Does initial treatment for back pain affect opioid risks?
A study of 399,500 people finds associations between early treatment and later opioid-related diagnoses.
Early decisions about treating acute lower back pain may be associated with longer-term opioid-related harms. A large American study examined records for 399,500 adults under 65 who had Medicaid insurance, were previously opioid-naïve and received treatment within a month of a new diagnosis of acute lower back pain. Researchers assessed treatments in the first month and opioid use disorder or overdose diagnoses over the following 12 months.
What did the researchers find?
The estimated cumulative incidence of opioid use disorder or overdose diagnosis was 2.3% by 13 months. Compared with patients not receiving each treatment, starting opioids at more than 50 morphine milligram equivalents per day was associated with a 147% higher relative risk. Lower-dose opioids prescribed for more than seven days were associated with a 105% higher risk, and gabapentinoids with a 102% higher risk.
By contrast, initial physiotherapy was associated with a 31% lower relative risk, and chiropractic care with a 33% lower risk. These are relative comparisons: they do not mean that 31% of patients avoided opioid dependence, or that any treatment caused the observed difference.
Can this prove which treatment is safest?
No. This was a retrospective observational study, not a randomised trial. People offered physiotherapy, opioids or gabapentinoids may differ in pain severity, underlying health and circumstances. Statistical adjustments cannot remove every such difference. The study used insurance records, which may miss unrecognised problems, self-funded treatment and actual medication consumption. Its findings may not generalise to NHS patients.
What should patients take from this?
Most episodes of acute lower back pain improve over time. Staying active where possible, reassurance and appropriate non-drug care are often sensible starting points. Opioids sometimes have a limited role after individual assessment, but high doses and unnecessarily long courses deserve particular caution. Gabapentinoids are not routinely recommended for non-specific lower back pain in UK guidance. The study strengthens the case for discussing both immediate symptom relief and longer-term safety when choosing treatment.
Original research
JAMA Network Open, 19 October 2026. Read the original research.
This information is educational and does not replace individual medical advice.