Starting low back pain care with physical therapy was linked to a lower risk of opioid problems
Acute low back pain is one of the most common reasons people see a doctor. Guidelines say the first treatment should usually be non-drug care, such as exercise and physical therapy. But many patients are still given strong pain medicines first. A new study asked a simple question: does the first treatment a patient gets for new low back pain change their risk of developing an opioid problem later?
The study was published on 19 October 2026 in JAMA Network Open by researchers from Columbia University and New York University in the United States.
What did the researchers do?
This was a retrospective cohort study. That means the researchers did not give anyone a treatment; they looked back at existing health records and followed what happened to people over time.
- They used US Medicaid insurance records (Medicaid covers people on low incomes) from 25 US states, from 2016 to 2019.
- They included 399,500 adults under 65 who had new acute low back pain and had never used opioids before. The median age was 39, and 59.5% were women.
- They recorded which treatments each person started in the first month after diagnosis, then followed them for 12 more months.
- The outcome was a new opioid use disorder or overdose diagnosis. Opioid use disorder means a person cannot control their use of opioid medicines (such as morphine or oxycodone) even when it harms them.
What did they find?
Overall, 1.4% of patients had an opioid use disorder or overdose diagnosis by 7 months and 2.3% by 13 months.
Compared with people who did not start that treatment:
- Higher-dose opioids (more than 50 mg of morphine equivalent a day) were linked to the biggest rise in risk: 146.6% higher.
- Lower-dose opioids for more than 7 days were linked to a 105.2% higher risk, and gabapentinoids (nerve-pain medicines such as gabapentin and pregabalin) to a 101.6% higher risk.
- Even short, low-dose opioid courses (7 days or less) were linked to a 31.2% higher risk.
- Chiropractic care was linked to a 32.8% lower risk, and physical therapy to a 31.1% lower risk.
About 16% of patients (65,305 people) started physical therapy in the first month.
Why we should be careful
This is a strong, very large study, but it cannot prove cause and effect. The authors list the main limits themselves:
- It used insurance records, so it could not fully measure how bad each person's pain was or how well they could move. People sent to physical therapy may have been different from people given opioids.
- Diagnosis codes can be wrong or missing, and medicines bought without a prescription were not counted.
- Exercise advice given by a doctor was not recorded.
- All patients were on US Medicaid, so the results may not apply in the same way to other countries, including Egypt and the Gulf.
The percentages above are relative changes in a risk that was small to begin with (about 2 in 100 people over a year).
What does this mean for health students?
For physiotherapy students, this study adds to the evidence behind a message you already learn: non-drug care should come first for acute low back pain. It also shows how much we can learn from large health records when a randomised trial would be hard to run.
A thesis idea angle
The study opens several questions you could explore in a local thesis:
- How are patients with new low back pain first treated in your hospital or clinic — and how many are referred to physical therapy?
- How long do patients wait before their first physiotherapy session, and does an earlier start change their pain, function or medicine use?
- A survey of doctors' and physiotherapists' views on first-line care for low back pain in Egypt or the Gulf.
Before you register any idea like this, check whether it has already been studied. You can check your thesis idea for free in Neura — it shows you the closest published studies.
Source: Doan LV, Hung AM, Olfson M, Williams NT, Rudolph KE, et al. Initial Treatment for Acute Low Back Pain and Risk of Opioid Use Disorder and Overdose. JAMA Network Open. 2026;9(10):e2639420. https://doi.org/10.1001/jamanetworkopen.2026.39420
