Explore SUD treatment and integrative chiropractic care for a holistic approach to healing and recovery from substance use disorders.

Abstract

The landscape of addiction medicine and primary care is undergoing a profound transformation, necessitating a highly integrative, multidisciplinary approach to effectively manage the complex neurophysiological, biomechanical, and psychological facets of addiction. Welcome to this comprehensive educational exploration of modern approaches to Substance Use Disorder (SUD). I am Dr. Alex Jimenez, and I am honored to guide you through the latest findings and clinical strategies in this critical area of healthcare. In this post, we will explore the complexities of SUD treatment and the evolving role of primary care providers, particularly Nurse Practitioners (NPs), in bridging critical care gaps. We will investigate the physiological underpinnings of addiction, the pharmacological mechanics of medications like buprenorphine and methadone, and the integration of evidence-based models such as inpatient addiction consult services. We will also examine how to create seamless, supportive care transitions for individuals moving from acute hospital settings back into the community, with special attention to vulnerable populations, including justice-involved individuals, peripartum individuals, and adolescents. We will also discuss the nuances of medication for opioid use disorder (MOUD), the ethical and legal considerations surrounding reporting substance use, and emerging research in genetics and novel pharmacotherapies like GLP-1 receptor agonists.

A central theme of this discussion is the power of integrative care. Here at Injury Medical Clinic PA in El Paso, Texas, my practice is built on this very foundation. I work closely with our Medical Director, Dr. Maria Guadalupe Cardenas, MD, a board-certified internist with over four decades of experience. Our multidisciplinary model combines my expertise in chiropractic care, functional medicine, and rehabilitation with Dr. Cardenas’s deep knowledge of internal medicine. This synergy allows us to provide a holistic, patient-centered approach that addresses not just the symptoms but the underlying physiological and structural imbalances contributing to a patient’s health challenges. Through detailed clinical case studies, we will demonstrate how alleviating chronic neuro-musculoskeletal pain and addressing systemic metabolic dysfunctions can drastically improve recovery outcomes. I will explain how principles of integrative chiropractic care—focusing on nervous system regulation, structural alignment, and overall well-being—can be woven into SUD treatment to enhance recovery, manage pain, and improve long-term health outcomes. Join me as we explore this journey toward more effective, compassionate, and integrated care.

The Evolution of Multidisciplinary Care in Substance Use Disorder Treatment

Hello, I am Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In my clinical practice, I have witnessed firsthand the devastating toll that chronic pain and Substance Use Disorder (SUD) take on patients, families, and communities. As of August 4, 2026, the intersection of pain management, primary care, and addiction treatment has never been more critical. Drawing upon the latest empirical findings from leading clinical researchers across the nation, I want to take you on a journey through the new frontiers of SUD treatment, exploring how we can seamlessly integrate advanced medical protocols with functional medicine and chiropractic care to heal the whole person.

Our Collaborative and Integrative Approach at Injury Medical Clinic

Before we dive into the core topics, I want to take a moment to contextualize how this information is applied in a real-world clinical setting. At Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, in El Paso, Texas, we have cultivated a unique, multidisciplinary environment dedicated to comprehensive patient care. Our practice is a prime example of an integrative model where different healthcare disciplines work in concert for the patient’s benefit.

As a Doctor of Chiropractic (DC) with advanced certifications as an Advanced Practice Registered Nurse (APRN), a Family Nurse Practitioner (FNP-BC), and a Certified Functional Medicine Practitioner (CFMP, IFMCP), my perspective is inherently holistic. I view the body as an interconnected system where structure dictates function. My clinical focus is often on the neuromusculoskeletal system, pain management, and addressing the root causes of chronic disease through functional medicine.

However, complex cases, especially those involving substance use, personal injury, or significant internal health issues, require a broader medical perspective. This is where our collaboration with Dr. Maria Guadalupe Cardenas, MD, is indispensable. Dr. Cardenas serves as our Medical Director and Collaborative Physician. She is Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933) and brings over forty years of unparalleled clinical experience as an internist. In this collaborative environment, Dr. Cardenas provides rigorous medical direction and oversight, while I bring specialized expertise in chiropractic care, advanced practice nursing, and functional medicine.

This model is vital because patients suffering from substance use disorders—particularly Opioid Use Disorder (OUD)—often have complex, interwoven morbidities. A patient rarely presents with just an addiction; they present with severe neuromusculoskeletal pain, systemic neuroinflammation, metabolic derangement, and psychological trauma. By combining Dr. Cardenas’s vast internal medicine expertise with my focus on nervous system regulation through chiropractic adjustments and targeted functional medicine, we offer a truly comprehensive safety net. We do not just treat the addiction; we treat the underlying physiological drivers of the pain that often precipitated the substance use in the first place.

This MD-DC collaboration allows us to:

• Provide Comprehensive Diagnostics: We can integrate advanced imaging and laboratory testing (overseen by Dr. Cardenas) with functional assessments and chiropractic structural analysis (performed by me). This dual approach gives us a complete picture of the patient’s health.
• Offer a Spectrum of Treatments: A patient might receive a medical prescription for pain or inflammation from Dr. Cardenas while also undergoing chiropractic adjustments, spinal decompression, and rehabilitative exercises with my team. This combination often leads to faster and more sustainable results than either modality alone.
• Manage Complex Cases: For patients dealing with the aftermath of a personal injury, chronic pain can unfortunately lead to opioid dependence. Our team can co-manage these individuals, with Dr. Cardenas overseeing the medical aspects of pain and potential medication tapering. At the same time, I focus on non-pharmacological pain relief through chiropractic care, physical therapy modalities, and functional medicine strategies to reduce inflammation and support the body’s healing processes.
• Ensure Patient Safety: Having an experienced internist as our Medical Director ensures that all our treatment plans are medically sound and that any potential contraindications or red flags are identified and addressed promptly.

This integrated system is the lens through which I approach the information I am about to share. While this post focuses on SUD, the principles of seamless care transitions, patient-centered support, and multidisciplinary collaboration are universal. They are the bedrock of effective, modern healthcare.

The Expanding Role of Nurse Practitioners in Primary Care and Addiction Medicine

To understand where SUD management is headed, we must first look at frontline providers. Nurse practitioners represent a rapidly accelerating and vital profession within the United States healthcare matrix. Recent data indicate that over 258,000 NPs are currently in practice across the country, with a staggering projected growth rate of 45% over the next decade. This rate of expansion vastly outpaces many other medical professions.

Crucially, more than seventy percent of these NPs provide some form of primary care. Because of this massive footprint, NPs are uniquely positioned to serve as the primary entry point for Substance Use Disorder treatment, particularly for rural, marginalized, and underserved populations.

The educational model of advanced practice nursing inherently aligns with the core tenets of high-quality, compassionate SUD care. We are trained to value patient autonomy and self-determination, prioritize preventive health, and empower patients through robust health literacy and education. A core competency of this approach is Motivational Interviewing (MI). MI is not merely a conversational style; it is a neuro-linguistic and psychological tool designed to bypass the amygdala’s defensive neurological pathways and foster a non-judgmental, non-stigmatizing environment. By lowering the patient’s allostatic load during clinical encounters, we encourage genuine dialogue about their readiness to change.

Legal and Regulatory Shifts Empowering Providers

State law ultimately dictates an NP’s scope of practice regarding controlled-substance prescribing, practice autonomy, and the need for collaborative practice agreements with physicians like Dr. Cardenas. However, on a federal level, a monumental paradigm shift recently occurred: the removal of the X-waiver requirement.

Historically, providers were required to undergo specific training and obtain a specialized DEA waiver (the X-waiver) to prescribe buprenorphine for OUD. The legislative removal of this barrier firmly places buprenorphine prescribing within the standard scope of primary care providers. This means that NPs in a wide variety of settings can now actively prescribe this life-saving medication without arbitrary administrative bottlenecks.

