Chiropractic Rehabilitation Benefits for Integrative OUD Care

Find out how integrative OUD care combined with chiropractic rehabilitation can enhance health outcomes and support recovery journeys.

Abstract: Navigating Opioid Use Disorder in Special Populations: An Integrative Approach

Hello, I’m Dr. Alex Jimenez. Welcome to our educational series where we explore complex health challenges through the lens of integrative and functional medicine. My extensive background as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), board-certified Family Nurse Practitioner (FNP-BC), and a dual-certified practitioner in Functional Medicine (CFMP, IFMCP), alongside my work in advanced topics in nutrigenomics (ATN) and chiropractic spinal trauma (CCST), has shaped my comprehensive approach to patient care. At Injury Medical Clinic, we are deeply committed to a multidisciplinary model. This is made possible through our collaborative partnership with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected, board-certified Internist with over four decades of experience and serves as our Medical Director and Collaborative Physician. Together, our team provides a unique fusion of medical oversight, advanced chiropractic care, functional medicine, rehabilitation, and personal injury services, ensuring our patients in El Paso, Texas, receive the most thorough and personalized care possible.
In this comprehensive post, we will delve into the multifaceted challenges of treating Opioid Use Disorder (OUD), particularly within special populations. Our journey will cover the intricate relationship between OUD and co-occurring mental health conditions like depression, anxiety, and PTSD. We will analyze evidence-based treatment strategies, including pharmacotherapy and trauma-informed care, and discuss how to integrate these with our foundational chiropractic and functional medicine principles. We will then navigate the complexities of managing OUD during pregnancy, emphasizing the safety and efficacy of Medications for Opioid Use Disorder (MOUD) for both mother and child. Following this, we will explore the alarming rise of OUD among adolescents, highlighting key risk factors, screening tools, and age-appropriate interventions. We will also address the unique considerations for treating older adults with OUD and, finally, tackle the clinical challenge of managing patients who use Central Nervous System (CNS) depressants, such as benzodiazepines, concurrently with MOUD. Throughout this discussion, I will share clinical insights from our practice, showing how an integrative team that combines medical expertise with chiropractic and functional wellness can create a powerful synergy for healing and recovery. This post is based on the latest findings from leading researchers and aims to provide a clear, evidence-based roadmap for understanding and addressing this critical public health issue.

Our Collaborative and Integrative Care Model at Injury Medical Clinic

At the heart of Injury Medical Clinic is a philosophy of integrative care, where different healthcare disciplines converge to provide a holistic and patient-centered treatment experience. The close collaboration between me, Dr. Alex Jimenez, and our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, exemplifies this model.
Dr. Cardenas, a board-certified Internist with an impressive career spanning over 40 years, provides the essential medical oversight for our practice. Her NPI number is 1164426749, and she holds Texas MD License #J2933. Her extensive experience in internal medicine brings a depth of knowledge in diagnostics, pharmacology, and the management of complex systemic diseases that is invaluable to our patients, especially those dealing with multifaceted conditions like OUD co-occurring with chronic pain or mental health disorders. As our collaborative physician, Dr. Cardenas reviews complex cases, provides medical direction, and ensures all our treatment protocols meet the highest standards of medical safety and efficacy. This is a common and highly effective setup in multidisciplinary clinics focused on integrative or injury care, where the expertise of a medical doctor and a chiropractor are combined to optimize patient outcomes.
My role is to integrate this medical foundation with advanced chiropractic care and functional medicine. As a Doctor of Chiropractic, I focus on the biomechanical and neurological aspects of health. Many patients with OUD have a history of chronic pain, often stemming from musculoskeletal injuries like degenerative disc disease or trauma from an accident. My expertise in chiropractic spinal trauma (CCST) allows me to address these root physical issues. Through precise spinal adjustments, mobilization techniques, and targeted rehabilitation exercises, we can often reduce a patient’s reliance on pain medication by improving function, alleviating nerve compression, and restoring structural integrity. This is a crucial component of a non-pharmacological approach to pain management, which is essential in the context of OUD.
Furthermore, my certifications as a Functional Medicine Practitioner (CFMP, IFMCP) and Advanced Practice Registered Nurse (APRN) allow me to bridge conventional and holistic care. Functional medicine seeks to understand the “why” behind disease by examining genetic, environmental, and lifestyle factors that influence long-term health. For a patient with OUD and depression, for example, we might use advanced lab testing to investigate neurotransmitter imbalances, nutrient deficiencies (like B vitamins or magnesium), gut dysbiosis, or inflammatory markers that could be contributing to both their mood and their substance use patterns. This allows us to create highly personalized interventions, including targeted nutritional supplementation, dietary changes, and stress management strategies that support brain health and reduce cravings.
Our combined approach means a patient at Injury Medical Clinic benefits from the best of both worlds:

• Medical Oversight (Dr. Cardenas): Ensuring the safe prescription and management of medications like MOUD or antidepressants, monitoring for drug interactions (e.g., QTc prolongation), and managing co-existing medical conditions.
• Chiropractic and Rehabilitative Care (Dr. Jimenez): Addressing the underlying physical pain generators through non-invasive techniques, improving mobility, and empowering patients with physical strategies to manage their pain.
• Functional Medicine (Dr. Jimenez): Investigating and correcting the biochemical and physiological imbalances that contribute to addiction, mental health issues, and chronic disease.
• Team-Based Strategy: Regular case conferences between Dr. Cardenas and me ensure that every aspect of the patient’s health is considered, and the treatment plan is synergistic, cohesive, and continuously optimized.

This integrated framework is not just about offering multiple services under one roof; it’s about creating a unified treatment plan where each modality supports and enhances the others. For a patient with OUD, this means we are not just managing their addiction; we are rebuilding their health from the ground up—physically, biochemically, and emotionally.

