Integrative OUD Care Methods With Chiropractic Rehabilitation

Discover how integrative OUD care combined with chiropractic rehabilitation can support recovery and enhance your overall health.

Abstract

As a Doctor of Chiropractic and board-certified Family Nurse Practitioner with extensive training in functional medicine, I am deeply committed to a holistic, integrative approach to patient care. My journey has led me to understand the profound connections between the body’s systems, particularly how musculoskeletal health, mental well-being, and substance use are intricately linked. This educational post delves into the complexities of Opioid Use Disorder (OUD), a condition that continues to challenge our healthcare systems and devastate communities. From my clinical perspective, managing OUD is not merely about addressing the addiction itself; it involves understanding and treating the whole person, including their co-occurring mental health conditions, unique life stages, and other medical complexities.

In this comprehensive discussion, we will explore the latest evidence-based findings from leading researchers on treating OUD in several special populations. We will begin by examining the significant overlap between OUD and mental health disorders such as major depressive disorder, anxiety, and PTSD. We will then transition to the delicate and critical topic of OUD during pregnancy, focusing on strategies that protect both maternal and neonatal health. Following that, we will address the rising crisis of OUD among adolescents, a vulnerable group requiring specialized care and intervention. Finally, we will consider the unique challenges faced by older adults and individuals who concurrently use Central Nervous System (CNS) depressants.

At Injury Medical Clinic PA in El Paso, Texas, our practice is built on multidisciplinary collaboration. I work alongside our esteemed Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is board-certified in Internal Medicine and brings over four decades of invaluable experience to our team. Her medical oversight is crucial in our integrative model, where we merge chiropractic care, functional medicine, rehabilitation, and conventional medical treatments. This post will highlight how our integrated team, under the medical direction of Dr. Cardenas, provides comprehensive care that addresses the multifaceted nature of OUD and its associated conditions, always prioritizing patient safety, empowerment, and long-term well-being.

Understanding the Landscape: My Perspective on Integrative Care for Opioid Use Disorder

As Dr. Alex Jimenez, I have dedicated my career to understanding the human body as an integrated system. With credentials spanning chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP), I have witnessed firsthand how pain, mental health, and substance use are deeply intertwined. The opioid crisis is not just a headline; it is a reality I see in my patients who often first come to me seeking relief from chronic pain, perhaps from a personal injury or a degenerative condition.

My practice, Injury Medical Clinic PA, operates on a principle of collaborative, patient-centered care. This is why I am honored to work with Dr. Maria Guadalupe Cardenas, MD, our Medical Director. Dr. Cardenas, an internist with over 40 years of experience, provides the essential medical oversight that allows us to offer a truly integrative spectrum of services. Her expertise ensures that our medical and pharmacological interventions are safe, evidence-based, and harmonized with the other modalities we provide.

Our multidisciplinary model is designed to address health from multiple angles. When a patient walks through our doors, they are not just seeing a chiropractor or a medical doctor; they are entering a system of care.

• Chiropractic Care (Dr. Jimenez): I focus on the biomechanical and neurological aspects of health. For patients with OUD, many of whom suffer from chronic pain, chiropractic adjustments can offer a non-pharmacological pathway to pain relief, reducing the reliance on opioids that may have initiated or exacerbated their condition. By restoring proper spinal alignment and nerve function, we can alleviate pain and improve overall physical well-being.
• Medical Oversight (Dr. Cardenas): Cardenas manages the medical aspects of care, including prescribing and overseeing medications for OUD (MOUD), managing co-occurring conditions like hypertension or diabetes, and ensuring that all treatments are medically sound. Her role is vital in complex cases, such as pregnancy or when patients are on multiple medications.
• Functional Medicine: We delve deep to identify the root causes of dysfunction. This involves comprehensive lab testing, nutritional counseling, and lifestyle modifications to support detoxification, reduce inflammation, and balance neurochemistry—all of which are critical for recovery from OUD and associated mental health issues.
• Rehabilitation & Personal Injury Care: Our team of therapists works to restore function and mobility, helping patients return to their daily lives after an injury. This physical recovery is a cornerstone of mental and emotional healing.

This integrated approach allows us to create personalized treatment plans that address the full spectrum of a patient’s needs. We believe that by treating the underlying pain, supporting mental health, and providing robust medical and rehabilitative care, we can offer a more sustainable path to recovery from Opioid Use Disorder.

The Critical Link: Opioid Use Disorder and Co-Occurring Mental Health Conditions

One of the most significant challenges we face in treating OUD is its frequent co-occurrence with mental health disorders. It’s often a “chicken or egg” scenario: Did the mental health condition lead to substance use as a form of self-medication, or did the substance use trigger or worsen the mental health condition? From my clinical experience, it is almost always a bidirectional relationship, where each condition fuels the other.

The Staggering Statistics

The data paints a stark picture of this overlap. A 2022 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration (SAMHSA) revealed some sobering statistics:

• Approximately 5 million adults in the United States have a co-occurring mental health and substance use disorder.
• A concerning 40% of these individuals received no treatment for either condition.
• Of those who did receive care, the majority were treated for their mental health disorder, while the substance use disorder often went unaddressed.

When we look specifically at OUD, the prevalence of certain mental health conditions is alarmingly high. The literature consistently shows a strong association with:

• Major Depressive Disorder (MDD): Found in up to 50% of individuals with a substance use disorder.
• Anxiety Disorders: Affecting approximately 30% of this population.
• Post-Traumatic Stress Disorder (PTSD): Present in nearly 20%.