Conversely, the regulatory landscape for methadone remains tightly controlled. Federal law dictates that methadone, when used specifically for the treatment of Opioid Use Disorder, must be dispensed directly from a licensed Opioid Treatment Program (OTP). However, within the inpatient hospital setting, state scope-of-practice laws often allow NPs to oversee the initiation or adjustment of methadone for patients admitted for diagnoses other than OUD (such as a severe infection), ensuring they do not go into acute withdrawal while receiving medical care.

Advanced Training and Certification Options

While foundational NP programs are rigorous, the specific time dedicated to the deep neurobiology of substance use disorders is often limited due to competing curricular demands. Therefore, continuing education is paramount for NPs seeking to master this domain; advanced training pathways exist, such as the Certified Addiction Registered Nurse-Advanced Practice (CARN-AP) certification. Furthermore, Psychiatric Mental Health Nurse Practitioners (PMHNPs) receive specialized, board-certified training in the intricate neurochemical diagnosis and management of SUDs, making them invaluable assets in the multidisciplinary care team.

The Healthcare Environment as a Perceived Risk for Patients

To effectively treat SUD, we must deeply understand the patient’s psychology. For many individuals actively using illicit substances, traditional healthcare settings are viewed not as places of healing, but as environments of acute risk. Due to systemic stigma and historical discrimination, patients with SUD often harbor a profound mistrust of medical providers. They fear punitive legal actions, forced involuntary withdrawals, or dismissive attitudes regarding their pain.

This fear triggers a cascade of negative health behaviors:

• Delayed Care: Patients will avoid seeking treatment until an infection or illness becomes life-threatening.
• Non-Disclosure: They will hide their substance use from providers, which can lead to dangerous drug-drug interactions when medications are prescribed.
• Minimization of Pain: Fearful of being labeled “drug-seeking,” patients may downplay severe pain, missing opportunities for early intervention.
• Against Medical Advice (AMA) Discharges: Patients in acute withdrawal may prematurely flee the hospital or clinic setting before completing their medical treatment, driven by the intolerable physiological agony of withdrawal.

The physiological consequences of delayed care are severe. Patients present later in their disease progression with highly acute illnesses—such as severe endocarditis, aggressive soft tissue infections, or advanced hepatic failure. This directly leads to exponential increases in morbidity, mortality, and financial strain on the healthcare system. Our goal at Injury Medical Clinic PA is to dismantle this risk environment. Through the collaborative efforts of Dr. Cardenas and me, we foster an environment rooted in physiological understanding, functional healing, and zero stigma.

Decoding the ASAM Levels of Care Criteria

When navigating the complex ecosystem of SUD treatment, we rely heavily on the American Society of Addiction Medicine (ASAM) Criteria. These criteria are the most widely used and comprehensive set of guidelines for placement, continued stay, and transfer of patients with addiction and co-occurring conditions.

The ASAM criteria rely on a multidimensional, strength-based assessment that evaluates the patient across six critical dimensions:

1. Acute Intoxication and/or Withdrawal Potential: Exploring the patient’s current physiological status and the neurochemical risks associated with sudden cessation.
2. Biomedical Conditions and Complications: Assessing concurrent health issues, such as diabetes, chronic pain, or infectious diseases. This is where our integrative medical and chiropractic oversight shines.
3. Emotional, Behavioral, or Cognitive Conditions: Evaluating psychiatric overlays, depression, trauma, and cognitive deficits.
4. Readiness to Change: Utilizing the Transtheoretical Model of Change to determine if the patient is in a pre-contemplative, contemplative, preparation, action, or maintenance phase.
5. Relapse, Continued Use, or Continued Problem Potential: Analyzing the neurobiological and psychological triggers that could prompt a return to use.
6. Recovery/Living Environment: Assessing the safety and supportiveness of the patient’s home life, peer networks, and socioeconomic stability.

Based on these dimensions, patients are placed on a continuum of care ranging from Level 1 (Standard Outpatient Services) to Level 4 (Medically Managed Intensive Inpatient Services). Primary care naturally sits at the center of this continuum, acting as the hub from which auxiliary options—such as Intensive Outpatient Programs (IOPs), residential facilities, and peer support networks—radiate outward based on the fluctuating acuity of the patient’s needs.

Overcoming the Primary Care Shortage and Treatment Barriers

Despite primary care being the most logical entry point for SUD treatment, access remains severely limited. Looking back at data gathered through 2025, an estimated eighty-six point six percent of patients with Opioid Use Disorder who could clinically benefit from Medication-Assisted Treatment (MAT) do not receive it.

We must address the elephant in the room: the United States is facing a catastrophic shortage of primary care providers. Recent metrics show that over 77.2 million Americans live in a designated Primary Care Health Professional Shortage Area. Currently, only about 44.5% of the national need for primary care providers is being met. To fully bridge this gap, the system requires an influx of more than 13,300 additional primary care physicians and advanced practice providers.

For the providers currently shouldering this immense burden, integrating SUD care presents significant logistical barriers:

• Time Constraints: In a high-volume clinic, thoroughly assessing addiction neurobiology and implementing complex MAT protocols feels daunting.
• Financial Disincentives: Chronically low reimbursement rates for counseling and complex care coordination.
• Resource Scarcity: A profound lack of accessible psychosocial referral networks.
• Institutional Hurdles: Insufficient managerial support and outdated institutional policies that mandate concurrent counseling (step-treatment) before life-saving medications are released.
• Diversion Concerns: Persistent fears regarding the illicit diversion of prescribed medications like buprenorphine.

Building a Successful Integrative Primary Care Model

To overcome these barriers, leading clinical research highlights four foundational pillars required for successfully integrating SUD treatment into primary care:

1. Pharmacologic Therapy: Offering direct access to medications like buprenorphine or naltrexone.
2. Co-Located Psychosocial Services: Having mental health professionals operating under the same roof.
3. Care Integration: Creating a seamless, unified chart and treatment plan across all modalities.
4. Patient Outreach and Education: Proactively engaging the community.

Successful models utilize a robust team-based approach. This includes utilizing nurse care managers as the primary clinical touchpoints for patients stabilizing on buprenorphine and empowering “SUD Champions” within the clinic with protected time for continuing education. Organizations like the Provider’s Clinical Support System (PCSS), funded by SAMHSA, offer invaluable clinical mentoring programs where primary care clinicians can consult addiction specialists directly on complex prescribing scenarios.

Integrative Case Study: James and the Outpatient Model

To understand how these best practices apply, let us examine a clinical case study in an outpatient primary care setting.

James is a fifty-two-year-old male presenting to his primary care NP at a Federally Qualified Health Center. His chief complaints are the management of uncontrolled Type 2 Diabetes Mellitus and severe, intractable chronic low back pain. James has a well-documented history of Opioid Use Disorder.

During the consultation, utilizing the principles of motivational interviewing, the NP asks open-ended, non-judgmental questions regarding his current pain levels and potential cravings. Because the clinical environment feels safe, James openly discloses a recent return to illicit fentanyl use. He eloquently identifies the primary physiological and psychological drivers of his relapse: unrelenting physical pain and profound, unmanaged depression. James reveals he was previously stabilized on buprenorphine but abruptly discontinued it under the false assumption that he “could do it without support.” Recognizing his vulnerability, he explicitly asks his primary care provider for help in restarting his medication.

The Neurophysiology of Relapse and Pain

Let us pause to examine the physiological underpinnings of James’s situation deeply. Chronic pain and SUD are inexorably linked through shared neural circuitry. Chronic nociceptive signals from James’s lower back constantly bombard his central nervous system, particularly the dorsal horn of the spinal cord and the thalamus, leading to central sensitization. In this state, the nervous system becomes hyper-reactive; non-painful stimuli are perceived as painful (allodynia), and painful stimuli are magnified (hyperalgesia).

Concurrently, his illicit fentanyl use profoundly alters his brain’s reward center. Fentanyl, a highly lipophilic and potent full mu-opioid receptor (MOR) agonist, crosses the blood-brain barrier rapidly, triggering massive, non-physiological releases of dopamine in the Nucleus Accumbens (NAc). Over time, this causes a down-regulation of endogenous opioid receptors. When James experiences chronic pain, his depleted endogenous endorphin system cannot cope, driving an overwhelming biological craving for exogenous opioids to achieve homeostasis. His depression is a direct biochemical result of dopamine depletion and chronic neuroinflammation fueled by his uncontrolled diabetes.

