Integrative OUD Care Demystified With Chiropractic Rehabilitation

Integrative OUD care combined with chiropractic rehabilitation offers unique strategies for effective recovery and overall wellness.

Abstract

Hello, I’m Dr. Alex Jimenez. Welcome to our educational series. Today, we’re embarking on a crucial journey into the intricate world of Opioid Use Disorder (OUD) and its impact on what we term “special populations.” This includes individuals grappling with co-occurring mental health conditions like depression, anxiety, and PTSD; pregnant individuals facing the dual challenge of their health and their unborn child’s well-being; and diverse age groups, from adolescents navigating the pressures of youth to older adults managing chronic conditions. I’ll share insights from leading researchers, grounded in modern, evidence-based practices, from my perspective as a practitioner dedicated to integrative care.

In this post, we will explore:

• The high prevalence of mental health disorders co-occurring with OUD and the best practices for integrated treatment, including pharmacotherapy and trauma-informed care.
• The specific challenges and evidence-based treatment strategies for managing OUD during pregnancy, focusing on the well-being of both the mother and the neonate.
• The alarming rise in overdose deaths among adolescents, the importance of protective factors, and age-appropriate treatment guidelines.
• The unique considerations for treating OUD in older adults, including polypharmacy, metabolic changes, and medication adjustments.
• The critical risk-benefit analysis required when treating patients with OUD who are also using other Central Nervous System (CNS) depressants, such as benzodiazepines.

Throughout this discussion, I will explain how our unique, multidisciplinary model at Injury Medical Clinic integrates chiropractic care, functional medicine, rehabilitation, and personal injury services under the collaborative medical direction of Dr. Maria Guadalupe Cardenas, MD. This integrated framework is essential for providing holistic, patient-centered care that addresses the complex biopsychosocial factors at play in these challenging cases.

Our Integrative Practice: A Collaborative Model for Comprehensive Healing

At Injury Medical Clinic, PA (also known as Mission Plaza Injury Medical Clinic), we have built a practice centered on a multidisciplinary, integrative philosophy. My work as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), and a Board-Certified Family Nurse Practitioner (FNP-BC), combined with my certifications in Functional Medicine (CFMP, IFMCP), allows me to view patient health through a multifaceted lens. I focus on the structural, neurological, and biomechanical aspects of health, particularly in the context of personal injury and musculoskeletal pain, which are frequent gateways to opioid use.

This approach is powerfully complemented by the medical oversight of our esteemed Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. With over 40 years of experience, Dr. Cardenas is Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933) and brings a depth of medical knowledge that is indispensable to our practice. This collaborative MD-DC model is common in advanced injury and integrative care clinics. It ensures that our patients receive a full spectrum of care, from my focus on chiropractic adjustments, spinal rehabilitation, and functional medicine protocols to Dr. Cardenas’s expert medical management, diagnostics, and oversight of prescriptive therapies.

Together, our team provides:

• Chiropractic Care: Addressing the root causes of pain through spinal adjustments, mobilization, and soft tissue therapies to reduce reliance on pain medication.
• Medical Oversight: Cardenas provides essential medical diagnostics, manages complex comorbidities, and oversees the medical aspects of our patients’ care plans to ensure safety and efficacy.
• Functional Medicine: We investigate the underlying drivers of illness—inflammation, hormonal imbalances, gut dysbiosis, and nutritional deficiencies—that can contribute to both chronic pain and mental health disorders.
• Personal Injury and Rehabilitation: We create comprehensive recovery programs for patients injured in accidents, focusing on restoring function and preventing the transition from acute to chronic pain.

This integrated system allows us to treat the patient as a whole person, which is especially critical when addressing the complexities of OUD. Now, let’s delve into our first major topic: the intersection of OUD and mental health.

Navigating the Dual Diagnosis: OUD and Co-Occurring Mental Health Conditions

As a clinician, one of the most common and challenging scenarios I encounter is the patient presenting with both a substance use disorder and a concurrent mental health condition. The statistics are stark and paint a clear picture of this public health crisis.

The Overwhelming Statistics

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: approximately 21.5 million adults in the United States are living with a co-occurring disorder, meaning they have both a mental health and a substance use disorder.

The treatment gap is deeply concerning:

• About 60% of these individuals received treatment for either their mental health disorder or their substance use disorder, but not both.
• A startling 40% received no treatment whatsoever for either condition.
• When treatment is sought, it’s most often for the mental health component, with the substance use disorder frequently going unaddressed.

When we narrow our focus specifically to Opioid Use Disorder (OUD), the literature reveals a particularly high prevalence of specific mental health conditions:

• Major Depressive Disorder (MDD): This can affect up to 50% of individuals with a substance use disorder.
• Anxiety Disorders: We see a prevalence of around 30%.
• Post-Traumatic Stress Disorder (PTSD): This affects nearly 20% of this population.

These co-occurring conditions are not just diagnostic labels; they carry profound real-world consequences. We observe that individuals with this dual diagnosis, particularly women, face a significantly increased risk of both overdose and suicide attempts. This underscores the urgent need for an integrated and vigilant approach to care.

