Background: Opioid prescriptions for chronic spinal pain are generally high, even though long-term usage is associated with several risks. Tramadol has previously been the preferred opioid choice in Denmark, but recent concerns have been raised concerning the risk of developing an addiction. Unfortunately, evidence from long-term studies is lacking. The purpose of this study was to investigate the risk of long-term use of tramadol compared to other types of opioids over a 5-year follow-up period. Methods: The setting of this prospective cohort study was an outpatient healthcare Spine Center. Patient variables included clinical and registry data. The primary outcome parameter was Long-Term Opioid Therapy (LTOT) in the 5th follow-up year, indicated by 6+ opioid prescriptions per year. Results: For the primary outcome, we did not find any significant differences indicating tramadol to be more likely to develop LTOT status, but overall starters of tramadol had more prescriptions compared to starters of other opioids. Among tramadol starters, 25% shifted to other opioids during follow-up. A similar number in non-tramadol starters was 38%. The percentage of patients using 4-5 different opioids over the five years was significantly higher for the non-tramadol starters (8.8%) compared to tramadol starters (4.8%). Conclusions: The findings do not support tramadol starters to be more likely to develop LTOT status compared to other opioid starters. In fact, tramadol initiators and non-tramadols have a similar LTOT status 5 years following initiation opioids. The cautious conclusion could be that there are no clinically important differences in the risk of LTOT in tramadol versus non-tramadol opioids.