Chiropractic Rehabilitation Explained With Integrative OUD Care

Find effective strategies for integrative OUD care with chiropractic rehabilitation to enhance recovery and well-being.

Abstract

As a clinician with a diverse background in chiropractic care, advanced practice nursing, and functional medicine, I am deeply committed to an integrative, evidence-based approach to patient wellness. This educational post delves into the complex landscape of opioid use disorder (OUD), focusing on the specific challenges and treatment considerations for what we term “special populations.” These include individuals grappling with co-occurring mental health conditions, pregnant women, adolescents, and older adults. Drawing from my clinical experience and the latest research from leading experts in the field, I will explore the physiological underpinnings of these conditions and outline effective, modern treatment strategies. We will examine how to apply trauma-informed care, select appropriate pharmacotherapies like SSRIs, SNRIs, and medications for opioid use disorder (MOUD), and navigate the complexities of their interactions. A central theme of this discussion is the power of a multidisciplinary team. At our practice, Injury Medical Clinic PA, I work alongside our Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. With over 40 years of experience as a board-certified internist, Dr. Cardenas provides invaluable medical oversight, allowing us to create comprehensive, holistic treatment plans that integrate chiropractic care, functional medicine, rehabilitation, and conventional medical treatments. This post aims to guide you through this journey, providing a detailed roadmap for understanding and managing OUD in its most challenging presentations, grounded in evidence and a philosophy of patient-centered, integrative care.

Our Collaborative Care Model at Injury Medical Clinic

Before we dive into the clinical details of managing opioid use disorder, I believe it’s essential to set the stage by explaining our unique approach to healthcare at Injury Medical Clinic. My philosophy has always been rooted in looking at the whole person—not just a collection of symptoms or a single diagnosis. This is the very essence of integrative and functional medicine. My extensive training across multiple disciplines, from being a Doctor of Chiropractic (DC) to an Advanced Practice Registered Nurse (APRN) and a Board-Certified Family Nurse Practitioner (FNP-BC), has reinforced my belief that the most effective healing occurs when different modalities work in synergy.

At our clinic, we have cultivated a multidisciplinary environment designed to provide comprehensive, patient-centered care. This model is particularly common and effective in practices focusing on injury, rehabilitation, and complex chronic conditions. The cornerstone of this collaborative framework is my partnership with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected, board-certified internist with over four decades of experience. As our Medical Director and Collaborative Physician, she provides essential medical oversight and direction for the care we deliver. Her NPI is #1164426749, and she is licensed in Texas under #J2933.

This MD-DC collaboration helps bridge the gap between different fields of healthcare. Here’s how our integrated team functions:

• Chiropractic Care (Dr. Jimenez): My primary role as a chiropractor is to address the biomechanical and neurological aspects of health. For patients with OUD, particularly those whose journey began with chronic pain, chiropractic care is a vital component. We use manual adjustments, spinal decompression, and soft tissue therapies to alleviate pain, improve function, and reduce reliance on pain medication. This non-pharmacological approach directly targets the root physical issues that often contribute to opioid dependency.
• Medical Oversight (Dr. Cardenas, MD): Cardenas oversees all medical aspects of patient care. This includes diagnosing medical conditions, prescribing and managing medications (including those for OUD and co-occurring disorders), and ensuring that our treatment plans are medically sound and safe. Her internal medicine expertise is critical for managing the complex physiological interactions in patients with multiple comorbidities.
• Functional Medicine (Dr. Jimenez): As a certified functional medicine practitioner, I investigate the underlying root causes of dysfunction. This involves a deep dive into a patient’s genetics, lifestyle, and environmental factors. We utilize advanced diagnostic testing to understand biochemical imbalances, gut health, inflammation, and nutritional deficiencies that can contribute to both chronic pain and mental health disorders, which are often intertwined with OUD.
• Personal Injury and Rehabilitation: Many of our patients come to us after an injury. Our team is skilled in creating rehabilitation programs that combine physical therapies, chiropractic adjustments, and medical management to facilitate a full recovery and prevent the slide into chronic pain and potential opioid misuse.
• Integrated Services: Our team works in concert. A patient might see me for a chiropractic adjustment to manage back pain, consult with Dr. Cardenas to manage their buprenorphine prescription, and work with our health coaches on nutritional and lifestyle changes identified through a functional medicine lens. This seamless integration ensures that all aspects of the patient’s health—physical, mental, and biochemical—are addressed at the same time.

This collaborative structure is not just a model of practice; it’s a commitment to providing the highest standard of care. It allows us to offer a more complete and effective solution for complex conditions like OUD, moving beyond symptom management to foster true, sustainable healing.

The Overlooked Epidemic: OUD and Co-Occurring Mental Health Conditions

One of the most critical aspects of understanding and treating opioid use disorder is recognizing its profound connection to mental health. The two are often so deeply intertwined that treating one without addressing the other is like trying to fix a leak with a bucket instead of patching the pipe. The statistics paint a stark picture.

According to a comprehensive 2022 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration (SAMHSA), the numbers are staggering. An estimated 21.5 million adults in the United States are living with a co-occurring disorder, meaning they have both a mental health condition and a substance use disorder simultaneously (Substance Abuse and Mental Health Services Administration, 2023).

What’s even more concerning is the gap in treatment. Of these millions of individuals:

• Approximately 60% received treatment for either their substance use disorder or their mental health disorder, but not both.
• A startling 40% received no treatment for either condition.
• Among those who did get help, the vast majority were treated for their mental health condition, while the substance use disorder was often overlooked.