The Importance of Comprehensive Screening

Given these high rates of co-occurrence, screening for mental health conditions in any patient with OUD is not just good practice—it’s an absolute necessity. In primary care, we often screen for depression and anxiety, and this practice must be rigorously applied in the context of substance use treatment.

Here are the gold-standard screening tools we rely on:

• PHQ-9 (Patient Health Questionnaire-9): A nine-question tool for screening, diagnosing, and monitoring the severity of depression. It directly reflects the diagnostic criteria for MDD.
• GAD-7 (Generalized Anxiety Disorder-7): This is a seven-question scale used to screen for and measure the severity of generalized anxiety disorder.
• PCL-5 (Post-Traumatic Stress Disorder Checklist for DSM-5): This tool is crucial and, in my experience, underutilized in general practice. Given the high prevalence of trauma among individuals with OUD, this should be a standard part of our assessment.

A Deeper Look at the PCL-5

The PCL-5 is a 20-question self-report measure that assesses the 20 symptoms of PTSD as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The questions relate to symptoms experienced over the past month, which aligns with the diagnostic time frame. The patient rates how much each symptom has bothered them on a scale from 0 (“Not at all”) to 4 (“Extremely”).

The symptoms covered are consistent with the four main PTSD symptom clusters:

• Intrusion: Nightmares, flashbacks, intrusive thoughts.
• Avoidance: Avoiding memories, thoughts, feelings, or external reminders of the traumatic event.
• Negative Alterations in Cognition and Mood: Persistent negative beliefs, distorted blame of self or others, feelings of detachment, anhedonia (inability to feel pleasure), and social isolation.
• Alterations in Arousal and Reactivity: Irritability, angry outbursts, reckless behavior, hypervigilance, and sleep disturbances.

A score between 31 and 33 is generally considered a clinical cutoff, suggesting that treatment for PTSD is warranted. The PCL-5 is not just a one-time screening tool; it’s invaluable for monitoring treatment progress. A reduction of 10 points or more strongly indicates that the chosen therapeutic interventions are effective.

The Foundation of Healing: Trauma-Informed Care

When working with any patient, but especially those with OUD and a co-occurring mental health disorder, adopting a trauma-informed care approach is non-negotiable. This isn’t a specific technique but a philosophical framework that shapes every interaction. It involves recognizing that a person is more likely than not to have a history of trauma and that their behaviors and coping mechanisms—including substance use—are often adaptations to these experiences.

There are six core principles we must integrate into our practice:

1. Safety: We must create an environment that is both physically and emotionally safe. This means a calm waiting area, private consultation rooms, and predictable, non-threatening interactions. For a patient with a history of trauma, a chaotic or judgmental environment can be re-traumatizing and an immediate barrier to care.
2. Trustworthiness and Transparency: We must be honest, open, and respectful. This means clearly explaining procedures, being upfront about care plans, and avoiding surprises. Contingency management should be transparent, not a “gotcha” moment. Trust is fragile and, once broken, is incredibly difficult to rebuild.
3. Peer Support: Integrating individuals with lived experience into the care team can be transformative. Peer support specialists can build trust and establish a sense of safety in ways that a clinician sometimes cannot. They offer hope and a living example that recovery is possible, which is a powerful tool for empowerment.
4. Collaboration and Mutuality: We must move away from a paternalistic “doctor knows best” model and partner with our patients instead. We are guides, not directors. By leveling the power dynamic, we ensure the care is truly patient-centered and tailored to their unique needs, goals, and values.
5. Empowerment, Voice, and Choice: We cultivate empowerment by offering choices. The patient should feel they are in the driver’s seat of their recovery journey. We present the evidence-based options, discuss the risks and benefits of each, and then honor their decision. This restores a sense of agency that trauma and addiction often strip away.
6. Cultural, Historical, and Gender Issues: We must recognize that our own lived experience is not universal. We need to be sensitive to and actively explore the cultural, historical, and gender-related factors that shape our patients’ perceptions and experiences of trauma and the healthcare system. This requires humility, curiosity, and a commitment to cultural competency.

The Role of Therapy and Pharmacotherapy

An integrated treatment plan for co-occurring disorders must include both therapy and, when appropriate, medication.

Therapeutic Approaches

While many forms of therapy can be beneficial, certain evidence-based modalities have demonstrated particular efficacy for these conditions:

• Cognitive Behavioral Therapy (CBT): This is a cornerstone for treating both depression and anxiety. CBT helps patients identify, challenge, and reframe negative thought patterns and behaviors that contribute to their distress.
• For PTSD, more specialized therapies are often required:

• • Prolonged Exposure (PE): This involves carefully and gradually exposing the patient to trauma-related memories, feelings, and situations to help them process the trauma and reduce its emotional impact.
  • Cognitive Processing Therapy (CPT): This is a specific type of CBT that focuses on challenging and modifying unhelpful beliefs related to the trauma.
  • Eye Movement Desensitization and Reprocessing (EMDR): This therapy uses bilateral stimulation (e.g., eye movements) to help the brain reprocess traumatic memories, reducing their vividness and emotional charge.

As clinicians, it’s our responsibility to build a network of trusted therapists skilled in these evidence-based practices so we can make appropriate, effective referrals.

