Research Summary

Opioids for Acute Low Back Pain Linked to Higher OUD or Overdose Risk in Opioid-Naïve Patients

Ashton L. Stahl

Key Highlights

  • The cumulative incidence of opioid use disorder (OUD) or overdose diagnosis was 2.3% at 13 months after treatment initiation.
  • Opioid doses exceeding 50 morphine milligram equivalents (MME) daily were associated with the greatest risk increase.
  • Chiropractic care and physical therapy were associated with lower risk compared with not initiating those treatments.
  • The authors supported prioritizing nonpharmacologic, noninterventional care for acute low back pain.

Initial treatment with opioids or gabapentinoids was associated with higher subsequent risk of opioid use disorder (OUD) or overdose diagnosis among opioid-naïve Medicaid patients with acute low back pain, according to a retrospective cohort study published in JAMA Network Open. Nonpharmacologic, noninterventional treatments were associated with lower risk.

The study included 399,500 adults younger than 65 years from 25 US states that expanded Medicaid by 2014. Participants had a median age of 39 years, and 59.5% were female. All received pain treatment within one month of a new acute low back pain diagnosis.

Researchers analyzed 2016–2019 Transformed Medicaid Statistical Information System Analytic Files. Follow-up comprised a 1-month initial treatment assessment followed by 12 months of outcome observation. OUD or overdose was identified through diagnostic codes or prescriptions for medications treating OUD.

The analysis estimated associations of initiating versus not initiating individual therapies within initial treatment combinations, accounting for measured covariates and censoring. Treatments included medications, physical therapy, chiropractic care, and other modalities.

Study Findings

The cumulative incidence of OUD or overdose diagnosis was 1.4% at 7 months and 2.3% at 13 months. Opioid doses exceeding 50 morphine milligram equivalent (MME) daily were associated with a 146.6% higher risk at 12 months of outcome follow-up (95% CI, 121.5%–171.7%). Opioids prescribed at ≤50 MME daily for more than seven days were associated with 105.2% higher risk (95% CI, 89.0%–121.4%), while gabapentinoids were associated with 101.6% higher risk (95% CI, 84.9%–118.2%).

Opioid prescriptions at ≤50 MME daily for 7 days or fewer were associated with a smaller risk increase of 31.2% (95% CI, 21.7%–40.8%). Chiropractic care was associated with a 32.8% lower risk (95% CI, 26.8%–38.9%), and physical therapy with a 31.1% lower risk (95% CI, 22.1%–40.1%). Opioids were included in 21% of initial treatment episodes; physical therapy and chiropractic care were included in 16.3% and 10.2%, respectively.

Clinical Implications

The authors concluded that the findings support nonpharmacologic, noninterventional therapies as first-line care. They recommended weighing medication benefits against longer-term risks and minimizing opioid dose and duration when opioids are prescribed.

Limitations included residual confounding, diagnostic misclassification or underreporting, and unmeasured differences in pain severity and function.

Expert Commentary

“These findings support prioritizing guideline-recommended nonpharmacologic, noninterventional therapies as first-line care for acute lower back pain,” the researchers concluded.

Reference

Doan LV, Hung AM, Olfson M, Williams NT, Rudolph KE. Initial treatment for acute low back pain and risk of opioid use disorder and overdose. JAMA Netw Open. 2026;9(10). doi:10.1001/jamanetworkopen.2026.39420