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A study using Medicaid data from 25 states found that patients with acute low back pain who started opioids or gabapentinoids had about twice the risk of a later opioid use disorder or overdose diagnosis compared with patients who did not start those drugs. Chiropractic and physical therapy as initial treatments were associated with lower risk, but the observational study cannot establish that treatment choices caused the differences.
A study of 399,500 Medicaid enrollees with newly diagnosed acute low back pain found that those initially prescribed opioids or gabapentinoids had about twice the risk of a later opioid use disorder or overdose diagnosis as patients who did not start with those drugs. The findings, published in JAMA Network Open, add evidence relevant to guidance favoring nondrug approaches before prescription painkillers, but the observational data cannot show that the treatments themselves caused the differences.
Researchers led by Kara E. Rudolph of Columbia University analyzed Medicaid records from 25 states for 2016-2019. The patients had a new acute low-back-pain diagnosis and no recent opioid use recorded. Within a month of diagnosis, 21% received an opioid prescription and 5.8% received gabapentin or a similar drug. About 35% received a nondrug treatment, including chiropractic, physical therapy or massage.
Compared with patients who did not start an opioid, those prescribed a dose below 50 milligrams in morphine equivalents for at least seven days had a 105.2% higher likelihood of the combined outcome, the researchers reported. The corresponding increase for gabapentinoids was 101.6%; starting opioids above 50 milligrams in morphine equivalents was associated with a 146.6% increase. The study reported confidence intervals for these estimates, reflecting statistical uncertainty.
Starting with chiropractic care was associated with a 32.8% lower risk of the combined outcome than not starting that therapy; physical therapy was associated with a 31.1% lower risk. The researchers tracked diagnostic codes for opioid abuse or dependence, opioid-involved overdose, or a prescription for medication used to treat opioid use disorder. The combined outcome occurred in 1.4% of the cohort by month seven and 2.3% by month 13.
Risks of Starting With Painkillers
The results matter because acute low back pain is commonly treated, and opioids remain an initial option for some patients despite longstanding guidelines that favor trying nondrug care first. In this study, 21% of the Medicaid cohort received an opioid within a month of diagnosis. The findings reinforce the potential value of discussing treatment choices and the risks associated with opioid exposure.
They do not establish that chiropractic or physical therapy prevents opioid use disorder or overdose, or that a prescription caused either outcome. Treatment selection can reflect a patient’s health, pain severity, access to care and other factors that records may not fully capture. The researchers said pharmacologic treatment can be considered after weighing potential benefits against longer-term risks; when opioids are prescribed, they said, minimizing dose and duration is prudent.
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Guidelines and Prescribing Patterns
Guidelines have recommended nondrug therapies as an initial approach to acute low back pain for more than a decade. Yet prior research cited by the study authors found that 12% to 20% of privately insured or Medicaid patients received opioid prescriptions in 2017-2018. The authors also noted that gabapentinoids, including gabapentin and pregabalin, have been promoted as alternatives to opioids, although evidence of their effectiveness for low back pain is limited.
The study included Medicaid enrollees in states that adopted expanded eligibility under the Affordable Care Act; Maryland was excluded because the researchers considered its diagnostic coding unreliable. The cohort’s average age was 39, 60% were women, and 98% had incomes below 138% of the federal poverty level. Those details are relevant when considering how well the findings apply to patients with other insurance or access to care.
“Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.”
— Kara E. Rudolph and colleagues, as quoted in the study report
Limits of the Medicaid Records
The study was observational, so it can identify associations but cannot establish that a first-line treatment caused a later diagnosis or overdose. The authors’ outcome combined opioid use disorder and overdose, and the report did not separate their contributions; it is therefore unclear which outcome accounted for more cases. The overall cumulative rates were 1.4% at month seven and 2.3% at month 13.
Claims data also may miss medications obtained without a prescription, drugs paid for out of pocket, or care that was not recorded in Medicaid claims. The researchers identified later opioid prescriptions among patients who had not started with one, meaning the comparison concerns initial treatment rather than opioid exposure throughout follow-up. The study’s focus on lower-income Medicaid enrollees also limits how directly its findings apply to the broader population.
Applying Findings to Care
The report does not announce a change to clinical guidance. Its findings add observational evidence to existing recommendations to consider nondrug care first for acute low back pain and to weigh medication benefits against risks. Clinicians and patients can use the results as one part of a treatment discussion, while accounting for individual symptoms, medical history and access to therapy.
Further research could help clarify whether the differences reflect treatment effects, patient characteristics, access to care or a combination of factors. The source report does not specify a next study or a policy action. For now, the key unresolved questions include how much of the combined outcome was opioid use disorder versus overdose, and whether similar patterns appear in populations outside Medicaid.
Key Questions
What did the study find about opioids for acute low back pain?
In Medicaid records, starting opioids for acute low back pain was associated with higher later rates of the combined outcome of opioid use disorder or overdose than not starting an opioid. The study found a 105.2% higher likelihood for initial opioid doses below 50 milligrams in morphine equivalents taken for at least seven days, and a 146.6% increase for doses above 50 milligrams.
Were gabapentinoids also linked to higher risk?
Yes. Starting gabapentin or a similar drug was associated with a 101.6% higher likelihood of the combined opioid use disorder or overdose outcome compared with not starting those drugs. This is an association from observational records, not proof that the medication caused the outcome.
Did physical therapy or chiropractic care reduce risk?
Patients who started with physical therapy or chiropractic care had lower rates of the combined outcome than patients who did not start those respective therapies. The study found associations, not proof that either treatment prevents opioid use disorder or overdose.
Does the study mean nobody with acute back pain should take prescription medication?
No. The study does not establish that medication is inappropriate for every patient. Its authors said pharmacologic therapies may be considered after weighing potential benefits against longer-term risks, and advised minimizing opioid dose and duration when opioids are prescribed. Treatment decisions should be made with a qualified health professional.
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