Understanding OUD and Co-Occurring Mental Health Conditions

One of the most critical aspects of treating Opioid Use Disorder (OUD) is recognizing that it rarely exists in a vacuum. More often than not, it is deeply intertwined with other mental health challenges. From my clinical experience, addressing the substance use without simultaneously addressing the underlying psychological distress is like trying to fix a leaking roof by only mopping the floor. To achieve lasting recovery, we must treat the whole person, and that begins with understanding the profound connection between OUD and conditions like depression, anxiety, and PTSD.

The Overwhelming Statistics

The data paints a stark picture of this co-occurrence. According to the 2022 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration (SAMHSA), 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 (SAMHSA, 2023).
The treatment gap is deeply concerning:

• Approximately 60% of these individuals received treatment for either their substance use or their mental health issue, but not necessarily both.
• A staggering 40% received no treatment at all for either condition.
• Of those who did receive care, the majority were treated for their mental health disorder, with the substance use disorder often going unaddressed.

When we focus specifically on OUD, the prevalence of co-occurring mental health conditions is exceptionally high. The research consistently shows:

• Major Depressive Disorder (MDD): Can be found in up to 50% of individuals with a substance use disorder. This is a staggering statistic that highlights the deep symbiotic relationship between mood and substance use.
• Anxiety Disorders: Affect approximately 30% of this population. Often, opioids are initially used to self-medicate the overwhelming feelings of worry and panic associated with anxiety.
• Post-Traumatic Stress Disorder (PTSD): Is present in nearly 20% of individuals with OUD. The link between trauma and substance use is powerful and undeniable.

Furthermore, these co-occurring conditions are more likely to affect females and significantly increase the risk of both overdose and suicide attempts (Davis et al., 2021). This is a life-or-death issue that demands a comprehensive and integrated screening and treatment approach.

Essential Screening Tools in Clinical Practice

In our practice, we believe proactive and universal screening is the cornerstone of effective care. We cannot treat what we do not identify. For this reason, we routinely integrate standardized screening tools into patient intake and follow-up. It’s not enough to ask, “How are you feeling?” We need objective measures to quantify symptoms and track progress over time.

• PHQ-9 (Patient Health Questionnaire-9): This is our go-to tool for screening for depression. It’s a simple, nine-question survey that aligns with the diagnostic criteria for major depressive disorder. Patients rate the frequency of symptoms like anhedonia (loss of pleasure), sleep disturbances, and feelings of worthlessness over the past two weeks. The score helps us gauge the severity—mild, moderate, or severe—and guides our treatment decisions.
• GAD-7 (Generalized Anxiety Disorder-7): This seven-item questionnaire is highly effective for screening for anxiety. It assesses how often a patient has been bothered by symptoms like uncontrollable worrying, restlessness, and irritability. Like the PHQ-9, the GAD-7 provides a severity score that helps us tailor our therapeutic approach.
• PCL-5 (Post-Traumatic Stress Disorder Checklist for DSM-5): While depression and anxiety are often screened for in primary care, PTSD can be overlooked, despite its high prevalence in the OUD population. The PCL-5 is a 20-question self-report measure that assesses the 20 DSM-5 symptoms of PTSD. It asks about symptoms experienced in the past month, such as nightmares, flashbacks, avoidance behaviors, and hypervigilance.
  • Scoring and Interpretation: A score between 31 and 33 is generally considered a clinical cutoff, suggesting that treatment for PTSD is warranted.
  • Monitoring Progress: One of the great benefits of the PCL-5 is its utility in tracking treatment efficacy. A reduction of 10 points or more strongly indicates that our interventions are working and the patient’s symptoms are meaningfully improving.

By consistently using these tools, we move from subjective impressions to objective data, allowing us to have more informed conversations with our patients and make evidence-based decisions about their care.

The Imperative of Trauma-Informed Care

Given the high prevalence of PTSD and the fact that many individuals with OUD have a history of trauma (whether physical, emotional, or psychological), adopting a trauma-informed care approach is not just best practice—it is an ethical necessity. This is more than a buzzword; it’s a fundamental shift in perspective, moving from asking “What’s wrong with you?” to “What happened to you?” It involves recognizing that a patient’s behaviors, including substance use, may be adaptive responses to traumatic experiences.
At Injury Medical Clinic, we embed the six core principles of trauma-informed care into every patient interaction:

1. Safety: We strive to create an environment that is both physically and emotionally safe. This means everything from the layout of our clinic to the tone of our voice. For a patient who has experienced trauma, a predictable and calm environment can be profoundly healing. From a chiropractic perspective, this also means ensuring physical treatments are performed with the utmost care and explaining every step of an adjustment or procedure. This helps the patient feel in control and not re-traumatized by unexpected physical contact.
2. Trustworthiness and Transparency: Building trust is paramount, especially with individuals who healthcare systems may have let down in the past. We are committed to being open, honest, and respectful. This means no surprises. If we need to conduct a urine drug screen, we explain why. If we are recommending a new therapy, we discuss the rationale, benefits, and potential side effects. Transparency builds the therapeutic alliance that underpins all healing.
3. Peer Support: We strongly encourage and facilitate connections to peer support networks. Hearing from others with lived experience can be incredibly powerful. It helps to build trust, establish a sense of safety, and combat the isolation that so often accompanies addiction and mental illness. Peers can offer a type of hope and understanding that we, as clinicians, cannot.
4. Collaboration and Mutuality: We reject the old, paternalistic model of healthcare where the doctor dictates and the patient complies. Instead, we view our relationship with patients as a partnership. We work with them to develop a treatment plan that aligns with their goals and values. The patient is the expert on their own life, and we provide our expertise to help them achieve their vision of health.
5. Empowerment, Voice, and Choice: Recovery is about reclaiming one’s agency. We empower our patients by consistently offering choices. This can be as simple as asking, “Which of these two exercises would you like to start with today?” or as significant as discussing different medication options. By ensuring the patient drives their care, we help them build self-efficacy and confidence.
6. Cultural, Historical, and Gender Issues: We recognize that each patient comes with a unique set of experiences shaped by their culture, history, and gender identity. Our lived experiences as providers are not universal. We must remain humble, curious, and committed to understanding the social and historical contexts that may be influencing our patients’ health, perceptions, and interactions with the healthcare system.