Pharmacological Treatment

For MDD, GAD, and PTSD, Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are the first-line pharmacological treatments. Understanding the nuances of these medications is important to make the best choice for each patient.

Here’s a breakdown of some commonly used medications and their FDA-approved indications and key characteristics:

SSRIs:

• Paroxetine (Paxil): Indicated for all three conditions (MDD, GAD, PTSD). However, it’s crucial to note that it has one of the highest rates of sexual dysfunction among the SSRIs, which can be a significant barrier to adherence.
• Sertraline (Zoloft): Indicated for MDD and PTSD. It is often associated with gastrointestinal (GI) side effects, like nausea and diarrhea, particularly when starting treatment. These effects are usually transient and resolve within a few weeks.
• Fluoxetine (Prozac): Indicated for MDD. Its key feature is a very long half-life. This can be an advantage for patients who struggle with medication adherence, as a missed dose is less likely to cause withdrawal symptoms. However, this same property makes it more dangerous in an overdose attempt, a critical consideration for patients with suicidal ideation.
• Escitalopram (Lexapro): Indicated for MDD and GAD. It is generally one of the best-tolerated SSRIs, though it can be associated with some weight gain.

SNRIs:

• Duloxetine (Cymbalta): Indicated for MDD and GAD. It tends to have less sexual dysfunction than many SSRIs. It also has an indication for neuropathic pain and fibromyalgia, which can be a significant benefit in our patient population, especially those whose opioid use began with chronic pain.
• Venlafaxine (Effexor): Indicated for MDD and GAD. It can cause GI side effects and may be associated with weight gain. Also monitor blood pressure, as it can cause dose-dependent hypertension.

Critical Drug Interactions: Navigating MOUD and Psychotropics

When we prescribe these antidepressants, we must consider their interaction with the medications for opioid use disorder (MOUD) our patients are taking. The three primary MOUD medications are buprenorphine, methadone, and naltrexone.

Buprenorphine and Serotonin Syndrome

Buprenorphine (a partial opioid agonist) does possess some serotonergic properties. When combined with an SSRI or SNRI, there is a theoretical, albeit low, risk of serotonin syndrome. However, the clinical evidence is overwhelmingly clear: the benefit of treating the underlying depression or anxiety far outweighs this risk. Research has consistently found that treating co-occurring mental health conditions with antidepressants increases retention in OUD treatment. This is a critical point. An untreated mental health disorder is a major driver of relapse. Therefore, withholding an SSRI out of an abundance of caution is often counterproductive.

As a reminder, the signs and symptoms of serotonin syndrome can be remembered with the acronym SHIVERS:

• Shivering
• Hyperreflexia and Myoclonus (muscle twitching)
• Increased Temperature
• Vital Sign Instability (tachycardia, hypertension)
• Encephalopathy (confusion, delirium)
• Restlessness and Agitation
• Sweating (diaphoresis)

Methadone and QTc Prolongation

With methadone (a full opioid agonist), our primary concern is its potential to prolong the QTc interval on an electrocardiogram (ECG). A prolonged QTc interval increases the risk of a life-threatening arrhythmia called Torsades de Pointes. Many other medications, including some SSRIs and SNRIs, also carry this risk.

• Citalopram (Celexa) is a particular medication to watch. The FDA recommends against doses higher than 40 mg per day (and 20 mg in patients over 60) due to this risk.
• Venlafaxine also tends to have a slightly higher risk of QTc prolongation compared to other SSRIs/SNRIs.

When a patient on methadone requires an antidepressant, our protocol involves:

1. Obtaining a baseline ECG before starting the new medication.
2. Monitoring for symptoms like palpitations, lightheadedness, dizziness, syncope (fainting), chest pain, or shortness of breath.
3. Repeating the ECG after the new medication has reached a steady state (typically after five half-lives).
4. Performing an ECG if any concerning symptoms emerge.
5. Conducting annual ECGs thereafter.

As a general guideline, a QTc interval over 450 milliseconds in men and 460 milliseconds in women requires close monitoring and may necessitate a dose reduction or a change in medication.

Naltrexone and Mental Health Warnings

Naltrexone (an opioid antagonist) is unique. While it doesn’t have the same cardiac or serotonergic risks, its label includes a warning that it can increase or cause depression and suicidality. This is compounded by the fact that all SSRIs and SNRIs carry a black box warning for an increased risk of suicidality, particularly in children, adolescents, and young adults.

This does not mean these medications are contraindicated. It means we must have a very frank and thorough conversation with the patient about these risks. We must weigh them against the immense risk posed by untreated depression, which often leads individuals to self-medicate with opioids or alcohol—the very substances that dramatically increase the risk of death by suicide. The benefit of treatment almost always outweighs the risk, but it requires vigilant monitoring and robust patient education.

Integrative Chiropractic and Functional Medicine in Dual Diagnosis

In my practice, this is where the integrative model truly shines. A patient with OUD and depression doesn’t just have a neurochemical imbalance; they often have a body riddled with inflammation, nutritional deficiencies, and musculoskeletal pain.

