TL;DR
A study of nearly 400,000 Medicaid enrollees with acute low back pain found that starting with opioids or gabapentinoids was associated with higher rates of opioid use disorder or overdose than not starting those drugs. Chiropractic and physical therapy as initial treatment were associated with lower rates, but the observational study cannot establish that any treatment caused the outcomes.
A study of 399,500 Medicaid enrollees with acute low back pain found that people who started treatment with opioids or gabapentinoids had about twice the risk of a later diagnosis of opioid use disorder or overdose compared with patients who did not start with those drugs. The findings, published in JAMA Network Open and reported by MedPage Today on October 20, 2026, add evidence against making prescription painkillers the first treatment for a new episode of low back pain, while not proving that the drugs caused the outcomes.
Researchers led by Kara E. Rudolph of Columbia University analyzed Medicaid records from 25 states for 2016 through 2019. The cohort included people with 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 nondrug treatment such as chiropractic care, physical therapy or massage.
Compared with patients who did not start an opioid, those who began with a dose below 50 milligrams of morphine equivalents per day and continued for at least seven days had a 105.2% higher likelihood of the combined outcome, the researchers reported. Starting with a higher opioid dose was associated with a 146.6% increase. Starting with gabapentin-like medication was associated with a 101.6% increase. These are relative differences reported by the study, not percentage-point increases in the number of patients affected.
Starting with chiropractic care was associated with a 32.8% lower risk of the combined outcome than not starting that therapy; physical therapy was associated with a 31.1% lower risk. The analysis also found a smaller association with lower risk for massage. Overall, the combined outcome was recorded in 1.4% of patients by month seven and 2.3% by month 13 after diagnosis. The study counted later diagnostic codes for opioid abuse or dependence, opioid-involved overdose, or a prescription for medication to treat opioid use disorder.
The Risks of Starting With Medication
The findings matter because opioids remain a common first-line prescription for acute low back pain, despite longstanding guidance favoring nondrug care first. In this study, more than one in five patients received an opioid within a month of diagnosis. The results provide a large, real-world comparison of subsequent outcomes across initial treatment choices in a Medicaid population.
They do not establish that avoiding opioids or choosing physical therapy would, by itself, prevent opioid use disorder or overdose. Treatment was not assigned at random, and patients receiving different care may have differed in health, pain severity, access to services or other factors. Still, the observed pattern supports careful consideration of potential harms when selecting initial treatment. The researchers said medication can be considered after weighing benefits against longer-term risks, and that lower opioid doses and shorter durations are prudent when opioids are prescribed.
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Guidance and Prescribing Patterns
Clinical guidelines have recommended trying nonpharmacological treatment first for acute low back pain for more than a decade. Yet earlier studies cited by Rudolph and colleagues found that about 12% to 20% of privately insured or Medicaid patients received opioid prescriptions in 2017 and 2018. The new analysis tests whether initial treatment choice is associated with later opioid-related outcomes in a much larger Medicaid cohort.
Gabapentinoids, including gabapentin and pregabalin, have also been used as alternatives to opioids, although the source report says evidence for their effectiveness in low back pain is limited. In the current study, the association between gabapentinoid initiation and the combined outcome was similar in size to the association for lower-dose opioid initiation. The results concern acute low back pain; they should not be treated as a direct finding about chronic pain or every individual patient’s circumstances.
“Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.”
— Kara E. Rudolph, PhD, MPH, MHS, and colleagues
Limits of the Medicaid Records
The study was observational, so its comparisons show associations rather than cause and effect. The researchers did not distinguish whether opioid use disorder or overdose accounted for most of the combined outcomes, leaving the balance between those events unclear. The overall recorded rates were relatively low, but the study does not provide a separate breakdown of each outcome in the supplied report.
The analysis covered Medicaid enrollees in 25 states, a population that may not represent people with other types of insurance or no insurance. The source report also notes that records cannot reliably capture nonprescription drugs or medications paid for out of pocket. It remains unclear how those unrecorded treatments, access to nondrug care, and differences in patients’ initial pain or health influenced the results.
How Clinicians May Apply the Findings
The study adds support to existing recommendations to consider nondrug options first for acute low back pain, but it does not announce a change to clinical guidelines. Clinicians and patients will still need to make treatment decisions based on an individual’s symptoms, medical history, available services and preferences. Where medication is considered, the authors’ stated guidance is to weigh potential benefits against longer-term risks and, if prescribing opioids, limit dose and duration.
Further research could test whether the associations hold in populations beyond Medicaid and clarify how much of the combined outcome reflects opioid use disorder versus overdose. The supplied report does not describe a planned follow-up study or a new guideline review, so the next formal research or policy milestone is not specified.
Key Questions
What did the study find about opioids for acute low back pain?
In Medicaid records, starting with an opioid was associated with a higher subsequent rate of the combined outcome of opioid use disorder or overdose than not starting with an opioid. The association was larger for higher initial doses. The study does not show that opioids caused those outcomes.
Were gabapentin-like drugs associated with the same outcome?
Yes. Starting with gabapentin or a similar drug was associated with a 101.6% higher likelihood of the combined outcome compared with not starting that therapy, according to the researchers. This is an observational association, not proof of causation.
Did physical therapy or chiropractic care lower the risk?
Initial physical therapy and chiropractic care were associated with lower rates of the combined outcome than not starting those respective treatments. The study cannot establish that these therapies caused the reduction or that the comparison applies to every patient.
How many people in the study had an opioid-related outcome?
The combined outcome was recorded in 1.4% of participants by month seven and 2.3% by month 13 after diagnosis. The researchers combined opioid use disorder and overdose-related measures, so the supplied report does not say how many cases were in each category.
Does this mean patients should never receive prescription painkillers?
No. The researchers said medication may be considered after weighing potential benefits against longer-term risks. They advised minimizing opioid dose and duration when an opioid is prescribed; treatment choices depend on the patient’s circumstances.
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