Evidence-Based Therapy and Pharmacotherapy

A truly integrative approach combines psychosocial support with appropriate medical interventions. Therapy is a cornerstone of treating co-occurring OUD and mental health disorders.

• Therapeutic Modalities: While many forms of therapy can be beneficial, we emphasize evidence-based practices.
  • For Depression and Anxiety, Cognitive Behavioral Therapy (CBT) is a well-established and highly effective approach. CBT helps patients identify and challenge negative thought patterns and behaviors that contribute to their distress.
  • For PTSD, more specialized therapies are often required. These include Prolonged Exposure (PE), which helps patients gradually confront trauma-related memories and situations; Cognitive Processing Therapy (CPT), which focuses on changing unhelpful beliefs related to the trauma; and Eye Movement Desensitization and Reprocessing (EMDR), a unique therapy that uses bilateral stimulation to help the brain process traumatic memories.
  • We maintain a strong referral network of therapists skilled in these modalities, ensuring our patients receive the specialized care they need.
• Pharmacotherapy: SSRIs and SNRIs: For moderate to severe MDD, GAD, and PTSD, Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are considered first-line medications. These medications work by increasing the levels of key neurotransmitters in the brain, which can help regulate mood and anxiety.

Here is a breakdown of some commonly used medications and their clinical considerations:

Medication	Class	FDA Indications (for these conditions)	Key Clinical Notes
Paroxetine	SSRI	MDD, GAD, PTSD	Indicated for all three, but has a notoriously high rate of sexual dysfunction, which is a common reason for non-adherence. It’s a critical point to discuss with patients.
Sertraline	SSRI	MDD, PTSD	Often associated with gastrointestinal (GI) side effects like nausea or diarrhea, particularly when starting. These are usually transient but can be bothersome initially.
Fluoxetine	SSRI	MDD	Has a very long half-life, which can be forgiving for patients who occasionally forget a dose. However, this also means it can be dangerous in an overdose attempt, requiring careful patient selection.
Escitalopram	SSRI	MDD, GAD	Generally one of the best-tolerated SSRIs, but can be associated with weight gain, which should be monitored.
Duloxetine	SNRI	MDD, GAD	Tends to have less sexual dysfunction than many SSRIs. It also has an indication for neuropathic pain, which can be a significant benefit for our patients with co-occurring chronic pain syndromes.
Venlafaxine	SNRI	MDD, GAD	Also known for GI side effects and potential weight gain. It can also increase blood pressure, so monitoring is required.

Integrating MOUD with Psychiatric Medications: A Balancing Act

This is where our collaborative model with Dr. Cardenas is absolutely crucial. Managing a patient on both Medications for Opioid Use Disorder (MOUD) and psychiatric medications requires a deep understanding of pharmacology and potential drug-drug interactions.

• Buprenorphine and Serotonin Syndrome: Buprenorphine (a key component of Suboxone) is a partial opioid agonist, but it also has 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 benefits of treating both OUD and depression/anxiety concurrently far outweigh this small risk. Research has consistently found that treating the underlying mental health condition significantly increases retention in OUD treatment (Schuman-Olivier et al., 2014). We discuss this risk-benefit profile openly with our patients to make a shared, informed decision.
• Methadone and QTc Prolongation: Methadone is a highly effective medication for OUD, but it carries a known risk of prolonging the QTc interval on an electrocardiogram (ECG). A prolonged QTc interval can increase the risk of a life-threatening cardiac arrhythmia called Torsades de Pointes. Many other medications, including some SSRIs, can also prolong the QTc interval.
  • Citalopram is a particular concern, especially at doses above 40 mg per day (or 20 mg in adults over 60).
  • Venlafaxine also has a slightly higher risk profile for QTc prolongation compared to other antidepressants.
  • Our Protocol: For any patient on methadone, especially if we are adding another QTc-prolonging agent, our protocol, overseen by Dr. Cardenas, is strict:
    • Obtain a baseline ECG before starting the new medication.
    • Monitor for symptoms like palpitations, dizziness, lightheadedness, or syncope (fainting).
    • Obtain a follow-up ECG after the new medication has reached a steady state (typically after five half-lives).
    • Perform annual ECGs thereafter.
    • We pay close attention to QTc values, especially if they exceed 450 milliseconds for men or 460 milliseconds for women, as these are the thresholds where risk begins to increase significantly.
• Naltrexone and Depression: Naltrexone is an opioid antagonist used for both OUD and alcohol use disorder. It’s important to be aware that naltrexone itself carries a warning that it can increase or cause depression and suicidality. This doesn’t mean it’s contraindicated for a patient with depression, but it demands a crucial conversation. Again, we must weigh the risks and benefits. Often, the patient was using opioids or alcohol to self-medicate their depression, and those substances carry a far higher risk of overdose and death by suicide. The key is to initiate naltrexone concurrently with robust mental health support and vigilant monitoring.

Recognizing Serotonin Syndrome

All clinicians and patients on serotonergic medications should be aware of the signs and symptoms of serotonin syndrome. It’s a rare but potentially fatal condition. The mnemonic SHIVERS can be a helpful way to remember the key features:

• S – Shivering: A very characteristic early sign.
• H – Hyperreflexia and Myoclonus: Exaggerated reflexes and sudden muscle twitching or jerking.
• I – Increased Temperature: Fever indicates increasing severity.
• V – Vital Sign Instability: Tachycardia (fast heart rate) and hypertension (high blood pressure) are common.
• E – Encephalopathy: Mental status changes, such as confusion, agitation, or delirium.
• R – Restlessness: A feeling of inner turmoil and inability to stay still.
• S – Sweating: Diaphoresis, often profuse and unrelated to the ambient temperature.