• Chronic Pain and Inflammation: Many of my patients’ opioid journeys began with an injury or chronic pain. Chiropractic care can be a powerful, non-pharmacological tool to manage this pain. By performing spinal adjustments, we can improve joint mobility, reduce nerve irritation, and decrease pain signals. This can directly reduce the patient’s perceived need for opioids to cope with physical discomfort.
• The Gut-Brain Axis: Functional medicine highlights the profound connection between the gut and the brain. Chronic stress, poor diet, and opioid use itself can devastate the gut microbiome, leading to a “leaky gut” and systemic inflammation. This inflammation is a known driver of depression. By implementing functional medicine protocols—such as anti-inflammatory diets, targeted supplementation with probiotics and prebiotics, and gut-healing nutrients—we can reduce neuroinflammation and support mental health from the inside out.
• HPA Axis Dysregulation: Chronic stress and trauma can dysregulate the Hypothalamic-Pituitary-Adrenal (HPA) axis, our central stress response system. This results in cortisol imbalances that can fuel both anxiety and depression. Chiropractic adjustments have been shown to modulate the autonomic nervous system, helping to shift the body from a “fight-or-flight” (sympathetic) state to a “rest-and-digest” (parasympathetic) state. Combined with adaptogenic herbs and lifestyle interventions like mindfulness and exercise, this can help restore HPA axis balance.

Case Study in Action: A Holistic Approach

Let’s apply these concepts to a real-world scenario.

Patient Profile:

A 32-year-old divorced female, mother of two, working part-time in retail.

• Medical History: Chronic low back pain from degenerative disc disease, history of opioid misuse following an injury. She is currently stable on buprenorphine/naloxone 8 mg three times a day.
• Family History: Father with alcohol use disorder (in remission), mother with depression.
• Social History: Lives with her mother and children, has a limited support network, and a history of intimate partner violence. She attends peer recovery groups.

Presentation:

She comes in for a follow-up. While she denies any return to illicit opioid use, she reports debilitating symptoms of depression and anxiety that interfere with her daily functioning. She feels exhausted, overwhelmed by worry, and is unable to enjoy time with her children. She denies suicidal ideation but states, “I am staying away from pills, but I feel like I am drowning most days.”

Our Integrated Assessment and Plan:

1. Screening: We administer the standard screening tools.

• • PHQ-9: Score of 18 (Moderately Severe Depression).
  • GAD-7: Score of 15 (Severe Anxiety).
  • PCL-5: Score of 10 (Does not indicate current PTSD, but her history of intimate partner violence is a critical piece of information that informs our trauma-informed approach).

• Immediate Verifications:

• • Urine Drug Screen (UDS): Positive for buprenorphine, negative for all other substances. This confirms her adherence to her MOUD and her self-report.
  • Continue Buprenorphine/Naloxone: She is stable on her current dose so that we will maintain it.

• Multifaceted Treatment Plan:

• • Pharmacotherapy: We initiate an SSRI to treat her MDD and GAD. Given that her GI system may already be sensitive from the buprenorphine, we might choose escitalopram for its good tolerability profile, starting at a low dose and titrating up. We have a detailed discussion about the low risk of serotonin syndrome and the high benefit of treating her depression.
  • Therapy: We provide a warm handoff referral to a trusted therapist specializing in Cognitive Behavioral Therapy (CBT) and who practices from a trauma-informed perspective.
  • Safety Planning: We provide her with the 988 Suicide & Crisis Lifeline number and discuss when to go to the emergency room, ensuring she has a clear safety plan. We also prescribe naloxone and ensure she and her mother know how to use it.
  • Chiropractic Care: I would conduct a full musculoskeletal evaluation. Given her history of degenerative disc disease, she is an ideal candidate for chiropractic care. Gentle adjustments, spinal decompression therapy, and targeted exercises can alleviate her chronic low back pain. Reducing her physical pain burden can free up emotional and mental resources, making it easier for her to engage in her mental health treatment.
  • Functional Medicine: We would explore the inflammatory component of her condition. We’d discuss an anti-inflammatory diet, rich in omega-3s, and consider supplements like Vitamin D and magnesium, which are often deficient in individuals with depression and can support mood regulation.
  • Social Support: We commend her for attending peer recovery groups and encourage her to continue. We also explore resources for survivors of intimate partner violence, as addressing this past trauma is key to long-term healing.

This comprehensive, integrated approach addresses her neurochemistry, her physical pain, her psychological state, her nutritional status, and her social context. This is the essence of treating the whole person, not just the diagnosis.

Opioid Use Disorder in Pregnancy: Protecting Two Lives

The intersection of OUD and pregnancy is one of the most sensitive and critical areas in our field. Statistics show a dramatic and tragic increase in recent decades.

A Troubling Trend

• From 1999 to 2014, OUD in pregnancy increased fourfold.
• From 2010 to 2017, OUD documented at the time of delivery increased by 131%.
• The impact on newborns is equally devastating. Neonatal Opioid Withdrawal Syndrome (NOWS) increased fivefold between 2002 and 2009, with another 82% increase between 2010 and 2017.
• Current data from 2021 shows that a baby is born experiencing opioid withdrawal every 24 minutes in the United States.

We also see geographic disparities, with higher rates often reported in rural versus urban areas, highlighting issues of access to care and concentrated socioeconomic stressors.