These conditions are not just diagnostic labels; they represent profound suffering that complicates recovery. Individuals with these co-occurring disorders, particularly women, face an elevated risk of overdose and suicide attempts. This underscores the absolute necessity of integrated treatment that addresses both the OUD and the underlying mental health struggles simultaneously.

The Importance of Comprehensive Screening

In our clinic, we believe you cannot treat what you do not identify. That is why we have integrated routine mental health screenings into our initial patient evaluations and ongoing care, a protocol strongly supported by Dr. Cardenas’s internal medicine background. We don’t wait for a patient to report symptoms of depression or anxiety; we proactively screen for them, especially when a history of chronic pain or substance use is present.

Some of the gold-standard, evidence-based screening tools we utilize include:

• PHQ-9 (Patient Health Questionnaire-9): This simple, nine-question tool screens for the presence and severity of depression. It helps us gauge whether a patient’s condition is mild, moderate, or severe, which in turn guides our treatment decisions.
• GAD-7 (Generalized Anxiety Disorder-7): Similarly, this seven-question screener helps us identify and quantify the severity of anxiety symptoms.
• PCL-5 (PTSD Checklist for DSM-5): While screening for depression and anxiety has become more common in primary care, PTSD often goes undetected. Given the high prevalence of trauma among individuals with OUD, this screening is crucial. The PCL-5 is a 20-item self-report measure that assesses the 20 symptoms of PTSD as defined by the DSM-5.

• • How it works: Patients rate how much each symptom has bothered them over the past month on a scale from 0 (not at all) to 4 (extremely).
  • Symptoms assessed: These include intrusive memories or nightmares, flashbacks, emotional numbness, avoidance of trauma-related triggers, persistent negative beliefs (e.g., self-blame), anhedonia (inability to feel pleasure), social isolation, irritability, and sleep disturbances.
  • Scoring and Interpretation: A score between 31 and 33 is generally considered a clinical cutoff, suggesting that a formal PTSD assessment and treatment are warranted. We also use the PCL-5 to monitor progress; a reduction of 10 points or more typically indicates an effective treatment response.

By employing these tools, we create a clear, data-driven picture of our patient’s mental state, allowing us to tailor a truly comprehensive and effective treatment plan.

Implementing Trauma-Informed Care: A Foundational Principle

Given the high rates of trauma in this population, a trauma-informed care approach is not just a best practice—it is an ethical imperative. This framework shifts the question from “What’s wrong with you?” to “What happened to you?” It acknowledges that a patient’s behaviors and symptoms are often adaptive responses to traumatic experiences. In our practice, we are committed to integrating the six core principles of trauma-informed care into every patient interaction.

1. Safety: Our priority is to create an environment where patients feel physically and emotionally safe. This means a calm, welcoming clinic space, clear communication about procedures, and a team trained to be sensitive to potential triggers. For someone who has experienced trauma, the world often feels like an unsafe place; the healthcare setting should be a sanctuary.
2. Trustworthiness and Transparency: We build trust by being honest, open, and reliable. This involves explaining every step of the treatment plan, being clear about expectations and policies (like contingency management), and ensuring there are no surprises. Trust is fragile, especially for those whom systems or individuals have let down in the past.
3. Peer Support: We recognize the immense power of shared experience. Connecting patients with peer support groups can be transformative. Peers who have walked a similar path can offer a unique form of empathy, build trust, and instill hope in ways clinicians sometimes cannot. This support helps establish safety and fosters empowerment.
4. Collaboration and Mutuality: We reject the old, paternalistic model of healthcare where the provider dictates and the patient complies. Instead, we partner with our patients. We see them as the experts on their own lives and experiences. Treatment planning is a collaborative process, ensuring that the care we provide is truly patient-centered and aligned with their goals and needs.
5. Empowerment, Voice, and Choice: Recovery is built on a foundation of self-efficacy. We empower our patients by offering them choices and respecting their decisions. They drive their own care. We provide education and guidance, but ultimately, they are in control. This sense of agency is crucial for rebuilding a life that has been dismantled by addiction and trauma.
6. Cultural, Historical, and Gender Issues: We strive to be aware of our own biases and to understand the unique cultural, historical, and gender-related factors that shape our patients’ lives and perceptions. A person’s identity and background influence their lived experience, and we must honor and incorporate this understanding into our care to be truly effective.

Evidence-Based Therapies for Co-Occurring Conditions

While our clinic provides foundational support through chiropractic, functional medicine, and medical management, we know that specialized psychotherapy is a cornerstone of recovery for co-occurring disorders. We maintain a strong referral network of therapists who are skilled in evidence-based practices. Educating our patients about these options is part of our collaborative approach.

• For Depression and Anxiety: Cognitive Behavioral Therapy (CBT) is one of the most well-researched and effective therapies. CBT helps patients identify, challenge, and reframe the negative thought patterns and behaviors that fuel depression and anxiety. It is a practical, skills-based approach that empowers patients with tools they can use for the rest of their lives.
• For PTSD: More specialized therapies are often required to process the trauma. We recommend that patients seek therapists trained in modalities such as:

• • Prolonged Exposure (PE) Therapy: This involves gradually and safely confronting trauma-related memories, feelings, and situations to reduce their power.
  • Cognitive Processing Therapy (CPT): This is a specific type of CBT that helps patients learn how to challenge and modify unhelpful beliefs related to the trauma.
  • Eye Movement Desensitization and Reprocessing (EMDR): This therapy uses bilateral stimulation (such as eye movements) to help the brain process and integrate traumatic memories, reducing their emotional charge.

Finding the right therapist and the right therapeutic approach is a crucial part of the recovery journey. We see it as our responsibility to guide patients toward these evidence-based resources.

