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

October 27, 2026-- 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 percent higher relative risk for patients whose first-month treatment included opioids above 50 milligrams of morphine equivalent per day. 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, MD, 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.”

Anti-inflammatory drugs and muscle relaxants were the most usually prescribed initial treatments at 48 percent and 44 percent, respectively. Physical therapy was the most common nonpharmacologic treatment at 16 percent, followed by chiropractic care (10 percent). Among patients who filled an opioid prescription [21 percent]), most received prescriptions for a maximum of 50 MME/d or less and 7 or fewer days of supply.

Opioid prescription dosages greater than 50 MME/d were associated with the largest increase in risk of new-onset diagnosis of OUD or overdose, increasing risk by 147 percent. Lower-dosage opioids (≤50 MME/d) prescribed for more than 7 days were associated with a two-fold increased risk in OUD. Opioid dosages of 50 MME/d or less for 7 days or less were associated with a much smaller increase in risk (31 percent).

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

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

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

The researchers used data from January 1, 2016, to December 31, 2019, for 399,500 adults from the Transformed Medicaid Statistical Information System Analytic Files from 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.”

Co-authors are Anton M. Hung and Nicholas T. Williams, Columbia Mailman School of Public Health; and Mark Olfson, Columbia Mailman School of Public Health and Columbia University Irving Medical Center.

The study was supported by the National Institute on Drug Abuse, R01DA053243.

One author reported receiving financial fees from a health media company outside the submitted work. No other disclosures were reported.

Columbia University Mailman School of Public Health

Founded in 1922, the Columbia University Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Columbia Mailman School is the third largest recipient of NIH grants among schools of public health. Its nearly 300 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change and health, and public health preparedness. It is a leader in public health education with more than 1,300 graduate students from 55 nations pursuing a variety of master’s and doctoral degree programs. The Columbia Mailman School is also home to numerous world-renowned research centers, including ICAP and the Center for Infection and Immunity. For more information, please visit www.mailman.columbia.edu.