The Barrier of Stigma

For this patient population, stigma is an enormous and often insurmountable barrier to care. Pregnant individuals with OUD frequently face deeply ingrained stereotypes: they are labeled as “unfit mothers,” “drug-seeking,” or “criminals.” This judgment often comes directly from healthcare staff, through both verbal and non-verbal interactions.

My own clinical observations confirm this. I’ve had patients recount stories of being treated with contempt or suspicion in clinical settings, which led them to avoid prenatal care altogether. This is not only counterproductive to recovery but can also trigger a return to use or even a fatal overdose. As healthcare professionals, we have an absolute duty to dismantle this stigma and create a sanctuary of compassionate, non-judgmental care.

The Mandate for Universal Screening

Because of the high prevalence and the dangers of stigma-driven assumptions, universal screening for substance use in all pregnant patients is the standard of care. We must not single out patients we think might be at risk.

Several validated screening tools are available:

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

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

• NIDA Quick Screen: This looks at substance use within the past year. For women, it flags any use of tobacco or illicit drugs, or having four or more alcoholic drinks in a single day. A positive screen requires a substance-specific follow-up.
• CRAFFT: This tool is validated for individuals up to age 26 and is excellent for screening adolescents and young adults. 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’re alone?
  • Forget: Do you ever forget things you did while using alcohol or drugs?
  • Family/Friends: Do your family or friends ever tell you to cut down?
  • Trouble: Have you ever gotten into trouble while using?

• Two or more positive answers indicate a need for further assessment.

Complications of Untreated OUD in Pregnancy

Untreated OUD poses significant risks to both the mother and the fetus. These complications often arise from the dangerous cycle of use and withdrawal. When an individual uses an opioid, their body is flooded with the substance; as it wears off, they enter withdrawal. This cycle causes drastic physiological fluctuations that are extremely dangerous for a developing fetus. It can lead to uterine contractions and decreased blood flow to the placenta. Furthermore, the chaos of active addiction often results in inconsistent or non-existent prenatal care.

Specific risks include:

• Placental abruption
• Intrauterine growth restriction (IUGR)
• Preterm birth
• Stillbirth
• Maternal overdose

Understanding Neonatal Opioid Withdrawal Syndrome (NOWS)

Use precise language here. A newborn baby cannot be “addicted.” The DSM-5 defines a substance use disorder based on a pattern of maladaptive behaviors (loss of control, craving, etc.), which a neonate is incapable of exhibiting. A baby born to a mother who used opioids during pregnancy can, however, be physiologically dependent and experience withdrawal. This condition is called Neonatal Opioid Withdrawal Syndrome (NOWS), formerly known as Neonatal Abstinence Syndrome (NAS).

Symptoms of NOWS include:

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

Assessing and Managing NOWS

The traditional assessment tool is the complex Finnegan Neonatal Abstinence Scoring System. This 21-item checklist scores factors such as the duration of high-pitched crying, the intensity of tremors, sweating, sneezing, respiratory rate, and more.

However, many institutions are moving toward a simpler, family-centered approach called Eat, Sleep, Console (ESC). This method focuses on the baby’s ability to function. The criteria are:

• Eat: Can the baby eat at least one ounce per 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 meet these functional milestones, pharmacological intervention may be avoided. The duration of NOWS can range from days to weeks, depending on the specific substance used and its half-life.

The most reassuring message we can give to mothers is that, with proper care, there are no known long-term physical or intellectual problems associated with NOWS.

The primary treatment for NOWS is non-pharmacological. We encourage:

• Rooming-in with the mother.
• Swaddling and a low-stimulation environment.
• Skin-to-skin contact.
• Breastfeeding, if not contraindicated.

If pharmacological intervention is needed, morphine is typically the first-line therapy. Naloxone must never be given to a newborn, as it can precipitate a severe, life-threatening withdrawal. Secondary medications like clonidine or phenobarbital may be used in more severe cases.

The Critical Role of Breastfeeding

The benefits of breastfeeding are immense and apply equally to mothers with OUD who are stable on MOUD.

• Neonatal Benefits: Decreased risk of asthma, leukemia, obesity, ear infections, SIDS, and diabetes.
• Maternal Benefits: Decreased risk of breast and ovarian cancer, postpartum depression, and diabetes. It also promotes a faster recovery from childbirth, including weight loss, and, crucially, decreases maternal stress and increases mother-child bonding. This bonding can be a powerful protective factor against child neglect.

Breastfeeding is contraindicated if the mother returns to illicit street drug use, has HIV, or is taking other specific contraindicated medications. However, it is essential to emphasize that buprenorphine and methadone are safe with breastfeeding. Only very small amounts pass into the breast milk, and the benefits to both mother and baby are substantial.

Gold-Standard Treatment: MOUD in Pregnancy

The evidence is unequivocal: Medications for Opioid Use Disorder (MOUD) are the standard of care for pregnant individuals with OUD.

• Buprenorphine and methadone are the first-line treatments.
• They are FDA-approved and recommended by ACOG, SAMHSA, and the WHO.
• They significantly improve both maternal and neonatal outcomes by stabilizing the mother, eliminating the dangerous use-withdrawal cycle, and allowing her to engage in consistent prenatal care.

