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A study of nearly 400,000 Medicaid enrollees found that starting acute low back pain treatment with opioids or gabapentinoids was associated with higher subsequent rates of opioid use disorder or overdose than not starting those drugs. Chiropractic and physical therapy as initial treatments were associated with lower rates. The observational study cannot establish that the treatments caused these outcomes, and its results may not apply to all patients.
A study of 399,500 Medicaid enrollees with new acute low back pain diagnoses found that starting treatment with an opioid or a gabapentinoid was associated with roughly twice the risk of a later diagnosis of opioid use disorder or overdose, compared with not starting an opioid. The findings, published in JAMA Network Open, add evidence relevant to decisions about first-line treatment, but do not prove the drugs caused the outcomes.
Researchers led by Kara E. Rudolph of Columbia University examined Medicaid claims from 25 states between 2016 and 2019. The enrollees 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 related drug. About 35% received a non-drug treatment such as chiropractic care, physical therapy or massage.
Compared with not starting an opioid, beginning one at a dose below 50 milligrams in morphine equivalents for at least seven days was associated with a 105.2% higher likelihood of the combined outcome. Starting a higher dose was associated with a 146.6% higher likelihood. Starting a gabapentinoid was associated with a 101.6% higher likelihood. The researchers also reported lower likelihoods relative to not starting those therapies for chiropractic care, by 32.8%, and physical therapy, by 31.1%.
The study tracked diagnoses or treatment indicators for opioid use disorder or opioid-involved overdose at six and 12 months after treatment began. The combined outcome occurred in 1.4% by six months and 2.3% by 12 months. The analysis grouped opioid use disorder and overdose together, so it did not show which outcome accounted for more cases. These are associations from health records, not proof that a particular treatment caused an outcome.
Treatment Choices and Later Risks
The results matter because opioids remain a common first treatment for acute low back pain, despite longstanding guidance favoring non-drug approaches first. Among the Medicaid enrollees studied, more than one in five received an opioid within a month of diagnosis. The study adds a large, real-world comparison of treatment starts and later outcomes to a debate about how to manage short-term back pain while limiting exposure to medications that carry risks.
The findings do not mean that chiropractic or physical therapy prevents opioid use disorder or overdose, nor that every patient should avoid medication. People may receive different treatments because of differences in pain severity, access to care, health history or other factors that claims data may not capture. The authors said pharmacologic treatment can be considered after weighing potential benefits against longer-term risks; when opioids are prescribed, they said, minimizing dose and duration remains prudent.
Guidelines and Prescribing Patterns
Guidelines for acute low back pain have recommended trying nonpharmacological care before opioids for more than a decade. However, prior research cited by the investigators found that 12% to 20% of patients with private insurance or Medicaid received opioid prescriptions in 2017 and 2018. Gabapentinoids, including gabapentin and pregabalin, have also been used as alternatives, although the source report notes concerns about limited evidence of benefit for low back pain.
The study population was relatively young, with a mean age of 39 years; 60% were women, and 98% had incomes below 138% of the federal poverty level. The researchers used Medicaid data from states that expanded eligibility under the Affordable Care Act, excluding Maryland because of concerns about diagnostic coding. More than 90,000 people who did not start an opioid immediately later received one, including about 20% of that group between months one and three.
“Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.”
— Kara E. Rudolph and colleagues
Limits of the Medicaid Analysis
The study was observational, so it cannot establish cause and effect. Claims records may not capture factors that influenced treatment choice, including pain severity, patients’ use of nonprescription medicines, or drugs paid for out of pocket. The source report also notes that access barriers to physical therapy or other care could affect which treatments Medicaid patients received.
The results may not generalize to people with different insurance or income levels. In addition, the study combined opioid use disorder and overdose rather than reporting each outcome separately. Although overall rates were reported at six and 12 months, the available findings do not establish how much the observed association reflects treatment itself versus differences among patients.
How Clinicians May Apply Findings
The study does not announce a change to clinical guidelines. Its findings may inform discussions between patients and clinicians about initial care for acute low back pain, including the availability of physical therapy and other non-drug options and the potential benefits and risks of medication. The source report provides no planned follow-up study or new guideline timetable; further research would be needed to clarify the separate risks and benefits of specific treatments and how well the findings apply beyond Medicaid.
Key Questions
What did the study find about opioids for acute low back pain?
In Medicaid claims, starting with an opioid was associated with a higher likelihood of a later combined outcome of opioid use disorder or overdose than not starting an opioid. The association was higher for starts above 50 milligrams in morphine equivalents than for lower-dose starts lasting at least seven days. The study does not prove the medication caused the outcome.
What are gabapentinoids?
Gabapentinoids are medicines that include gabapentin and pregabalin. In this analysis, starting a gabapentinoid was associated with a higher likelihood of the combined opioid use disorder or overdose outcome, but the observational design cannot show that the drug caused it.
Were physical therapy and chiropractic care linked to lower risk?
Yes. Starting physical therapy or chiropractic care was associated with a lower likelihood of the combined outcome compared with not starting those therapies. The findings do not prove that either treatment reduces risk, since patients who received different care may have differed in other ways.
Does the study mean patients should never take prescription painkillers?
No. The researchers said medication may be considered after weighing potential benefits against longer-term risks. The report says that when opioids are prescribed, minimizing dose and duration is prudent. Treatment decisions should be discussed with a qualified clinician.
What is the main limitation of the findings?
The study used Medicaid claims, which may miss important details such as pain severity and medicines bought without insurance. It also combined opioid use disorder and overdose into one outcome, and its results may not apply to every patient or insurance population.
Source: rss
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