Integrative Chiropractic Care: Understanding Medications & OUD

Learn about integrative chiropractic care, OUD, and effective harm reduction methods to address opioid use disorder in this informative guide.

Abstract

In this educational article, I present an evidence-based roadmap for identifying, treating, and preventing opioid use disorder (OUD) by pairing standard-of-care medical therapies with integrative chiropractic care, functional rehabilitation, and radical empathy. While Medications for Opioid Use Disorder (MOUD)—such as buprenorphine, methadone, and naltrexone—remain indispensable for stabilizing brain chemistry and preventing fatal overdoses, addressing the biomechanical and neurophysiological drivers of chronic pain is essential to resolve the root causes of opioid dependency.

Drawing from ongoing clinical observations at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, I explore how targeted spinal manipulative therapy (SMT), myofascial release, and neuromuscular re-education modulate nociceptive input, downregulate central sensitization, and alleviate secondary musculoskeletal comorbidities commonly exacerbated by chronic opioid use, including opioid-induced hyperalgesia (OIH), muscular splinting, and postural collapse. Working alongside our Medical Director, Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine; NPI #1164426749; Texas MD License #J2933), our collaborative model blends internal medicine oversight with non-pharmacological pain strategies and harm reduction protocols. By restoring functional mobility and autonomic balance, integrative chiropractic care provides a durable, non-opioid pathway to long-term recovery and whole-person rehabilitation.

Introduction: Bridging Biomechanics, Medicine, and Radical Empathy

Hello, I am Dr. Alex Jimenez. In my clinical practice as a Doctor of Chiropractic (DC) and Family Nurse Practitioner (APRN, FNP-BC), dually trained in functional medicine (CFMP, IFMCP) and rehabilitation, my life’s work centers on understanding how the nervous system, biomechanics, and metabolic pathways intersect. Patients rarely begin taking opioids with the intention of developing a substance use disorder; they typically arrive at this crossroads following severe mechanical injuries, unmanaged chronic pain, trauma, or systemic functional collapse.

At Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic) in El Paso, Texas, I practice alongside our Medical Director, Dr. Maria Guadalupe Cardenas, MD, a board-certified internist with over four decades of clinical experience (NPI #1164426749, Texas MD License #J2933). Together, we treat complex cases involving personal injuries, spinal trauma, and substance dependency. A central lesson from our clinical observations—regularly detailed across our clinical platforms at PushasRx and my LinkedIn Professional Profile—is that treating the chemical component of addiction without addressing underlying musculoskeletal dysfunction creates a precarious cycle of relapse.

Medications for Opioid Use Disorder (MOUD) save lives by restoring neurochemical equilibrium, but they do not correct spinal subluxations, myofascial trigger points, joint restrictions, or faulty movement patterns. By integrating chiropractic care into the OUD treatment continuum, we introduce a potent non-pharmacological modality that dampens pain signaling, restores physical capacity, and reduces biomechanical reliance on opioid analgesia.

The Opioid Crisis Landscape: The Intersection of Pain and Dependency

The modern overdose crisis continues to escalate due to an unregulated drug supply dominated by illicitly manufactured synthetic opioids like fentanyl, often co-ingested with non-opioid sedatives like xylazine (Centers for Disease Control and Prevention [CDC], 2024). Approximately 6% of Americans report past-year illicit opioid use, spanning from recreational experimentation to severe, diagnosed OUD (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023).

Crucially, a substantial percentage of individuals who develop OUD trace their first opioid exposure to a prescription written for acute or chronic musculoskeletal pain—such as lower back pain, cervical radiculopathy, or post-traumatic motor vehicle injuries (Paige et al., 2017). When pain persists despite tissue healing, neuroplastic remodeling occurs, transforming localized nociceptive pain into generalized hypersensitivity. If clinical management relies exclusively on escalations in opioid dose, patients encounter tolerance, physical dependence, and hyperalgesia rather than lasting recovery.

Diagnostic Criteria and Clinical Assessment

Under the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR), OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress within 12 months, manifested by at least 2 of 11 criteria spanning tolerance, withdrawal, craving, and behavioral interference (American Psychiatric Association [APA], 2022).

In our El Paso practice, our diagnostic protocol integrates psychiatric screening with comprehensive musculoskeletal and neurological evaluations:

• Validated Pain and Risk Screeners: Utilizing instruments such as the Screener and Opioid Assessment for Patients with Pain (SOAPP-R; Butler et al., 2008), the Opioid Risk Tool (ORT; Webster & Webster, 2005), and the PEG (Pain, Enjoyment, General Activity) scale (Krebs et al., 2009).

