New research suggests that people with low back pain who begin treatment with spinal manipulative therapy may be less likely to use opioids or develop opioid-related complications compared to those who start with medication.
The findings come as healthcare systems continue to reassess how common conditions like back pain are managed, particularly in light of ongoing concerns around opioid dependence and long-term medication use.
Large-scale analysis of treatment approaches
The study, published in Health Science Reports in 2025, examined medical data from around 50,000 adults diagnosed with low back pain, including cases with and without sciatica.
Researchers used a retrospective cohort design, analysing existing patient records rather than assigning treatments in a controlled setting. All participants were opioid-naïve at the start of the study, meaning they had no prior history of opioid use disorder.
Patients were grouped based on how their care began:
- Those who received spinal manipulative therapy (SMT), often delivered by chiropractors
- Those who were prescribed ibuprofen, a commonly used non-opioid anti-inflammatory medication
The study followed these patients for up to two years to observe differences in opioid-related outcomes.
Differences in opioid exposure
The analysis found that individuals who received spinal manipulative therapy were less likely to be prescribed opioids at any point during the follow-up period.
They were also less likely to develop opioid use disorder or continue using opioids over time.
In numerical terms, 0.24% of patients in the spinal manipulation group were diagnosed with opioid use disorder within two years, compared to 1.51% of those in the ibuprofen group — representing an approximate 80% lower relative risk. Rates of long-term opioid use were also lower, along with the likelihood of receiving any opioid prescription.
“What this study highlights is that the initial treatment approach for low back pain may be associated with different opioid-related outcomes over time. While we can’t draw firm conclusions from observational data alone, the findings are consistent with what many clinicians observe — that patients who engage with non-pharmacological care early may be less likely to move toward opioid-based management,” said Dr. Alissar Ayouby (Chiropractor).
While the results do not demonstrate causation, they suggest that early treatment decisions may play a role in shaping how care progresses.
Understanding the broader context
Low back pain remains one of the most common health complaints worldwide and is a leading reason for seeking medical care. In many cases, it has historically led to the use of prescription medications, including opioids.
Although opioids may provide short-term relief, they are associated with significant risks when used beyond the acute phase, including dependence and reduced effectiveness over time.
As a result, there has been growing emphasis on identifying alternative approaches that may reduce reliance on medication where appropriate.
“Many patients are increasingly looking for ways to manage pain without relying heavily on medication, particularly given the wider concerns around opioid use. There’s a growing awareness that non-drug approaches can play a role, depending on the individual case,” Dr. Ayouby (Chiropractor) said.
Interpreting the findings carefully
The researchers emphasised that the study shows an association between treatment type and opioid-related outcomes, rather than a direct cause-and-effect relationship.
Because the analysis was based on observational data, patients were not randomly assigned to each treatment group. This means there may be underlying differences between those who chose spinal manipulation and those who were prescribed medication.
Factors such as patient preferences, health behaviours, and baseline risk levels may all have influenced the results.
Implications for current care approaches
The study adds to ongoing discussions about the role of conservative care in managing musculoskeletal conditions.
Many clinical guidelines now recommend beginning with non-pharmacological options — including manual therapy, movement-based interventions, and education — particularly for uncomplicated low back pain.
The findings may support the idea that early engagement with these approaches could be linked to different long-term outcomes, including lower exposure to opioids.
Need for further research
The authors noted that more research is required to better understand the relationship between treatment pathways and opioid use.
Randomised controlled trials, in particular, would help clarify whether spinal manipulative therapy directly contributes to reduced opioid reliance or whether other factors are responsible for the observed differences.
Conclusion
The study suggests that patients who start care for low back pain with spinal manipulative therapy may experience lower rates of opioid use and related risks compared to those who begin with ibuprofen.
However, as the findings are based on observational data, they should be interpreted with caution. Further research will be needed to determine the extent to which treatment choice directly influences these outcomes.
Article contribution and clinical commentary provided by Dr. Alissar Ayouby (Chiropractor), chiropractor based in Sydney, with an interest in evidence-based care for back pain and musculoskeletal conditions.