Pharmacological Treatment: Navigating Medications with Care

Under the medical direction of Dr. Cardenas, we carefully consider pharmacological interventions for MDD, GAD, and PTSD. Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the first-line medication treatments for these conditions. The choice of a specific agent depends on the patient’s specific symptoms, potential side effects, co-occurring medical conditions, and other medications they may be taking.

Here is a breakdown of some commonly used medications and their key considerations, which we discuss thoroughly with our patients:

SSRIs (Selective Serotonin Reuptake Inhibitors)

• Paroxetine (Paxil): This medication is FDA-indicated for all three conditions (MDD, GAD, and PTSD). However, we make patients aware that it has one of the higher rates of sexual dysfunction among the SSRIs, which can be a significant concern for many.
• Sertraline (Zoloft): Indicated for MDD and PTSD. It is known for causing transient gastrointestinal (GI) side effects like nausea or diarrhea, which usually resolve within a few weeks.
• Fluoxetine (Prozac): Indicated for MDD. Its most notable feature is its long half-life. This can be an advantage for patients who sometimes forget to take their medication, as it provides a more stable blood level. However, this same property makes it more dangerous in an overdose attempt, a critical consideration for patients with suicidal ideation.
• Escitalopram (Lexapro): Indicated for MDD and GAD. It is generally one of the best-tolerated SSRIs but can be associated with weight gain.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Duloxetine (Cymbalta): Indicated for MDD and GAD. A key advantage is its lower incidence of sexual dysfunction compared to many SSRIs. It can also be beneficial for patients with co-occurring chronic pain conditions, such as fibromyalgia or diabetic neuropathy. Like sertraline, it can cause GI side effects.
• Venlafaxine (Effexor XR): Indicated for MDD and GAD. It is effective but can also cause GI side effects and is associated with weight gain. It also carries a slightly higher risk of QTc prolongation, which we will discuss next.

Critical Drug Interactions: MOUD and Psychiatric Medications

Prescribing SSRIs or SNRIs to a patient on Medications for Opioid Use Disorder (MOUD) requires careful consideration of potential drug interactions. This is where our team’s collaborative expertise, with Dr. Cardenas’s medical oversight, becomes indispensable.

• Buprenorphine (e.g., Suboxone): Buprenorphine itself has some serotonergic properties, meaning it affects serotonin levels in the brain. When combined with an SSRI or SNRI, there is a theoretical, though low, risk of Serotonin Syndrome. However, the clinical evidence is overwhelmingly clear: the benefits of treating the underlying depression or anxiety far outweigh this risk. Research has consistently found that treating these co-occurring conditions with antidepressants increases retention in OUD treatment, which is a primary goal for saving lives. We have a detailed conversation with our patients about this, explaining the risks and benefits and teaching them the signs of serotonin syndrome to watch for.
• Methadone: The primary concern with methadone is its potential to cause QTc prolongation, an electrical disturbance in the heart that can lead to a dangerous arrhythmia called Torsades de Pointes. Many other medications, including some antidepressants, can also prolong the QTc interval.
  • Citalopram (Celexa) is a particular SSRI that we watch closely, especially at doses higher than 40 mg per day (or 20 mg in adults over 60).
  • Venlafaxine (Effexor) also tends to have a slightly higher risk of QTc prolongation than some other options.
  • Our Protocol: When combining methadone with a QTc-prolonging medication, our protocol, overseen by Dr. Cardenas, includes:

1. 1. 1. A baseline ECG before starting the new medication.
      2. A follow-up ECG after the new medication has reached a steady state (typically after five half-lives).
      3. Annual ECGs thereafter, and any time the patient reports symptoms like palpitations, lightheadedness, dizziness, syncope (fainting), chest pain, or shortness of breath.

• • We pay close attention to QTc values, especially if they exceed 450 milliseconds for men or 460 milliseconds for women, as these are the thresholds where risk begins to increase significantly.
• Naltrexone (e.g., Vivitrol): Naltrexone itself carries a warning that it can increase depression or suicidality in some individuals. This is particularly important to remember when considering that SSRIs and SNRIs also carry a black box warning for increased suicidality, especially in younger adults. This does not mean these medications are contraindicated. In fact, for many patients, untreated depression is the single greatest risk factor for suicide. We approach this with a thorough risk-benefit discussion. Often, individuals use opioids or alcohol to self-medicate their depression, and this substance use itself carries an extremely high risk of death. Treating the depression effectively can be life-saving.

Recognizing Serotonin Syndrome

As part of our commitment to patient education and safety, we teach all patients on serotonergic medications the signs and symptoms of Serotonin Syndrome. This is a potentially life-threatening condition caused by excessive serotonin activity. We use the helpful acronym SHIVERS:

• Shivering
• Hyperreflexia (overactive reflexes) and Myoclonus (muscle twitching/jerking)
• Increased temperature (fever)
• Vital sign instability (often tachycardia and hypertension)
• Encephalopathy (mental confusion, delirium)
• Restlessness and agitation
• Sweating (diaphoresis)

We instruct patients to seek immediate medical attention if they experience a combination of these symptoms.

Case Study: A Holistic Approach to Depression, Anxiety, and OUD

Let’s apply these concepts to a real-world scenario, representative of patients we see in our clinic.

Patient Profile:

• Demographics: A 32-year-old divorced female, mother of two, working part-time in retail.
• Medical History: Chronic low back pain due to degenerative disc disease, which led to a history of opioid misuse. She is currently stable on buprenorphine-naloxone (8 mg, three times a day).
• Family History: Father with alcohol use disorder (in remission), mother with depression.
• Social History: Lives with her mother and two children, has a limited support network, a history of intimate partner violence, and currently attends peer recovery groups.

