Acute Back Pain: Why Avoid Opioids as First Treatment?
Quick Facts
What did the new acute back pain study find?
Published October 19 in JAMA Network Open, the study examined Medicaid claims for adults under 65. Starting gabapentinoids or lower-dose opioids prescribed for more than seven days was associated with roughly twice the subsequent risk of opioid use disorder or overdose compared with not starting that treatment, after adjustment for measured differences. Higher-dose opioids had the strongest association. [Published study](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855474).
Researchers assessed initial treatment over one month and outcomes over the following year. Prescribing was not randomized: pain severity, diagnostic coding and unmeasured differences could influence the findings. The analysis therefore cannot establish that a medicine caused an individual patient's outcome or determine which treatment relieved pain best.
Do opioids or gabapentinoids provide better back pain relief?
The randomized OPAL trial provides a separate test of benefit. Published in The Lancet in 2023, it enrolled 347 adults with low back pain, neck pain or both lasting up to 12 weeks. Participants received recommended care plus either oxycodone–naloxone or placebo for up to six weeks. The opioid regimen did not significantly improve pain at six weeks compared with placebo. This finding concerns the regimen and population studied; it does not mean opioids have no role in other conditions, such as severe traumatic injuries. [OPAL trial](https://pubmed.ncbi.nlm.nih.gov/37392748/).
Gabapentin and pregabalin require a different assessment. These medicines have approved uses for certain seizure disorders and nerve-pain conditions, but those indications do not establish effectiveness for ordinary back pain. NICE recommends against gabapentinoids for low back pain and sciatica. The FDA also warns that these medicines can cause serious breathing difficulties in susceptible patients, especially when combined with opioids or other sedating drugs. Older adults and people with impaired lung function face additional risk. [NICE recommendations](https://www.nice.org.uk/guidance/ng59/chapter/Recommendations), [FDA safety communication](https://www.fda.gov/safety/medical-product-safety-information/neurontin-gralise-horizant-gabapentin-and-lyrica-lyrica-cr-pregabalin-drug-safety-communication).
What should patients try first for acute low back pain?
NICE recommends helping people continue normal activities and considering exercise adapted to their needs and capabilities. The CDC identifies superficial heat as an option supported by evidence for acute low back pain. When medication is appropriate, an oral nonsteroidal anti-inflammatory drug may be considered after reviewing gastrointestinal, kidney and cardiovascular risks. NICE advises using the smallest effective dose for the briefest necessary period. A prescription should support recovery and function within an individualized care plan. [NICE treatment guidance](https://www.nice.org.uk/guidance/ng59/chapter/Recommendations), [CDC pain guideline](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm).
Opioids remain an option for selected circumstances when anticipated benefits outweigh risks and alternatives are unsuitable or ineffective. The CDC recommends immediate-release formulations, cautious dosing and a duration matched to the expected period of severe pain. Patients already taking opioids regularly should arrange a medication review rather than abruptly stopping treatment. Decisions should address pain control, function, interactions and withdrawal risk; a new research headline alone is not a reason to suddenly discontinue established care. [CDC prescribing recommendations](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm).
Frequently Asked Questions
No. Treatment depends on the diagnosis, expected benefit and individual risks. Guidelines allow selected medicines, including oral anti-inflammatory drugs when appropriate, while discouraging routine initial opioid treatment for acute low back pain.
NICE recommends against gabapentinoids for sciatica because the evidence does not show an overall benefit and does show harm. A prescription for another condition requires a separate assessment.
Do not abruptly stop regular opioid treatment solely because of this study. Ask the prescriber to review benefits and risks and, if appropriate, agree on a gradual reduction plan.
The trial did not demonstrate better pain relief at six weeks from adding oxycodone–naloxone to recommended care compared with adding placebo.
Slow or difficult breathing, extreme sleepiness or inability to wake someone require emergency medical help. The FDA highlights these warning signs for gabapentinoids, particularly when combined with opioids.
References
- Doan LV, Hung AM, Olfson M, Williams NT, Rudolph KE. Initial Treatment for Acute Low Back Pain and Risk of Opioid Use Disorder and Overdose. JAMA Network Open. 2026;9(10):e2639420. doi:10.1001/jamanetworkopen.2026.39420.
- Jones CMP, et al. Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. The Lancet. 2023;402(10398):304–312. doi:10.1016/S0140-6736(23)00404-X.
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. Guideline NG59. Recommendations.
- Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95.
- U.S. Food and Drug Administration. Neurontin, Gralise, Horizant (gabapentin) and Lyrica, Lyrica CR (pregabalin): Drug Safety Communication — Serious Breathing Problems. December 19, 2019.