Explore SUD treatment and integrative chiropractic care for a holistic approach to healing and recovery from substance use disorders.
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.
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.
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:
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.
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.
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.
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.
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:
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.
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:
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.
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:
To overcome these barriers, leading clinical research highlights four foundational pillars required for successfully integrating SUD treatment into primary care:
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.
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.
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.
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.
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.
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:
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.
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).
Lisa’s clinical presentation requires a deep physiological deconstruction.
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.
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.
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:
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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:
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.
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
Now, Liz is postpartum. What are the key considerations for her post-discharge care transition?
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.
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.
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.
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.
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.
Given the unique challenges of this population, what are the best practices for supporting adolescents with SUD, particularly during care transitions?
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.
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.
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.
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.
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.
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.
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General Disclaimer, Licenses and Board Certifications *
Professional Scope of Practice *
The information herein on "Integrative Chiropractic Care Strategies for SUD Treatment" is not intended to replace a one-on-one relationship with a qualified health care professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional.
Blog Information & Scope Discussions
Welcome to El Paso's Premier Wellness and Injury Care Clinic & Wellness Blog, where Dr. Alex Jimenez, DC, FNP-C, a Multi-State board-certified Family Practice Nurse Practitioner (FNP-BC) and Chiropractor (DC), presents insights on how our multidisciplinary team is dedicated to holistic healing and personalized care. Our practice aligns with evidence-based treatment protocols inspired by integrative medicine principles, similar to those on this site and on our family practice-based chiromed.com site, focusing on naturally restoring health for patients of all ages.
Our areas of multidisciplinary practice include Wellness & Nutrition, Chronic Pain, Personal Injury, Auto Accident Care, Work Injuries, Back Injury, Low Back Pain, Neck Pain, Migraine Headaches, Sports Injuries, Severe Sciatica, Scoliosis, Complex Herniated Discs, Fibromyalgia, Chronic Pain, Complex Injuries, Stress Management, Functional Medicine Treatments, and in-scope care protocols.
Our information scope is multidisciplinary, focusing on musculoskeletal and physical medicine; wellness; contributing etiological viscerosomatic disturbances within clinical presentations; associated somato-visceral reflex clinical dynamics; subluxation complexes; sensitive health issues; and functional medicine articles, topics, and discussions.
We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and licensure jurisdiction. We use functional health & wellness protocols to treat and support care for musculoskeletal injuries or disorders.
Our videos, posts, topics, and insights address clinical matters and issues that directly or indirectly relate to our clinical scope of practice.
Our office has made a reasonable effort to provide supportive citations and has identified relevant research studies that support our posts. We provide copies of supporting research studies upon request to regulatory boards and the public.
We understand that we cover matters that require an additional explanation of how they may assist in a particular care plan or treatment protocol; therefore, to discuss the subject matter above further, please feel free to ask Dr. Alex Jimenez, DC, APRN, FNP-BC, or contact us at 915-850-0900.
We are here to help you and your family.
Blessings
Dr. Alex Jimenez DC, MSACP, APRN, FNP-BC*, CCST, IFMCP, CFMP, ATN
email: coach@elpasofunctionalmedicine.com
Multidisciplinary Licensing & Board Certifications:
Licensed as a Doctor of Chiropractic (DC) in Texas & New Mexico*
Texas DC License #: TX5807, Verified: TX5807
New Mexico DC License #: NM-DC2182, Verified: NM-DC2182
Multi-State Advanced Practice Registered Nurse (APRN*) in Texas & Multi-States
Multi-state Compact APRN License by Endorsement (42 States)
Texas APRN License #: 1191402, Verified: 1191402 *
Florida APRN License #: 11043890, Verified: APRN11043890 *
Colorado License #: C-APN.0105610-C-NP, Verified: C-APN.0105610-C-NP
New York License #: N25929, Verified N25929
License Verification Link: Nursys License Verifier
* Prescriptive Authority Authorized
ANCC FNP-BC: Board Certified Nurse Practitioner*
Compact Status: Multi-State License: Authorized to Practice in 40 States*
Graduate with Honors: ICHS: MSN-FNP (Family Nurse Practitioner Program)
Degree Granted. Master's in Family Practice MSN Diploma (Cum Laude)
Dr. Alex Jimenez, DC, APRN, FNP-BC*, CFMP, IFMCP, ATN, CCST
(Board Certified: Family Practice Nurse Practitioner—Multistate)*
(Licensed Nurse Practitioner & Chiropractor - Multistate)*
Clinical Director
Digital Business Card
Dr. Maria Cardenas, MD
(Board Certified: Internal Medicine)
(Licensed Medical Doctor)
Medical Director, Clinical Director & Collaborative Physician
NPI # 1164426749
MD License #: J2933
Licenses and Board Certifications:
MD: Medical Doctor
DC: Doctor of Chiropractic
APRNP: Advanced Practice Registered Nurse
FNP-BC: Family Practice Specialization (Multi-State Board Certified)
RN: Registered Nurse (Multi-State Compact License)
CFMP: Certified Functional Medicine Provider
MSN-FNP: Master of Science in Family Practice Medicine
MSACP: Master of Science in Advanced Clinical Practice
IFMCP: Institute of Functional Medicine
CCST: Certified Chiropractic Spinal Trauma
ATN: Advanced Translational Neutrogenomics
Memberships & Associations:
TCA: Texas Chiropractic Association: Member ID: 104311
AANP: American Association of Nurse Practitioners: Member ID: 2198960
ANA: American Nurse Association: Member ID: 06458222 (District TX01)
TNA: Texas Nurse Association: Member ID: 06458222
NPI: 1205907805
| Primary Taxonomy | Selected Taxonomy | State | License Number |
|---|---|---|---|
| No | 111N00000X - Chiropractor | NM | DC2182 |
| Yes | 111N00000X - Chiropractor | TX | DC5807 |
| Yes | 363LF0000X - Nurse Practitioner - Family | TX | 1191402 |
| Yes | 363LF0000X - Nurse Practitioner - Family | FL | 11043890 |
| Yes | 363LF0000X - Nurse Practitioner - Family | CO | C-APN.0105610-C-NP |
| Yes | 363LF0000X - Nurse Practitioner - Family | NY | N25929 |
Dr. Alex Jimenez, DC, APRN, FNP-BC*, CFMP, IFMCP, ATN, CCST
(Board Certified: Family Practice Nurse Practitioner—Multistate)*
(Licensed Nurse Practitioner & Chiropractor - Multistate)*
Clinical Director
Digital Business Card
Dr. Maria Cardenas, MD
(Board Certified: Internal Medicine)*
(Licensed Medical Doctor)*
Medical Director, Clinical Director & Collaborative Physician
NPI # 1164426749
MD License #: J2933