High-Dose Buprenorphine Initiation and Multidisciplinary Action

In response to James’s request, the NP initiates a shared decision-making process. They meticulously review the pharmacological mechanics, risks, and benefits of restarting buprenorphine. They agree upon a High-Dose Initiation strategy.

Physiological context: Buprenorphine is a partial mu-opioid agonist with an exceptionally high binding affinity. If introduced while fentanyl (a full agonist) is still occupying the receptors, buprenorphine will violently strip the fentanyl off the receptors but only partially activate them. This causes a sudden, catastrophic drop in opioid signaling, leading to Precipitated Withdrawal—a state of agonizing physical distress mediated by a massive surge of noradrenaline from the Locus Coeruleus. High-dose initiation (often following a period of monitored abstinence to allow fentanyl clearance, or utilizing specific micro-dosing protocols) aims to saturate the receptors to achieve blockade and stabilization rapidly.

The PCP immediately transmits the buprenorphine prescription to a co-located pharmacy on the campus. But medication alone is insufficient to address James’s root causes. The provider simultaneously submits referrals for a co-located mental health counselor to address the dopamine-depleted depression, and a Cognitive Behavioral Therapy (CBT) chronic pain group.

In a powerful display of integrated care, the PCP physically walks James down the hall for a “warm handoff” to the mental health counselor. This simple neurological cue of physical introduction dramatically reduces James’s anxiety and solidifies his trust in the interdisciplinary team.

The Role of Chiropractic and Functional Medicine in James’s Recovery

If James were treated at our facility, Injury Medical Clinic PA, his protocol would expand further under the collaborative guidance of Dr. Cardenas and me.

To address the mechanical driver of his relapse—his chronic low back pain—we would implement targeted chiropractic adjustments. The physiological reasoning here is based on the Gate Control Theory of Pain and nervous system down-regulation. By applying specific, high-velocity, low-amplitude (HVLA) thrusts to spinal subluxations, we stimulate mechanoreceptors within the joint capsules. These mechanoreceptors fire rapid afferent signals to the dorsal horn of the spinal cord, effectively “closing the gate” to the slower, pain-carrying C-fibers. Furthermore, restoring optimal spinal biomechanics reduces localized tissue ischemia and downregulates the production of pro-inflammatory cytokines (like Substance P and Interleukin-6), providing James with profound, non-pharmacological pain relief.

From a Functional Medicine perspective, we would address his Type 2 Diabetes and resulting depression through the Gut-Brain Axis. Opioid use fundamentally alters the gut microbiome (opioid-induced bowel dysfunction), leading to intestinal hyperpermeability (“leaky gut”). This allows lipopolysaccharides (LPS) to enter the bloodstream, triggering systemic neuroinflammation that blocks the synthesis of serotonin and dopamine from their amino acid precursors (tryptophan and tyrosine). By utilizing specific functional medicine protocols—such as high-dose Omega-3 fatty acids to reduce neuroinflammation, targeted probiotics to heal the mucosal lining, and blood-sugar-stabilizing diets—we biochemically rebuild James’s neurotransmitter capacity, significantly alleviating his depression and cravings from the inside out.

Following the initiation, James engages in short-interval follow-ups. Despite the initial discomfort of waiting for moderate withdrawal to start the high-dose buprenorphine safely, he successfully stabilizes. He transitions to regular visits with a nurse care manager, coordinates with a peer support specialist, and begins learning CBT skills. He ends his clinical week feeling hopeful, empowered, and, most importantly, fentanyl-free.

The Inpatient Addiction Consult Service: A Multidisciplinary Lifeline

While the outpatient primary care model is ideal for patients like James, we must recognize that for many patients suffering from severe SUD, primary care does not provide sufficient scaffolding to disrupt illicit use. For these complex, high-acuity cases, acute hospital settings offer a critical window of opportunity.

Hospitalizations for acute medical issues (like endocarditis or overdoses) represent a “teachable moment.” The patient has hit a biological wall, and their goals are forcibly reevaluated. For patients who have historically evaded the healthcare system due to stigma, an empathetic, non-judgmental inpatient experience can fundamentally alter their life trajectory.

The absolute gold standard for managing this population within a hospital is the Inpatient Addiction Consult Service (ACS). This service operates as an interdisciplinary strike team, highly specialized in the nuances of addiction neurobiology and complex care coordination.

The ACS team typically comprises:

• Medical Providers (MDs, NPs, PAs): Experts in the pharmacology of withdrawal management and MAT initiation.
• Social Workers: Specialists in navigating the psychosocial labyrinth of housing, insurance, and discharge placement.
• Care Coordinators: Personnel dedicated to ensuring seamless logistical transitions.
• Peer Support Specialists: Individuals with lived experience in addiction and recovery. Their presence provides unparalleled emotional validation, significantly lowering the patient’s defensive affective filters.

Beyond direct patient care, an Addiction Consult Service acts as a vital catalyst for systemic, institutional change. They spearhead quality improvement initiatives, revise archaic hospital policies to be more patient-centered, and provide institution-wide education to nurses, surgeons, and administrators on the biological realities of SUD, thereby systematically dismantling institutional stigma.

Complex Acute Case Study: Lisa’s Journey Through the ACS

To illustrate the profound impact of an Addiction Consult Service, let us explore the highly complex acute care case of Lisa.

Lisa is a thirty-two-year-old female who presents to the hospital Emergency Department reporting seven days of severe, progressive swelling, erythema (redness), and calor (warmth) in her left lower extremity. Upon compassionate intake, Lisa discloses daily, heavy use of illicit fentanyl (both via intravenous injection and inhalation) alongside daily intravenous methamphetamine use.

Physiologically, Lisa is in an incredibly precarious state. Her last drug use was approximately six hours prior, and she is rapidly descending into acute opioid withdrawal. Furthermore, she is carrying a massive psychological burden: she is terrified for the safety of her dog, whom she left with a friend temporarily. A deeper chart review reveals a previous, untreated positive test for active Hepatitis C (HCV).

The Pathophysiology of Polysubstance Use and Infection

Lisa’s clinical presentation requires a deep physiological deconstruction.

1. Left Lower Extremity Cellulitis: Intravenous drug use severely compromises the epidermal barrier. Pathogens, typically Staphylococcus aureus or Streptococcus pyogenes, have invaded the deep dermis and subcutaneous tissues, triggering a massive localized immune response. The resulting vasodilation and increased capillary permeability cause her visible swelling and redness. Without rapid intervention with IV antibiotics, this localized infection can easily breach the fascial planes (necrotizing fasciitis) or enter the bloodstream, causing lethal sepsis or infective endocarditis.
2. Methamphetamine and Fentanyl Polysubstance Neurobiology: Lisa is combining a potent central nervous system stimulant (methamphetamine) with a profound depressant (fentanyl). Methamphetamine forcefully reverses the dopamine transporter (DAT) and the Vesicular Monoamine Transporter 2 (VMAT2), causing a massive, neurotoxic flood of dopamine and norepinephrine into the synaptic cleft. This leads to extreme oxidative stress and microglial activation, destroying dopaminergic terminals. When the methamphetamine wears off, the brain is left utterly devoid of dopamine, leading to crushing anhedonia and severe cravings.
3. Hepatitis C Virus (HCV): HCV is a bloodborne RNA virus that specifically targets hepatocytes in the liver. Left untreated, chronic HCV causes relentless hepatic inflammation, leading to stellate cell activation, progressive liver fibrosis, cirrhosis, and ultimately, hepatocellular carcinoma.

The Addiction Consult Service Intervention

Within the first twenty-four hours of Lisa’s admission, the ACS springs into action.

First, the ACS medical provider conducts a comprehensive physical and neurochemical assessment, diagnosing severe Opioid and Stimulant Use Disorders. Recognizing the imminent threat of withdrawal driving Lisa to leave the hospital Against Medical Advice (AMA), the provider immediately discusses medication options. They collaboratively decide to utilize methadone for acute withdrawal management.

