Initiating Vs Not Initiating Chiropractic Care Associated with Largest Relative Risk Reduction (-32.8%)
Conclusion: Results Support Recommendations Favoring Nonpharmacologic Treatments as First-Line Therapy for Acute Low Back Pain
A retrospective cohort study published in JAMA Network Open conducted by researchers at Columbia University and New York University found that chiropractic and other conservative, nonpharmacologic therapies greatly reduce the risk of both an opioid-related overdose or developing opioid use disorder (OUD), when compared to opioids, gabapentinoids, benzodiazepine, acetaminophen, and other interventions when prescribed as first-line therapy for acute low-back pain (aLBP).
Researchers at Columbia University and New York University examined nationwide Medicaid data from 399,500 Medicaid patients who initiated treatment for newly diagnosed aLBP between 2016 and 2019. Their critical question: What is the incidence of opioid use disorder or overdose diagnoses after initiating treatment for acute low-back pain, and what is the comparative risk for different treatment options? Initial pharmacologic and nonpharmacologic treatments for aLBP were examined.
While chiropractic care was associated with the largest relative risk reduction (-32.8%), it unfortunately was initially prescribed much less frequently than other interventions (only 10.2% of the study cohort). The most commonly prescribed initial treatments were anti-inflammatory drugs (48.4%) and muscle relaxants (44.8%). Patients initially prescribed an opioid accounted for 21% of the study cohort. Gabapentinoids, nerve medications widely prescribed off-label for acute and chronic pain, were initially prescribed in nearly 6% of cases, despite little evidence to justify their use in pain management. The most common nonpharmacologic treatment initially prescribed was physical therapy (16.3%).
Findings included:
- Among the study cohort, the cumulative incidence of OUD or overdose diagnosis was 1.4% at 7 months and 2.3% at 13 months.
- Initiating vs not initiating higher-dose opioids (>50 mg of morphine equivalent) as part of the initial treatment was associated with the greatest risk, increasing risk of OUD or overdose by 146.6%.
- Initiating vs not initiating lower-dose opioids prescribed for more than 7 days or gabapentinoids each increased risk by 105.2% and 101.6%, respectively.
- Nonpharmacologic, noninterventional therapies were associated with reductions in risk of OUD or overdose diagnosis.
- Initiating vs not initiating chiropractic care was associated with the largest relative risk reduction, decreasing risk by 32.8%
- Initiating physical therapy was associated with 31.1% decreased risk.
The researchers’ conclusion? “[I]nitial treatment decisions were associated with meaningful downstream consequences. Pharmacologic therapies, especially higher-dose or longer-duration opioid prescriptions and gabapentinoids, were associated with increased risk of subsequent diagnosis of OUD or overdose. In contrast, nonpharmacologic, noninterventional therapies, chiropractic care, and physical therapy in particular were associated with reductions in risk. These findings support prioritizing guideline-recommended nonpharmacologic, noninterventional therapies as first-line care for aLBP. Pharmacologic therapies can be considered after weighing potential benefits against longer-term risks.”
Another conclusion from an analysis of the study published in Pain Network News: “What’s also clear from the study is that many of the doctors treating Medicaid patients weren’t following clinical guidelines for acute low back pain… The American College of Physicians recommends chiropractic care and other nonpharmacologic therapies as first-line treatments for low back pain, but less than 50% of patients in the study received those therapies as part of their initial care.”
Sources:
Doan LV, et al “Initial treatment for acute low back pain and risk of opioid use disorder and overdose” JAMA Netw Open 2026; DOI: 10.1001/jamanetworkopen.2026.39420.
Anson, Pat, “Gabapentinoids Nearly as Risky as Opioids in Back Pain Study,” Pain Network News, October 20, 2026
