Guideline-discordant care remains common for acute low back pain

Clinical takeaway: Guideline-recommended nonpharmacologic therapies remain underused in acute low back pain. In this large cohort, initial treatment with opioids and gabapentin was associated with substantially higher risks of opioid use disorder or overdose, whereas physical therapy and chiropractic care were associated with risk reduction.

Acute low back pain is among the most common reasons adults seek medical care, yet guideline-discordant treatment remains common. Current recommendations favor nonpharmacologic therapies first, with nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants as preferred pharmacologic options when medication is needed. However, fewer than half of patients in this cohort received a nonpharmacologic therapy as part of initial care, and opioids were included in 21% of initial treatment episodes. Nearly one in five patients (18.3%) received an opioid prescription within the first week of treatment.

In a retrospective cohort study, researchers analyzed 399,500 opioid-naive adults younger than 65 years with Medicaid coverage who initiated treatment for newly diagnosed acute low back pain. The cumulative incidence of opioid use disorder (OUD) or overdose diagnosis was 1.4% at 7 months and 2.3% at 13 months.

Initial higher-dose opioid prescriptions (>50 mg morphine equivalents per day) were associated with the greatest increase in risk, with a 146.6% higher risk of OUD or overdose diagnosis compared with not receiving that treatment. Lower-dose opioid prescriptions lasting more than seven days and gabapentin were each associated with approximately doubled risk, increasing risk by 105.2% and 101.6%, respectively. Even lower-dose opioid prescriptions for seven days or less were associated with a 31% increase in risk.

By contrast, all nonpharmacologic, noninterventional therapies evaluated in the study were associated with reduced risk. Chiropractic care was associated with the largest relative risk reduction at 32.8%, followed closely by physical therapy at 31.1%. Anti-inflammatory drugs and muscle relaxants were among the most commonly used initial treatments.

The authors concluded that “initial treatment decisions were associated with meaningful downstream consequences,” supporting guideline recommendations that favor nonpharmacologic approaches as first-line therapy for acute low back pain. Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks. When opioids are prescribed, minimizing dose and duration remain prudent.

Source: Doan LV, et al. (2026 Oct 19) JAMA Netw Open. Initial Treatment for Acute Low Back Pain and Risk of Opioid Use Disorder and Overdose