• Targeted Physical Examination: Evaluating postural alignment, spinal joint range of motion, segmental biomechanical dysfunction, myofascial tender points, and dermatomal/myotomal integrity.

• Withdrawal Quantification: Utilizing the Clinical Opiate Withdrawal Scale (COWS) to objectively score signs such as tachycardia, tremor, pupil dilation, gastrointestinal distress, and bone/joint aches (Wesson & Ling, 2003).

How Chiropractic Care Directly Reduces OUD Risk and Comorbidities

Chiropractic care serves both as an upstream preventative intervention and an adjunct recovery therapy for patients actively managing OUD. It interrupts the cycle of opioid dependency through several physiological pathways within the musculoskeletal and central nervous systems.

Chronic Musculoskeletal Injury / Joint Fixation
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Aberrant Nociceptive Input & Sympathetic Overdrive
                      │
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           Central Sensitization
 (Amplified spinal/cortical pain signaling)
                      │
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Opioid Escalation & Opioid-Induced Hyperalgesia (OIH)
                      │
                      ▼
Integrated SMT & Dynamic Neuro-Rehabilitation
                      │
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High-velocity stretch of mechanoreceptors (Type I & II)
                      │
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   Pre-synaptic inhibition of C-fiber nociception 
        (Gate Control + Endogenous Hypoalgesia)
                      │
                      ▼
Downregulated dorsal horn wind-up & restored mechanical mobility

1. Neurophysiological Modulation of Pain (Spinal Gating and Hypoalgesia)

Joint fixations and segmental hypomobility flood the spinal cord’s dorsal horn with sustained noxious input. High-velocity, low-amplitude (HVLA) spinal manipulative therapy (SMT) and low-force mobilizations introduce rapid mechanical stimulation to articular mechanoreceptors (Type I and II) and muscle spindles (Bialosky et al., 2018).

This afferent flood closes the presynaptic neurological gate (Melzack & Wall’s Gate Control Theory), inhibiting incoming C-fiber and A-delta nociceptive input. Furthermore, spinal adjustments stimulate descending inhibitory pathways originating in the periaqueductal gray (PAG) and rostral ventromedial medulla (RVM), triggering the release of endogenous endorphins and neurotensin that naturally elevate systemic pain thresholds (Bialosky et al., 2018; Paige et al., 2017).

2. Attenuating Opioid-Induced Hyperalgesia (OIH) and Central Sensitization

A common comorbidity observed in long-term opioid use is Opioid-Induced Hyperalgesia (OIH)—a neurobiological state wherein chronic opioid administration paradoxically increases pain sensitivity (Kosten & George, 2002; Woolf, 2011). Patients on chronic opioids often present with widespread, diffuse musculoskeletal tenderness, allodynia, and severe myofascial stiffness that do not match the original injury profile.

By normalizing biomechanical motion and reducing persistent peripheral inflammatory signaling, manual joint corrections quiet dorsal horn wind-up in the spinal cord (Woolf, 2011). In our clinical practice at PushasRx, we observe that integrating manual spinal therapy during opioid tapering or MOUD maintenance helps recalibrate central sensory processing, enabling patients to differentiate true peripheral tissue distress from central sensitization.

3. Resolving Musculoskeletal Comorbidities Associated with OUD

Chronic OUD frequently induces severe secondary physical comorbidities that impair daily activities and trigger relapse:

• Muscular Splinting and Trigger Point Clusters: Sustained drug-induced sedation, erratic sleep postures, and physical withdrawal cause widespread muscular spasms, particularly along the paraspinal musculature, upper trapezius, and piriformis. Myofascial release, instrument-assisted soft tissue mobilization (IASTM), and trigger point therapy eliminate these ischemic knots and restore tissue perfusion.

• Postural Collapse and Kinesiophobia: Chronic central nervous system (CNS) depression leads to thoracic hyperkyphosis, forward head carriage, and pelvic unleveling, which strain axial joints. Fear of movement (kinesiophobia) accelerates deconditioning. Chiropractic adjustments realign the structural frame, while graded motor-control therapies reactivate core stabilizers (e.g., multifidus, transversus abdominis), breaking the immobility cycle(Qaseem et al., 2017).