When we focus specifically on individuals with opioid use disorder, the prevalence of certain mental health conditions is exceptionally high. The literature consistently highlights three major co-occurring diagnoses:

• Major Depressive Disorder (MDD): Research shows that up to 50% of individuals with a substance use disorder also suffer from MDD (Davis et al., 2021). This is not a coincidence. The neurobiological pathways affected by opioids—such as dopamine and serotonin systems—are the very same pathways implicated in depression.
• Anxiety Disorders: We see a prevalence of about 30% for anxiety disorders among this population. Often, individuals begin using opioids to self-medicate the overwhelming feelings of worry, panic, and social anxiety.
• Post-Traumatic Stress Disorder (PTSD): Nearly 20% of individuals with OUD also have PTSD. Trauma can create a state of chronic hypervigilance and emotional dysregulation, and opioids can provide a temporary, albeit destructive, escape from these intrusive symptoms.

These co-occurring conditions are not just a secondary issue; they are a significant factor that increases the risk of the most tragic outcomes, including overdose and suicide attempts. Furthermore, we observe that individuals with these dual diagnoses are more likely to be female, highlighting a need for gender-specific considerations in our treatment approaches.

Essential Screening Tools for a Complete Diagnosis

In a primary care or integrative setting, we often screen for depression and anxiety as a standard part of care. When a patient presents with a substance use disorder, this practice becomes non-negotiable. We must actively look for these co-occurring conditions to formulate a complete and effective treatment plan. We use standardized, validated screening tools to assess the severity of these conditions and to track progress over time.

• PHQ-9 (Patient Health Questionnaire-9): This is the gold standard for screening, diagnosing, and monitoring depression severity. It’s a nine-item questionnaire that aligns with the diagnostic criteria for major depressive disorder in the DSM-5. The score helps us classify the depression as mild, moderate, or severe, which directly informs our treatment decisions.
• GAD-7 (Generalized Anxiety Disorder-7): Similar to the PHQ-9, this is a seven-item tool used to screen for and measure the severity of generalized anxiety disorder. It helps us quantify the patient’s level of worry and anxiety, providing a baseline to measure treatment effectiveness.
• PCL-5 (Post-Traumatic Stress Disorder Checklist for DSM-5): While we might not screen for PTSD as routinely as depression and anxiety, it’s a critical tool for any patient with a substance use history. Trauma is an incredibly common precursor to substance use. The PCL-5 is a 20-question self-report measure that assesses the 20 DSM-5 symptoms of PTSD.

• • How it Works: The patient rates how much each symptom has bothered them over the past month on a scale from 0 (Not at all) to 4 (Extremely). The symptoms cover the core clusters of PTSD, including intrusive memories like nightmares and flashbacks, avoidance of trauma-related stimuli, negative alterations in mood and cognition like blame and anhedonia (the inability to feel pleasure), and marked alterations in arousal and reactivity, such as irritability, hypervigilance, and sleep disturbances.
  • Interpreting the Score: A score between 31 and 33 is generally considered a clinical cutoff, suggesting that a full assessment for PTSD is warranted and that treatment should be considered. We also use the PCL-5 to monitor progress. A reduction of 10 points or more strongly indicates that our treatment interventions are effective.

By using these tools, we move from subjective impressions to objective data, allowing us to tailor our therapies with precision and demonstrate tangible improvement to our patients, which can be incredibly empowering.

The Foundation of Healing: Trauma-Informed Care

For any patient, but especially for those with OUD and co-occurring mental health disorders, a trauma-informed care approach is not just a best practice—it is the only ethical and effective way to engage. This framework requires us to shift our perspective from “What’s wrong with you?” to “What happened to you?” It acknowledges that a person’s behaviors and symptoms are often adaptive responses to traumatic experiences. We build our entire clinical interaction around six core principles.

1. Safety: This is the absolute bedrock. We must create an environment that is physically and emotionally safe. This means everything from the layout of the clinic to the tone of our voice. For a patient who has experienced trauma, the world can feel like a threatening place. Our clinic must be their sanctuary, a place where they can let their guard down without fear of judgment or harm.
2. Trustworthiness and Transparency: We build trust by being honest, open, and respectful. There should be no surprises. We explain every step of the treatment process, discuss potential outcomes, and are transparent about costs and policies. We avoid creating any situation where the patient feels tricked or manipulated, such as suddenly introducing a “contingency piece” they weren’t expecting. This predictability helps rebuild a sense of control for individuals whose lives have often been chaotic.
3. Peer Support: Incorporating individuals with lived experience into the care team can be transformative. Peer support specialists can help establish trust and safety in ways clinicians sometimes cannot. They offer a unique form of empathy and validation, demonstrating that recovery is possible. This connection is a powerful tool for fostering hope and empowerment.
4. Collaboration and Mutuality: We abandon the old, paternalistic model of “doctor knows best.” Instead, we partner with our patients. We are guides, not dictators. We level the power differential by acknowledging that the patient is the expert on their own life. This collaborative approach ensures that the care plan is truly patient-centered and aligned with their individual needs, values, and goals.
5. Empowerment, Voice, and Choice: Trauma often strips individuals of their sense of agency. A core part of healing is restoring it. We do this by consistently offering choices. We present different treatment options, discuss the pros and cons of each, and respect the patient’s decision. We make it clear that they drive their care. This empowers them to reclaim control over their health and their life.
6. Cultural, Historical, and Gender Issues: We must recognize that our own lived experience is not universal. We must be humble and curious about the cultural, historical, and gender-related factors that shape our patients’ perceptions and experiences of trauma and healing. This requires ongoing education and self-reflection to avoid imposing our own biases and to provide care that is truly culturally sensitive and relevant.

In my practice, integrating chiropractic care fits beautifully within this model. The hands-on nature of chiropractic treatment can be a powerful way to re-establish a positive connection with one’s body, especially for those who feel disconnected or betrayed by it due to pain or trauma. A gentle, respectful adjustment can be a profound experience of safe, therapeutic touch, helping to down-regulate a hyperactive nervous system and build the trust that is so fundamental to healing.

Therapeutic Modalities and Pharmacological Interventions

Once we have established a safe, collaborative therapeutic relationship, we can begin implementing evidence-based treatments. For co-occurring MDD, anxiety, and PTSD, this typically involves a combination of therapy and medication.