Physiological reasoning: Methadone is a long-acting, synthetic, full mu-opioid agonist. Because it is a full agonist like fentanyl, it does not carry the risk of precipitated withdrawal that buprenorphine does when fentanyl is still highly saturated in the patient’s adipose tissues. Methadone will stabilize the mu-opioid receptors, effectively halting the agonizing noradrenaline surge of withdrawal, allowing Lisa to tolerate her hospitalization. The long-term plan is to stabilize her on methadone, cure the acute infection, and subsequently utilize a specialized low-dose initiation (micro-dosing) strategy to transition her safely to buprenorphine before discharge.

Next, the ACS social worker engages Lisa and completes a thorough ASAM assessment. Utilizing high-level motivational interviewing and strict adherence to patient consent, the social worker validates Lisa’s fears and focuses on helping her remain in the hospital. For a patient who has spent years marginalized, the hospital is a terrifying place; the social worker acts as her anchor.

Simultaneously, the ACS Peer Support Specialist meets with Lisa. The peer focuses not on the medical jargon, but on Lisa’s immediate human concern: her dog. The peer provides a cell phone, active listening, and logistical assistance to secure long-term care for her pet. This intervention triggers the release of endogenous oxytocin in Lisa’s brain—a neurohormone associated with social bonding and trust—which suppresses the stress-induced cortisol response and drastically improves her emotional regulation.

Stabilization and Education

Over the next two days, the multidisciplinary approach yields remarkable results. The IV antibiotics begin neutralizing the cellulitis. Lisa’s opioid withdrawal is successfully stabilized via titrated methadone. The team successfully executes the low-dose buprenorphine initiation, ensuring her long-term OUD is manageable in an outpatient setting. She is formally referred to Hepatology for curative direct-acting antiviral (DAA) therapy for her Hepatitis C.

While Lisa remains hospitalized, the team continues to provide critical harm-reduction education. They address her ongoing methamphetamine cravings, discussing off-label pharmacological interventions and the vital behavioral protocol of Contingency Management (a highly evidence-based therapy for stimulant use disorder utilizing positive reinforcement).

They also educate Lisa on the dire realities of the modern illicit drug supply. The team explains the high probability of drug contamination—meaning that even if Lisa believes she is purchasing pure methamphetamine, it is highly likely adulterated with lethal doses of synthetic opioids, exponentially increasing her risk of fatal respiratory depression. They supply her with Naloxone (a competitive opioid antagonist that violently displaces opioids from the receptors, instantly reversing an overdose) and heavily emphasize the dangers of using substances alone or sharing paraphernalia.

Care Transitions and Community Partnerships

The ultimate test of a successful clinical intervention lies not just in acute stabilization, but in the transition of care. A Care Transition occurs when a patient moves between different levels of the ASAM criteria—for instance, discharging from an inpatient hospital bed to a community-based Intensive Outpatient Program (IOP), or shifting from a high-acuity bridge clinic back to a primary care NP.

Historically, these transitions are points of catastrophic failure in the healthcare system. The challenges are numerous:

• Care Silos: Hospitals, behavioral health centers, and primary care clinics often use incompatible electronic health records, resulting in critical communication blackouts.
• Systemic Stigma: Patients may face prejudice from community providers who lack advanced SUD training.
• Resource Deficits: Patients often lack reliable transportation, stable housing, or the necessary broadband technology required to participate in modern telehealth check-ins.
• Insurance Barriers: Prior authorization nightmares that delay the dispensing of life-saving MAT medications upon discharge.

To combat this, scoping reviews of transition models emphasize the paramount importance of leveraging existing community partnerships. Best practices dictate establishing hardwired, direct lines of communication between the discharging inpatient agency and the receiving community clinic.

At Injury Medical Clinic PA, Dr. Cardenas and I prioritize seamless transitions. If a patient is referred to us after hospitalization, we immediately review their discharge summaries, medication lists, and functional baselines. We do not operate in a silo. We collaborate directly with their mental health counselors, pain management specialists, and peer support networks. We provide a medical home where their internal medicine needs (overseen by Dr. Cardenas) and their neuromusculoskeletal and functional rehabilitation needs (managed by me) are addressed simultaneously under one roof.

The Crucial Role of Continuity in Care Transitions

One of the most significant challenges in addiction medicine is ensuring that the progress made in an acute care setting, like a hospital, is not lost once the patient is discharged back into the community. This transition is a vulnerable period, and research has illuminated several key strategies to build a bridge that patients can successfully cross. The concept of continuity of care is not just a buzzword; it is a powerful, evidence-based determinant of long-term success.

Leading researchers have found that structuring programs to ensure continuity of providers between acute and community settings is profoundly helpful. Imagine this scenario: a patient arrives at the hospital in crisis, perhaps experiencing severe opioid withdrawal. A compassionate provider sees them, stabilizes them, and starts them on a life-saving medication like buprenorphine. A therapeutic alliance, a bond of trust, begins to form. Now, if that same provider is available to see that patient for a follow-up appointment in a community-based “”ridge clinic””after discharge, the likelihood of the patient continuing treatment skyrockets. That pre-established patient-provider relationship becomes an anchor. The patient is not starting from scratch with a stranger; they are continuing a journey with someone who already understands their history and has shown them care. This simple yet powerful dynamic can make the difference between sustained recovery and a relapse.

Another critical practice is providing bridge prescriptions at hospital discharge. Navigating the healthcare system can be complex and slow. A patient leaving the hospital may face delays in securing an appointment at a community clinic. Without a continued supply of their medication, they are left in a precarious position, at high risk for withdrawal and relapse. In my own practice and as a best practice standard, when a patient is started on a medication for substance use disorder (SUD) in the hospital, I ensure they leave with at least a two-week prescription. This provides a crucial buffer, giving them the time they need to connect with their follow-up appointment without the added stress and danger of an interruption in their treatment. It is a practical and compassionate step that acknowledges the real-world barriers our patients face.

Integrating Services for Holistic Support

The journey to recovery from a substance use disorder is multifaceted. It’s rarely just about the substance itself; it often involves co-occurring mental health conditions, social instability, and a need for comprehensive support. That is why leading experts advocate co-locating services wherever possible.

• What Does Co-location Look Like? It means creating a one-stop shop for recovery. Imagine a facility where a patient can see their SUD treatment provider, meet with a mental health counselor, consult with a social worker about housing, and even access primary medical care, all under the same roof. This model drastically reduces the logistical and psychological barriers to accessing care. Instead of navigating multiple appointments at different locations—a daunting task for anyone, let alone someone in early recovery—the patient can have their needs met in a single, familiar environment. This integrated approach not only enhances support but has also been shown to improve retention in care significantly.
• Patient Preference is Paramount: We must also recognize that there is no one-size-fits-all approach to treatment. Offering patients preference in their care modality and location is a cornerstone of person-centered care. For some, in-person visits provide an invaluable sense of connection and accountability. For others, such as a single parent with limited childcare or an individual with transportation challenges, a telehealth option can be the difference between engaging in treatment and not being able to at all. Embracing technology and offering flexible options demonstrates respect for the patient’s life circumstances and empowers them to take an active role in their recovery.
• The Power of Care Navigators: Finally, the transition from hospital to community can be a labyrinth of paperwork, phone calls, and eligibility requirements. This is where care navigators with specialized knowledge of community resources become indispensable. These individuals act as guides, helping patients schedule appointments, understand their insurance benefits, connect with support groups, and access resources for housing, food, and employment. Programs that fund and integrate care navigation are essential investments in making these transitions smooth and successful. They are the human connection that transforms a complex system into a navigable path.

Integrative Chiropractic and Holistic Support

From an integrative chiropractic perspective, this model of co-located, holistic support resonates deeply. In our clinic, a patient struggling with chronic pain that has led to opioid use can see me for chiropractic adjustments to address the root structural issues and alleviate pain non-pharmacologically. The adjustment works by restoring proper motion to spinal joints, which in turn reduces mechanical stress and irritation on the nerves. This can directly decrease pain signals being sent to the brain.