• Severe Withdrawal Arthralgia and Myalgia: During buprenorphine induction or taper phases, rebound sympathetic drive precipitates severe bone, joint, and muscle pain (Wesson & Ling, 2003). Non-force mobilization and gentle extremity adjustments relieve the somatic discomfort of acute withdrawal, improving patient tolerance and retention during early recovery.

Core Pharmacotherapy: Evidence-Based MOUD

Chiropractic care acts as a physical catalyst for functional restoration. At the same time, Medications for Opioid Use Disorder (MOUD) provide the necessary chemical stabilization to prevent mortality (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019; Volkow et al., 2014).

Buprenorphine Induction and Microdosing in the Fentanyl Era

Because buprenorphine binds to mu-opioid receptors with higher affinity than morphine, heroin, or fentanyl, administering it while full agonists occupy receptors displaces those agents rapidly, causing a sharp drop in receptor activation and precipitating severe withdrawal.

With illicit fentanyl’s high lipophilicity causing slow, unpredictable release from adipose tissue, traditional induction protocols based on early COWS elevation can fail (Ahmed et al., 2021). Our clinic adapts to this clinical reality by using low-dose micro-induction (the Bernese method):

• Start microscopic doses of buprenorphine (e.g., 0.5 mg daily) while full-agonist use continues.

• Gradually escalating the buprenorphine dose over 7 to 10 days as receptor occupancy shifts safely.

• Discontinuing the full agonist once therapeutic buprenorphine levels (typically 8–16 mg daily) are achieved (Ahmed et al., 2021; SAMHSA, 2023).

Comprehensive Harm Reduction and Clinical Safety

Harm reduction is grounded in pragmatism and patient autonomy: keeping individuals alive and reducing health complications, regardless of their current readiness for abstinence.

Essential Community and Clinical Interventions

1. Naloxone (Narcan): An opioid antagonist that rapidly displaces opioids from receptors to reverse life-threatening respiratory depression. Because synthetic fentanyl and xylazine analogs extend overdose vulnerability, patients and families are counseled on repeat dosing, the 60-to-90-minute half-life of naloxone, and calling emergency services immediately (Walley et al., 2013).

2. Syringe Service Programs (SSPs): Evidence shows that SSPs reduce HIV and viral hepatitis transmission by over 50% without increasing community drug use, serving as non-stigmatizing gateways to clinical care (CDC, 2021; Des Jarlais et al., 2015).

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3. Point-of-Use Test Strips: Fentanyl and xylazine test strips detect hidden adulterants. Clinical education highlights the chocolate chip cookie effect—a negative test strip on one section of a pill or powder does not ensure the entire supply is unadulterated (Galanis & Patsali, 2022).

4. Xylazine Wound Management: Xylazine adulteration induces peripheral alpha-2 adrenergic vasoconstriction, driving severe distal skin necrosis, punched-out ischemic ulcers, and secondary infections (National Institute on Drug Abuse [NIDA], 2023). Under Dr. Cardenas’s medical direction, our protocol combines conservative staged debridement, moisture-retentive dressings (alginates, hydrogels), culture-directed antibiotic therapy, and manual lymphatic drainage around adjacent margins to support vascular flow.

The Multidisciplinary Clinic Model in Practice

At Injury Medical Clinic PA in El Paso, Dr. Maria Guadalupe Cardenas, MD, and I structure care around a coordinated continuum:

[ Patient Presentation: Pain, Trauma, or OUD ]
                       │
       ┌───────────────┴───────────────┐
       ▼                               ▼
[ Internal Medicine Oversight ]   [ Integrative Chiropractic & Rehab ]
  • Dr. Cardenas, MD                • Dr. Jimenez, DC, APRN
  • Medical Risk Stratification     • Spinal & Extremity Manipulation
  • Diagnostic Labs / EKGs          • Myofascial Release & Gating
  • MOUD Protocols & Toxicology     • Neuromuscular Re-education
  • Antibiotic & Wound Care Plans   • Functional Movement Restoration
       └───────────────┬───────────────┘
                       │
                       ▼
    [ Motivational Interviewing & Trauma Care ]
  • OARS Communication Framework
  • Harm Reduction & Overdose Safety Planning
  • Collaborative Goal Tracking (PEG Scale)
                       │
                       ▼
      [ Durable Functional Recovery ]

1. Initial Rapid Triad: Patients undergo baseline risk evaluation, COWS evaluation, toxicological screening, and acute naloxone distribution alongside diagnostic imaging and a full structural musculoskeletal workup.

