid use and would
be less likely to undergo subsequent surgery than those
patients receiving fewer injections.
METHODS
We used national VA administrative data during a 2-year
period from October 2001 through September 2003 to ex-
amine the use of ESIs and their relationship to lumbar
surgery and opioid use. Clinical encounters in the VA’s
health care system are captured in this administrative dataset
in a similar manner to commercial claims data. These na-
tional data are stored in a central location and made avail-
able for research purposes. We abstracted clinical data re-
lating to all ESIs performed within the VA health care
system during the study period. The dataset included the
Current Procedural Technology (CPT) procedure codes, the
International Classification of Diseases–9th Revision–Clini-
cal Modifications (ICD-9-CM) diagnosis codes, dates of
service, patient age, sex, ethnicity, use of fluoroscopy, lum-
bar surgeries, and use of opioids in the 6-month period
before and after ESI administration. Patients undergoing
ESIs during the study period with CPT codes 62311 (inter-
laminar or caudal) and 64483 (transforaminal) for specific
LBP diagnoses were included in this analysis. In addition,
the injection codes must have been associated with 1 of 5
diagnostic categories of LBP ICD-9 codes (herniated disk,
radiculopathy, spinal stenosis, degenerative disease, other
LBP). These categories were chosen to be consistent with
studies on LBP and lumbar surgery rates and have been
previously described and validated.30,31 The other LBP cat-
egory included ICD-9 codes for LBP, lumbago, and lumbo-
sacral sprain. The scope of this analysis was limited to
lumbosacral injections. We excluded cervical and thoracic
steroid injections for 2 reasons. First, cervical spine disor-
ders differ clinically from lumbar spine disorders and may
be the result of different disease processes. Second, cervical
and thoracic ESIs are much less common, representing less
than 10% of all ESIs performed.1,32 Lumbar surgeries were
identified by using Healthcare Common Procedure Coding
System codes for 6 months before and after ESIs, and opioid
use was determined by examining VA pharmacy data for 6
months before and after an ESI. Opioid use was classified
into use or nonuse such that if a patient had any prescription
for opioids filled during the 6-month period, he/she was
considered to use opioids. For those patients who underwent
multiple ESIs during the study period, prior lumbar surgery
and opioid use were calculated from the date of the first
injection performed, whereas subsequent surgery and opioid
use were calculated based on the date of the last injection
performed.
Statistical analyses were performed by using SPSS soft-
ware.a Demographics were analyzed descriptively. The Pear-
son chi-square test was used for dichotomous, nominal out-
comes measures (ie, surgery and opioid use) that met the
assumptions for using this test (ie, large enough sample size,
categorical data). ESI use (exposure) was divided into 2 groups
(⬎3, ⱕ3). A P value of .05 (2-tailed for all analyses) was
considered statistically significant. Odds ratios (ORs) with 95%
confidence intervals (CIs) were reported for the outcome mea-
sure, lumbar surgery after ESI.
Arch Phys Med Rehabil Vol 89, June 2008
RESULTS
Demographics
During the 2-year study period, 13,741 VA patients under-
went an ESI for LBP, and a total of 25,733 injections were
performed. The average age of patients in this study was
57⫾13 years. Most patients were male (93%). Over half
(52.4%) of the patients had 1 injection, and the vast majority
(91%) had 3 or fewer injections during the 2-year study period.
The mean ⫾ standard deviation number of injections a patient
received over the 2-year study period was 1.9⫾1.3. Two hun-
dred fifty-three people (1.8%) had 6 or more injections over the
2-year study period. Patients aged 60 and over were more
likely to have greater than 3 injections (25% vs 18%, P⬍.001).
Of the injections performed, 85% were caudal or interlaminar,
and 15% were transforaminal.
Diagnoses
Most patients who received injections were diagnosed with
lumbar spinal stenosis (n⫽10,119 [74%]). Approximately 30%
of patients had diagnoses of herniated disk or radiculitis or
radiculopathy, and the vast majority of patients (90%) were
assigned more than 1 LBP diagnosis. Every patient with spinal
stenosis was also assigned another LBP diagnosis. Approxi-
mately one third (37%) of patients with lumbar spinal stenosis
were also diagnosed with radiculitis or radiculopathy or herni-
ated disk, and two thirds (68%) were described as also having
nonspecific LBP. Therefore, 46% (n⫽6375) of patients overall
had injections for spinal stenosis without a documented diag-
nosis of radiculopathy or herniated disk. Patients with spinal
stenosis were also twice as likely as patients with other diag-
noses to have greater than 3 injections (10% vs 5%, P⬍.001).