Presentation:

She comes for a follow-up appointment. While she denies any return to non-prescribed opioid use, she reports debilitating symptoms of depression and anxiety. She describes feeling “exhausted,” “overwhelmed by worry,” and “unable to enjoy time with her children.” She says, “I am staying away from pills, but I feel like I am drowning most days.” She denies any suicidal ideation.

Our Integrated Treatment Plan:

1. Screening and Assessment:

• • We administer the standard screening tools. Her scores are:

• • • PHQ-9: 18 (indicative of moderately severe depression)
    • GAD-7: 15 (indicative of severe anxiety)
    • PCL-5: 10 (does not indicate PTSD, which helps narrow our diagnostic focus)

• • A urine drug screen (UDS) is conducted, which is positive only for buprenorphine, confirming her treatment adherence.
• Multifaceted Intervention:
  • Continue MOUD: We continue her current dose of buprenorphine-naloxone, as it has been effective in preventing relapse.
  • Address Co-Occurring Disorders: We initiate treatment for her MDD and GAD. After a thorough discussion of the options, risks, and benefits, we might start a well-tolerated SSRI like escitalopram or an SNRI like duloxetine (which could also offer some benefit for her chronic back pain).
  • Chiropractic Care: I would perform a thorough musculoskeletal evaluation. Her chronic back pain is a significant contributor to her overall stress and a potential trigger for a return to use. A course of chiropractic adjustments could help manage her pain without additional medication, improve her physical function, and lower her overall stress levels.
  • Therapy Referral: We refer her to a therapist specializing in Cognitive Behavioral Therapy (CBT) to help her develop coping skills for her depression and anxiety.
  • Safety Planning:

• • • We prescribe naloxone and ensure she and her mother know how and when to use it. This is a standard harm reduction practice for all patients on MOUD.
    • We provide her with the 988 Suicide & Crisis Lifeline number and discuss a plan for her to go to the nearest emergency room if she ever feels she is in crisis. This proactive safety planning empowers her with resources before she needs them.

This case illustrates our integrative philosophy in action. We are not just managing her OUD; we are treating her depression, anxiety, and chronic pain, while providing a safety net of resources and support. This holistic approach gives her the best possible chance not just to survive, but to thrive.

A Delicate Balance: Opioid Use Disorder and Pregnancy

The intersection of Opioid Use Disorder and pregnancy is one of the most challenging and emotionally charged areas in healthcare. The statistics are deeply concerning and reflect a growing public health crisis.

The Alarming Trends

• From 1999 to 2014, the rate of OUD in pregnancy increased fourfold.
• More recently, from 2010 to 2017, OUD documented at the time of delivery increased by a staggering 131%.
• This has had a direct and devastating impact on newborns. The incidence of Neonatal Opioid Withdrawal Syndrome (NOWS) increased fivefold between 2002 and 2009, and then another 82% between 2010 and 2017.
• Current data from 2021 shows that a baby is born with NOWS approximately every 24 minutes in the United States.
• Research also suggests these rates are often higher in rural areas than in urban centers, highlighting disparities in access to care.

The Pervasive Barrier of Stigma

Beyond the medical complexities, pregnant individuals with OUD face a crushing weight of stigma. They are often unfairly stereotyped as “unfit mothers,” “drug seekers,” or “criminals.” Tragically, this judgment frequently comes from healthcare staff themselves. The literature is replete with accounts of pregnant patients experiencing both verbal and non-verbal discrimination, causing them to feel shamed and unwelcome.

This poor treatment is not only unethical; it is profoundly counterproductive. It creates a significant barrier to care, causing pregnant individuals to avoid prenatal appointments and OUD treatment. This avoidance can lead to a dangerous cycle of untreated OUD, triggering a return to use and increasing the risk of overdose, which is now a leading cause of maternal mortality.

The Imperative of Universal Screening

To combat stigma and ensure every pregnant person gets the help they need, universal screening for substance use is the standard of care. This means we screen every pregnant patient, not just those we “think” might be at risk. This approach normalizes the conversation and avoids biased profiling.

Several validated screening tools can be used in the prenatal setting:

• The 4 P’s: A simple and effective mnemonic. A “yes” to any question triggers a more in-depth assessment.

• • Parents: Did any of your parents have a problem with alcohol or other drugs?
  • Partner: Does your partner have a problem with alcohol or drugs?
  • Past: In the past, have you had difficulties in your life because of alcohol or other drugs?
  • Present: In the present (past month), have you drunk any alcohol or used any other drugs?

• NIDA Quick Screen: This tool asks about substance use in the past year. For women, it flags use if they have had four or more drinks in a single day, or any use of tobacco products or other drugs. A positive screen necessitates a more detailed assessment of specific substances.
• CRAFFT: This tool is validated for adolescents and young adults (up to age 26) and is excellent for screening for problematic behaviors associated with substance use. Two or more positive answers indicate the need for further evaluation.

• • Car: Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs?
  • Relax: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
  • Alone: Do you ever use alcohol or drugs while you are by yourself, or ALONE?
  • Forget: Do you ever FORGET things you did while using alcohol or drugs?
  • Family/Friends: Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
  • Trouble: Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Pregnancy Complications Associated with Untreated OUD

Untreated OUD poses significant risks to both the mother and the fetus. Many of these complications arise from the dangerous cycle of use and withdrawal. When a pregnant person uses an illicit opioid, the fetus is exposed. As the drug wears off, both mother and fetus go into withdrawal, which can cause uterine contractions and fetal distress. This cycle, combined with the often-inconsistent prenatal care that results from stigma and other barriers, increases the risk of severe complications, including:

• Placental abruption (the placenta detaching from the uterine wall)
• Problems with fetal growth (intrauterine growth restriction)
• Preterm birth
• Stillbirth
• Maternal overdose and death

This is why stabilizing the mother with MOUD is so critically important. It stops this dangerous cycle and provides a steady, safe environment for the fetus to grow.