If these symptoms emerge, it is a medical emergency requiring immediate attention.

Case Study: Integrating Care for Depression and OUD

Let’s apply these concepts to a real-world scenario, representative of many patients we see at our clinic.

• Patient Profile: A 32-year-old divorced female, mother of two, working part-time in retail.
• History: She has chronic low back pain from degenerative disc disease, which led to opioid misuse following an injury. She is currently stable on buprenorphine-naloxone 8mg three times a day for severe OUD. Her father has a history of alcohol use disorder, and her mother has depression, highlighting a potential genetic predisposition. She lives with her mother and children, has a limited support network, but does attend peer recovery groups. She has a history of intimate partner violence, a significant traumatic experience.
• Presentation: At her follow-up, she denies any return to non-prescribed opioid use. However, she reports debilitating symptoms of depression and anxiety. She feels “exhausted,” is unable to enjoy time with her children (anhedonia), and is “overwhelmed by worry.” She emphatically states, “I am staying away from pills, but I feel like I am drowning most days.” She denies any suicidal ideation.
• Our Assessment:
  • Screenings: We administer our standard panel. Her PHQ-9 score is 18 (moderately severe depression), and her GAD-7 is 15 (severe anxiety). Her PCL-5 is 10, which does not indicate active PTSD, but her history of intimate partner violence remains a crucial part of her story.
  • Urine Drug Screen (UDS): Her UDS is positive for buprenorphine (as expected) and negative for all other substances. This confirms her adherence to her MOUD.
• Our Integrated Treatment Plan:
  1. Continue MOUD: We will continue her buprenorphine-naloxone. It is working effectively to manage her OUD, and stability is key.
  2. Initiate Antidepressant: We need to treat her MDD and GAD. After a thorough discussion with her about options, side effect profiles, and the small risk of serotonin syndrome, we decide to start a well-tolerated SSRI like escitalopram. Dr. Cardenas will manage the prescription and titration.
  3. Referral for Therapy: We refer her to a therapist in our network who specializes in Cognitive Behavioral Therapy (CBT) to equip her with coping skills for both depression and anxiety.
  4. Chiropractic and Functional Medicine: I will work with her to address the root cause of her chronic back pain. This will involve gentle chiropractic adjustments to improve spinal mechanics, core strengthening exercises to provide better support for her degenerative discs, and anti-inflammatory nutritional guidance to reduce systemic inflammation that can exacerbate both pain and depression. This addresses the original trigger for her opioid use.
  5. Safety Planning: We prescribe naloxone (Narcan) for her and her family to have on hand as a universal precaution. We also provide her with the 988 National Suicide & Crisis Lifeline number and clear instructions to go to the nearest emergency room if she ever feels she is in crisis.
  6. Follow-Up: We schedule a close follow-up appointment in two weeks to monitor her response to the new medication and provide ongoing support.

This case perfectly illustrates our multidisciplinary approach. Dr. Cardenas manages the pharmacology, I address the biomechanical and functional root causes, we refer for specialized therapy, and the entire team works together to create a safety net of support around the patient.

Navigating Opioid Use Disorder and Pregnancy

The intersection of opioid use disorder and pregnancy presents one of the most complex and emotionally charged challenges in healthcare. The statistics are alarming and reflect a growing crisis that demands a compassionate, evidence-based, and non-judgmental approach.

A Sobering Trend

The increase in OUD during pregnancy has been dramatic and devastating:

• From 1999 to 2014, the incidence of OUD in pregnancy quadrupled (Haight et al., 2018).
• Between 2010 and 2017 alone, OUD documented at the time of delivery increased by 131% (Admon et al., 2021).
• This has had a direct and tragic impact on newborns. Neonatal Opioid Withdrawal Syndrome (NOWS), a condition affecting babies exposed to opioids in utero, increased fivefold from 2002 to 2009. It then rose another 82% between 2010 and 2017 (Winkelman et al., 2018).
• Current data from 2021 indicates that a baby is born experiencing opioid withdrawal approximately every 24 minutes in the United States.
• Research also suggests that rates are often higher in rural areas, where access to specialized care may be limited.

The Pervasive Barrier of Stigma

Beyond the physiological challenges, pregnant individuals with OUD face a crushing weight of stigma. They are often subjected to harmful stereotypes—labeled as “unfit mothers,” “drug seekers,” or “criminals.” Tragically, this poor treatment often comes from the very healthcare professionals they turn to for help. The literature is filled with reports of patients experiencing judgmental verbal and non-verbal interactions that leave them feeling shamed and alienated (Stone, 2015).
This stigma is not just hurtful; it is dangerous. It creates a massive barrier to care, causing pregnant individuals to avoid prenatal appointments, hide their substance use, and disengage from treatment. This is counterproductive to recovery and can directly lead to a return to use and an increased risk of overdose. At our clinic, we are fiercely committed to creating a sanctuary free from judgment, where pregnant patients feel safe, respected, and supported.

Universal Screening: A Non-Negotiable Standard

Because of the high prevalence and the dangers of stigma, universal screening for substance use in all pregnant patients is the only ethical and effective approach. We cannot and should not “pick and choose” who we think might be at risk. This avoids bias and normalizes the conversation about substance use as a standard part of comprehensive healthcare.
Several validated screening tools are available:

• The 4 P’s: This is a simple and quick tool. An affirmative answer to any of these questions triggers a more in-depth assessment.
  • Parents: Did any of your parents have a problem with alcohol or other drugs?
  • Partner: Does your partner have a problem with alcohol or drugs?
  • Past: In the past, have you had difficulties in your life because of alcohol or other drugs?
  • Present: In the present, have you drunk any alcohol or used any drugs?
• NIDA Quick Screen: This tool asks about substance use in the past year, with specific questions for women about drinking more than four drinks in a day and any use of tobacco or other drugs.
• CRAFFT: This tool is validated for individuals under 27 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?
  • 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?
  • Family/Friends: Do your family or friends ever tell you to cut down?
  • Trouble: Have you ever gotten into trouble while you were using?
  • Two or more “yes” answers indicate a high risk and the need for a comprehensive assessment.