With MOUD, babies are more likely to be born at a normal birth weight and at full term. Not all babies exposed to MOUD will experience NOWS, but all must be observed in the hospital for 3-4 days due to the long half-lives of these medications. Importantly, no evidence shows that MOUD causes congenital disabilities.

Medically supervised withdrawal or “detox” is NOT recommended during pregnancy. It carries an extremely high rate of return to use, which exposes the fetus to the dangerous withdrawal-intoxication cycle and puts the mother at a very high risk of overdose, as her tolerance will have decreased.

Naltrexone is not a first-line treatment and is generally avoided. Its use would require a fully detoxified patient and carries the risk of precipitating severe withdrawal if any opioids are still in the patient’s system.

Psychosocial therapy and support are also essential components of the treatment plan.

Case Study: A Path to a Healthy Pregnancy

Let’s consider another case.

Patient Profile:

A 28-year-old female, 18 weeks pregnant (G2P1, meaning this is her second pregnancy and she has one living child).

• Medical History: Mild asthma.
• Psychiatric History: Generalized Anxiety Disorder (GAD).
• Social History: Lives with a supportive partner, works part-time, denies alcohol or tobacco use. She reports daily misuse of prescription oxycodone ER, about 60 mg per day.

Presentation:

She presents to her provider, reporting that she cannot stop using opioids despite knowing the risks to her pregnancy. She is terrified of withdrawal and cravings. She is highly motivated and states, “I want to be healthy for my baby and myself. I’ve tried quitting on my own, but I can’t.”

Our Integrated Treatment Plan:

1. Immediate Labs and Screening:

• • UDS: Positive for oxycodone, negative for other substances.
  • Labs: We draw a CBC, CMP, HIV test, hepatitis panel, and STI panel. All results are within normal limits.

• Initiation of MOUD:

• • We initiate buprenorphine. Since she is using an extended-release (ER) formulation of oxycodone, we must be careful about the timing to avoid precipitated withdrawal. We would start it at least 24 hours after her last dose, once she is in mild to moderate withdrawal.
  • We begin with a low dose of 2 mg and titrate up as tolerated, aiming for a therapeutic dose that eliminates cravings and withdrawal symptoms (up to a maximum of 24 mg per day).

• Comprehensive Care Coordination:

• • Naloxone: We prescribe naloxone and provide education to her and her partner.
  • Prenatal Care: We make an immediate and warm handoff referral to a trusted, non-judgmental OB/GYN practice for prenatal care.
  • Psychosocial Support: We recommend individual therapy to address her GAD and the stressors of her OUD, as well as peer support groups for pregnant and parenting individuals in recovery.
  • Breastfeeding Education: We begin the conversation about breastfeeding early, explain the benefits, and confirm that it is safe with buprenorphine. This empowers her and gives her something positive to focus on.
  • Chiropractic and Functional Medicine: During pregnancy, the body undergoes significant biomechanical changes. Lower back pain, sciatica, and pelvic pain are common. Gentle, pregnancy-specific chiropractic adjustments can safely and effectively manage this pain, reducing her stress and improving her quality of life without medication. We would also provide nutritional counseling to support a healthy pregnancy, focusing on anti-inflammatory foods, adequate protein, and essential prenatal nutrients to support both her and her baby’s development.

This proactive, supportive, and integrated plan gives her the best possible chance for a healthy pregnancy and a successful start to her recovery journey.

Opioid Use in Adolescents: A Generation in Crisis

The opioid crisis has not spared our youth. The data on adolescent overdose deaths is particularly heartbreaking and signals a dramatic shift in the drug landscape.

Alarming Increases in Overdose Deaths

• From 2019 to 2020, overdose deaths among 14- to 18-year-olds increased by a staggering 94%.
• From 2020 to 2021, they rose by another 20%.

The paradox here is that overall adolescent drug use has actually decreased. The driver of these deaths is the unprecedented potency of the available drug supply, specifically the proliferation of illicitly manufactured fentanyl (IMF). Deaths involving IMFs among this age group increased by 182%. Fentanyl is often pressed into counterfeit pills made to look like oxycodone or Xanax, so a teenager who thinks they are experimenting with a prescription pill may be ingesting a lethal dose of fentanyl.

Of the adolescents who died from overdose:

• 40% had a known mental health history.
• 35% had a prior history of opioid use.
• Only 5% had ever received treatment for OUD. This massive treatment gap represents a catastrophic failure to protect our most vulnerable.

Identifying Risk and Protective Factors

Understanding the factors that either protect or endanger an adolescent is key to prevention and early intervention.

Protective Factors:

• Family Engagement: Strong, supportive family relationships.
• Guardian Disapproval of Substance Use: Clear boundaries and expectations from parents or guardians.
• 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.
• As clinicians and community members, our goal is to bolster these protective factors wherever possible.

Risk Factors:

• Social Determinants of Health: Poverty, unstable housing, community violence.
• Other Substance Use: Early use of alcohol, tobacco, or cannabis is a strong predictor of later, more dangerous drug use.
• Early Age of Onset: The younger a person starts using substances, the higher their risk of developing a severe disorder.
• History of Impulsivity or other behavioral issues like ADHD.
• Co-occurring Psychiatric Disorders: Depression, anxiety, trauma.
• Maltreatment: A history of physical, emotional, or sexual abuse.
• Family History of substance use disorders.