Understanding Neonatal Opioid Withdrawal Syndrome (NOWS)

Precise language is essential here. Babies cannot be born “addicted.” Addiction, as defined by the DSM-5, is a complex behavioral disorder characterized by a pattern of compulsive use despite negative consequences. A newborn cannot exhibit these behaviors. What they can experience is physical dependence and subsequent withdrawal. The correct term for this is Neonatal Opioid Withdrawal Syndrome (NOWS) (formerly known as Neonatal Abstinence Syndrome or NAS).

Symptoms of NOWS can appear within hours to days after birth and include:

• Shaking and tremors
• High-pitched, excessive crying and irritability
• Poor feeding or sucking
• Fever, sweating, and sneezing
• Diarrhea and vomiting
• Sleep problems
• Hyperactive reflexes (e.g., an exaggerated Moro reflex)
• In severe cases, seizures

To assess for NOWS, clinical teams use standardized scoring systems. A newer, simplified, and family-centered approach is the “Eat, Sleep, Console” (ESC) method. It focuses on the baby’s ability to function.

• Eat: Can the baby eat at least one ounce at every feeding?
• Sleep: Can the baby sleep for at least one hour uninterrupted?
• Console: Can a caregiver console the baby within 10 minutes?

If the baby is meeting these functional goals, pharmacological intervention is often not needed. The more traditional and complex tool is the Finnegan Neonatal Abstinence Scoring System, a 21-item assessment that rates the severity of various withdrawal symptoms. While more detailed, it is also more time-consuming, which is why many institutions are moving toward the ESC model.

The duration of NOWS can range from days to weeks, depending on the specific opioid the mother was using and its half-life. The most important message we can give to mothers is one of reassurance: There are no known long-term physical or intellectual problems associated with NOWS.

Treatment for NOWS starts with non-pharmacological care. This is the first and most important intervention:

• Rooming-in: The baby should stay in the mother’s room. This reduces stress for both mother and baby and is crucial for bonding.
• Swaddling: Tight swaddling provides comfort and can reduce tremors.
• Skin-to-skin contact: This helps regulate the baby’s temperature, heart rate, and breathing, and it is profoundly calming.
• Breastfeeding: This provides both nutrition and comfort.

If these measures are not sufficient, pharmacological treatment may be necessary. Morphine is typically the first-line medication used to manage withdrawal symptoms, with secondary options like clonidine or phenobarbital. It is critical to note that naloxone is never given to a newborn in opioid withdrawal, as it can precipitate a sudden, severe withdrawal that can cause seizures.

The Overwhelming Benefits of Breastfeeding

We strongly encourage breastfeeding for mothers with OUD, provided there are no other contraindications. The benefits are immense for both baby and mother.

• Neonatal Benefits: Decreased risk of numerous childhood diseases, including asthma, leukemia, obesity, ear infections, eczema, SIDS, and diabetes.
• Maternal Benefits:

• • Decreased risk of breast and ovarian cancer, postpartum depression, and diabetes.
  • Faster recovery from childbirth, including weight loss.
  • Decreased maternal stress.
  • Crucially, it increases mother-child bonding and is associated with decreased rates of maternal neglect and child abuse.

It is a common misconception that mothers on MOUD cannot breastfeed. This is false. Buprenorphine and methadone are safe with breastfeeding. Very small amounts of the medication pass into the breast milk, not enough to be harmful, but potentially enough to slightly ease withdrawal symptoms in the baby.

Contraindications to breastfeeding would include a return to use of non-prescribed opioids or other street substances, an HIV diagnosis, or the use of other specific contraindicated medications.

The Gold Standard: Medications for Opioid Use Disorder (MOUD) in Pregnancy

The evidence is unequivocal: Buprenorphine and methadone are the first-line, gold-standard treatments for OUD in pregnancy. They are FDA-approved and recommended by every major medical organization, including the American College of Obstetricians and Gynecologists (ACOG), SAMHSA, and the World Health Organization (WHO).

Why are they so strongly recommended?

• They save lives. By stabilizing the mother, MOUD prevents the cycle of use and withdrawal, dramatically reducing the risk of overdose, stillbirth, and other obstetric complications.
• They improve outcomes. Mothers on MOUD are far more likely to carry their babies to full term and have them be born at a normal birth weight.
• They provide a platform for recovery. A stable mother can engage in prenatal care and therapy and prepare for parenthood.

In contrast, medically supervised withdrawal (detox) is NOT recommended during pregnancy. This approach carries a very high rate of return to use. A return to use after a period of abstinence is incredibly dangerous because the mother’s tolerance to opioids has decreased, putting her at an extremely high risk of a fatal overdose.

While naltrexone is not a first-line treatment, it is not strictly contraindicated. It would require a very careful discussion with the patient about the risks and limitations, including the need for complete detoxification before starting and the high overdose risk if they return to use.

In our practice, we always combine MOUD with psychosocial support and therapy to address the underlying issues contributing to the OUD.

Case Study: Supporting a Pregnant Patient with OUD

Let’s consider another case that highlights our approach to care during pregnancy.