Those aged 60 and over were also more likely to be diagnosed
with spinal stenosis (75% vs 70%, P⫽.003). Diagnoses were
not correlated with prior surgery; however, patients with diag-
noses of radiculopathy were slightly more likely than patients
without radiculopathy to undergo lumbar surgery within 6
months after their injection (8.3% vs 6.9%, P⫽.008). There
were no other differences between diagnoses in terms of sub-
sequent lumbar surgery rates. Diagnosis was not statistically
related to prior or subsequent opioid use in this study.
Opioid Use
The majority of all patients were using opioids in the 6
months before their ESI (64%) as were the majority after their
ESI (67%). Therefore, overall opioid use did not decrease in
this patient population in the 6 months after an ESI. Of the
patients not on opioids before the ESI, 38% were prescribed
opioids afterward, whereas only 16% of people on opioids
before the ESI stopped using opioids afterward. The majority
of patients on opioids before their ESI continued to use opioids
after ESI (84%). Patients on opioids before ESI were more
likely than patients not on opioids before ESI to take them
within 6 months after ESI (84% vs 38%, P⬍.001). Conversely,
patients not on opioids before were more likely not to be taking
them after ESI (62% vs 16%, P⬍.001). Diagnosis, age, and sex
were not correlated with prior or subsequent opioid use.
Patients who received multiple injections during the study
period (ie, ⬎3) were less likely to stop taking opioids than
patients receiving fewer injections (8% vs 11%, P⬍.001) and
were more likely to start taking opioids after treatment with
ESIs (19% vs 13%, P⬍.001) (tables 1, 2). These findings
persisted when patients with a history of surgery either before
or after ESI were removed from the sample. A smaller per-
centage of patients who received greater than 3 injections were
 EPIDURAL STEROID INJECTIONS ON OPIOID USE AND LUMBAR SURGERY, Friedly 1013

Table 1: The Relationship Between Repeated ESIs and Opioid Use Table 3: The Effect of Frequency of ESIs on Surgery Rates
After ESI
Started Opioids No Change in Stopped Opioids Total No. of
Number After ESI Opioid Use After ESI Patients Surgery After ESI
of ESIs (n⫽1840) (n⫽10,465) (n⫽1436) Receiving ESI
No. of ESIs Yes No Total
ⱕ3 1607 (13)* 9571 (76)* 1344 (11)* 12,522 (100)
ⱕ3 878 (7.0)* 11,644 (93.0) 12,522 (100.0)
ESIs
⬎3 111 (9.1)* 1108 (90.9) 1219 (100.0)
⬎3 233 (19) 894 (73) 92 (8) 1219 (100)
Total 989 (7.2) 12,752 (92.8) 13,741 (100.0)
ESIs
NOTE. Values are n (%).
NOTE. Values are n (%). *P⬍.001.
*P⬍.001.