Screening for these risk factors can help us identify at-risk youth before a crisis occurs.

Screening Adolescents: The Importance of Confidentiality

When screening an adolescent, the first and most important step is to explain the rules of confidentiality. I must be completely transparent with them about what I can keep between us and what I am legally or ethically required to disclose to their parents or authorities (e.g., imminent risk of harm to self or others). Building trust is impossible without this transparency. Breaking that trust by disclosing something they thought was confidential is a surefire way to lose them forever.

It is also crucial to have one-on-one time with the adolescent, without a parent in the room. This is often the only time they will feel safe enough to be honest. Even if all we do in that time is provide education or harm reduction strategies, it is invaluable.

Recommended screening tools for this population include:

• S2BI (Screening to Brief Intervention): Asks about the frequency (never, once/twice, monthly, weekly) of using different substances in the past year.
• BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs): Asks about the number of days a substance was used in the past year and gets very specific about different classes of drugs, including prescription medications.
• CRAFFT: As discussed earlier, this is excellent for identifying the problematic behaviors associated with a substance use disorder.

Treatment Recommendations for Adolescents

1. Naloxone, Naloxone, Naloxone: This is the top priority. We must ensure the adolescent, their family, and their friends have naloxone and know how to use it. Many schools are now stocking it, but we need to discuss high-risk scenarios (e.g., parties, using alone) and make sure they have a plan and carry it.
2. Behavioral Health Services: Therapy is crucial. This can happen in various settings, but school-based health centers can be an accessible resource for therapy and peer support.
3. Medications for Opioid Use Disorder (MOUD):

• • Buprenorphine is FDA-approved for adolescents aged 16 and older. For a 16- or 17-year-old with moderate to severe OUD, this is a life-saving, first-line treatment.
  • Naltrexone and methadone are currently only approved for those 18 years and older.
  • Keep an eye on upcoming guidelines. The American Society of Addiction Medicine (ASAM) is expected to release updated guidelines for adolescents and transition-age youth in 2026, which may bring important changes to these recommendations.

Case Study: A Teenager’s Descent and Recovery

Let’s examine a typical, tragic case.

Patient Profile:

A 16-year-old female in 11th grade.

• History: Formerly a competitive soccer player, but now has declining grades and school attendance. At age 15, she sustained an ankle fracture that required surgery, for which she was prescribed oxycodone.
• Family History: Father with alcohol use disorder (in remission), mother with depression.
• Social History: Lives with her mother and younger brother. After her injury, she drifted away from her athletic 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 that after her surgery, she continued taking her leftover oxycodone because it made her feel calm and less stressed. When the pills ran out, her new peers introduced her to heroin as a cheaper, more available alternative. She states, “At first I needed the pills for pain, but then I needed them to feel okay. When I couldn’t get them anymore, heroin was the only thing around.”

Our Treatment Plan:

1. Urine Drug Screen: Positive for heroin, but importantly, negative for fentanyl and other substances. This is a crucial harm reduction teaching moment. We must explain to her that next time, the heroin could be laced with fentanyl, and she might not be so lucky.
2. Initiation of MOUD: 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 2 mg to a therapeutic level (up to 24 mg) that controls her cravings.
3. Comprehensive Support:

• • Naloxone: We prescribe naloxone and provide extensive education to her and her mother.
  • Psychosocial Support: A referral to an adolescent-specific substance use treatment program is critical. This would include individual therapy, family therapy (to address family dynamics and build support), and peer support groups with other teens in recovery.
  • Chiropractic and Rehabilitation: Her journey started with an injury. We would assess her for any lingering musculoskeletal imbalances from her ankle fracture that could be contributing to chronic pain or altered biomechanics. Providing rehabilitation and chiropractic care could address any residual physical issues and reinforce the message that there are non-opioid ways to manage pain.
    

    Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

    Other Special Populations: Older Adults and Users of CNS Depressants

Our discussion wouldn’t be complete without touching on two other crucial populations.

OUD in Older Adults: A Hidden Epidemic

We are also seeing a concerning rise in OUD among older adults.

• Since 2013, there has been a threefold increase in OUD among adults aged 65-69.
• The increase is more pronounced in patients with both Medicare and Medicaid compared to those with Medicare alone, pointing to socioeconomic vulnerability.
• Race and ethnicity data show increased vulnerability among Black Americans, Native Americans, and Alaska Natives.

MOUD Considerations in Older Adults

Treating older adults requires extreme caution and a careful risk-benefit analysis. However, given the lethality of the illicit drug supply, the benefits of MOUD almost always outweigh the risks. Having an older adult on a stable dose of methadone or buprenorphine is far safer than them using street fentanyl.

Key considerations include:

• Lack of Data: Clinical trials for these medications have included few participants over age 65, so our guidance is less robust.
• Hepatic and Renal Function: Organ function naturally declines with age.