Patient Profile:

• Demographics: A 28-year-old female, pregnant for the second time (G2P1), at 18 weeks gestation.
• Medical & Psychiatric History: Mild asthma, generalized anxiety disorder.
• Social History: Lives with a supportive partner, works part-time, denies alcohol or tobacco use.
• Substance Use: Reports daily misuse of prescription extended-release oxycodone, approximately 60 mg per day.

Presentation:

She presents to our clinic, expressing a strong desire to stop using opioids but fears the withdrawal symptoms and the potential harm to her fetus. She states, “I want to be healthy for my baby and myself. I’ve tried quitting on my own, but I can’t.” This statement reflects both her motivation and the powerful grip of physical dependence.

Our Integrated Treatment Plan:

1. Immediate Assessment and Lab Work:

• • We perform a UDS, which is positive for opioids, as expected, and negative for other substances.
  • Cardenas orders a comprehensive set of prenatal labs, including a CBC, CMP, HIV test, hepatitis panel, and STI panel, all of which come back within normal limits.

• Initiation of MOUD:

• • Given her motivation and the clear risks of untreated OUD, we decide to initiate buprenorphine. Buprenorphine is often preferred in pregnancy as it is associated with less severe NOWS compared to methadone.
  • We start the induction process 12-24 hours after her last dose of oxycodone, beginning with a small dose of 2 mg and gradually titrating up as tolerated, with a target dose range up to 24 mg per day to control her cravings and prevent withdrawal.

• Comprehensive Support and Referrals:

• • Prescribe Naloxone: We immediately prescribe naloxone and provide training to both her and her partner.
  • Refer to Prenatal Care: We ensure she is connected with a supportive, non-judgmental OB/GYN for prenatal care. We coordinate our care with her obstetric team.
  • Psychosocial Support: We refer her for individual therapy to address her anxiety and the underlying factors of her OUD. We also connect her with support groups for pregnant and parenting women in recovery.
  • Chiropractic and Functional Medicine: I would offer gentle chiropractic care to help manage any pregnancy-related musculoskeletal pain, such as low back or pelvic pain, providing a non-pharmacological pain management option. Our functional medicine approach would focus on optimizing her nutrition to support a healthy pregnancy.
  • Postpartum Planning: We begin the conversation early about the postpartum period. We encourage breastfeeding, reassuring her that it is safe with buprenorphine, and discuss a plan for continued OUD treatment and support after delivery.

This proactive, supportive, and non-judgmental approach is essential to help pregnant individuals navigate this challenging time and achieve the best possible outcomes for themselves and their babies.

Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

A Growing Crisis: Opioid Use Disorder in Adolescents

The opioid crisis has not spared our youth. In fact, recent trends among adolescents are particularly terrifying, driven by the increasing prevalence of illicitly manufactured fentanyl.

The Frightening Data on Adolescent Overdose

• From 2019 to 2020, overdose deaths among 14- to 18-year-olds increased by a shocking 94%.
• This was followed by another 20% increase from 2020 to 2021.
• The paradox here is that overall substance use among teens actually decreased during this period. The spike in deaths is almost entirely attributable to the extreme potency of the drugs available. Teens are dying not because more are using, but because the substances they are experimenting with are lethally potent.
• Deaths involving illicitly manufactured fentanyl (IMFs) among teens increased by 182%. Often, these teens believe they are taking a counterfeit prescription pill (like oxycodone or Xanax) but are unknowingly ingesting a fatal dose of fentanyl.
• Looking at the histories of the teens who died, we see that:

• • 40% had a known mental health history.
  • 35% had a prior history of opioid use.
  • Tragically, only 5% had ever received treatment for OUD. This is a massive gap in our healthcare system.

Identifying Risk and Protective Factors

In our practice, we believe in prevention and early intervention. This means understanding the factors that put a young person at risk and those that can protect them.

Protective Factors (What we want to build):

• Family Engagement: Strong, supportive family relationships.
• Guardian Disapproval of Substance Use: Clear messages from parents and guardians that substance use is harmful.
• School Connectedness: Feeling like a valued part of the school community.
• Self-Efficacy: A belief in one’s own ability to handle challenges and make good decisions.

Risk Factors (What we need to screen for):

• Social Determinants of Health: Factors like poverty, unstable housing, and community violence.
• Other Substance Use: Early use of alcohol, tobacco, or marijuana is a strong predictor of later, more dangerous substance use.
• Early Age of Onset: The younger a person starts using substances, the higher their risk of developing a disorder.
• History of Impulsivity: Conditions like ADHD can increase risk.
• Co-occurring Psychiatric Disorders: Depression, anxiety, and trauma are major risk factors.
• Maltreatment: A history of physical, emotional, or sexual abuse.
• Family History of Substance Use Disorders: A genetic and environmental predisposition.

Screening Adolescents: The Importance of Confidentiality

Screening teens for substance use is essential, but it must be done with skill and sensitivity. The first and most important step is to explain the rules of confidentiality. We must be transparent with the adolescent about what we can keep private between us and what we are legally or ethically required to disclose to their parents or authorities (e.g., imminent risk of harm to self or others). Building trust is impossible if the teen feels betrayed later.

Whenever possible, we conduct at least part of the visit as one-on-one time with the adolescent. This private time allows for more honest conversation and provides an opportunity for crucial education and harm reduction counseling, even if they are not ready for formal treatment.

Several screening tools are validated for this age group:

• S2BI (Screening to Brief Intervention): Asks about the frequency of use (never, once or twice, monthly, weekly) for various substances over the past year.
• Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD): Asks about the number of days a substance was used in the past year and is very specific, listing drugs like cocaine, heroin, meth, hallucinogens, and a wide range of prescription pills.
• CRAFFT: As discussed earlier, this tool is excellent for screening for the negative consequences and problematic behaviors associated with substance use in youth.