The Risks of Untreated OUD in Pregnancy

It is crucial to understand that the greatest danger to both mother and fetus comes from untreated opioid use disorder. The cyclical nature of using illicit substances—going from intoxication to withdrawal—creates a state of profound physiological instability. This cycle, combined with the inconsistent prenatal care that often results from stigma and fear, leads to a host of severe complications:

• Placental abruption: The premature separation of the placenta from the uterine wall, a life-threatening emergency.
• Problems with fetal growth: Including fetal growth restriction.
• Preterm birth: Delivery before 37 weeks of gestation.
• Stillbirth: Fetal death.
• Maternal overdose: The risk of which is tragically high.

Understanding Neonatal Opioid Withdrawal Syndrome (NOWS)

It is vital to use precise and non-stigmatizing language when discussing the effects of in-utero opioid exposure on a newborn. The term Neonatal Abstinence Syndrome (NAS) has largely been replaced by Neonatal Opioid Withdrawal Syndrome (NOWS) to be more specific.
A critical point of education for patients and even other healthcare providers is this: babies cannot be born “addicted.” According to the DSM-5, a substance use disorder is diagnosed based on a pattern of maladaptive behaviors. A newborn cannot exhibit these behaviors. What the baby is experiencing is physiological dependence and subsequent withdrawal after being exposed to opioids in the womb.
Symptoms of NOWS we watch for in newborns include:

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

There are formal assessment tools to quantify the severity of NOWS:

• Eat, Sleep, Console (ESC): A newer, simplified, function-based approach that is gaining popularity. It focuses on three key questions:
  • Can the baby eat at least one ounce per feeding?
  • Can the baby sleep for at least one hour uninterrupted?
  • Can a caregiver console the baby within ten minutes?
    • This approach prioritizes non-pharmacological care and keeping the mother and baby together.
• Finnegan Neonatal Abstinence Scoring System (FNASS): This older, more complex system includes 21 items scored to assess everything from the pitch of the baby’s cry to the intensity of their reflexes, respiratory rate, and yawning. While comprehensive, it can be cumbersome, which is why many institutions are shifting to the ESC model.

The withdrawal period can last from days to weeks, depending on the substance and its half-life. The most important message of reassurance we can give to an expecting mother is that there are no known long-term physical or intellectual problems associated with NOWS itself if the baby is properly cared for (Jansson et al., 2017). The baby should be roomed-in with the mother, and non-pharmacological interventions like swaddling, skin-to-skin contact, and a low-stimulation environment should be the first line of treatment.
In some cases, pharmacological intervention is necessary. Morphine is typically the first-line medication used to taper the baby slowly. It is critical to note that naloxone (Narcan) should never be given to a newborn in withdrawal, as it can precipitate a sudden, severe, and potentially fatal withdrawal.

Breastfeeding: A Powerful Tool for Healing

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 asthma, obesity, SIDS, ear infections, diabetes, and more.
• Maternal Benefits: Decreased risk of breast and ovarian cancer, postpartum depression, and diabetes. It also promotes a faster recovery from childbirth and, most importantly, strengthens the maternal-infant bond. This bonding can be a powerful protective factor against maternal neglect and a cornerstone of the mother’s own recovery journey.

It is a common misconception that breastfeeding is unsafe. It is absolutely safe for mothers to breastfeed while on stable doses of buprenorphine or methadone. The amount of medication that passes into the breast milk is minimal and can actually help to ease the baby’s withdrawal symptoms slightly.
Breastfeeding would only be contraindicated if the mother returns to using non-prescribed or illicit substances, has HIV, or is on other specific medications that are not safe for lactation.

Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

The Gold Standard: MOUD in Pregnancy

The message from every major medical organization, including the American College of Obstetricians and Gynecologists (ACOG), SAMHSA, and the World Health Organization (WHO), is unanimous and unequivocal: Medications for Opioid Use Disorder (MOUD), specifically buprenorphine and methadone, are the first-line, gold-standard treatment for OUD in pregnancy.

• Why MOUD is Safer: MOUD eliminates the dangerous cycle of use and withdrawal. It provides a stable level of the medication in the mother’s system, which in turn creates a stable environment for the developing fetus. This dramatically improves both maternal and neonatal outcomes, increasing the likelihood of a full-term birth and normal birth weight.
• Not All Babies Experience Withdrawal: Even with MOUD, not all babies will experience clinically significant NOWS. They do need to be observed in the hospital for about 3-4 days after birth to monitor for withdrawal symptoms, as the half-life of methadone and buprenorphine is long.
• No Evidence of Birth Defects: There is no evidence that buprenorphine or methadone cause congenital disabilities.
• Medically Supervised Withdrawal is NOT Recommended: Attempting to detox or taper a pregnant patient completely off opioids (“medically assisted withdrawal”) is strongly discouraged. This practice is associated with an extremely high rate of return to use. A return to use after a period of abstinence is incredibly dangerous, as the mother’s tolerance is lowered, placing her at a very high risk of a fatal overdose.

Naltrexone is not considered a first-line treatment during pregnancy, but it is not strictly contraindicated. This would require a careful, detailed conversation with the patient about the limited data and potential risks.

Case Study: A Hopeful Path Forward in Pregnancy

Let’s consider another common scenario that illustrates our approach.