Evidence-Based Psychotherapy

While many therapeutic approaches can be helpful, it’s important to guide patients toward those with the strongest evidence base for their specific condition. It’s not about a “one-size-fits-all” solution, but about matching the right tool to the right problem.

• For Depression and Anxiety, Cognitive Behavioral Therapy (CBT) is a cornerstone. CBT helps patients identify, challenge, and reframe the negative thought patterns and behaviors that drive their symptoms. It’s a practical, skills-based approach that empowers patients with tools they can use for the rest of their lives.
• For PTSD, several specialized, highly effective therapies are considered first-line:

• Prolonged Exposure (PE): This therapy involves gradually and systematically confronting trauma-related memories, feelings, and situations in a safe environment. By doing so, the patient learns these triggers are no longer dangerous, reducing fear and avoidance.
• Cognitive Processing Therapy (CPT): CPT focuses on helping patients challenge and modify unhelpful beliefs related to the trauma. It helps them create a new understanding of the traumatic event, which can reduce its ongoing negative impact on their life.
• Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a unique therapy that uses bilateral stimulation (such as eye movements) while the patient focuses on traumatic memories. The exact mechanism is still being studied, but it appears to help the brain reprocess these memories, reducing their intensity and emotional charge.

As clinicians, part of our job is to build a network of trusted therapists who are skilled in these evidence-based practices. This allows us to make effective referrals and educate our patients on what to look for in a therapist, ensuring they receive the highest quality of care.

First-Line Medications: SSRIs and SNRIs

For moderate to severe MDD, GAD, and PTSD, Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the first-line pharmacological treatments. These medications work by increasing the levels of key neurotransmitters—serotonin and, in the case of SNRIs, norepinephrine—in the brain, which helps regulate mood and anxiety. While many medications in these classes are used, it helps to know which ones have specific FDA indications for these conditions, as well as their unique side effect profiles.

SSRIs:

• Paroxetine (Paxil): This medication is notable for being FDA-indicated for all three conditions: MDD, GAD, and PTSD. However, it’s crucial to inform patients that it has one of the highest rates of sexual dysfunction among the SSRIs. This is a common side effect across the class, but paroxetine is a particular offender, and this can be a major reason for non-adherence.
• Sertraline (Zoloft): Indicated for MDD and PTSD, sertraline is a very commonly prescribed and effective option. Its most notable side effect is a higher incidence of gastrointestinal (GI) symptoms, such as nausea and diarrhea. We always counsel patients that these effects are usually transient and tend to resolve within the first couple of weeks.
• Fluoxetine (Prozac): Indicated for MDD, fluoxetine has a very long half-life. This can be a significant advantage for patients who may struggle with adherence and occasionally forget a dose. However, this same property makes it more dangerous in the event of an overdose, as the drug remains in the system for a longer period. This is a critical consideration for patients with suicidal ideation.
• Escitalopram (Lexapro): Indicated for MDD and GAD, escitalopram is often considered one of the best-tolerated SSRIs. It has a “cleaner” side effect profile than many others, though it is associated with some potential for weight gain.

SNRIs:

• Duloxetine (Cymbalta): Indicated for MDD and GAD, duloxetine also helps with certain types of chronic pain, such as diabetic neuropathy and fibromyalgia. This can make it an excellent choice for patients whose OUD is linked to a chronic pain condition. It also tends to have less sexual dysfunction than many SSRIs, though it can still cause GI side effects.
• Venlafaxine (Effexor): Also indicated for MDD and GAD, venlafaxine is a potent and effective SNRI. It is associated with GI side effects and potential weight gain. A key consideration with venlafaxine is its potential to increase blood pressure, so monitoring is important. It also has a short half-life, which can lead to uncomfortable discontinuation symptoms if doses are missed.

Choosing the right medication is a collaborative process that involves a careful discussion of the patient’s specific symptoms, comorbidities, and tolerance for potential side effects.

Navigating Drug Interactions: MOUD and Psychotropics

When we treat a patient for both OUD and a co-occurring mental health disorder, we must be vigilant about potential drug interactions. The primary medications for opioid use disorder (MOUD) are buprenorphine, methadone, and naltrexone. Each has a unique profile that influences how it interacts with SSRIs and SNRIs.

• Buprenorphine: This medication is a partial opioid agonist and has some serotonergic properties. This means that when it’s combined with an SSRI or SNRI, there is a theoretical, albeit low, risk of serotonin syndrome. However, in clinical practice, the benefit of treating both conditions far outweighs this small risk. In fact, research has clearly found that treating underlying depression and anxiety with an SSRI significantly increases retention in OUD treatment (Krupitsky et al., 2006). Patients are more likely to stay on their buprenorphine and succeed in their recovery when their mental health is also stabilized. This is a classic example of a risk-benefit calculation that overwhelmingly favors combined treatment.
• Methadone: The biggest concern with methadone, a full opioid agonist, is its potential to cause QTc prolongation. The QTc interval is a measure of the time it takes for the heart’s ventricles to repolarize after a contraction. A prolonged QTc interval increases the risk of a life-threatening arrhythmia called Torsades de Pointes. Many medications, including some SSRIs and SNRIs, can also prolong the QTc interval.

• • Citalopram (Celexa) is a particular medication to watch. The FDA recommends against doses higher than 40 mg per day (and 20 mg in older adults) due to this risk.
  • Venlafaxine also has a slightly higher risk of QTc prolongation compared to other antidepressants.
  • Clinical Monitoring Protocol: When a patient on methadone is started on a medication known to affect the QTc interval, we must be diligent. We need to get a baseline ECG before starting the new medication. We then repeat the ECG after five half-lives of the new drug have passed, which is when it reaches a steady state in the body. We should also get an ECG if the patient reports new symptoms such as palpitations, lightheadedness, dizziness, syncope (fainting), chest pain, or shortness of breath. Annual ECGs are also recommended.
  • QTc Thresholds: As a general guideline, we become especially watchful when the QTc interval exceeds 450 milliseconds for men and 460 milliseconds for women.