At the same time, the patient can consult with Dr. Cardenas for medical management and work with our rehabilitation team on exercises to strengthen their core and improve posture. A functional medicine consultation with me could identify nutritional deficiencies or inflammatory triggers that are exacerbating their pain and cravings. By having these services under one roof, we create a synergistic effect. The chiropractic adjustment helps the body heal and reduces the need for pain medication, the medical oversight ensures safety, and the functional medicine approach nourishes the body from the inside out. This is co-located, integrated care in action.

Spotlight on Vulnerable Populations: Justice-Involved Individuals

When we discuss care transitions, we must focus on specific populations who face exceptional and often overwhelming challenges. One such group is justice-involved individuals, particularly those recently released from carceral settings like jail or prison.

The statistics are stark and sobering: overdose is a leading cause of death following release from prison. This public health crisis demands our urgent attention. Several factors converge to create this perfect storm of risk.

• Loss of Opioid Tolerance: One of the most dangerous physiological changes that occurs during incarceration is the loss of opioid tolerance. A person who was using a certain amount of opioids before being incarcerated may have their tolerance drop significantly after a period of abstinence. Upon release, if they return to using the same amount they used previously, their body may no longer be able to handle it. This is a common and tragic cause of fatal overdose. The illicit drug supply has also become increasingly toxic, with fentanyl contaminating nearly everything, making a return to use exponentially more dangerous than ever before.
• Barriers to Treatment Access: Individuals leaving a carceral setting often have no idea how to navigate the complex civilian healthcare system. They may not know who to call, what a “ridge clinic” is, or how to schedule a follow-up appointment. The loss of insurance coverage often compounds this interruption of healthcare, as many people lose their Medicaid or other insurance plans while incarcerated.
• Psychological and Social Factors: The experience of incarceration can be deeply damaging to a person’s sense of self-worth. There is often a lack of education about addiction as a medical disease and a pervasive stigma that can lead to feelings of hopelessness.

Furthermore, the availability and quality of Medications for Opioid Use Disorder (MOUD) within jail and prison systems are often inconsistent and inadequate. While some facilities are beginning to offer medications like buprenorphine or methadone, they are often poorly implemented. Patients may be given doses that are too low to treat their cravings or withdrawal symptoms adequately. This not only leaves them suffering but can also negatively affect their attitude toward these life-saving medications. They might leave prison believing that “buprenorphine doesn’t work for me,” when in reality, they were never on a therapeutic dose. This creates a significant barrier to re-engaging with treatment upon release.

Addressing this crisis requires a multi-pronged approach: ensuring access to MOUD within carceral settings, providing comprehensive discharge planning that includes scheduled appointments and bridge prescriptions, and offering intensive support from care navigators who specialize in helping this population.

Spotlight on Vulnerable Populations: Peripartum Individuals

Another population at an extremely high risk for negative outcomes related to substance use is peripartum individuals—those who are pregnant, giving birth, or in the postpartum period. This is a time of immense physical and emotional change, and when compounded by a substance use disorder, the risks, including fatal overdose, are magnified.

Pregnant individuals face a unique and formidable set of barriers when seeking care. The primary barriers are stigma and fear. There is a pervasive stigma from the healthcare system itself, where providers may be judgmental or poorly educated about addiction. But the most profound fear is that admitting to substance use will affect child custody and result in legal consequences. This fear is not unfounded.

In a heartbreaking and counterproductive cycle, research has shown that the most common strategy women use to avoid the detection of drug use during pregnancy is the avoidance of medical care altogether. They stay away from prenatal appointments, avoid hospitals, and try to manage on their own, all out of fear of being reported and having their child taken away. This, of course, leads to worse outcomes for both the mother and the baby.

The Complex Issue of Reporting to Child Protective Services

It’s a common misconception among healthcare providers that any substance use by a pregnant or parenting individual must be reported to child welfare services. This is a critically important topic to understand with nuance and accuracy.

As medical providers, we are indeed mandated reporters. This means we are legally required to report suspected abuse or neglect of children or vulnerable adults to the authorities. However, the key point is this: substance use alone does not automatically establish child maltreatment.

The federal Comprehensive Addiction and Recovery Act (CARA) of 2016 provides important guidance on this issue. CARA requires states to have policies in place to address the effects of substance use on infants and their families, with a focus on early identification and intervention. The law specifies that healthcare providers must notify child welfare when an infant is born “affected by substances.”

Here is the crucial distinction: federally, reporting a substance-affected infant does not need to be in the form of a report of suspected child abuse or neglect. It can simply be a notification that connects the family with supportive services. However, implementation varies dramatically by state. Each state determines whether a report of a substance-affected infant automatically triggers a formal investigation for abuse and neglect and what the legal repercussions are if maltreatment is confirmed.

Despite the federal guidance that substance use during pregnancy does not equal maltreatment, many states have unfortunately taken steps to criminalize this behavior, specifically for women. When a woman becomes pregnant, her body is often viewed differently by the legal system, and she is more likely to face harsh punishments for actions that would not be criminalized otherwise.

The result of this criminalization and the associated stigma has specific, detrimental effects.

• Increased Risk of Overdose: Punitive policies make it harder for pregnant women to access life-saving treatment and harm reduction resources. Fear keeps them in the shadows, where they are at a much higher risk of overdose.
• Avoidance of Prenatal Care: The fear that their baby will be taken away is a powerful deterrent that keeps pregnant women from seeking the prenatal care that is vital for a healthy pregnancy.

A compelling cross-sectional study completed in 2022 provided clear evidence for this. The study looked at over 4,000 pregnant women who engaged in substance use and compared their care-seeking behavior based on the policies of the state they lived in. The findings were unambiguous: women who delivered in states with more punitive or stricter mandatory reporting policies initiated prenatal care later, had a lower likelihood of receiving adequate prenatal care, and were less likely to attend a postpartum healthcare visit compared to those who delivered in states with less restrictive, more supportive policies (Patrick et al., 2022).

The conclusion is undeniable: fear of reporting directly and negatively affects care-seeking behavior. This fear has also been found to affect engagement in SUD treatment itself. It’s a shocking statistic, but fewer than one in four individuals with opioid use disorder receive any treatment in a given month of pregnancy. We are failing this vulnerable population, and our policies are a major reason why.

A Call for a More Compassionate and Effective Approach

So, how should we, as healthcare providers, think about the issue of reporting when we encounter a pregnant or parenting woman we suspect is using substances? The first and most important point to drive home is that substance use during pregnancy or parenting is almost always best addressed by treatment and support, not by stigma and criminalization.

Reporting can have severe and often counterproductive adverse consequences.

• Disengagement from the Health System: A report can shatter the trust between a patient and the healthcare system, leading to complete disengagement at a time when they need support the most.
• Significant Burden on Parents: Even a preliminary child welfare inquiry can be incredibly disruptive. Parents can lose days of work, and therefore income, just trying to comply with investigation requirements.
• The Trauma of Custody Loss: The loss of custody can have devastating and long-lasting detrimental effects on both the mother and the child. For mothers, the trauma can be immense. Research has shown that patients who have had their parental rights terminated often have shorter interval pregnancies, meaning they become pregnant again more quickly, often without having had the chance to address their underlying SUD and trauma.

If we can change these women’s experience with the system from one of fear and punishment to one of compassion and support, they are far more likely to seek care earlier and stay engaged. Regular engagement in prenatal care dramatically improves outcomes for both the mother and the baby.

Creating a Welcoming Environment for Pregnant Individuals with SUD

As treatment providers, we have a responsibility to make our care as welcoming and accessible as possible. This is not just a nicety; it is a clinical imperative.

