Steroids

When I talk to people about my job, I get asked a lot of questions about steroids.  Steroid shots, steroid pills- you name it- people are interested in whether or not steroids could help them.  I thought it might be useful to go into a little bit more detail about steroids, why we use them, and some of the pros/cons.

When we talk about a steroid, this is a term that describes a lot of different types of molecules that have a similar structure of interlocking rings.  Some occur naturally in the body, like testosterone and progesterone, and some are manufactured in a lab. Steroids are critical building blocks for the human body and also have a role in many different signaling pathways.  

One thing that is worth mentioning: despite everyone saying they’re going for a “cortisone shot”, we rarely use actual cortisone for pain treatments.  Instead, we use a few other types of manufactured steroids. The ones that I most commonly use are triamcinolone, methylprednisolone and dexamethasone.  In the pain world, there’s a lot of discussion about particulate and non-particulate steroids, which basically means how big or small the steroid molecules are in the liquid that we use for injections.  The first two I mentioned are considered particulate, and dexamethasone is not.

We use steroids for pain treatments mainly because they are very powerful anti-inflammatory medications.  The idea is, that if there is inflammation in an area, putting steroid nearby can help to reduce it. As an interventional pain management doctor, I am always trying to brainstorm ways to get the steroid as close as possible to the issue, which means I usually favor injections over taking steroid pills, which have to get digested in the stomach and go all throughout the body before reaching their destination.  But, it is important to know that even when steroids get injected some place like a joint, they still leak out into the entire body in small levels.

There are a few other interesting things about steroids that give them a role in pain management.  In addition to being powerful anti-inflammatory medications, steroids appear to have intrinsic pain relieving properties, meaning, that even before they’ve started to reduce inflammation, they help to reduce pain.  People notice this often with high doses of steroid pills. Second, using a steroid in a nerve block appears to prolong the effect. In other words, putting steroids around the nerve with numbing medicine causes the pain relief to last longer than the numbing medicine can by itself.  

You might be sitting here wondering why, if steroids are so great, we don’t just have everyone on them for long periods of time.  The issue is, because steroids are such important signalling molecules in the body, when we give extra steroids on top of the naturally occurring ones, it can cause a lot of these pathways to function abnormally.  So, unfortunately, when patients get too many steroids, this can lead to a lot of serious side effects.

The main risks of steroids that I talk to my patients about relate to the bones, blood sugar issues/weight gain, and adrenal insufficiency.  Chronic steroid use can lead to weakening of the bones, also known as osteoporosis and avascular necrosis, which can lead to sudden fractures. Not great, especially if I am treating someone who is prone to falls!  Steroids can also cause elevated blood sugar (think diabetes) and a lot of weight gain. Weight gain can be catastrophic for someone who already has joint or back pain. Adrenal insufficiency happens when the body gets used to having so much extra steroid around that it forgets how to produce its own steroids. This is a big problem during times of stress or illness.  There are also a lot of other risks of chronic steroids that include skin thinning/bruising, mood issues and stomach issues like ulcers.

How many doses of steroids is too much?  There aren’t enough high quality studies to weigh in definitively on this, but a general rule of thumb in the pain management community is no more than three doses in 12 months.  It is so important that you share with your pain management doctor if you’ve gotten steroids for another reason- like an asthma attack- because even that counts against those three doses.  Sometimes we will do more than this number, but only after carefully considering the pros and cons.

I do still use steroids a lot in my practice, but I really try to weigh the risks and benefits because as you can see, it’s more complicated than just a quick cortisone shot! Conditions that respond nicely to steroids include radiculopathies (commonly known as sciatica), bursitis and joint pain.  I try to avoid using steroids in areas where I know a muscle or tendon has torn or has inflammation, because steroids can actually worsen that weakness.

Luckily, I have a lot of other options in my arsenal for pain management treatments, and so if I decide a steroid injection isn’t a good idea, there are many other things that I can use.  The benefit of seeing a pain management specialist is that we are trained to look at all these treatments and come up with a tailored plan.

I hope this helped to explain steroids a little better!  Remember, the best way to see what treatments are right for you are to go see a pain management doctor in person.