Treatment Recommendations for Adolescents with OUD

Treating OUD in an adolescent requires a specialized, family-centered approach.

1. Naloxone, Naloxone, Naloxone: This is the top priority. We need to get naloxone into the hands of the adolescent, their friends, their family, and their school. We discuss high-risk scenarios (e.g., using alone, using after a period of abstinence) and develop a clear plan for how to respond to an overdose.
2. Behavioral Health Services: Therapy is critical. This can occur in various settings, but schools are increasingly becoming a vital resource for connecting students with mental health and substance use services. Family therapy is often a key component of successful treatment.
3. Medications for Opioid Use Disorder (MOUD):

• • Buprenorphine: Is FDA-approved for adolescents aged 16 and older. For a teen with moderate to severe OUD, buprenorphine is a life-saving intervention.
  • Naltrexone and Methadone: Are currently not FDA-approved for individuals under 18.
  • Future Guidance: The American Society of Addiction Medicine (ASAM) is expected to release updated guidelines for adolescents and transition-age youth in 2026, which we are eagerly anticipating. These guidelines will likely clarify the role of all MOUD options in this younger population.

Case Study: Responding to a Teen in Crisis

This case reflects the all-too-common pathway from a legitimate injury to a life-threatening OUD.

Patient Profile:

• Demographics: A 16-year-old female in 11th grade. Formerly a competitive soccer player, now with declining school attendance and grades.
• Medical History: Suffered an ankle fracture at age 15 that required surgery. She was prescribed oxycodone for postoperative pain.
• Family History: Father with alcohol use disorder (in remission), mother with depression.
• Social History: Lives with her mother and younger brother. After her injury, she drifted away from her old friends and began associating with an older crowd that misuses opioids.

Presentation:

She is brought to the emergency department by her mother after being found extremely drowsy and nauseated. She admits to snorting heroin daily for the past six months. She explains her story: “At first, I needed the pills for pain, but then I needed them to feel okay. When I couldn’t get them anymore, heroin was the only thing around.” This powerful statement captures the transition from pain management to coping to addiction.

Our Integrated Treatment Plan:

1. Immediate Medical Care and Harm Reduction:

• • A UDS is performed. It is positive for heroin but, importantly, negative for fentanyl and other substances. This finding is a critical educational opportunity. We have a direct, non-judgmental conversation with her about the extreme danger of fentanyl-laced drugs and the importance of harm reduction strategies like using fentanyl test strips.

• Initiation of MOUD:

• • Because she is 16, she is eligible for buprenorphine. We would start the induction process 12-24 hours after her last heroin use, beginning with a 2 mg dose and titrating up to a therapeutic level (e.g., up to 24 mg/day) that eliminates her withdrawal symptoms and cravings.

• Comprehensive Support System:

• • Prescribe Naloxone: We prescribe naloxone and ensure the entire family is trained to use it.
  • Psychosocial Support: This is non-negotiable. We would connect her and her family with an intensive outpatient program (IOP) or a therapist specializing in adolescent substance use and family systems. The goal is to address not just her substance use, but also the family dynamics, her declining school performance, and her social environment.
  • Chiropractic and Rehabilitative Care: As a former athlete with a significant injury, she may have residual musculoskeletal issues. I would assess her for any biomechanical imbalances related to her old ankle injury that could be contributing to chronic pain or dysfunction. Physical rehabilitation could also help her healthily reconnect with her body, potentially reopening the door to activities like soccer that were once a source of joy and self-esteem.

Treating an adolescent requires mobilizing a whole system of care around them—family, school, medical providers, and therapists—to create a robust network of support and safety.

Other Considerations: Older Adults and Polysubstance Use

The opioid crisis is often associated with younger people, but we are seeing alarming trends in other populations as well.

Opioid Use Disorder in Older Adults

The “graying” of the opioid crisis is a serious and often overlooked problem.

• Since 2013, there has been a threefold increase in OUD among adults aged 65-69.
• The increase is more pronounced among patients on both Medicare and Medicaid than among those with Medicare alone, suggesting a link to socioeconomic vulnerability.
• Data also show increased vulnerability among older Black Americans, Native Americans, and Alaska Natives, highlighting significant racial and ethnic disparities.

Treating Older Adults with MOUD: A Cautious Approach

Treating older adults with MOUD requires special considerations. The guiding principle is to use caution and always weigh the risks versus the benefits. However, given the lethality of the illicit drug supply, the benefits of MOUD almost always outweigh the risks. Having an older adult on a stable dose of methadone or buprenorphine is far safer than them using street fentanyl.

A major challenge is the lack of research; very few participants over age 65 are included in clinical trials for these medications, so our guidance is less robust. We must pay close attention to age-related physiological changes:

• Hepatic (Liver) and Renal (Kidney) Function: These functions naturally decline with age.
  • Methadone:

• • • Renal: If creatinine clearance is less than 10 mL/min (indicating severe kidney disease), we would consider reducing the methadone dose by 50-75%.
    • Hepatic: Methadone is less affected by liver impairment, so dose adjustments are not typically needed.
    • QTc Prolongation: This is a major concern in older adults, who are more likely to have underlying cardiac issues or be on other QTc-prolonging medications. We monitor ECGs very closely.

• • Buprenorphine:

• • • Renal: No dose adjustment is needed for kidney dysfunction.
    • Hepatic: For patients with severe hepatic impairment, a dose reduction may be necessary. The long-acting subcutaneous injections of buprenorphine are generally not recommended for patients with moderate to severe liver impairment.