• Naltrexone: This medication is an opioid antagonist, meaning it blocks the effects of opioids. It is a very effective treatment for OUD, particularly for highly motivated patients. However, the FDA label for naltrexone includes a warning that it can increase or cause depression and suicidality. This doesn’t mean we can’t use it in patients with depression, but it absolutely means we must have an open and honest conversation about this risk. We also need to be mindful of the black box warning on all SSRIs and SNRIs regarding a potential increase in suicidality, especially in younger adults. Again, we are weighing the benefits against the risks. For many patients, the greatest risk for suicide comes from the despair and hopelessness of active addiction, which is often a way of coping with untreated depression. Treating the depression and the OUD concurrently is almost always the safest path forward.

Recognizing Serotonin Syndrome

Because we are often combining serotonergic medications, every clinician on the team needs to be able to recognize the signs and symptoms of serotonin syndrome, a potentially life-threatening condition caused by excessive serotonergic activity in the nervous system. The mnemonic SHIVERS can be very helpful:

• Shivering: Often an early and prominent sign.
• Hyperreflexia and Myoclonus: Overactive reflexes and sudden, involuntary muscle jerks or twitching.
• Increased Temperature: Fever indicates more severe toxicity.
• Vital Sign Abnormality: This typically includes tachycardia (fast heart rate) and hypertension (high blood pressure).
• Encephalopathy: Mental status changes, such as confusion, agitation, or delirium.
• Restlessness: A sense of inner agitation and an inability to stay still.
• Sweating: Diaphoresis that is often profuse and out of proportion to the ambient temperature.

If serotonin syndrome is suspected, stop the offending agents immediately, and the patient needs prompt medical attention.

Case Study: Integrating Care for Depression, Anxiety, and OUD

Let’s bring these concepts to life with a case study that is representative of many patients we see.

• Patient Profile: We have a 32-year-old divorced woman and mother of two children. She works part-time in retail. Her medical history is significant for chronic low back pain resulting from degenerative disc disease, which led to a history of opioid misuse. She is currently stable on buprenorphine-naloxone 8 mg, taken three times a day. Her family history is positive for a father with alcohol use disorder (in remission) and a mother with depression, highlighting a genetic predisposition. Socially, she lives with her mother and children, has a limited support network, and has a history of intimate partner violence—a significant trauma. She is actively engaged in peer recovery groups.
• Presentation: She comes in for a follow-up. While she is proud to be abstinent from non-prescribed opioids, she reports ongoing, debilitating symptoms of depression and anxiety. She feels exhausted, cannot enjoy time with her children, and is constantly overwhelmed by worry. She denies any suicidal ideation but poignantly states, “I am staying away from pills, but I feel like I am drowning most days.” This statement captures the essence of a co-occurring disorder—winning the battle against substance use but still losing the war for mental wellness.
• Screening and Assessment: We immediately administer our standard screening tools.

• • PHQ-9: Her score is 18, indicating moderate-to-severe depression.
  • GAD-7: Her score is 15, indicating severe anxiety.
  • PCL-5: Her score is 10, which does not suggest a current diagnosis of PTSD, though her history of intimate partner violence remains a crucial piece of her story that we must hold in our awareness.
  • Urine Drug Screen (UDS): Her UDS is positive for buprenorphine, as expected, and negative for all other substances. This confirms her adherence to treatment and her self-report of abstinence.

• Integrated Treatment Plan:

1. 1. Continue MOUD: She is stable on buprenorphine-naloxone so that we will continue this regimen. It is the foundation of her recovery from OUD.
   2. Initiate Antidepressant Therapy: We need to treat her MDD and GAD aggressively. We would have a collaborative discussion with her about starting either an SSRI or an SNRI. Given her chronic back pain, a medication like duloxetine (Cymbalta) could be an excellent choice, as it could simultaneously address her mood, anxiety, and pain symptoms.
   3. Refer to Therapy: We will refer her to a therapist who specializes in Cognitive Behavioral Therapy (CBT) to equip her with coping skills for her depression and anxiety.
   4. Prescribe Naloxone: Every patient with a history of OUD should have naloxone and be trained on how to use it. This is a critical harm reduction measure.
   5. Safety Planning: Even though she denies suicidal ideation, her level of distress is high. We will discuss the 988 Suicide & Crisis Lifeline with her, ensuring she knows there is a resource available 24/7 if she ever feels she is in crisis. We also review emergency room protocols.
   6. Integrative Chiropractic Care: Given her history of degenerative disc disease, I would also incorporate chiropractic adjustments and functional movement therapies. This would help manage her chronic pain non-pharmacologically, improve her physical function, and potentially reduce the pain-related stress that can exacerbate her anxiety and depression. This holistic approach addresses her from all angles: biochemical, psychological, and biomechanical.

A Special Consideration: Opioid Use Disorder in Pregnancy

Treating opioid use disorder during pregnancy is one of the most delicate and high-stakes challenges we face as clinicians. It requires profound compassion, a nonjudgmental attitude, and a firm grasp of the evidence. Recent trends are deeply concerning.

• From 1999 to 2014, the rate of opioid use disorder in pregnancy increased fourfold.
• From 2010 to 2017 alone, OUD documented at the time of delivery increased by 131%.
• This has had a direct and devastating impact on newborns. The incidence of Neonatal Opioid Withdrawal Syndrome (NOWS) increased fivefold between 2002 and 2009, and then saw another 82% increase between 2010 and 2017.
• Current data from 2021 indicates that a baby is born experiencing opioid withdrawal approximately every 24 minutes in the United States (Winkelman et al., 2018; Hirai et al., 2021).

We also see geographic disparities, with higher rates often found in rural versus urban areas, where access to specialized care may be more limited.

