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IMPORTANCE Amitriptyline is an established medication used off-label for the treatment of fibromyalgia, but pregabalin, duloxetine, and milnacipran are the only pharmacological agents approved by the US Food and Drug Administration (FDA) to treat fibromyalgia. OBJECTIVE To investigate the comparative effectiveness and acceptability associated with pharmacological treatment options for fibromyalgia.

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individuals, 18-63 years of age, with at least 18 months of continuous eligibility and a primary care or emergency department visit for LBP. Baseline covariates were captured in in the six-month period prior to their initial LBP diagnosis (index date) and opioid use was captured in the 12-month follow up period. Long-term opioid use was defined as at least 90 days of opioid use. PT and chiropractic were assessed in the 30-day period after index date. Multivariable logistic regression models were estimated to explore the influence of PT and chiropractic care adjusted for patient demographics and comorbidities. Results: 40,929 individuals met inclusion/exclusion criteria. Average age was 41 years, 64.5% were female and 79.9% had commercial health insurance coverage. PT and chiropractic care was used by 5.4% and 5.9% of the sample, respectively. Any opioid use after LBP diagnosis was observed in 54.3% of subjects, 4.4% used opioids long-term. PT was not associated with any opioid use (OR: 1.07; 95% CI: 0.98-1.18) or long-term opioid use (OR: 1.19; 95% CI: 0.97-1.45). Persons who received chiropractic care were less likely to be prescribed an opioid (OR: 0.88; 95% CI: 0.80-0.97) or to use opioids long-term (OR: 0.56; 95% CI: 040-0.77). Conclusions: Utilization of PT or chiropractic care in early management of back pain was low. Chiropractic care but not PT was associated with a lower likelihood of opioid use and long term opioid use.