• Respiratory Depression: As a full opioid agonist, methadone carries a higher risk of respiratory depression, especially in older adults who may have reduced metabolic clearance and are more sensitive to its effects.

In our practice, we start with lower doses and titrate more slowly in our older patients, monitoring them more frequently for side effects.

The Challenge of Polysubstance Use: Benzodiazepines and Other CNS Depressants

One of the most common clinical dilemmas we face is the patient with OUD who is also taking other Central Nervous System (CNS) depressants, most notably benzodiazepines (e.g., alprazolam, clonazepam, diazepam).

For years, there was a great deal of fear around this combination, and many providers would refuse to prescribe MOUD to patients taking benzodiazepines. However, in 2017, the FDA issued a critical safety communication clarifying its stance. They urged caution but explicitly warned against withholding MOUD from these patients.

The reasoning is based on a risk-benefit analysis:

• The Risk: Yes, combining MOUD (especially methadone) with a benzodiazepine increases the risk of respiratory depression and overdose compared to taking MOUD alone.
• The Greater Risk: The risk of a patient taking a benzodiazepine and then using illicit fentanyl or heroin is exponentially higher. Refusing to treat their OUD is, in essence, consigning them to a much more dangerous fate.

Therefore, the current standard of care is that concurrent benzodiazepine use is NOT a contraindication to MOUD. We do not use arbitrary dose limits (e.g., we don’t automatically reduce a patient’s buprenorphine dose just because they are on a benzodiazepine).

Our approach is one of harm reduction and patient education:

1. Treat the OUD: This is the immediate, life-saving priority.
2. Educate the Patient: We have a frank conversation, explaining that the combination of medications puts them at a higher risk for respiratory depression and overdose. We re-emphasize the importance of having and knowing how to use naloxone.
3. Taper if Possible: We then work with the patient to create a plan to slowly and safely taper the benzodiazepine.

• • It is important to remember that benzodiazepines are not the first-line treatment for anxiety disorders; SSRIs and SNRIs are. We would work on transitioning them to a safer, more appropriate long-term medication for their anxiety.
  • For some patients who have been on benzodiazepines for many years, a taper may not be feasible or safe, and our goal becomes managing the combination as safely as possible.

This same risk-benefit approach applies to other CNS depressants, including:

• “Z-drugs” for sleep (e.g., zolpidem)
• Muscle relaxants (e.g., baclofen, carisoprodol)
• Antipsychotics (e.g., aripiprazole, quetiapine, olanzapine)

While we would always seek to minimize polypharmacy, if a patient needs an antipsychotic for schizophrenia or bipolar disorder, we will not withhold life-saving MOUD. We manage the combination with careful monitoring and education.

Conclusion: An Integrative, Compassionate Path Forward

Treating Opioid Use Disorder is one of the most complex and rewarding challenges in modern healthcare. As we have explored, it rarely exists in a vacuum. It is deeply interwoven with mental health, chronic pain, trauma, and the unique physiological and social circumstances of each individual’s life stage.

From my perspective as an integrative practitioner, a siloed approach is doomed to fail. We cannot simply prescribe a medication and hope for the best. True, lasting recovery requires a holistic, compassionate, and evidence-based strategy.

Key Takeaways from Our Discussion:

• Treat the Whole Person: Depression, anxiety, and PTSD are not secondary issues; they are part of the primary disease process and must be treated concurrently with OUD using evidence-based therapies and medications.
• Protect Mothers and Babies: MOUD is the life-saving standard of care for pregnant individuals with OUD. We must combat stigma and provide supportive, non-judgmental care that encourages breastfeeding and mother-child bonding.
• Intervene Early for Adolescents: The rise in fentanyl-related deaths among teens is a call to action. We must prioritize naloxone distribution, universal screening, and access to age-appropriate MOUD and behavioral health services.
• Apply a Risk-Benefit Approach: For all patients, especially older adults and those on other CNS depressants, our decisions must be guided by a careful risk analysis. In the era of fentanyl, the benefits of MOUD in preventing a fatal overdose almost always outweigh the risks of the medication itself or its potential interactions.

At Injury Medical Clinic, our multidisciplinary team, with the invaluable medical oversight of Dr. Maria Cardenas, is committed to this integrative model. By combining the best of chiropractic care, functional medicine, rehabilitation, and conventional medicine, we strive to offer our patients a comprehensive and personalized path to healing. We address their pain, support their mental health, stabilize their OUD, and empower them to rebuild their lives. It is a journey we are honored to take with them.

Thank you for joining me in this important educational discussion. If you have any questions, please do not hesitate to reach out.

References

• Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health (HHS Publication No. PEP23-07-01-006, NSDUH Series H-58). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. [https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report](https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report)
• The American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy. [https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy](https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy)
• U.S. Food and Drug Administration. (2017). FDA urges caution about withholding opioid addiction medications from patients taking benzodiazepines or other CNS depressants. [https://www.fda.gov/media/127624/download](https://www.fda.gov/media/127624/download)

SEO Tags: Opioid Use Disorder, OUD Treatment, Integrative Chiropractic Care, Dr. Alex Jimenez, Dr. Maria Cardenas, Injury Medical Clinic, Functional Medicine, Co-occurring Disorders, Depression, Anxiety, PTSD, OUD in Pregnancy, Neonatal Opioid Withdrawal Syndrome, NOWS, OUD in Adolescents, Fentanyl Overdose, MOUD, Buprenorphine, Methadone, Naltrexone, Trauma-Informed Care, Serotonin Syndrome, QTc Prolongation, Benzodiazepines and Opioids, Personal Injury Care El Paso, Chronic Pain Management, El Paso Chiropractor