• Patient Profile: A 28-year-old female, pregnant for the second time (G2P1), at 18 weeks gestation. She has a history of mild asthma and generalized anxiety disorder.
• History: She lives with a supportive partner and works part-time. She reports daily misuse of prescription oxycodone, taking about 60mg per day.
• Presentation: She comes to our clinic expressing a strong desire to stop using opioids, aware of the risks to her pregnancy. She is terrified of withdrawal and cravings. She says, “I want to be healthy for my baby and myself. I’ve tried quitting on my own, but I can’t.” This statement is a powerful cry for help, filled with motivation.
• Our Assessment:
  • UDS: Positive for opioids, negative for other substances.
  • Labs: We order a comprehensive panel including a CBC, CMP, HIV test, hepatitis panel, and STI screening, all of which come back within normal limits.
• Our Integrated Treatment Plan:
  1. Initiate MOUD: We explain the benefits and safety of MOUD in pregnancy. Buprenorphine is often preferred in pregnancy as it is associated with less severe NOWS compared to methadone (Jones et al., 2010). We would start her on buprenorphine about 24 hours after her last dose of oxycodone to ensure she is in mild withdrawal, preventing precipitated withdrawal. We would titrate the dose up from an initial 2-4 mg to a therapeutic level, which could be up to 24 mg, that eliminates her cravings and withdrawal symptoms. This is managed under the direct supervision of Dr. Cardenas.
  2. Harm Reduction: We prescribe naloxone and educate both her and her partner on how to use it.
  3. Collaborative Care: We immediately refer her to, and collaborate with, a high-risk OB/GYN for prenatal care. Communication between our clinic and her obstetrician is key.
  4. Psychosocial and Biomechanical Support: We recommend psychosocial support, such as therapy or support groups, to address her anxiety and the emotional aspects of her recovery. As a chiropractor, I would also offer gentle, pregnancy-safe chiropractic care. Many pregnant women experience back pain, sciatica, and pelvic pain. By addressing these biomechanical issues, we can improve her comfort, reduce her stress levels, and reinforce the principle of managing physical discomfort without resorting to opioids.
  5. Postpartum Planning: We begin the conversation early about her postpartum plan. We encourage breastfeeding if no contraindications arise and discuss continuing her MOUD after delivery to support her long-term recovery.

This comprehensive, supportive, and non-judgmental approach gives this mother and her baby the best possible chance for a healthy future.

Addressing the Adolescent Opioid Crisis

The landscape of opioid use among young people has shifted dramatically and terrifyingly in recent years. While overall substance use among teenagers has shown some decline, the lethality of the available drug supply has led to a catastrophic increase in overdose deaths. This is a public health emergency that requires a unique approach tailored to adolescents’ developmental, social, and psychological needs.

A Frightening New Era

The statistics are a wake-up call:

• From 2019 to 2020, overdose deaths among 14- to 18-year-olds increased by 94%.
• From 2020 to 2021, they rose another 20% (Friedman et al., 2022).
• The key driver of this tragedy is not an increase in use, but a devastating increase in the potency of the drugs. The illicit drug market is flooded with Illicitly Manufactured Fentanyl (IMF) and its analogs.
• Deaths involving IMFs in this age group surged by 182%. Teenagers who believe they are experimenting with a counterfeit prescription pill (like Percocet or Xanax) are often unknowingly ingesting a fatal dose of fentanyl.

Looking at the profiles of the young people we have lost:

• 40% had a known history of mental health conditions.
• 35% had a prior history of opioid use.
• But only 5% had ever received treatment for OUD. This is a monumental failure of our systems to identify and engage these vulnerable youth in care.

Understanding Risk and Protective Factors

In our work with adolescents, we focus on bolstering protective factors while mitigating risks. This framework guides our screening and counseling efforts.
Protective Factors:

• Family Engagement and Guardian Disapproval: A strong, supportive family environment where substance use is openly discouraged is a powerful protective shield.
• School Connectedness: Feeling connected to school—to teachers, activities, and peers—gives adolescents a sense of purpose and belonging.
• Self-Efficacy: A young person’s belief in their own ability to handle challenges and make good decisions is crucial for resisting peer pressure and navigating stress.

Risk Factors:

• Social Determinants of Health: Factors like poverty, community violence, and lack of opportunity create a backdrop of stress and hopelessness that can drive substance use.
• Other Substance Use: Early use of substances like alcohol or marijuana 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 substance use disorder.
• History of Impulsivity or Risk-Taking Behavior: Some adolescents are wired for higher sensation-seeking, which can increase their vulnerability.
• Co-occurring Psychiatric Disorders: Conditions like ADHD, depression, and anxiety are significant risk factors.
• Maltreatment: A history of physical, emotional, or sexual abuse is a profound trauma that dramatically increases the risk of substance use as a coping mechanism.
• Family History of Substance Use Disorder: Genetics and the family environment both play a role.

Screening Adolescents: The Importance of Confidentiality

Effective screening in this population hinges on one critical element: confidentiality. Before asking a single question, we must have a clear, transparent conversation with the adolescent about the limits of confidentiality. We explain what we can keep between us and the circumstances that would legally or ethically require us to disclose information to their parents or guardians (e.g., imminent risk of harm to self or others).
Building this trust is essential. If a teen does not feel safe, they will not be honest. We always aim to have some one-on-one time with the adolescent patient, without a parent in the room. This private space can be invaluable for providing education, harm reduction counseling, and building a therapeutic rapport.
Recommended screening tools for adolescents include:

• S2BI (Screening to Brief Intervention): This tool asks about the frequency of use (from never to weekly) for various substances over the past year.
• BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs): This screener asks for the number of days a substance was used in the past year and gets very specific, listing street drugs, inhalants, and a wide range of prescription medications.
• CRAFFT: As mentioned earlier, this tool is specifically designed for youth and screens for the negative consequences and 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, their family, and a team of healthcare professionals.

