Objective: To determine the prevalence, reported harms and factors associated with opioid use among adults with spinal cord injury (SCI) living in the community.Study design: Systematic review and meta-analysis. Methods: Comprehensive literature searches were conducted in PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Scopus for articles published between 2000 and 2023. Risk of bias was assessed using a prevalence-specific tool. Random effects meta-analyses were conducted to pool prevalence data for any context of opioids. Sensitivity and subgroup analyses were also performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study protocol was registered via Prospero (blinded for review). Results: Of the 4,969 potential studies, 38 were included in the review. Half (53%) of studies had a low risk of bias, with a high risk of bias in 5% of studies. The pooled prevalence for the 38 studies included in the meta-analysis (total cohort size of 50,473) across any opioid context was 39% (95% confidence interval [CI], 32–47). High heterogeneity was evident, with a prediction interval twice as wide as the 95% CI (prediction interval, 7–84%). Mean or median opioid dose was unreported in 95% of studies. Opioid dose and factors related to opioids were also rarely explored in the SCI populations. Conclusions: Results should be interpreted with caution based on the high heterogeneity and imprecise pooled prevalence of opioids. Contextual details including pain, cohort specific injury characteristics and opioid dosage were inconsistently reported, indicating a clear need for additional studies in a population at greater risk of experiencing opioid-related adverse effects.