taking opioids before ESI treatment than those patients who There has been growing concern regarding chronic opioid use
received fewer injections (55% vs 64%, P⬍.001) (see table 2). because of risks associated with dependence, side effects, and
addiction. Opioid use is frequently considered 1 outcome mea-
Lumbar Surgery sure of interventions for a variety of pain syndromes. Although
Thirteen percent (n⫽1791) of patients had at least 1 surgery in this study we did not examine the indications for opioid
within 6 months before ESIs, and 7% (n⫽989) of patients had prescription and concomitant pain syndromes in addition to
at least 1 surgery within 6 months after ESIs. Of the patients LBP, it is reasonable to hypothesize that opioid use would
who had a history of surgery before the ESIs, 960 (54%) decrease after ESI for LBP. However, contrary to our hypoth-
underwent a fusion, 92 (5%) underwent a laminectomy with esis, opioid use did not decrease in the 6 months after an ESI
diskectomy, 280 (16%) had a diskectomy, and 459 (26%) had in this population, and over a third of patients who were not
a laminectomy alone. Patients with a history of surgery in the taking opioids before the ESI received opioids afterward. In
6 months before ESIs were twice as likely to undergo a sub- addition, we found that patients who underwent more frequent
sequent surgery after their ESIs (12% vs 6%; OR⫽1.75; 95% injections were more likely than patients receiving fewer in-
CI, 1.54 –1.99; P⬍.001). Controlling for the history of prior jections to start opioids if they were not taking them before
surgery, patients who received 4 or more injections during the their first ESI and were less likely to stop taking opioids if they
study period were also more likely to undergo lumbar surgery were taking them before their first ESI. This finding may reflect
after receiving the ESIs (8.7% vs 6.3%, P⫽.003) (see tables 2, that patients with more severe pathology or pain are more
3). Patients with diagnoses of radiculopathy were slightly more likely to undergo multiple ESIs and therefore may be more
likely than patients without radiculopathy to undergo lumbar likely to use opioid medications. However, patients undergoing
surgery within 6 months after their injection (8.3% vs 6.9%; repeated ESIs in this study were no more likely to have been
OR⫽1.16; 95% CI, 1.04 –1.293; P⫽.008). Patients with radic- taking opioids before receiving the injections than those only
ulopathy were less likely to undergo a fusion procedure as undergoing 1 to 2 injections. In fact, patients receiving fewer
compared with patients without radiculopathy (50% vs 54%, injections were more likely to be taking opioids before ESI
P⫽.012). Age and sex did not correlate with prior or subse- treatment (64%) than those receiving a repeat ESI (56%). In
quent lumbar surgery. addition, diagnoses did not vary between those receiving 4 or
more injections and those receiving fewer injections (ie, each
DISCUSSION group had similar numbers of patients with documented radic-
In this national study of VA patients, we found that the ulopathy and spinal stenosis).
majority receiving ESIs were also using opioid medications. In this population, ESIs were primarily used for spinal
This finding is consistent with a prior study3 of opioid use stenosis (73%) despite the lack of evidence to support their use
among patients in a VA orthopedic spine clinic (66% use). for this diagnosis. The best evidence regarding the effective-
ness of ESIs is for symptoms of sciatica or radiculopathy.
However, during this study period, nearly half of the veterans
Table 2: VA Patients Receiving ESIs and Opioid Use and Surgery receiving injections had spinal stenosis without documented
Total No. No. Receiving No. Receiving
radiculopathy. We also found that patients over the age of 60
ESIs and Opioid Use Receiving ESIs ⱕ3 ESIs ⬎3 ESIs were more likely to receive repeat injections (⬎3 in the 2-year
study period) and were more likely to be diagnosed with spinal
Total 13,741 12,522 1219 stenosis. Patients who received more than 3 injections during
Opioid use before 8728 (64) 8051 (64) 677 (55) the study period were also no more likely to stop using opioids
No use after 1436 1344 92 and were more likely to undergo subsequent lumbar surgery.
No change 7292 6707 585 These findings suggest that ESIs in this VA population are not
No opioid use 5013 (36) 4471 (36) 542 (45) being substituted for lumbar surgery and are not decreasing
before opioid use.
No change 3173 2864 309 There are several potential reasons for these findings. First,
Use after 1840 1607 233 it must be acknowledged that this study reflects outcomes in
Surgery before 1791 (13) 1626 (13) 165 (14) actual clinical practice rather than in the controlled environ-
No surgery after 1577 1431 146 ment of a randomized clinical trial. Therefore, these findings
Surgery after 214 195 19 suggest that the use of ESIs in an uncontrolled environment (ie,
No surgery before 11,950 (87) 10,896 (87) 1054 (86) outside of the realm of a controlled trial with very specific
No surgery after 11,175 10,213 962 inclusion and exclusion criteria and standardized techniques) is
Surgery after 775 683 92 not associated with decreasing opioid use and is not substitut-
ing for lumbar surgery. These outcomes certainly may be
NOTE. Values are n (%) for the main subgroups and n otherwise. different than those in a controlled setting with standardized

Arch Phys Med Rehabil Vol 89, June 2008

1014 EPIDURAL STEROID INJECTIONS ON OPIOID USE AND LUMBAR SURGERY, Friedly
patient selection criteria and injection techniques. These find-
ings suggest that it may be important to have more standardized
criteria for patient selection and/or injection technique to im-
prove outcomes in actual clinical practice.