The Pernicious Barrier of Stigma

For pregnant individuals with OUD, stigma is not just an emotional burden; it is a direct and dangerous barrier to care. These women often face devastating stereotypes from society, family, and, most tragically, from healthcare staff. They are labeled as “unfit mothers,” “drug-seeking,” or “criminals.”

My clinical observations have shown me that this poor treatment, whether through overt verbal comments or subtle non-verbal cues of disapproval, has catastrophic consequences. Patients feel judged, shamed, and unsafe. This can cause them to avoid prenatal care, hide their substance use, and disengage from the very systems that are supposed to help them. This is not only counterproductive to recovery; it can be a direct trigger for a return to use and, consequently, an increased risk of overdose.

Universal Screening: The Only Equitable Approach

Given the high prevalence of OUD and the dangers of stigma, we must implement universal screening for substance use in all pregnant patients. This means we screen everyone, regardless of their appearance, socioeconomic status, or background. We don’t “pick and choose” who we think might be at risk. This removes bias and normalizes the conversation about substance use, making it a standard part of comprehensive prenatal care. Several simple and effective screening tools are available.

• The 4 P’s: A quick, easy-to-remember tool.

• • Parents: Did your parents have a problem with alcohol or other drug use?
  • Partner: Does your partner have a problem with alcohol or drug use?
  • Past: In the past, have you had difficulties in your life because of alcohol or other drugs?
  • Present: In the present (past month), have you drunk any alcohol or used any other drugs?
  • A “yes” to any of these questions triggers the need for a more in-depth assessment.

• NIDA Quick Screen: This tool asks about substance use within the past year. For women, it flags a risk if they report having four or more drinks in a single day, or any use of tobacco products or other non-prescribed drugs. A positive screen requires further questioning about specific substances.
• CRAFFT: This tool is validated for use in individuals up to age 26, making it suitable for many pregnant patients. The acronym stands for:

• • Car: Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
  • Relax: Do you ever use alcohol or drugs to relax or feel better about yourself?
  • Alone: Do you ever use alcohol or drugs while you are alone?
  • Forget: Do you ever forget things you did while using alcohol or drugs?
  • Family/Friends: Do your family or friends ever tell you that you should cut down on your drinking or drug use?
  • Trouble: Have you ever gotten into trouble while you were using alcohol or drugs?
  • Two or more “yes” answers on this screening indicate a high risk and a need for further assessment.

The Risks of Untreated OUD in Pregnancy

It’s crucial to understand that the greatest harm to both mother and fetus comes from untreated opioid use disorder. The danger lies in the chaotic cycle of use and withdrawal. When a pregnant woman uses street opioids, she experiences a surge of the drug, followed by a period of withdrawal as the substance leaves her system. This cycle causes dramatic fluctuations in opioid levels in both her and the fetus’s bloodstream.

This repeated withdrawal can cause the uterus to contract, leading to severe complications:

• Placental Abruption: The premature separation of the placenta from the uterine wall, a life-threatening emergency.
• Problems with Fetal Growth: Leading to low birth weight.
• Preterm Birth: Delivery before 37 weeks of gestation.
• Stillbirth: Fetal death in utero.
• Overdose Risk: The mother is at an extremely high risk of overdose due to the unpredictable potency of street drugs like illicitly manufactured fentanyl.

Furthermore, the lifestyle associated with active addiction often leads to inconsistent or non-existent prenatal care, compounding these risks.

Understanding Neonatal Opioid Withdrawal Syndrome (NOWS)

When a baby is exposed to opioids in utero, their body becomes physically dependent on the substance, just like the mother’s. After birth, when the supply of the opioid via the placenta is cut off, the baby begins to experience withdrawal. This is known as Neonatal Opioid Withdrawal Syndrome (NOWS).

It is critically important to use precise language here. A baby cannot be “addicted.” The DSM-5 defines a substance use disorder based on a pattern of compulsive behaviors (e.g., trying to cut down and failing, spending a great deal of time obtaining the substance, etc.). A newborn cannot exhibit these behaviors. They are not addicted; they are in withdrawal from a substance they were passively exposed to. Using the correct terminology is vital to destigmatizing the condition for the mother.

The symptoms of NOWS typically appear within 24 to 72 hours after birth and can include:

• Shaking and tremors
• Poor feeding or an uncoordinated suck
• High-pitched, incessant crying
• Fever, sweating, and yawning
• Diarrhea and vomiting
• Sleep problems

Formal assessment tools can score NOWS severity. The traditional method is the Finnegan Neonatal Abstinence Scoring System, a complex 21-item checklist that rates symptoms like the duration of high-pitched crying, the intensity of the Moro (startle) reflex, the presence of seizures, sweating, hyperthermia, sneezing, nasal flaring, and respiratory rate.

Because of its complexity, many institutions are moving toward a simplified, function-based approach called Eat, Sleep, Console. This method focuses on the baby’s ability to function.

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

If the baby can do these three things, they are managed with non-pharmacological care. If they cannot, they may require medication. The duration of NOWS can range from days to weeks, depending on the substance involved and its half-life.

The good news, and a point of profound reassurance for mothers, is that there are no known long-term physical or intellectual problems associated with NOWS itself. With proper care, these babies can and do thrive. The standard of care is for the baby to room-in with the mother, just like any other newborn, to promote bonding and facilitate non-pharmacological care like swaddling, breastfeeding, and skin-to-skin contact.

If pharmacological intervention is needed, morphine is typically the first-line therapy. It is given in small, tapering doses to manage the withdrawal symptoms. Naloxone must never be given to a newborn, as it can precipitate a sudden, severe, and potentially fatal withdrawal. Secondary medications like clonidine or phenobarbital may also be used in more severe cases.

The Importance of Breastfeeding

We strongly encourage breastfeeding for mothers with OUD who are stable in treatment, as the benefits are immense for both mother and child.