• • Methadone: If creatinine clearance is less than 10 mL/min (severe kidney disease), we may need to reduce the dose by 50-75%. Liver-related dose adjustments are less common.
  • Buprenorphine: No dose adjustment is needed for renal impairment. However, for patients with severe hepatic impairment, a dose reduction is necessary. The subcutaneous, long-acting injections of buprenorphine are contraindicated in moderate or severe liver impairment.

• QTc Prolongation: This is an even greater concern in older adults, who are more likely to have underlying cardiac issues or be on other QTc-prolonging medications. If a patient on methadone has a QTc above 450 ms, a dose reduction or alternative should be strongly considered.
• Respiratory Depression: Methadone, as a full agonist, carries a higher risk of respiratory depression. This risk is amplified in older adults due to changes in pharmacokinetics and slower drug clearance.

We must monitor these patients very closely, with more frequent follow-ups, especially when initiating or titrating MOUD.

The Complex Issue of Benzodiazepines and Other CNS Depressants

For years, clinicians have been extremely hesitant to prescribe MOUD to patients who also use benzodiazepines (e.g., Xanax, Klonopin) or other CNS depressants due to the combined risk of respiratory depression.

However, the FDA issued a crucial statement several years ago, urging caution against withholding MOUD from these patients. The reasoning is based on a stark risk-benefit analysis:

• Yes, combining buprenorphine or methadone with a benzodiazepine increases the risk of respiratory depression.
• However, the risk of a patient taking a benzodiazepine and then using illicit fentanyl or heroin is exponentially higher and far more likely to be fatal.

Therefore, the presence of a benzodiazepine is NOT an absolute contraindication for MOUD. Our primary goal must be to treat the OUD, as it poses the greatest immediate threat to life.

Our approach should be:

1. Educate the Patient: Have a frank conversation about the increased risk.
2. Prescribe Naloxone: This is non-negotiable.
3. Taper the CNS Depressant (If Possible): If the patient is on a benzodiazepine for a condition like GAD, for which it is not a first-line treatment, we should create a slow, careful taper plan while initiating a safer alternative like an SSRI.
4. Do Not Arbitrarily Reduce MOUD Dose: Reducing the buprenorphine or methadone dose to “compensate” is dangerous. An inadequate MOUD dose will lead to cravings and a return to illicit use, which is the worst possible outcome.

This same logic applies to other CNS depressants, including:

• Sleep Medications: (e.g., zolpidem)
• Muscle Relaxants: (e.g., baclofen, cyclobenzaprine)
• Antipsychotics: (e.g., aripiprazole, quetiapine, olanzapine)

For many of these medications, especially antipsychotics for conditions like schizophrenia, discontinuation is not an option. We must manage the patient on both medications, with heightened monitoring and extensive education.

Conclusion: A Call for Integrated, Compassionate Care

As we’ve journeyed through these complex topics, a few key themes have emerged:

1. Integration is Essential: Co-occurring conditions like depression, anxiety, and PTSD are the rule, not the exception, in OUD. They must be treated concurrently using evidence-based practices.
2. MOUD is Life-Saving: For pregnant individuals, adolescents, older adults, and those using other CNS depressants, MOUD is the cornerstone of treatment. It is a harm-reduction tool that saves lives and provides the stability needed for true recovery to begin.
3. A Risk-Benefit Approach is Paramount: We must constantly weigh the risks of our treatments against the far greater risks of untreated OUD. Fear should not paralyze us into inaction.
4. Holistic Care Matters: My experiences as a Doctor of Chiropractic and Functional Medicine practitioner have shown me time and again that we cannot separate the mind from the body. Addressing structural pain, systemic inflammation, and nutritional deficiencies through an integrative model provides a more robust foundation for recovery. The collaborative partnership with medical experts like Dr. Cardenas ensures this care is safe, comprehensive, and synergistic.

Treating individuals with OUD, especially within these special populations, requires more than just a prescription pad. It demands compassion, a commitment to evidence-based practice, and a willingness to see and treat the whole person in front of us. Thank you for joining me in this important discussion.

References

• American College of Obstetricians and Gynecologists. (2017). ACOG Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy. Obstetrics and Gynecology, 130(2), e81-e94.
• 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.
• Substance Abuse and Mental Health Services Administration. (2022). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health.
• S. Food and Drug Administration. (2017). FDA urges caution about withholding opioid addiction medications from patients taking benzodiazepines or other CNS depressants.
• Weich, S., Pearce, E., Croft, P., Singh, S. (2014). Quality of mental and physical health care for people with and without comorbid mental illness in the UK: a population-based, cross-sectional study. The Lancet Psychiatry, 1(2), 121-130.
• World Health Organization. (2014). Guidelines for the identification and management of substance use and substance use disorders in pregnancy.

SEO Tags: Opioid Use Disorder, OUD Treatment, Integrative Care, Dr. Alex Jimenez, Dr. Maria Cardenas, El Paso Chiropractor, Functional Medicine, Co-Occurring Disorders, Depression, Anxiety, PTSD, OUD in Pregnancy, Neonatal Opioid Withdrawal Syndrome, Adolescent Opioid Use, Older Adults and Opioids, Buprenorphine, Methadone, Naltrexone, Serotonin Syndrome, QTc Prolongation, Trauma-Informed Care, Chiropractic for Pain Management, Gut-Brain Axis, Personal Injury Care