Jan Carstoniu (J) responds to a question from a participant (P) during one of our sessions. This was condensed and edited from an audio recording.
P: I have a question. Last week you and I spoke about injections that people get. You were saying that you felt that injections of local anesthetic was something that can be taken regularly but you didn’t go for the steroid part of it and I was wondering if you would speak a little more about why.
J: Ok, that’s a big topic but we can try to do it. As some of you know there are a number of clinics in the city in which things like nerve blocks, trigger point injections and Botox injections are offered to people with various types of chronic pain. We were talking about this and the practice of using cortisone in some of these injections. There are physicians who will regularly put small amounts of cortisone into a syringe mixed with a local anesthetic – the stuff that freezes your mouth when you go to the dentist.
I mentioned that I generally do not add cortisone because I have never seen good evidence for doing this since I started using nerve blocks and trigger point injections for chronic pain in 1993. There is little hard evidence based on well-designed clinical trials that show adding cortisone to a local anesthetic makes any difference in the long run or even the short run for most patients. However, ‘no evidence’ does not mean ‘evidence against’ and there are doctors who will still do it.
Part of the problem is that cortisone is an amazing drug. It’s powerful and has probably saved millions of lives. People who’ve had organ transplants would probably not survive without cortisone to prevent rejection. It’s a wonder drug in the treatment of certain kinds of inflammatory disease. But it can cause serious side effects including high blood pressure, diabetes, osteoporosis, acne, mood changes, delirium, immune system suppression and typical patterns of weight gain. Avascular necrosis is a serious condition that causes bone to die, usually in the hip, when people take relatively high doses for a long time. Repeated injections into the same spot can thin the skin in this area. My wife (who is also a rheumatologist) and I can walk down the street and say “oh, there’s someone on prednisone (a form of cortisone). If you know what to look for, it’s pretty easy to see.
These are all long-term effects. You don’t get them when you have your tennis elbow or your rotator cuff injury treated with a cortisone shot. Sometimes high doses are given for a short time and rapidly tapered depending on the condition being treated. This generally does not cause serious problems with side effects either.
One example of how to get serious side effects is with asthma treatment. If you have really bad asthma and you’re having a really bad summer you may have to take cortisone all summer. This puts you at risk but it may be saving your life too. It is very important however to remember that many side effects go away when cortisone is stopped but not osteoporosis, avascular necrosis, thin skin and sometimes, diabetes.
So this is a drug which saves lives and is absolutely incredible when used in the right way. But when it’s used for a long time it may lead to other conditions that might even become life threatening. Therefore, my personal feeling is that people with chronic pain who don’t have a condition requiring cortisone shouldn’t use it. I have seen at least a couple of patients who got cortisone mixed with local anesthetic for nerve blocks (from other doctors) regularly over a couple of months. They were starting to show signs of side effects.
To me it doesn’t make sense to use cortisone when there is not a good indication for its use. Do you all know what trigger point injections are? A trigger point injection is an injection into a painful knot or pressure point in a muscle. You know you have one when you touch one spot it’s really tender but if you move your finger just a little bit over it’s not. You usually feel a vague little lump in muscle right at the most tender spot.
We don’t know what causes them. We know they exist and that when a needle is inserted into one, the whole muscle can jump. That’s how I know I’m right on the money when I do a trigger point injection.
Studies have shown that trigger points respond to injections of local anesthetic with or without cortisone, injections of cortisone alone, injections of sterile water and sometimes just sticking in a dry needle. Given that they respond the same to all those things, it does not make sense to me to add cortisone. However, if your doctor gives you a couple of trigger point injections once in a while and adds a little bit of cortisone, I have no complaints. I don’t think this is risky.
Nevertheless the only time I will do it is if a patient comes to me and says that their previous doctor used to give trigger point injections with a little cortisone in them and got pain relief for 2-3 months. If the trigger point injections I give to this patient wear off after 3 days then I’d give it a try. A small amount once in a while is no big deal. But large amounts on a regular basis are a very big deal. I hope that answers your question.
P: That helps a great deal. I wanted to be informed because so often my rheumatologist makes the decision to use this injection but I don’t have the second opinion I need to determine whether to accept it, or how often to accept it or even what’s going on.
J: What you need is knowledge. Everyone with chronic pain needs knowledge. The doctors who treat you sure need knowledge because there’s so much we don’t know. I think all of you should get into the habit of asking questions even if those questions are uncomfortable. At the beginning of each of these sessions, I ask “does anyone have any questions?” I’m inviting this and if I get into trouble, it’s my own fault. I think that is one thing this group can be useful for, getting questions answered.
P: Well I really appreciate your answers because I know that I’ve had injections. The first time I was pulled out of the apathy and lethargy, so it made a big difference. The second time, it had side effects and I became fearful.
J: For the kind of injection you’ve described to me the amounts of cortisone used are generally very small, not enough to have a big effect on your immune system or other body systems. You need a very big shot for that. It can sometimes be really difficult to know whether your response to small doses is to the cortisone or to something else. Never underestimate the power of the placebo.
The kind of cortisone I use is called Depomedrol. It is very commonly used for things like tennis elbow, bursitis and tendonitis. The usual dose for these kinds of things varies from 40 to 80 mg depending on where you need the injection. Sometimes I may give more than one injection in a single session and the total dose may be 160 mg. Some people will react to that size of a dose and most often they’ll say how good they felt for a few days after treatment, like they got a boost in energy. This usually doesn’t last long.
For a single trigger point injection, I may use 5-10 mg of Depomedrol and have never given more than 4-5 such injections at a time on those rare occasions when I’ll add cortisone. I would not do this kind of thing more than 3-4 times a year. This is hardly enough to affect your physiology significantly. If your doctor is using doses of 80 mg or less, 3-4 times a year I’d be hard pressed to explain your side effects.
P: What I had noticed was that another chronic condition I’d had suddenly flared up (after my injection) after being quiet for a long period of time.
J: In that case I don’t know what to say. I need more information about the dose you got and the nature of the condition. A flare of pain in the place you get the injection is very common. It happens about 50% of the time and may last a few days. Also, coincidences happen. Maybe this was one. I just don’t know. I strongly suggest asking your rheumatologist.
When you’re faced with therapeutic choices about cortisone, it really pays to ask questions. What is this supposed to do? How does it work? What should I expect, be it good or bad? If you ask, you are doing what you can to get your doctor to do a good job of informing you. By knowing what to expect you’ll be better prepared. I hope this information helps.