Higher-Dose Opioids for New Low Back Pain Linked to Sharply Raised Risk of Opioid Use Disorder and Overdose

Adults on Medicaid who began treatment for a new bout of acute 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 new 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 of treatment included opioids above 50 milligrams of morphine equivalent per day. The findings are published in JAMA Network Open.

The analysis is described as the first study to evaluate the association between treatment types for acute lower back pain and opioid use disorder outcomes among patients with Medicaid coverage. It drew on data from January 1, 2016, to December 31, 2019, covering 399,500 adults in the Transformed Medicaid Statistical Information System Analytic Files from 25 states that had 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, a scope limitation that matters when generalizing the results nationwide.

The dose and duration of the initial opioid prescription appeared to matter considerably. Opioid dosages greater than 50 MME per day were associated with the largest increase in risk of a new-onset diagnosis of opioid use disorder or overdose, raising risk by 147 percent. Lower-dosage opioids, at 50 MME per day or less, prescribed for more than 7 days were associated with a two-fold increased risk. By contrast, opioid dosages of 50 MME per day or less for 7 days or fewer were associated with a much smaller increase in risk, at 31 percent.

The picture was different for non-drug approaches. All nonpharmacologic, noninterventional therapies were associated with reductions in the risk of a new-onset diagnosis of opioid use disorder or overdose. Among the initial treatments recorded in the data, anti-inflammatory drugs and muscle relaxants were the most commonly prescribed, at 48 percent and 44 percent respectively. Physical therapy was the most common nonpharmacologic treatment at 16 percent, followed by chiropractic care at 10 percent. Among patients who filled an opioid prescription, a group accounting for 21 percent, most received prescriptions for a maximum of 50 MME per day or less and 7 or fewer days of supply.

Overall, 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. The study is observational, so the associations it reports describe patterns in claims data rather than the effects of randomized treatment assignment, and the outcomes were measured as new diagnoses, overdoses and addiction-treatment prescriptions within the Medicaid records.

“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 of the study. “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.”

“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.

“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.” The study was supported by the National Institute on Drug Abuse under grant R01DA053243. Co-authors are Anton M. Hung and Nicholas T. Williams of the Columbia Mailman School of Public Health, and Mark Olfson of the Columbia Mailman School of Public Health and Columbia University Irving Medical Center. One author reported receiving financial fees from a health media company outside the submitted work; no other disclosures were reported.

Subject of Research: The association between initial treatment choices for acute low back pain and subsequent risk of opioid use disorder and overdose among Medicaid adults.

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

Article References: Initial treatment for lower back pain is associated with subsequent risk of opioid use disorder and overdose. Original publication (Bibliographic details unavailable.)

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Keywords: acute low back pain, opioid use disorder, overdose, opioid prescribing, Medicaid, JAMA Network Open, physical therapy, nonpharmacologic therapy, morphine equivalent dose, Columbia University, NYU Grossman School of Medicine, public health