Initial treatment for lower back pain is associated with subsequent risk of opioid use disorder and overdose

by Columbia University's Mailman School of Public Health

edited by Swati Mestri, reviewed by Robert Egan

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Adults on Medicaid who began treatment for a new bout of low back pain with a higher-dose opioid prescription were about two and a half times as likely to later show signs of opioid use disorder or overdose, according to a study conducted at Columbia University Mailman School of Public Health and NYU Grossman School of Medicine.

The researchers reported a 147% higher relative risk for patients whose first-month treatment included opioids above 50 milligrams of morphine equivalent per day (MME/d).

The findings are published in JAMA Network Open.

This is the first study to evaluate the association between treatment types for acute lower back pain (aLBP) and opioid use disorder outcomes among patients with Medicaid coverage.

"Our findings support prioritizing guideline-recommended nonpharmacologic, noninterventional therapies as first-line care for aLBP," said Lisa Doan, associate professor in the Department of Anesthesiology at NYU Langone and first author. "Pharmacologic therapies might be considered after weighing potential benefits against longer-term risks. However, we urge caution when opioids are prescribed, minimizing dose and duration."

Risk varied with opioid dose and duration

Anti-inflammatory drugs and muscle relaxants were the most commonly prescribed initial treatments at 48% and 44%, respectively. Physical therapy was the most common nonpharmacologic treatment at 16%, followed by chiropractic care (10%). Among patients who filled an opioid prescription (21%), most received prescriptions for 50 MME/d or less and a supply of seven or fewer days.

Opioid prescription dosages greater than 50 MME/d were associated with the largest increase in risk of a new diagnosis of opioid use disorder (OUD) or overdose, increasing risk by 147%. Lower-dosage opioids (≤50 MME/d) prescribed for more than seven days were associated with a twofold increase in risk of OUD. Opioid dosages of 50 MME/d or less for seven days or less were associated with a much smaller increase in risk (31%).

Conversely, all nonpharmacologic, noninterventional therapies were associated with reductions in risk of a new diagnosis of OUD or overdose.

Among patients followed for 13 months, slightly more than 2% had a new opioid use disorder diagnosis, a nonfatal overdose or a prescription for an addiction treatment drug such as buprenorphine or methadone.

Opioid prescribing persisted despite guidelines

"Despite guidelines recommending nonopioid and nonpharmacologic therapies as first-line treatment for acute pain, prescriptions involving opioids and/or gabapentin during the first month of treatment remained common," noted Kara Rudolph, associate professor of epidemiology at Columbia Mailman and the senior author on the study.

The researchers used data from the Transformed Medicaid Statistical Information System Analytic Files covering Jan. 1, 2016, to Dec. 31, 2019, for 399,500 adults in 25 states that expanded Medicaid under the Patient Protection and Affordable Care Act by 2014, including California, New York, Illinois, Ohio and Massachusetts. States that had not expanded Medicaid by 2014, such as Texas, Florida and Georgia, were not included.

"We believe that nonopioid therapies are at least as effective as opioids for many common types of acute pain," said Doan. "When opioids are prescribed, we emphasize minimizing dose and duration as the cautious approach."

Publication details

Lisa V. Doan et al., Initial Treatment for Acute Low Back Pain and Risk of Opioid Use Disorder and Overdose, JAMA Network Open (2026). DOI: 10.1001/jamanetworkopen.2026.39420

Journal information: JAMA Network Open

Key medical concepts

acute low back painOpioids and Opioid Use Disorder (OUD)

Clinical categories

AnesthesiologyCommon illnesses & PreventionClinical pharmacologyFamily medicine Provided by Columbia University's Mailman School of Public Health Who's behind this story?

Swati Mestri

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