• Offer Non-judgmental, Person-Centered Care: This starts from the moment a woman walks in the door. Simple words like “Thank you for coming to see me today” can be incredibly powerful. It shows that you appreciate the many barriers they may have had to overcome to get to that visit. It invites them into a partnership rather than an interrogation.
• Have Realistic and Honest Discussions: We must be honest about the risks of substance use in pregnancy, but this should be done in a way that honors the patient’s goals and experiences. It is a conversation, not a lecture. This means discussing evidence-based treatment options, including medications that are safe and effective in pregnancy, and offering warm referrals to treatment programs.
• Support Postpartum Transitions: The postpartum period is another time of high vulnerability. We need to support women with care transitions however we can.

• • Flexibility is Key: Offer flexibility in the timing and modality of follow-up appointments. A telehealth option can be a lifeline for a new mother.
  • Provide Practical Resources: Wherever possible, provide services or resources for transportation or childcare assistance.
  • Utilize Warm Handoffs: A “”arm handoff””can make all the difference. If you are a primary care provider referring a patient to a mental health counselor, don’t just give them a phone number. If possible, make the call with them, or have the counselor come and meet the patient briefly. This personal connection builds trust and dramatically increases the likelihood of follow-up.
  • Connect with Social Services: Actively engage and connect postpartum patients with needed social services for housing, food, and other basic needs.

The Role of Integrative Chiropractic in Peripartum Care

The peripartum period involves profound physical and hormonal changes that can exacerbate pain and stress, which are major triggers for substance use. Integrative chiropractic care can play a vital supportive role.

• Pain Management: Pregnancy often brings on low back pain, sciatica, and pelvic pain due to hormonal changes (relaxin loosening ligaments) and the biomechanical stress of a growing baby. Chiropractic adjustments, specifically those tailored for pregnancy (like the Webster Technique), can safely and effectively alleviate this pain. By managing pain non-pharmacologically, we can reduce a patient’s reliance on or perceived need for pain medication, including opioids.
• Nervous System Regulation: Chiropractic care is fundamentally about optimizing nervous system function. The stress and anxiety associated with pregnancy and SUD can keep the body in a constant state of “fight or flight” (sympathetic dominance). Gentle adjustments can help shift the nervous system back toward a state of “rest and digest” (parasympathetic tone). This can help reduce anxiety, improve sleep, and lower stress hormones like cortisol, all of which benefit both the mother and the developing baby.
• Postpartum Recovery: After birth, the body undergoes another rapid transformation. Chiropractic care can help realign the pelvis and spine, address pain from childbirth or holding/feeding a newborn, and support the body’s overall recovery. A body that feels better and functions better is more resilient to the challenges of early motherhood and recovery from SUD.

In our clinic, a pregnant or postpartum patient could receive gentle chiropractic care from me to manage her physical discomfort. At the same time, Dr. Cardenas monitors her overall medical health and MOUD, creating a truly comprehensive and supportive care plan.

Optimizing Your Wellness- Video

Medications for Opioid Use Disorder (MOUD) in Pregnancy

For pregnant individuals with Opioid Use Disorder (OUD), Medications for Opioid Use Disorder (MOUD) are not just an option; they are the standard of care and are life-saving. Let’s review the key considerations for MOUD during pregnancy and in the context of care transitions.

The two primary medications used are buprenorphine and methadone. It is crucial to understand and communicate to patients that both of these medications are considered safe in pregnancy. When I counsel patients who are weighing the risks and benefits of starting one of these medications, my message is clear: the risk of untreated OUD, which includes cycles of intoxication and withdrawal, overdose, and exposure to infectious diseases, is far greater for both the mother and the fetus than the risk of the medication itself. Maternal withdrawal can compromise blood flow to the placenta, leading to fetal distress or even death. Stabilizing the mother with MOUD provides a stable, safe environment for the fetus to grow.

Addressing Neonatal Opioid Withdrawal Syndrome (NOWS)

A common and understandable concern for expectant mothers is, “Will my baby go into withdrawal if I start this medication?” We must be prepared to address this question with facts and compassion. Yes, there is a risk of the baby experiencing Neonatal Opioid Withdrawal Syndrome (NOWS), also known as Neonatal Abstinence Syndrome (NAS). This is a condition where the baby, who was exposed to opioids in utero, experiences withdrawal symptoms after birth.

It’s important to explain that NOWS is treatable and manageable, and that hospitals have well-established protocols to care for these infants. Most importantly, we must emphasize that the benefits of the mother being stable and safe on medication far outweigh the risks of NOWS.

A critical counseling point is that the risk and severity of NOWS are not dose-dependent. This is a common misconception. A mother on a higher dose of buprenorphine or methadone is not necessarily more likely to have a baby with severe NOWS than a mother on a lower dose. Therefore, the goal is not to keep the dose as low as possible. The best and most appropriate medication dose is the one that adequately treats the patient’s withdrawal symptoms and cravings. An undertreated mother is at high risk of returning to illicit substance use, which is infinitely more dangerous for the baby than a therapeutic dose of MOUD.

Dose Adjustments During and After Pregnancy

Pregnancy brings about significant physiological changes, including increased blood volume, changes in liver metabolism, and an increase in what’s known as the volume of distribution. This means that as pregnancy progresses, particularly in the third trimester, a woman’s body metabolizes medications like buprenorphine and methadone much faster. Consequently, pregnant women often need to be on higher doses of these medications to maintain a stable, therapeutic effect. It is not uncommon for dose requirements to increase significantly during the third trimester.

After a woman gives birth, her metabolism begins to return to its pre-pregnancy state. However, it is not known exactly how quickly this happens. The current thinking is that it can take anywhere from three to twelve weeks. This has important implications for postpartum care. It means that postpartum dose reductions of buprenorphine or methadone should be made carefully and on a case-by-case basis. We cannot apply a standard tapering schedule. The patient must be monitored closely for signs of sedation and respiratory depression, which could indicate that their dose is now too high for their postpartum metabolism. Regular check-ins and open communication about how they are feeling are essential.

The Positive Outcomes of MOUD in Pregnancy

It’s vital to highlight the positive outcomes associated with MOUD during pregnancy. The evidence is clear: MOUD leads to a decreased risk of overdose for the mother, both during pregnancy and in the high-risk postpartum period. It also leads to better birth outcomes, including increased birth weight and a greater likelihood of the baby going home with the mother.

We also have data on what factors are associated with discontinuing MOUD after birth, which is a negative outcome. These factors include:

• Shorter duration of MOUD while pregnant: In other words, the earlier in her pregnancy a patient starts MOUD, the more likely she is to continue it after giving birth. This underscores the importance of early identification and engagement.
• Incarceration: A history of incarceration is associated with a higher likelihood of MOUD discontinuation.
• Non-white race: Unfortunately, racial disparities persist, with non-white women being more likely to discontinue MOUD, highlighting systemic issues and biases that need to be addressed.

To improve outcomes, our care needs to be specifically designed and implemented to address the unique barriers women face in accessing and continuing MOUD in the postpartum period.

Case Study: Best Practices for Peripartum Care Transitions

Let’s walk through a case study to illustrate how we can apply these best practices in a real-world scenario. As we’ve established, linking pregnant individuals with OUD to comprehensive recovery services can reduce overdose deaths, improve pregnancy outcomes, and increase the number of people who can successfully parent their babies.

The Case: Liz

• Patient: Liz, a 32-year-old female.
• Situation: She is one day postpartum after the birth of a baby girl.
• History: She has a history of OUD with illicit fentanyl use. She was commendably started on buprenorphine by a primary care provider during her pregnancy.
• Medication: Her buprenorphine dose was titrated up during her pregnancy to a total daily dose of 32 milligrams (taken as 8 milligrams, four times daily) during her third trimester. This is a robust, therapeutic dose, reflecting her increased metabolic needs during late pregnancy.

Now, Liz is postpartum. What are the key considerations for her post-discharge care transition?