2. Parallel Stabilization: While Dr. Cardenas evaluates systemic stability, liver enzymes, cardiovascular status, and MOUD titration, our chiropractic team initiates low-force articular therapies, diaphragmatic breathing mechanics, and targeted myofascial release.

3. Active Rehabilitation: As neurochemical stability is attained via MOUD, the patient transitions to active rehabilitation. Restoring joint mobility and resolving chronic spinal subluxations reduces peripheral nociceptive input, stabilizing the nervous system against chronic pain relapse triggers (Bialosky et al., 2018; Paige et al., 2017).

References

• Ahmed, S., Bhivandkar, S., Lonergan, B. B., Suzuki, J., & Wakeman, S. E. (2021). Low-dose buprenorphine initiation in the era of fentanyl. Canadian Family Physician, 67(6), 437–439.

• American College of Obstetricians and Gynecologists. (2017). Opioid use and opioid use disorder in pregnancy (Committee Opinion No. 711).

• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

• Bialosky, J. E., Beneciuk, J. M., & Bishop, M. D. (2018). Spinal manipulative therapy-induced hypoalgesia: A systematic review and meta-analysis. Journal of Electromyography and Kinesiology, 42, 62–71.

• Butler, S. F., Fernandez, K., Chang, A., Benoit, C., & Katz, N. (2008). Development and validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). The Journal of Pain, 9(4), 360–372.

• Centers for Disease Control and Prevention. (2021). Summary of information on the safety and effectiveness of syringe services programs. U.S. Department of Health and Human Services.

• Centers for Disease Control and Prevention. (2024). Drug overdose deaths in the U.S. National Center for Health Statistics.

• Des Jarlais, D. C., Nugent, A., Solberg, A., Feelemyer, J., & Mermin, J. (2015). Syringe service programs for persons who inject drugs in urban, suburban, and rural areas—United States, 2013. Morbidity and Mortality Weekly Report, 64(48), 1337–1341.

• Galanis, P., & Patsali, M. (2022). The ‘chocolate chip cookie effect’ in harm reduction: A qualitative analysis. Journal of Substance Abuse Treatment, 138, Article 108745.

• Kampman, K., & Jarvis, M. (2015). American Society of Addiction Medicine (ASAM) national practice guideline for the use of medications in the treatment of addiction involving opioid use. Journal of Addiction Medicine, 9(5), 358–367.

• Kosten, T. R., & George, T. P. (2002). The neurobiology of opioid dependence: Implications for treatment. Science & Practice Perspectives, 1(1), 13–20.

• Krebs, E. E., Lorenz, K. A., Bair, M. J., Damush, T. M., Wu, J., Sutherland, J. M., Asch, S. M., & Kroenke, K. (2009). Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. Journal of General Internal Medicine, 24(6), 733–738.

• Kreek, M. J., Reed, B., & Bartlett, S. E. (2019). History and current status of opioid maintenance treatments: Science and politics. Journal of Substance Abuse Treatment, 103, 1–12.

• National Academies of Sciences, Engineering, and Medicine. (2019). Medications for opioid use disorder save lives. The National Academies Press.

• National Institute on Drug Abuse. (2023). Xylazine mixed with fentanyl: Why health officials are concerned. National Institutes of Health.

• Paige, N. M., Miake-Lye, I. M., Booth, M. S., Shannon, I. V., Shanman, R., Beroes, J. M., & Shekelle, P. G. (2017). Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: Systematic review and meta-analysis. JAMA, 317(14), 1451–1460.

• Qaseem, A., Wilt, T. J., McLean, R. M., & Forciea, M. A. (2017). Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 166(7), 514–530.

• Sordo, L., Barrio, G., Bravo, M. J., Indave, B. I., Degenhardt, L., Wiessing, L., Ferri, M., & Pastor-Barriuso, R. (2017). Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis. BMJ, 357, Article j1550.

• Substance Abuse and Mental Health Services Administration. (2023). Buprenorphine quick start guide. U.S. Department of Health and Human Services.

• Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies—Tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063–2066.

• Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, Article f174.

• Webster, L. R., & Webster, R. M. (2005). Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Medicine, 6(6), 432–442.

• Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs, 35(2), 253–259.

• Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(Suppl. 3), S2–S15.

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