Second, chronic pain syndromes may be more prevalent
within the VA population and therefore patients may be using
opioids for reasons other than LBP or sciatica. One would not
expect to see changes in opioid use after ESI for those patients
who take opioids for other pain conditions. We did not have
access to specific information regarding comorbidities and
other pain complaints or diagnoses for which opioids may have
been used. We also did not have access to data regarding the
indication for the opioid prescription. Pain relief from the ESI
in this study may also not have been substantial enough for
patients to discontinue use of opioids or to prevent surgery. We
did not include self-reported pain as an outcome measure in
this study and chose to use opioid use as 1 measure of pain.
Additionally, the reasons for choosing to undergo an ESI
may be different in the VA health care system than in others.
For example, patients may undergo ESI as routine care pre-
ceding an anticipated surgery to better delineate the pain gen-
erator or to provide temporary pain relief in anticipation of
surgery. The VA health care system may be different from the
private sector in that there is less direct financial influence on
procedures performed and less constraint in the use of proce-
dures because of insurance coverage.
Currently, there are no evidence-based guidelines regarding
the appropriate number of injections, the optimal frequency
and timing of injections, or the appropriate use for the injec-
tions in patients considering lumbar surgery. Our data suggest
that patients who receive repeat injections are more likely to
use opioids and are more likely to undergo surgery, calling into
question the rationale for using repeat injections, particularly in
this population of patients with primarily spinal stenosis.
Further research is needed to better understand this relation-
ship between the use of repeated ESIs and the effect on sub-
sequent surgical rates and opioid use. In addition, more re-
search is needed to determine if repeated ESIs are of benefit in
the long-term management of spinal stenosis for those patients
who are not candidates for surgery, particularly in terms of
function and quality of life measures.
Study Limitations
There are several limitations to our study. This retrospective
study examines a specific patient population, VA patients who
are primarily men. The use of steroid injections in this popu-
lation may be different than in a more general population. The
distribution of diagnoses for which these injections are per-
formed may be different than in other populations. Another
limitation is that some of the variations in diagnoses may be
related to coding errors, diagnostic ambiguity, or local conven-
tions. Because the VA system is not reliant on third-party
reimbursement, coding may not be as accurate as in the private
sector. However, prior studies33 on other conditions have found
that the VA database is very accurate in coding diagnoses. In
this study, we classified opioid use as simply yes or no rather
than determining dosing. Therefore, we were only able to tell
if patients stopped opioid use or started using opioids after their
injections. It is possible that patients were able to decrease their
dose of opioids after ESI. We also were not able to capture any
data outside of the VA system. If patients received medications
or services from alternative providers, we may have underes-
timated the number of people using opioids or undergoing
lumbar surgery both before and after ESI. Another limitation is
that patients were tracked for only 6 months before and after
receiving ESIs. It is possible that some patients received lum-
Arch Phys Med Rehabil Vol 89, June 2008
bar surgery either before or after the study period. However,
this would suggest that our findings underestimate the number
of people receiving surgery after ESI and would not contradict
our findings. It is also possible that patients undergoing ESI
discontinued the use of opioids after 6 months of treatment;
however, the benefits, if any, of ESIs are typically less than 6
months in duration. Therefore, we would not expect that dis-
continuation of opioids after 6 months was directly because of
treatment with ESIs and was likely because of another inter-
vention or natural recovery.
Study Strengths
The strengths of this study are that it represents the first
published study on ESIs using national VA data with a large
sample size. We also were able to capture both clinical and
pharmacy data to determine the actual use of various interven-
tions commonly used in clinical practice. This study provides
important information regarding how ESIs are used outside of
the confines of clinical trials and their effect of subsequent
opioid use and lumbar surgery rates.
CONCLUSIONS
Three quarters of all lumbar ESIs were performed for spinal
stenosis, and nearly half were for spinal stenosis without ra-
diculopathy despite the equivocal data to support their use in
this clinical situation. Patients with spinal stenosis were more
likely to receive repeated ESIs (ⱖ4). Patients receiving re-
peated ESIs were more likely to start opioid use after ESI than
patients receiving fewer ESIs and were more likely to undergo
subsequent lumbar surgery than patients receiving fewer ESIs.
These findings are concerning given the equivocal data to
support ESI use for lumbar spinal stenosis and our data that
suggest ESIs are not reducing opioid use in this population of
veterans.
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Supplier
a. Version 13; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL
60606.
Arch Phys Med Rehabil Vol 89, June 2008