Oregon’s Medicaid program doesn’t cover steroid injections for back pain, and a state commission that determines what’s covered under the program is poised to keep it that way.

The debate over whether the Oregon Health Plan should cover the injections has drawn passionate testimony from patients and physicians alike. Doctors often inject steroids into the spinal column to relieve pain in the back and legs caused by inflamed nerves. The pain often occurs when discs in the spinal column place pressure on adjacent nerves.

In order to approve coverage for the treatment, the state’s Health Evidence Review Commission would need assurance that they improve patients’ long-term and short-term function, reduce their pain and lower their need for surgery later, among other factors. So far, the commission has found little scientific evidence on most of those fronts.

But critics, including both patients and physicians, argue the commission’s process doesn’t allow enough room for patients’ experiences with the injections to shape coverage. Several patients tearfully told commission members at public hearings they wouldn’t have been able to attend without the treatments.

“If you take a normal person like me, I’m evidence,” Tracy Titus, a patient who uses the injections, said at an April 6 meeting on the subject. “I’m here. I’m here because of these injections. I can get up out of bed. I can move around. I can pick things up, something that for a while I couldn’t do.”

Doctors argue pain medicine is a unique specialty that doesn’t easily lend itself to randomized controlled trials, which — while the gold standard of scientific research — require that a set of patients receive a placebo. The HERC relies mainly on randomized controlled trials to make its coverage determinations.

“How would you tell somebody, ‘I’m going to inject your back and put saline inside or sugar water?’” said Dr. Asokumar Buvanendran, an anesthesiology professor at Rush University in Chicago. “That’s very hard to do in these clinical trials nowadays. None of my patients would agree to that.”

In this case, Buvanendran, the chairman of the American Society of Anesthesiologists’ Committee on Pain Medicine, said the results observed in clinical practice should influence the decision, as it’s such a difficult topic to study. He did not testify on the subject, but said in an interview he has been using the injections on patients for 18 years. In his experience, they relieve pain and complications are rare, he said.

The commission is recommending against coverage for steroid injections in several scenarios.

One is into the epidural space around the spinal cord in people with or without pain that extends down into the legs, otherwise known as radiculopathy or sciatica. They’re also considering providing the injections for other types of pain, such as that which originates in the facet joints and sacroiliac joints.

Dr. Cat Livingston, the HERC’s associate medical director, said in an interview she disagrees with the claim that there is inadequate medical evidence on the injections. On the contrary, she said the commission’s review included a wealth of randomized controlled trials featuring thousands of patients, but they did not show strong evidence of improved outcomes.

“There are going to be some conditions in which it’s not possible or it would be very challenging to do a randomized controlled trial,” Livingston said. “This is not one of those conditions. There are many randomized controlled trials that have been done clearly showing that there have been a lot of patients willing to participate in these.”

Dr. David Sibell, a professor in Oregon Health & Science University’s departments of anesthesiology and perioperative medicine and clinical informatics, thinks spinal injections are used too often for too many things for which there is little evidence they work.

That said, Sibell said he believes there is enough evidence to support their use to treat sciatica, which is among the indications the commission is considering.

That use is currently not recommended for coverage, although the recommendation against coverage is considered weak, whereas the recommendations against coverage in the other indications are strong.

Several private health insurers cover spinal injections, with caveats, for people who experience radiating pain, or sciatica, including Moda Health, Aetna and Cigna, according to commission documents.

Medicare also provides coverage for the injections. It pays about $160 if they take place in an office and about $91 if they take place in a medical facility, according to the American Society of Anesthesiologists.

The commission’s draft guidelines argue in part that the pain relief from the injections is temporary.

In many cases, Sibell argues, so is the pain. Many patients with sciatica feel pain for between two or three months. An injection that lasts six to eight weeks, as these do, would overlap well, he said.

“Having a treatment that helps with pain control during that period is a useful way to help people as they heal,” Sibell said.

So far, a HERC’s subcommittee has had three meetings on the subject. The full commission is scheduled to take up the issue on May 18. At that meeting, it is likely to make a decision for the Medicaid program, as well as issue a recommendation that may influence coverage by private health insurers.

The HERC has made a number of changes in recent years to its coverage for back pain issues. Last July, a new rule took effect that allows more Oregon Health Plan members with low back pain to receive services like physical therapy, chiropractic manipulation, acupuncture or, in the most serious cases, surgery.

It’s part of a broader effort statewide and nationally to decrease the number of Medicaid patients using opioid pain medications.

If injections provide a modest benefit — decreasing their pain by between 30 and 50 percent — then it prevents them from taking opioids, which should be a priority, Buvanendran said.

“I have not seen a single patient die because of injections,” he said, “but I’ve seen them die from opioids. If you can prevent this, I think it’d be a good thing.”

— Reporter: tbannow@bendbulletin.com, 541-383-0304

“If you take a normal person like me, I’m evidence. I’m here. I’m here because of these injections. I can get up out of bed. I can move around. I can pick things up, something that for a while I couldn’t do.”— Back pain patient Tracy Titus