• Neonatal Benefits: Decreased risk of a host of diseases, including asthma, leukemia, obesity, ear infections, eczema, diarrhea, vomiting, SIDS, and diabetes.
• Maternal Benefits: Decreased risk of breast and ovarian cancer, postpartum depression, and diabetes. We also see a faster physical recovery from childbirth, including weight loss.
• Bonding and Mental Health: Breastfeeding decreases maternal stress, increases mother-child bonding, and is associated with decreased rates of maternal neglect and child abuse.

It is crucial to note that buprenorphine and methadone are safe with breastfeeding. The amount of medication that passes into the breast milk is minuscule and is not harmful to the infant. In fact, it may even help to ease withdrawal symptoms slightly.

The only contraindications to breastfeeding in this context are:

• A return to use of non-prescribed or street opioids.
• A co-occurring diagnosis of HIV.
• The use of other specific contraindicated medications.

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

The evidence is clear and overwhelming: medically assisted withdrawal or “detox” is NOT recommended during pregnancy. This approach carries a very high rate of return to use, which re-exposes the fetus to the dangerous cycle of use and withdrawal and puts the mother at an extremely high risk of overdose, as her tolerance will have decreased during the period of abstinence.

The standard of care, recommended by ACOG, SAMHSA, and the WHO, is treatment with buprenorphine or methadone. These medications are the first-line, FDA-approved treatments for OUD in pregnancy.

• How they work: Buprenorphine and methadone work by occupying the opioid receptors in the brain, which eliminates cravings and prevents withdrawal symptoms. This stabilizes the mother’s physiology and, in turn, stabilizes the in-utero environment for the fetus. It provides a steady, consistent level of the medication, eliminating the dangerous peaks and troughs associated with street opioid use.
• Impact on the Neonate: Using MOUD during pregnancy leads to dramatically improved outcomes. We see a higher likelihood of the baby being born at a normal birth weight and at full term. These medications do not cause congenital disabilities.
• Naltrexone: Naltrexone is not considered a first-line treatment during pregnancy. It requires a patient to be fully detoxed before starting, which, as noted, is not recommended. However, it is not strictly contraindicated. If a woman was stable on naltrexone before becoming pregnant, a careful discussion about the risks and benefits of continuing versus switching to buprenorphine or methadone is warranted.

All newborns exposed to MOUD in utero need to be observed in the hospital for about three to five days after birth to monitor for signs of NOWS, as the long half-life of these medications means withdrawal can have a delayed onset. This is a crucial safety measure. Psychosocial therapy and support are also recommended as an essential component of the treatment plan.

Case Study: A Pregnant Patient Seeking Help

Let’s consider a typical scenario.

• Patient Profile: A 28-year-old female who is 18 weeks pregnant (G2P1, meaning this is her second pregnancy and she has one prior birth). She has mild asthma but is otherwise healthy, with a history of generalized anxiety disorder. She lives with a supportive partner, works part-time, and denies alcohol or tobacco use.
• Presentation: She reports daily misuse of prescription oxycodone ER, taking about 60 mg per day. She comes to her provider because she is terrified. She knows the risks to her pregnancy but has been unable to stop on her own due to intense withdrawal symptoms and cravings. She is highly motivated and expresses this clearly: “I want to be healthy for my baby and myself. I’ve tried quitting on my own but I can’t.” This plea for help is a critical opening for intervention.
• Potential Treatment Plan:

1. 1. Assessment: We would perform a UDS, which is positive for opioids but negative for other substances. We would also draw routine prenatal labs, including a CBC, CMP, HIV test, hepatitis panel, and STI panel, all of which come back within normal limits.
   2. Initiate Buprenorphine: We can start buprenorphine quickly and safely. We would instruct her to wait until she is in mild to moderate withdrawal, typically 12-24 hours after her last dose of oxycodone. We would start with a small initial dose of 2-4 mg of buprenorphine and titrate it up over several days, as tolerated, to a stable, therapeutic dose (up to a max of 24 mg/day) that completely controls her cravings and withdrawal.
   3. Comprehensive Care Coordination:

• • • Prescribe naloxone as a safety measure.
    • Ensure she is referred to and engaged with prenatal care.
    • Recommend psychosocial support, such as individual therapy or a support group for pregnant women in recovery.
    • Proactively encourage breastfeeding postpartum, assuming no contraindications arise, and provide her with the education and reassurance she needs to feel confident in this choice.

This proactive, compassionate, and evidence-based approach can turn a high-risk situation into a story of hope and recovery, resulting in a healthy mother and a healthy baby.

Adolescents and the Opioid Crisis: A New and Deadly Landscape

The opioid crisis has taken a particularly tragic turn among adolescents. The data reveals a frightening new reality where the danger is not necessarily from increased use, but from the incredible potency of the drugs available.

• Between 2019 and 2020, overdose deaths among 14- to 18-year-olds increased by a staggering 94%.
• From 2020 to 2021, overdose deaths increased another 20%.
• The paradox is that during this same period, overall opioid use among adolescents actually decreased. The driver of these deaths is the proliferation of illicitly manufactured fentanyl (IMFs) and other potent synthetic opioids. Deaths involving IMFs in this age group increased by 183%.

A review of these tragic cases reveals some important patterns:

• 40% of the deceased had a known history of mental health conditions.
• 35% had a prior history of opioid use.
• However, only a minuscule 5% had ever received treatment for opioid use disorder (Friedman et al., 2022). This represents a massive, fatal gap in care.

Identifying Protective and Risk Factors

Working with adolescents requires a focus on both mitigating risks and bolstering protective factors.

• Protective Factors: Elements that build resilience.

• • Family Engagement: A strong, supportive connection with family or guardians.
  • Guardian Disapproval of Substance Use: Clear messages from caregivers that substance use is harmful.
  • School Connectedness: Feeling like a valued part of the school community.
  • Self-Efficacy: A belief in one’s own ability to succeed and overcome challenges.

• Risk Factors: Vulnerabilities we need to screen for and address.

