Study Background and Design
A 2026 study published in JAMA Network Open examined the relationship between initial treatment approaches for acute low back pain (aLBP) and subsequent risk of opioid use disorder (OUD) or overdose. The retrospective cohort study analyzed data from 399,500 Medicaid-enrolled adults aged under 65 who initiated treatment for newly diagnosed aLBP between 2016 and 2019. Researchers followed participants for up to 13 months, tracking outcomes such as OUD diagnoses or overdose events. The study focused on opioid-naive patients, excluding those with prior opioid exposure. Data came from the Transformed Medicaid Statistical Information System Analytic Files across 25 states that expanded Medicaid under the Affordable Care Act by 2014. The analysis period spanned from March 2025 to July 2026.
Key Findings
The study found that 1.4% of participants received an OUD or overdose diagnosis within seven months, rising to 2.3% by 13 months. Higher-risk treatment patterns included initiating higher-dose opioids (>50 mg morphine equivalent) or prolonged lower-dose opioid use (>7 days), which were associated with 146.6% and 105.2% increased risk, respectively. Gabapentinoids also showed a 101.6% increased risk. In contrast, nonpharmacologic, noninterventional therapies were linked to reduced risk. Chiropractic care was associated with a 32.8% risk reduction, while physical therapy showed a 31.1% reduction. The authors noted that guideline-discordant care was common, with less than 50% of patients receiving nonpharmacologic treatments as first-line therapy, despite American College of Physicians recommendations.
Limitations
The study's findings are limited to Medicaid-insured populations, which may not generalize to other insurance groups. The retrospective design prevents causal inferences, and the analysis focused on newly diagnosed aLBP cases without accounting for prior spinal conditions. Additionally, the study did not assess long-term outcomes beyond 13 months. Researchers acknowledged potential confounding factors, including variations in treatment patterns across states and the possibility of underreporting in administrative data. The authors emphasized that these results should be interpreted alongside clinical judgment and individual patient needs.
Implications for Spine Care
The study reinforces the importance of nonpharmacologic approaches in managing aLBP, aligning with clinical guidelines that prioritize nonpharmacologic therapies as first-line treatment. Chiropractic care and physical therapy were identified as interventions associated with the greatest risk reduction for OUD or overdose. However, the study did not evaluate the effectiveness of these treatments in pain relief or functional improvement, only their association with opioid-related outcomes. Clinicians are advised to consider these findings when developing treatment plans, while recognizing the need for further research on long-term patient outcomes. The results also highlight the potential role of nonpharmacologic modalities in addressing the opioid crisis, particularly in populations with high-risk profiles.
Conclusion
This study adds to the growing body of evidence supporting nonpharmacologic treatments for acute low back pain. While the findings suggest that higher-dose opioids and certain medications increase OUD and overdose risk, they also demonstrate that nonpharmacologic therapies like chiropractic care and physical therapy may mitigate these risks. However, the study's observational nature means that additional research is needed to confirm these associations and explore their clinical implications. The authors call for further investigation into the long-term effects of treatment choices and their impact on both pain management and public health outcomes.