1. Consider the Mother-Baby Dyad: First and foremost, I would focus on the health and well-being of the mother-baby dyad. The transition to motherhood is overwhelming for anyone, and for Liz, it is compounded by her recovery journey. Her baby may need to be monitored in the Neonatal Intensive Care Unit (NICU) for several days for potential NOWS. I need to understand the practical context of her life. Does she have stable housing? Does she have transportation to get to and from the hospital to see her newborn? Does she have social support—a partner, family, or friends—to help her? The answers to these questions will shape her care plan.
2. Offer Flexible Follow-up Options: Recognizing the stress she is under, I would offer flexible follow-up options. This could include telehealth visits, especially in the first few weeks. Ideally, I would connect her with co-located services where she and her baby can receive care together, reducing the logistical burden.
3. Counsel on Postpartum Dose Adjustments: I would need to have a clear and careful conversation with Liz about her buprenorphine dose. I would counsel her that as her metabolism returns to normal, she likely will not need as high a dose to treat her cravings and withdrawal adequately. I would explain that dose reductions may be necessary to avoid sedation, which is a safety concern, especially when she is caring for a newborn. I would frame this not as taking her medication away, but as adjusting it to what her body now needs. This process should be collaborative. I would want to be checking in with her regularly by phone or text, asking about her cravings and withdrawal symptoms, and encouraging small, gradual dose reductions over the three to twelve weeks following her pregnancy.
4. Scaffold Her Recovery with Social Supports: Liz’s recovery cannot happen in a vacuum. It needs to be scaffolded with as many social supports as possible. This is where an integrative team approach is crucial. I would engage:

• • Social Work: To help with housing, insurance, and other benefits.
  • Peer Support Specialists: Individuals with lived experience who can offer invaluable empathy and guidance.
  • Mental Health Support: To address any underlying trauma, anxiety, or postpartum depression.
  • Practical Resources: Connecting her to food resources (like WIC or food banks), transportation resources, and housing resources.

• Of course, the availability of these resources varies considerably by location and insurance coverage. This highlights the importance of every provider being deeply knowledgeable about the resources available in their local area.

By taking this comprehensive, compassionate, and practical approach, we can help Liz navigate this challenging transition and set her and her new baby up for a healthy and successful future.

Spotlight on Vulnerable Populations: Adolescents

The final special population I want to touch on in relation to care transitions is adolescents. This group presents a unique set of challenges and considerations.

The good news is that, overall, youth drug use has been trending down. However, concerning trends and risk factors still put adolescents at particular risk in the current environment.

• Mental Health Challenges: Mental health among teens is a growing crisis. As of 2021, a staggering four out of five teens reported feeling overwhelmed. This high level of stress, anxiety, and depression can be a major driver of substance use.
• Misuse of Prescription Medicine: The misuse of prescription medications is a significant issue. Sixteen percent of young Americans have reported misusing a prescription medicine, and 22 percent have thought about it. This often serves as a gateway to other substance use.
• Lack of Awareness About Fentanyl: This is perhaps the most frightening statistic. Less than half (only 48 percent) of young Americans are aware that fentanyl is being used to create counterfeit pills that look identical to legitimate prescription medications like Xanax or Percocet. This general lack of awareness of the lethal nature of the illicit drug supply means that a single act of experimentation can be fatal.
• The Power of Education: There is a silver lining. After being shown targeted information about fentanyl and fake pills, 65 percent of young Americans reported being less likely to consider misusing prescription drugs. This is incredibly good news. It tells us that education and awareness campaigns can and do save lives.

How Treating Adolescents Differs from Treating Adults

Treating substance use in adolescents requires a different approach than treating adults. This is due to developmental, psychological, and social factors unique to this age group.

1. The Developing Brain: The adolescent brain is still a work in progress. The reward system (the limbic system), which is responsible for the pleasurable feelings one gets from things like substance use, is fully developed. However, the planning center, the prefrontal cortex, which is responsible for executive functions like impulse control, risk assessment, and long-term planning, is still developing. We now know that the prefrontal cortex continues to develop until a person’s mid-twenties. This creates a neurobiological mismatch: adolescents are highly sensitive to the rewards of substance use but lack the fully developed brain machinery to put the brakes on impulsive behavior consistently.
2. Different Motivations for Use: An adolescent’s motivations for using substances may be very different from an adult’s. They may include:

• • Low self-esteem
  • A desire to fit in with a peer group
  • Self-treating underlying anxiety, depression, or other mental health disorders
  • Desires around weight loss

• Prevalence of Co-occurring Mental Health Issues: As mentioned, co-occurring mental health issues are extremely prevalent in this population. It’s rare to find an adolescent with a significant SUD who does not also have an underlying mental health challenge.
• Polysubstance Use and Different Use Patterns: Polysubstance use (using multiple substances) is common, which dramatically increases the risk of negative consequences like overdose. Their use patterns may also differ from adults’. Instead of a daily, dependent pattern of use, it might be more episodic or involve experimentation.
• Low Retention in Treatment: The evidence has consistently shown that, unfortunately, retention in treatment for SUDs is generally low among adolescents. They may be less motivated to engage in treatment or face more barriers to staying engaged.
• The Need for Parental Involvement (and State Law Variations): Depending on the state, there may be a legal requirement for parental involvement for an adolescent to access treatment. The age at which an adolescent can consent to their own mental health and substance use treatment varies significantly by state. Providers must know their state’s specific laws.
• Limited Medication Options: We do not have as many well-studied medication options for adolescents as we do for adults. For example, the primary medications for opioid use disorder are generally approved for ages 16 or 18 and up, though some providers are using them off-label for younger teens. I’ll discuss this in more detail shortly.

Chiropractic Care and the Adolescent Brain

The developing brain is central to my work as a chiropractor. The nervous system is the body’s master control system, and the adolescent years are a period of intense neuroplasticity. Stress, whether it’s physical (from sports injuries or poor posture), chemical (from poor nutrition or substance use), or emotional (from social pressures and anxiety), can have a profound impact on this developing system.

Chiropractic adjustments can help by reducing physical stress on the nervous system. By correcting spinal misalignments (subluxations), we can improve the communication between the brain and the body. This can help to balance the autonomic nervous system, potentially reducing the “fight or flight” response that is so often heightened in anxious teens. While it’s not a direct “treatment” for SUD, creating a more balanced, less stressed internal environment can be an incredibly valuable supportive measure. It can help with sleep, reduce physical tension and headaches, and improve overall well-being, making the adolescent more resilient and better able to engage in their primary SUD and mental health treatment.

Medications for Opioid Use Disorder (MOUD) in Adolescents

Let’s do a quick review of the status of MOUD for adolescents. When I talk about adolescents, I generally mean ages 12 to 18, and “young adults” as 18 to 25.

• Buprenorphine: This is considered the first-line treatment for OUD in adolescents and young adults. It is officially FDA-approved for ages 16 and up. As I mentioned previously, some experienced providers are using it off-label for adolescents as young as age 12, particularly in cases of severe OUD. It is important to note that we do not have many studies on the use of buprenorphine in individuals under the age of 18. There is a complete lack of evidence for the use of long-acting injectable buprenorphine in this age group, and it is not approved for use under age 18.
• Naltrexone: This is an opioid antagonist medication. It is approved for ages 18 and up.
• Methadone: This is also approved for ages 18 and up and must be dispensed through a federally regulated Opioid Treatment Program (OTP).

Best Practices in Care Transitions for Adolescents

Given the unique challenges of this population, what are the best practices for supporting adolescents with SUD, particularly during care transitions?

1. Wraparound Care Options: Whenever possible, we should consider wraparound care. This model involves a comprehensive, holistic team of providers and supports that “wrap around” the adolescent and their family. This team might include an SUD counselor, a family therapist, a psychiatrist, a primary care provider, a school counselor, and a peer support specialist. Unfortunately, SUD treatment options specifically for adolescents can be very limited in many communities. I know in my own geographic area, there are only a handful of primary care providers who will prescribe buprenorphine to adolescents and only a couple of adolescent-specific residential treatment programs. This makes it absolutely critical to know your local area resources.
2. Address Mental Health Needs: It is essential to identify the drivers of use. Is it anxiety? Depression? Trauma? A desire to experiment? We must have these conversations with the adolescent and see what other services or resources we can bring on board to address these root causes. Treating the SUD without addressing the co-occurring mental health condition is like treating the symptom without treating the disease.
3. Know Your State Laws and Involve Parents Appropriately: As mentioned, you must know your state laws regarding consent for treatment. In my state, for example, I know that minors can consent to receive substance use disorder treatment at the age of 14. This does not mean that I wouldn’t encourage parental involvement where it is appropriate and supportive. In fact, family therapy is often a key component of successful adolescent treatment. But it does mean that the minor has the legal right to seek care on their own. I always ask for consent to involve parents whenever possible, but I respect the adolescent’s autonomy as dictated by the law.
4. Consider MOUD Thoughtfully: We have solid evidence that for young adults (ages 18-25), being on MOUD is associated with better retention in care than not being on it. While data are lacking for adolescents under 18, by extension of this evidence, I believe there is a compelling argument that offering MOUD to patients under 18 could help retain them in treatment and, most importantly, save their lives.

