TL;DR
A study of nearly 400,000 Medicaid enrollees found that starting acute low back pain treatment with opioids or gabapentinoids was associated with about twice the risk of a combined opioid use disorder or overdose outcome, compared with not starting those drugs. Chiropractic and physical therapy were associated with lower risk, but the observational findings do not establish that any treatment caused the outcomes.
A study of 399,500 Medicaid enrollees with newly diagnosed acute low back pain found that patients whose first treatment included an opioid or gabapentinoid had roughly twice the risk of a combined opioid use disorder or overdose outcome as patients who did not start those drugs. The findings, published in JAMA Network Open and reported October 20, 2026, add evidence relevant to clinical guidance that recommends trying nondrug care before prescription painkillers for acute back pain.
Researchers analyzed Medicaid records from 25 states for 2016-2019. The study group had a new acute low back pain diagnosis and no recent record of opioid use. Within a month of diagnosis, 21% received an opioid and 5.8% received gabapentin or a similar drug. About 35% received a nonpharmacological treatment, including chiropractic care, 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 (95% confidence interval, 89.0%-121.4%). The corresponding increase was 146.6% for opioids started above 50 milligrams in morphine equivalents, and 101.6% for gabapentinoids. These are relative increases reported by the study, not percentage-point changes in a patient’s absolute risk.
Starting chiropractic care was associated with a 32.8% lower risk of the outcome, and physical therapy with a 31.1% lower risk, compared with not starting those therapies. The study also reported an overall cumulative outcome rate of 1.4% at six months and 2.3% at 12 months after treatment began. The researchers combined opioid use disorder and overdose in their outcome and did not report which made up most cases.
The Case for Nondrug First Care
The results matter because opioids continue to be prescribed for acute low back pain despite longstanding recommendations against using them as initial treatment. In the study, more than one in five participants received an opioid within a month of diagnosis, while fewer than 6% received a gabapentinoid. The findings add to concerns about the potential downstream harms of starting these medicines for a condition that often receives nondrug treatment.
The associations do not prove that opioids or gabapentinoids caused opioid use disorder or overdose, or that chiropractic care and physical therapy prevented them. Treatment choice may reflect differences in pain, health, access to care or other factors not fully captured in claims data. Still, the comparison gives clinicians and patients further reason to discuss potential benefits, risks and alternatives before starting prescription drugs, especially opioids.
Guidelines Meet Prescribing Practice
Clinical guidance has recommended nondrug approaches first for acute low back pain for more than a decade. The study authors said those recommendations were shaped in part by concerns about opioid-related harms. Gabapentinoids, including gabapentin and pregabalin, have also been used as alternatives to opioids, although the source report notes limited evidence of efficacy for low back pain.
Earlier studies cited in the report found that 12% to 20% of patients with private insurance or Medicaid received opioid prescriptions in 2017-2018. The current analysis examined Medicaid beneficiaries in states that adopted expanded Affordable Care Act eligibility; Maryland was excluded because the researchers considered its diagnostic coding unreliable. The average participant age was 39, 60% were women, and 98% had income below 138% of the federal poverty level.
“Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.”
— Kara E. Rudolph, PhD, MPH, MHS, of Columbia University, and colleagues
Limits of Claims-Based Evidence
The study was observational and relied on insurance records, so it cannot establish cause and effect. Claims may not capture pain severity, care patients paid for themselves, over-the-counter medicines or other factors affecting treatment and outcomes. Because the sample consisted of Medicaid enrollees, findings may not apply in the same way to people with other insurance or different access to care.
The outcome combined diagnoses of opioid use disorder, opioid-involved overdose and prescriptions for medication used to treat opioid use disorder. The researchers did not distinguish which events drove the association. The study also does not establish which treatment is best for an individual patient or whether the reported associations would be similar in other populations.
How Clinicians May Apply Findings
The report does not identify a new treatment rule or a change to clinical guidelines. Its authors said the findings support existing recommendations and that medication decisions should weigh potential benefits against longer-term risks. For patients, the practical next step is a discussion with a clinician about the available options and the expected risks and benefits; this study alone cannot determine an individual’s treatment.
Further research would be needed to clarify how much of the observed difference reflects treatment itself rather than patient circumstances, and to separate opioid use disorder outcomes from overdoses. Until then, the results should be read as associations from Medicaid data, not proof that a specific treatment caused or prevented harm.
Key Questions
What did the study find about opioids for acute back pain?
In Medicaid records, starting opioids as initial treatment was associated with a higher likelihood of a combined opioid use disorder or overdose outcome. The reported increase was 105.2% for lower-dose opioid treatment lasting at least seven days and 146.6% for doses above 50 milligrams in morphine equivalents, compared with not starting an opioid.
Did the study show that opioids caused overdose or opioid use disorder?
No. It was an observational analysis of claims data and found an association, not proof of cause and effect. Patient differences and factors missing from the records could have affected the results.
How did physical therapy and chiropractic care compare?
Starting physical therapy was associated with a 31.1% lower risk of the combined outcome, and starting chiropractic care with a 32.8% lower risk, compared with not starting those therapies. The study does not prove either treatment reduced risk.
Were overdose and opioid use disorder reported separately?
No. The researchers combined opioid use disorder and overdose-related measures into one outcome, so the report does not show which contributed more to the results.
Does this study mean everyone with acute back pain should avoid medication?
No. The investigators said pharmacologic treatments can be considered after weighing potential benefits against longer-term risks. The study supports discussion of options but does not determine the right treatment for every patient.
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