1. Naloxone, Naloxone, Naloxone: This is non-negotiable. The adolescent, their family, and even their friends should have naloxone and know how to use it. Many schools are now stocking naloxone, but we need to ensure it’s in the hands of the people closest to the at-risk youth. We have direct conversations about high-risk scenarios (e.g., using alone, using after a period of abstinence) and develop a safety plan.
2. Behavioral Health Services: Therapy is essential. This can take many forms, including individual, group, and family therapy. Multi-systemic therapy that involves the school, family, and community can be particularly effective.
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, buprenorphine is a life-saving intervention and should be strongly considered.
   • Methadone and Naltrexone are not FDA-approved until age 18. While off-label use may be considered in severe cases, buprenorphine is typically the preferred and more accessible option for 16- and 17-year-olds.
   • We are eagerly awaiting updated guidelines from the American Society of Addiction Medicine (ASAM) for this “transition-age youth” population, which are anticipated in 2026.

Case Study: A Teenager’s Path from Injury to Addiction

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

• Patient Profile: A 16-year-old female in 11th grade. She was formerly a competitive soccer player, but her grades and school attendance are now declining.
• History: At age 15, she suffered an ankle fracture that required surgery. She was prescribed oxycodone for postoperative pain. Her father has alcohol use disorder in remission, and her mother has depression. She 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: Her mother brings her to the emergency department after finding her extremely drowsy and nauseated. She admits to snorting heroin daily for the past six months. She explains the progression perfectly: “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.” This story—from a legitimate prescription for an injury, to misuse for emotional coping, to transitioning to illicit substances—is one we hear far too often.
• Our Assessment:
  • UDS: Positive for heroin, but importantly, negative for fentanyl. This is critical information for harm reduction counseling. We would have a frank conversation with her about the high likelihood of fentanyl being present in the heroin supply and that she may not be so lucky next time.
• Our Integrated Treatment Plan:
  1. Initiate Buprenorphine: As she is 16 years old and has a severe OUD, she is a clear candidate for buprenorphine. We would start it 12-24 hours after her last heroin use and titrate it to a dose that controls her cravings.
  2. Prescribe Naloxone: We provide naloxone to her and her mother with comprehensive training.
  3. Comprehensive Support: We would facilitate a referral to an adolescent-specific substance use treatment program that includes family therapy. Involving the mother is crucial for creating a supportive home environment.
  4. Address Root Causes: Part of her therapy would involve processing the loss of her identity as an athlete and developing new, healthy coping mechanisms for stress and emotional pain. From a chiropractic and functional medicine perspective, we would also ensure her ankle has fully healed and that she has no residual biomechanical issues causing chronic pain. We would explore nutritional support for mood and brain health, which can be particularly beneficial for the developing adolescent brain.

With a comprehensive, compassionate, evidence-based plan, we can help this young woman reclaim her future.

Other Special Populations and Considerations

The principles of treating OUD must be adapted to meet the unique physiological and social needs of different populations. Beyond the groups already discussed, older adults and individuals using other CNS depressants require special attention.

Opioid Use Disorder in Older Adults

The opioid crisis is often perceived as a problem of the young, but it is increasingly affecting older adults, a demographic with unique vulnerabilities.

• Rising Rates: Since 2013, OUD has increased threefold among adults aged 65-69. The increase is particularly pronounced in patients covered by both Medicare and Medicaid, who often have more complex health and socioeconomic challenges.
• Racial and Ethnic Disparities: Data show an increased vulnerability among Black Americans, Native Americans, and Alaska Natives, highlighting systemic inequities in pain management and addiction care.

Key Considerations for MOUD in Older Adults:
Treating OUD in this population requires a cautious, “start low, go slow” approach, but we must not let caution become a barrier to life-saving treatment. The risk of an older adult overdosing on street fentanyl is far greater than the risks associated with properly managed MOUD.

• Lack of Data: A major challenge is that most pivotal clinical trials for MOUD did not include enough participants over age 65. This leaves us with less specific guidance.
• Physiological Changes of Aging:
  • Renal and Hepatic Function: Always consider age-related declines in kidney and liver function, which affect how drugs are metabolized and cleared.
  • Methadone: If a patient’s creatinine clearance (a measure of kidney function) is less than 10 mL/min, a 50-75% dose reduction may be necessary. We also need to be hypervigilant about QTc prolongation, as older adults are more likely to be on other QTc-prolonging medications and have underlying cardiac issues.
  • Buprenorphine: Buprenorphine is generally safer in renal impairment, as it does not require a dose reduction. However, in cases of severe hepatic impairment, a dose reduction should be considered. The long-acting subcutaneous buprenorphine injections are not recommended for individuals with moderate to severe liver impairment.
• Respiratory Depression: Older adults may be more sensitive to the respiratory depressant effects of opioids. Methadone, as a full agonist, carries a higher risk than the partial agonist buprenorphine. We must monitor these patients closely, especially during initiation and dose titration.

The Challenge of Co-Prescribed CNS Depressants

One of the most common clinical dilemmas we face is managing a patient with OUD who is also taking other Central Nervous System (CNS) depressants, most notably benzodiazepines (e.g., Xanax, Klonopin, Ativan).
For years, many providers were hesitant or outright refused to prescribe MOUD to patients taking benzodiazepines, fearing the combined risk of respiratory depression. However, this practice is dangerous and deadly. In 2017, the FDA issued a crucial safety announcement clarifying its position. The agency urged caution but explicitly stated that the immense benefits of treating OUD with MOUD outweigh the risks of co-prescribing with benzodiazepines.
Our Guiding Principles:

• The Greater Risk: The risk of an individual combining a benzodiazepine with MOUD (like buprenorphine) pales in comparison to the risk of them combining that same benzodiazepine with illicit fentanyl or heroin. The latter combination is far more likely to be fatal. Therefore, withholding MOUD is the more dangerous option.
• Not a Contraindication: The presence of a benzodiazepine or other CNS depressant is not an absolute contraindication for starting or continuing MOUD.
• No Arbitrary Dose Reductions: We do not arbitrarily reduce a patient’s buprenorphine or methadone dose simply because they are on a benzodiazepine. Under-dosing MOUD leads to cravings, withdrawal, and a return to illicit use, which defeats the entire purpose of treatment.
• Education is Key: The cornerstone of our approach is patient education. We have a frank, non-judgmental conversation with the patient about the increased risk. We explain that the combination does increase the risk of respiratory depression and overdose, and we provide extensive harm reduction counseling (e.g., never using alone, having naloxone readily available).
• Tapering as the Goal: The ideal long-term strategy is to slowly and safely taper the patient off the benzodiazepine, if possible. Benzodiazepines are not considered a first-line long-term treatment for anxiety, and we would work with the patient to transition them to a safer alternative like an SSRI and evidence-based therapy.

