Importance: Medication management and cognitive behavioral therapy (CBT) are commonly used treatments for chronic low back pain (CLBP). However, little evidence is available comparing the effectiveness of these approaches.

Question: What are the most effective pain treatments for patients prescribed opioids?

Findings: In this randomized clinical trial of 261 veterans with chronic low back pain prescribed opioids, pain improvement on the Brief Pain Inventory was greater with medication optimization (decrease of 1.10 points) than cognitive behavioral therapy (decrease of 0.68 points) for 12 months, a significant but clinically modest difference.

Meaning: Both pharmacological and behavioral approaches are reasonable options for treating chronic low back pain in patients prescribed opioids.