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OBJECTIVE Utilization of nonpharmacological pain management may prevent unnecessary use of opioids. Our objective was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. DESIGN AND SETTING We employed a retrospective cohort design for analysis of health claims data from three contiguous states for the years 2012-2017. SUBJECTS We included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. We