Opioids and Gabapentinoids for Acute Low Back Pain Tied to Higher OUD Risk

In opioid-naive Medicaid enrollees with newly diagnosed acute low back pain (aLBP), initial treatment with opioids or gabapentinoids was associated with a higher risk of a later opioid use disorder (OUD) or overdose diagnosis, and chiropractic care and physical therapy with a lower risk, according to a study in JAMA Network Open.

The retrospective cohort study used Medicaid claims from 25 states that expanded Medicaid by 2014 to identify 399,500 adults aged 19 to 63 years who began a new pain treatment within 1 month of an aLBP diagnosis between 2016 and 2019. Each treatment started in the first 30 days was compared with not receiving it, adjusting for measured covariates and censoring. The outcome, identified by diagnostic codes or receipt of methadone or buprenorphine, was assessed from day 31 through month 13.

The cumulative incidence of OUD or overdose diagnosis was 1.4% at 7 months and 2.3% at 13 months. Opioid dosages greater than 50 milligrams of morphine equivalents per day (MME/d) had the strongest association, a 146.6% relative increase in risk (95% CI, 121.5%-171.7%), or 2.5-fold. Opioids at 50MME/d or less for more than 7 days and gabapentinoids were each associated with a 2.0-fold increase (105.2% and 101.6%, respectively), and opioids at 50MME/d or less for 7 days or less with a 31.2% increase.

All nonpharmacologic, noninterventional therapies were associated with lower risk, led by chiropractic care (32.8% relative reduction) and physical therapy (31.1%). Sensitivity analyses were directionally consistent. Fewer than half of patients received a nonpharmacologic therapy, and 21.0% filled an opioid prescription. The authors noted that the claims-based analysis may be affected by residual confounding, misclassification, and unmeasured pain severity and function, and that the findings may not generalize beyond Medicaid-insured adults.

The authors concluded that the findings support prioritizing guideline-recommended nonpharmacologic, noninterventional therapies as first-line care for aLBP and that minimizing dose and duration remains prudent when opioids are prescribed.

Source: 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):e2639420. doi:10.1001/jamanetworkopen.2026.39420