Return ED Visit Rates With Opioid vs Nonopioid Low Back Pain Treatments Evaluated

This study compares the use of opioids vs nonopioids in the emergency department for patients with low back pain and the proportion of patients who return within 30 days.

Opioid use for low back pain treatment in the emergency department setting may not be an effective treatment strategy given the high rate of return visits within 30 days of discharge, according to research published in The Journal of Emergency Medicine.

Data suggest that patients experiencing low back pain represent roughly 6% of all emergency department visits; among these patients, it is estimated that 40% are treated with an opioid during the visit and 40% are prescribed an opioid on discharge. Despite these numbers, there is considerable variability among emergency department providers regarding opioid use in this setting, and little consensus on the best initial treatment for these patients.

To address this, researchers conducted a retrospective multicenter observational study to evaluate the association between emergency department opioid use for low back pain and the proportion of patients with a return emergency department visit within 30 days, compared with those who receive nonopioid pain management in the emergency department setting.

Study data were extracted from electronic health records from 21 community and academic emergency departments at an integrated health system across the upper Midwest, Florida, and Arizona. All patients with ICD-10 diagnosed low back pain who visited an emergency department between November 2018 and April 2020 were included in the study.

The initial cohort included 1392 patients, of whom 516 were excluded due to hospital admission. The final study cohort included 836 adult patients (59% women; 88% White) with low back pain who visited and were later discharged from an emergency department.

Within the cohort, 36% of patients received an opioid prescription and 26% had a return emergency department visit within 30 days. Mean and median number of days between discharge and the return visit were 9 and 7 days, respectively.

Patients who received any opioid, an intravenous opioid, or intramuscular opioid were significantly more likely to return within the 30-day timeframe (32%, 33%, and 39%, respectively; odds ratios [ORs], 1.78, 1.83, and 2.38, respectively), compared with a 19% return rate for patients who received nonsteroidal anti-inflammatory drugs (NSAIDs), a 20% return rate for patients who received acetaminophen, and an 8% return rate for patients who received some combination of the two. Patients who received oral opioids, benzodiazepines, or antispasmodics were not associated with statistically significant differences in return visit rates.

Study limitations include the potential for patients with more severe back pain to receive stronger analgesics, including opioids, and these patients being more likely to return due to the severity of their condition; a lack of reliably reported patient pain data; and a lack of generalizability outside of this single health care system.

“This study suggests that use of opioid alternatives may have benefits beyond reduction in opioid use and misuse,” the researchers concluded. “Further study is needed to educate clinicians about the multiple shortcomings of continued reliance on opioids and to provide guidance on opioid alternatives.”


Ginsberg Z, Ghaith S, Pollock JR, et al. Relationship between pain management modality and return rates for lower back pain in the emergency department. J Emerg Med. Published online February 23, 2021. doi:10.1016/j.jemermed.2021.01.022