• • Social Determinants of Health: Factors like poverty, unstable housing, and community violence.
  • Other Substance Use: Use of alcohol, cannabis, or other drugs.
  • Early Age of Onset: Starting substance use at a young age is a major predictor of future disorders.
  • History of Impulsivity: Such as in ADHD.
  • Psychiatric Disorders: Depression, anxiety, and trauma.
  • Maltreatment: A history of abuse or neglect.
  • Family History of Substance Use Disorders: Genetic and environmental risk.

By understanding these factors, we can better identify at-risk youth and intervene early.

Screening Adolescents: The Importance of Confidentiality

When screening an adolescent, the first step is to have a clear, honest conversation about confidentiality. We must be aware of the specific state laws governing minor consent and confidentiality. We need to explain upfront what information can be kept private between us and the youth, and what circumstances would legally or ethically require us to disclose information to their parents or guardians (e.g., imminent risk of harm to self or others).

Establishing this trust is paramount. If a youth feels they can speak openly without fear of immediate reprisal, they are far more likely to be honest. The recommendation is to have dedicated one-on-one time with the adolescent, without a parent in the room. Even if it’s just a few minutes, this private space can be used for crucial education and harm reduction counseling.

Several screening tools are validated for this population:

• S2BI (Screening to Brief Intervention): This tool asks about the frequency of use (never, once or twice, monthly, weekly) for various substances over the past year.
• Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD): This asks for the number of days a substance was used in the past year and gets very specific, naming drugs like cocaine, heroin, meth, hallucinogens, and inhalants, as well as various prescription and over-the-counter medications.
• CRAFFT: As discussed earlier, this tool is excellent for screening for the problematic behaviors associated with substance use.

Treatment Recommendations for Adolescents with OUD

Treating an adolescent with OUD requires a multi-pronged approach that involves the youth, the family, and a team of healthcare professionals.

1. Naloxone, Naloxone, Naloxone: This is the most urgent intervention. We must ensure that the adolescent, their friends, and their family have access to naloxone and know how to use it. Many schools are now stocking naloxone, but personal access is key. We should discuss high-risk scenarios (e.g., using alone, using after a period of abstinence) and help them develop a safety plan.
2. Behavioral Health Services: Therapy is essential. This can occur in various settings, including outpatient clinics, intensive outpatient programs, or even school-based health centers. Family therapy is often a critical component.
3. Medications for Opioid Use Disorder (MOUD):

• • Buprenorphine: This medication is FDA-approved for adolescents aged 16 and older. For a 16- or 17-year-old with moderate to severe OUD, buprenorphine is the standard of care and can be life-saving.
  • Naltrexone and Methadone: These are currently only FDA-approved for individuals 18 years and older. However, the clinical landscape is evolving. The American Society of Addiction Medicine (ASAM) is expected to release new guidelines for adolescents and transition-age youth in 2026, so we will be watching for updates that may expand these options.

Case Study: An Adolescent in Crisis

This case illustrates a tragically common pathway to OUD in young people.

• Patient Profile: A 16-year-old female in the 11th grade. She was formerly a competitive soccer player, but her school attendance and grades are now declining. Her medical history is significant for an ankle fracture at age 15 that required surgery, for which she was prescribed oxycodone. Her family history includes a father with alcohol use disorder and a mother with depression. Socially, she lives with her mother and younger brother. After her injury, she drifted away from her old peer group and began associating with older friends who misuse opioids.
• Presentation: She is brought to the emergency department by her mother after being found extremely drowsy and nauseated. She admits to snorting heroin daily for the past six months. She explains her story: she started with the prescribed oxycodone for her pain, but continued taking leftover pills after the prescription ran out because they made her “feel calm and less stressed.” When the pills were gone, her new peers introduced her to heroin as a cheaper and more available alternative. Her statement is hauntingly insightful: “At first I needed the pills for pain, but then I needed them to feel okay.”
• Treatment Plan:

1. 1. Assessment in the ED: Her UDS is positive for heroin, but importantly, negative for fentanyl and other substances. This is crucial information. We need to have a harm reduction conversation with her, explaining that she was “lucky” this time, but that most heroin on the street today is contaminated with fentanyl, making every use a game of Russian roulette.
   2. Initiate Buprenorphine: Because she is 16, she is eligible for buprenorphine. We would start it 12-24 hours after her last heroin use, once she is in withdrawal. We would titrate the dose up from an initial 2-4 mg to a therapeutic level (up to 24 mg/day) that controls her cravings.
   3. Prescribe Naloxone: She and her mother must leave the hospital with a naloxone kit and training.
   4. Refer to Psychosocial Support: She needs immediate referral to an adolescent substance use treatment program that can provide individual, group, and family therapy. This is not optional; it is critical to her recovery.

Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

Other Special Populations and Considerations

The principles of OUD treatment must also be adapted for other specific populations.

Opioid Use Disorder in Older Adults

We are seeing a concerning trend of increasing OUD in older adults. Since 2013, there has been a threefold increase in OUD among adults aged 65-69. The intersection of chronic pain, polypharmacy, and age-related physiological changes often drives this. We see higher rates in patients covered by both Medicare and Medicaid compared to those with Medicare alone. We also see racial and ethnic disparities, with increased vulnerability among Black Americans, Native Americans, and Alaska Natives.

When considering MOUD for older adults, several key principles apply:

• Caution and Risk-Benefit Analysis: While we must always be cautious, the extreme risk posed by the toxic drug supply means the benefit of MOUD (methadone or buprenorphine) usually far outweighs the risk. A stable dose of a prescribed medication is infinitely safer than using street fentanyl.
• Limited Data: Unfortunately, most of the pivotal clinical trials for these medications excluded adults over 65, so our guidance is based more on clinical experience and pharmacokinetic principles than on robust trial data.
• Consider Hepatic and Renal Function: Organ function naturally declines with age.

