OBJECTIVES: The effects of opioids on long-term outcomes for patients with back pain are unclear. We compared patient-reported outcomes (PROs) and healthcare utilization of patients who received ≥2 versus no opioid prescriptions within 90 days of their index visits for back pain. METHODS: We used 1:1 propensity score matching on demographic and clinical characteristics to identify early-opioid prescription recipients and controls among patients ≥65 years with new back pain visits at an integrated healthcare system. We evaluated PROs (including the Roland-Morris Disability Questionnaire [RDQ]; 0-24 scale) at baseline and 3, 6, 12, and 24 months later, using linear mixed models. We summed relative value units (RVUs) to assess utilization from index visit through 24 months and evaluated these with generalized linear models. We also assessed the odds of receipt of ≥1 opioid prescription 18-24 months after index using conditional logistic regression. All models were adjusted for sex, age, baseline diagnosis, back pain duration, RVUs in the year prior to index, and baseline PROs. RESULTS: Among 1954 patients eligible for matching, 238 (12%) were early opioid prescription recipients and 231 of these were matched to controls. Early opioid prescription recipients had worse adjusted PROs compared to non-recipients at baseline, but no significant differences after baseline except for worse RDQ scores among opioid recipients (adjusted mean difference in 24-month RDQ = 1.3 (95% confidence interval (CI): 0.4-2.3)). Opioid recipients also had, on average, 55 more RVUs (95% CI: 6.5-100) in the 24 months after index. Early opioid prescription recipients were significantly more likely to receive ≥1 opioid prescription in the 18-24 months after index (odds ratio (95% CI) = 5.2 (2.4-11.5)). CONCLUSIONS: Receipt of ≥2 early opioid prescriptions was associated with slightly worse pain and functional outcomes, greater overall healthcare utilization, and increased likelihood of receiving opioid prescriptions 18-24 months later compared to controls.