Trends in Opioid Prescribing for Nonspecific Low Back Pain After CDC Guidelines and California Prescription Drug Monitoring Programs, 2012-2024

Objective: Nonspecific low back pain (ns-LBP) is a widespread health challenge, and opioids were frequently prescribed upon first LBP presentation in the United States during the opioid epidemic. We assessed temporal changes in quarterly (Q) opioid prescriptions for new-onset ns-LBP from 2012 through 2024 at a California medical center amid evolving voluntary federal recommendations and mandatory state regulations. Methods: We analyzed opioid prescription rates (prescription within 6 months of diagnosis) for ns-LBP patients diagnosed in all departments and stratified by emergency department (ED), and we compared high- versus low-dose prescription (≥50 morphine mg equivalents/day). Change point detection identified transitions without policy priors, and interrupted time series regression quantified level changes and trend modifications. Results: Of 31 940 ns-LBP patients, 2077 (6.5%) received opioids (mean [SD] age, 51.0 [17.6] y; 45.3% male; 53.7% White). Change points occurred at 2015 Q2 and 2018 Q4. Prescribing odds declined 2.7% per quarter from 2012 Q1 through 2024 Q4 (95% CI, 0.4%-5.0%; P = .02). ED patients (16.5% prescribed opioids vs 5.8% non-ED) showed a 54.2% immediate reduction at 2015 Q2 (95% CI, 18.8%-74.2%; P = .008), declining from 27.4% to 12.2% before plateauing; non-ED patients showed a 42.8% reduction at 2018 Q4 (95% CI, 27.5%-54.9%; P < .001). High-dose prescribing remained unchanged among opioid recipients. Conclusion: Change points coincided with anticipatory adoption of the 2016 Centers for Disease Control and Prevention recommendations and 2018 California mandatory drug monitoring implementation. ED settings showed disproportionate reductions at 2015 Q2, consistent with knowledge diffusion of voluntary guidelines in settings with frequent opioid prescribing, while non-ED reductions coincided with immediate regulatory compliance at 2018 Q4. This distinction can guide future policy selection to address environment-specific adoption barriers.