• • Methadone: For patients with significant renal impairment (creatinine clearance < 10 mL/min), we may need to reduce the methadone dose by 50-75%. The liver primarily metabolizes methadone, so dose adjustments for liver impairment are less common but should be considered in severe cases. As always with methadone, we must monitor the QTc interval
  • Buprenorphine: Buprenorphine is largely considered safe in renal impairment and does not require a dose reduction. However, in cases of severe hepatic impairment, a dose reduction is necessary. The long-acting subcutaneous buprenorphine injections are contraindicated in moderate or severe liver impairment.

• Respiratory Depression Risk: Methadone, as a full opioid agonist, carries a higher intrinsic risk of respiratory depression than buprenorphine. This risk is magnified in older adults due to age-related changes in respiratory drive and drug clearance.

The key is to start low, go slow, and monitor frequently. Older adults starting MOUD may need more frequent follow-up appointments.

The Complex Issue of Benzodiazepines and Other CNS Depressants

One of the most common and anxiety-provoking clinical scenarios is a patient with OUD who is also taking a benzodiazepine or another Central Nervous System (CNS) depressant. For years, many clinics had a strict policy of refusing to prescribe MOUD to such patients due to the combined risk of respiratory depression.

However, the FDA issued a crucial safety communication several years ago that changed this paradigm. The agency urged caution about withholding MOUD from patients taking benzodiazepines or other CNS depressants. The reasoning is based on a stark risk-benefit calculation.

• The Risk of Combined Use: Yes, combining a benzodiazepine with buprenorphine or methadone increases the risk of respiratory depression compared to taking the MOUD alone.
• The Risk of Untreated OUD: However, the risk of a patient taking their benzodiazepine and then using street fentanyl or heroin is far, far greater. This combination is exponentially more likely to be fatal.

Therefore, the current standard of care is that concurrent benzodiazepine use is NOT a contraindication for MOUD. We do not use arbitrary dose limits (e.g., cutting the buprenorphine dose in half) to compensate, as this can lead to undertreatment of the OUD, cravings, and a return to illicit use.

The approach should be:

1. Treat the OUD: Initiate MOUD to stabilize the patient and save their life.
2. Educate: Have a very direct conversation with the patient. “You are at a higher risk for overdose because you are taking these two medications together. But the highest risk of all is if you take your benzodiazepine and then use street drugs. You must not do that.”
3. Taper if Possible: If the benzodiazepine is being used for a condition like anxiety, for which it is not a first-line treatment, we should work with the patient to create a slow, careful tapering plan while simultaneously initiating a first-line agent like an SSRI.
4. Be Aware of Other CNS Depressants: The FDA statement also mentioned other drug classes to be aware of, including:

• • Other sleep drugs and tranquilizers (e.g., zolpidem, eszopiclone).
  • Muscle relaxants (e.g., baclofen, cyclobenzaprine).
  • Antipsychotics (e.g., aripiprazole, quetiapine, paliperidone).

For some of these medications, tapering may be possible. For others, like an antipsychotic needed for schizophrenia, the patient will need to remain on it. In these cases, ongoing education and harm reduction counseling are key.

Conclusion: Key Takeaways for Integrative Practice

As we conclude this deep dive into the complexities of OUD, I want to reiterate the most important takeaways that guide our work every day at Injury Medical Clinic.

1. Treat the Whole Person: Depression, anxiety, and PTSD are not side issues; they are fundamentally intertwined with OUD. We must screen for and treat these co-occurring conditions with evidence-based practices like CBT and appropriate pharmacotherapy (SSRIs/SNRIs) to achieve lasting recovery.
2. MOUD is the Standard of Care for Pregnant Women: Medications for opioid use disorder, specifically buprenorphine and methadone, are the life-saving, evidence-based standard of care for pregnant patients with OUD. They improve both maternal and neonatal outcomes.
3. Adapt Care for Age: Thoughtfully adapt the core principles of OUD treatment and medication considerations when treating adolescents (with a focus on buprenorphine for those 16+) and older adults (with careful attention to organ function and polypharmacy).
4. Embrace a Risk-Benefit Approach: Treating OUD with MOUD is a process of harm reduction. This is never clearer than when a patient is also using benzodiazepines or other CNS depressants. The benefit of preventing a fatal overdose from illicit drugs almost always outweighs the risk of co-prescribing, making it a necessary and life-saving intervention.

In my practice, integrating chiropractic and functional medicine into this framework provides a powerful synergy. By addressing the biomechanical pain drivers, optimizing underlying physiological function, and providing a foundation of medical safety through my collaboration with Dr. Cardenas, we can offer a truly holistic path to recovery. This comprehensive, multidisciplinary approach allows us to meet our patients where they are and guide them on their journey toward a healthier, fuller life.

If you have any questions about this material or our approach to care, please do not hesitate to reach out. Thank you for taking this journey with me.

References

• Davis, J. P., Smith, D. C., & Hernandez, M. (2021). Co-occurring major depressive disorder and substance use disorders. In StatPearls [Internet]. StatPearls Publishing.
• Friedman, J., Godvin, M., Shover, C. L., & Gone, J. P. (2022). Trends in drug overdose deaths among US adolescents, January 2010 to June 2021. JAMA, 327(14), 1398–1400.
• Hirai, A. H., Ko, J. Y., & Salvesvold, N. (2021). Opioid Use Disorder Documented at Delivery Hospitalization — United States, 2010–2017. MMWR Morbidity and Mortality Weekly Report, 70(18), 668–673.
• Krupitsky, E., Zvartau, E., & Blokhina, E. (2006). An open-label trial of sertraline and cognitive-behavioral therapy in the treatment of depression in heroin-addicted patients in St. Petersburg, Russia. Journal of Substance Abuse Treatment, 31(4), 397-403.
• Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health (HHS Publication No. PEP23-07-01-006, NSDUH Series H-58). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.
• Winkelman, T. N. A., Villapiano, N., & Kozhimannil, K. B. (2018). Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014. Pediatrics, 141(4), e20173520.

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