The FDA’s statement also mentioned other CNS depressants to be aware of, including:

• Sleep medications (e.g., zolpidem)
• Muscle relaxants (e.g., baclofen, cyclobenzaprine)
• Antipsychotics (e.g., quetiapine, aripiprazole)

With all these medications, the principle remains the same: weigh the risks and benefits, prioritize treating the OUD, educate the patient, and create a collaborative plan to reduce polypharmacy whenever it is safe and clinically appropriate.

Conclusion: An Integrated Path to Recovery

The journey through the complexities of opioid use disorder in special populations underscores a fundamental truth: effective treatment must be comprehensive, compassionate, and individualized. From the intricate dance of co-occurring mental health conditions to the delicate care required during pregnancy and the unique challenges of treating adolescents and older adults, a one-size-fits-all approach is doomed to fail.
As we have explored:

• Co-occurring disorders like depression, anxiety, and PTSD are the rule, not the exception. They must be proactively screened for and treated concurrently with OUD using evidence-based practices like therapy and appropriate pharmacotherapy.
• For pregnant individuals with OUD, Medications for Opioid Use Disorder (MOUD) are the life-saving, gold-standard of care, protecting both mother and child from the devastating consequences of untreated addiction.
• The alarming rise in adolescent overdose deaths demands a focus on harm reduction, family involvement, and age-appropriate MOUD, recognizing the lethal potency of the current drug supply.
• Treating older adults and those on other CNS depressants requires a careful risk-benefit analysis, where the profound benefit of MOUD in preventing fatal overdose almost always outweighs the risks of co-prescribed medications.

At Injury Medical Clinic, our collaborative model, uniting the medical direction of Dr. Maria Cardenas with my expertise in chiropractic and functional medicine, allows us to embody this integrated approach. We don’t just manage symptoms; we seek to heal the whole person. We address the biochemical imbalances with functional medicine, correct the structural pain generators with chiropractic care, support the psychological wounds with therapy referrals, and stabilize the addiction with evidence-based medical treatment.
This journey is not easy, but with a dedicated, multidisciplinary team and a commitment to trauma-informed, patient-centered care, we can offer our patients a real and lasting path to recovery. Thank you for joining me in this vital discussion. Please do not hesitate to reach out with any questions.

References

• Admon, L. K., Dalton, V. K., Kolenic, G. E., Winkelman, T. N. A., & Zivin, K. (2021). Trends in Opioid Use Disorder at Delivery Hospitalization in the United States, 2010-2017. American Journal of Public Health, 111(7), 1339-1342. [https://doi.org/10.2105/AJPH.2021.306263](https://doi.org/10.2105/AJPH.2021.306263)
• Davis, J. P., Smith, K. M., & Briand, L. A. (2021). The intersection of sex, trauma, and substance use disorder. Neuropharmacology, 197, 108731. [https://doi.org/10.1016/j.neuropharm.2021.108731](https://doi.org/10.1016/j.neuropharm.2021.108731)
• Friedman, J., Godvin, M., Shover, C. L., & Gone, J. P. (2022). Trends in Drug Overdose Deaths Among U.S. Adolescents, January 2010 to June 2021. JAMA, 327(14), 1398–1400. [https://doi.org/10.1001/jama.2022.2847](https://doi.org/10.1001/jama.2022.2847)
• Haight, S. C., Ko, J. Y., Tong, V. T., Bohm, M. K., & Callaghan, W. M. (2018). Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014. Morbidity and Mortality Weekly Report, 67(31), 845–849. [https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm](https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm)
• Jansson, L. M., Velez, M., & Harrow, C. (2017). The opioid-exposed newborn: Assessment and pharmacologic management. Journal of Opioid Management, 13(6), 415-428. [https://doi.org/10.5055/jom.2017.0409](https://doi.org/10.5055/jom.2017.0409)
• Jones, H. E., Kaltenbach, K., Heil, S. H., Stine, S. M., Coyle, M. G., Arria, A. M., … & Fischer, G. (2010). Neonatal abstinence syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24), 2320-2331. [https://www.nejm.org/doi/full/10.1056/nejmoa1005359](https://www.nejm.org/doi/full/10.1056/nejmoa1005359)
• Schuman-Olivier, Z., Weiss, R. D., & Hoeppner, B. B. (2014). The impact of psychiatric comorbidity on the efficacy of psychosocial interventions for addiction. Harvard Review of Psychiatry, 22(2), 73-83. [https://doi.org/10.1097/HRP.0000000000000030](https://doi.org/10.1097/HRP.0000000000000030)
• Stone, R. (2015). Pregnant women and substance use: Fear, stigma, and barriers to care. Health & Justice, 3(2). [https://doi.org/10.1186/s40352-015-0015-5](https://doi.org/10.1186/s40352-015-0015-5)
• 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. [https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report](https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report)
• Winkelman, T. N. A., Villapiano, N., Stauffer, C., & Davis, M. M. (2018). U.S. National and State-Level Trends in Opioid-Related Neonatal Abstinence Syndrome, 2010-2017. JAMA Pediatrics, 172(11), e183824. [https://doi.org/10.1001/jamapediatrics.2018.3824](https://doi.org/10.1001/jamapediatrics.2018.3824)

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