You walk into a doctor's office with a bad back. A few minutes later, you walk out with a prescription in hand. Most people never give that choice much thought once the pain starts easing.
A new study in JAMA Network Open followed nearly 400,000 Medicaid patients treated for a new episode of acute low back pain.
Those who started on a higher-dose opioid were about two and a half times more likely to later develop opioid use disorder or survive an overdose.
Low back pain is one of the most common reasons Americans see a doctor. The study, led by researchers at Columbia's Mailman School of Public Health and NYU Grossman School of Medicine, drew on Medicaid data from 25 states between 2016 and 2019.
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What the dose and the duration actually did
Patients whose first month of care included more than 50 milligrams of morphine equivalent per day had a 147 percent higher risk of later being diagnosed with opioid use disorder or surviving an overdose. That threshold is a standard measure of opioid strength.
Lower doses were not a clean escape. People who received opioids below that threshold for more than seven days still had about double the risk, the researchers reported.
Overall, 2.3 percent of patients had a new opioid use disorder diagnosis, a nonfatal overdose, or started addiction treatment within 13 months of that first prescription. The whole group had never taken opioids before the back pain episode.
The team flagged another finding that will surprise many patients. Gabapentinoids, a class of nerve-pain drugs that includes gabapentin and pregabalin, were tied to roughly a doubling of the same risk. They are often prescribed as a safer alternative to opioids.
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What federal guidance already recommends first
The pattern echoes guidance that has been on the books for years.
The CDC's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain states that opioids should not be considered first-line or routine therapy for subacute or chronic pain. Nonopioid options are at least as effective as opioids for acute low back pain, the guideline says.
The CDC and the American College of Physicians point to simpler first steps for a flare. These include heat, movement, over-the-counter anti-inflammatories, physical therapy, massage, acupuncture and spinal manipulation.
The Medicaid data matched that advice. Patients who started with chiropractic care had about a 33 percent lower risk of later opioid use disorder or overdose. Physical therapy was tied to a 31 percent lower risk, compared with other initial treatments.
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Why does the first prescription weigh so much?
Welltica has previously reported that nearly eight years on daily opioids did not ease chronic back pain for most patients in a separate trial. Once someone stays on the drugs, the hoped-for pain relief often does not arrive while the risks keep accumulating.
The practical takeaway sits in the first conversation with the clinician.
If an opioid is being considered for a new episode of back pain, the CDC's guideline urges the lowest effective dose, used only as needed rather than on a schedule.
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The duration should not exceed the expected length of severe pain, which for most acute back pain is a matter of days.
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This article is made and published by Mie Hermansen, who may have used AI in the preparation.