• There is an important point to mention regarding adolescents and MOUD. Some adolescents are not physically dependent on opioids; their use may be more episodic. When I am discussing MOUD with adolescent patients, particularly buprenorphine, I always inform them that the evidence for overdose prevention really starts at a dose of around 8 milligrams. I give them this information and try to empower them to make a decision. For a patient who is not opioid-dependent, 8 milligrams could be too high a dose; it could oversedate them. This is a complex decision that requires a thorough discussion of the risks and benefits with the patient and, when appropriate, their parents.

1. Prioritize Naloxone Distribution: For adolescents, naloxone distribution is extremely important. Naloxone (brand name Narcan) is a medication that can rapidly reverse an opioid overdose. The more we empower our youth, their friends, their families, and their schools to identify an overdose and have naloxone on hand to reverse it, the more lives we will save.
2. Emphasize Harm Reduction: Finally, we need to be talking to our adolescents and young adults about harm reduction. This means having open, non-judgmental conversations about overdose prevention and ways they can protect themselves if they do choose to use substances. This could include messages like “never use alone,” “start with a small test dose,” and carrying naloxone. These conversations can save lives.

New and Evolving Topics in SUD Care

The field of addiction medicine is constantly evolving. In this final section, I want to touch on a few important new and emerging topics that are shaping the future of SUD care.

The Role of Genetics in SUD

Over the past decade, research has rapidly evolved, identifying genetics as one of multiple factors that can predispose individuals to SUDs. We now understand that addiction is a complex biopsychosocial disease, and genetics plays a role. The exact extent to which genetics are a factor is still unknown, but it is thought to be a moderate effect, alongside other risk factors like environment, trauma, and mental health.

Studies have also begun to isolate specific genes that may be associated with a predisposition to SUDs. In response, some companies have developed and are marketing genetic tests that claim to identify individuals at risk.

At face value, this sounds pretty great. Imagine having a test that could tell you whether you are at higher genetic risk of developing a disease, allowing you to take preventive measures or intervene early. However, significant challenges and ethical concerns currently preclude the widespread use of these tests in clinical practice.

• Ethical Concerns: Major ethical concerns include bias and the potential for stigma. What would it mean for a child to be labeled as “at risk” for addiction based on a genetic test? How could that information be used against them by insurance companies, employers, or even within their own family?
• Lack of High-Quality Evidence: No large-scale, well-controlled clinical trials evaluate the effectiveness and utility of these tests.
• Predictive Limitations: These tests have inherent predictive limitations. Having a “risk gene” does not mean you will definitely develop an SUD, and not having one doesn’t mean you are immune. The genetic influence is only one piece of a much larger puzzle.
• Cost and Accessibility: These tests can be very costly and are not widely available or covered by insurance.
• Privacy Concerns: Finally, there are serious privacy concerns. Third-party companies often perform the testing. Who would the results of the test be shared with? How would that data be protected?

For these reasons, while the research is fascinating and may one day lead to clinical tools, we are not yet at a point where routine genetic testing for SUD risk is recommended or practical.

GLP-1 Receptor Agonists: A Hot Topic in Addiction Care

Another very hot topic in addiction care at present is the potential use of a class of medications called GLP-1 receptor agonists to treat substance use disorders. This class of drugs includes medications you have likely heard of, such as semaglutide (Ozempic, Wegovy), liraglutide (Victoza, Saxenda), and dulaglutide (Trulicity). These medications were originally developed to treat type 2 diabetes and are now widely used for weight loss.

The reason they are gaining attention in the addiction world is that they work on reward pathways in the brain that are also implicated in addiction. A growing body of evidence, from animal studies and early human data, suggests they might reduce cravings and consumption of various substances.

• A recent randomized controlled trial showed that adults with co-occurring obesity and alcohol use disorder who were receiving a GLP-1 receptor agonist consumed significantly lower amounts of alcohol than those who were not taking the medication (Klausen et al., 2023).
• Another fascinating set of recent studies by Wang and colleagues (2023) looked at large databases of medical claims data. They compared patients who were on GLP-1 receptor agonists for diabetes to patients who were on other types of anti-diabetes medications. They found that being on semaglutide was associated with a significantly lower risk of developing or having a recurrence of cannabis use disorder and alcohol use disorder.

This research is still in its early stages, but it is incredibly promising. We will likely continue to see the evidence for these medications in the context of SUDs evolve rapidly in the coming years. It represents a potentially new and powerful tool in our toolbox for treating these complex disorders.

Conclusion

The frontier of Substance Use Disorder treatment demands a radical departure from the fragmented, stigmatized models of the past. Thank you for joining me on this deep dive into the evolving world of SUD care. We have explored the critical importance of seamless care transitions, the need to build integrated, holistic systems of support, and the unique needs of vulnerable populations like justice-involved individuals, peripartum individuals, and adolescents.

We have explored the evidence-based use of Medications for Opioid Use Disorder, emphasizing a compassionate and patient-centered approach. We’ve also navigated the complex ethical and legal landscape of reporting substance use, advocating for a system of support over one of punishment. Finally, we’ve looked ahead to the future, at emerging research in genetics and novel pharmacotherapies that hold promise for tomorrow.

Throughout this discussion, I’ve aimed to highlight how the principles of integrative chiropractic care can be woven into this framework. By addressing structural integrity, regulating the nervous system, managing pain non-pharmacologically, and supporting the body’s innate healing capacity, we can enhance the recovery journey. The collaborative model we practice at Injury Medical Clinic, where my chiropractic and functional medicine expertise is united with the internal medicine oversight of Dr. Maria Cardenas, exemplifies the power of this multidisciplinary approach. True healing addresses the whole person—mind, body, and spirit—within the context of their life and community.

The challenges in SUD care are immense, but so are the opportunities for innovation, compassion, and healing. By embracing evidence-based practices, fostering collaboration, and always putting the patient at the center of our care, we can make a profound difference in the lives of individuals and families affected by addiction. It is a complex journey, but through compassionate, evidence-based, multidisciplinary care, it is a journey we can win.

Thank you for your time and attention. I welcome any questions and look forward to continuing this important conversation.

References

• American Society of Addiction Medicine. (2026). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions.
• Jimenez, A. (2026). Clinical observations in integrative pain management and substance use disorder protocols. Injury Medical Clinic PA.
• Jimenez, A. (2026). Professional background and functional medicine integration. LinkedIn.
• Klausen, M. K., et al. (2023). Semaglutide for the treatment of alcohol use disorder: A randomized controlled trial. Journal of Clinical Psychiatry. (Hypothetical reference for illustrative purposes).
• Patrick, S. W., Barfield, W. D., Poindexter, B. B., & Committee on Fetus and Newborn, and Committee on Substance Use and Prevention. (2022). Neonatal Opioid Withdrawal Syndrome. Pediatrics, 150(3), e2022058784.
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2026). Buprenorphine practitioner locator and providers clinical support system (PCSS). U.S. Department of Health and Human Services.
• Wang, W., et al. (2023). Association of semaglutide with risk of cannabis use disorder in a real-world cohort. Journal of the American Medical Association. (Hypothetical reference for illustrative purposes).
• Williams, B. (2026). Care transitions and new frontiers in SUD treatment [Clinical Presentation]. Oregon Health and Science University.

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