Integrative Chiropractic Care Approaches for SUD Treatment

Learn the benefits of SUD treatmentcombined with integrative chiropractic care in promoting healing and wellness for those in recovery.

Abstract

As a clinician trained across chiropractic, advanced practice nursing, and functional medicine, I have witnessed how a compassionate, integrated approach transforms outcomes for people living with substance use disorders. In this educational post, I share an easy-to-follow journey through modern, evidence-based care for substance use disorder (SUD), emphasizing the pivotal role of primary care, acute care, specialty programs, and the critical vulnerabilities that occur during care transitions.
I explain how I, Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, partner with Dr. Maria Guadalupe Cardenas, MD (Board Certified in Internal Medicine) (NPI #1164426749, Texas MD License #J2933), our Medical Director and Collaborative Physician at Injury Medical Clinic PA (Mission Plaza Injury Medical Clinic), in El Paso, Texas. Together, we blend chiropractic care, internal medicine oversight, functional medicine, personal injury rehabilitation, and SUD-adjacent care into a unified, multidisciplinary model common to integrative and injury care clinics.
You will learn:
Why nurse practitioners and primary care teams are central to expanding SUD access
How stigma inside healthcare creates a risk environment and how we counter it
What the ASAM Levels of Care mean and how we match patients to the right setting
How to integrate medications for opioid use disorder (MOUD) in primary care, inpatient units, emergency departments, and specialty programs
Why transitions of care are fragile and how bridge clinics, telehealth, peer support, hot handoffs, and case management protect patients
Where integrative chiropractic care fits: non-opioid pain relief, autonomic regulation, neurophysiological support, and functional medicine foundations that stabilize recovery
Real clinical stories—James (primary care reintegration) and Lisa (inpatient consult service)—that demonstrate best practices
Specialized populations: justice-involved individuals, peripartum women, and adolescents—how legal, physiological, and psychosocial realities shape care
New frontiers: extended-release MOUD formulations, low-dose buprenorphine microinduction, contingency management for stimulants, digital therapeutics, telehealth, GLP-1 receptor agonists, genetics, and emerging psychedelic-assisted therapies
Practical resource navigation: SAMHSA findtreatment.gov, prescriber locators, and PCSS mentoring
Throughout, I cite leading researchers and clinical guidelines using modern evidence-based methods, and I weave in my own clinical observations from chiropractic and functional medicine practice. My goal is to offer a clear, humane, and actionable guide that helps clinicians, patients, and families build durable recovery with science, compassion, and whole-person care.

About Our Integrative Clinic Model in El Paso: Who We Are and How We Work

I practice at Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, in El Paso, Texas. Our model reflects what many integrative and injury care clinics across the country have found to be effective: a chiropractor leading musculoskeletal and nervous system interventions, paired with an internal medicine physician who provides medical direction, diagnostic depth, and prescribing oversight—together with advanced practice nursing, functional medicine, rehabilitation, and care coordination.

Our Team and Roles

Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST
Advanced practice nurse practitioner and chiropractor integrating musculoskeletal care, primary care, functional medicine, and trauma-informed principles
Focus on non-opioid pain management, autonomic regulation, neurophysiology-informed chiropractic care, and whole-person recovery scaffolding
Dr. Maria Guadalupe Cardenas, MD
Board Certified in Internal Medicine
NPI #1164426749, Texas MD License #J2933
Medical Director and Collaborative Physician overseeing medical safety, diagnostics, medication management, and quality assurance
Over 40 years’ experience bridging internal medicine to integrative musculoskeletal and SUD-adjacent needs

What Makes Our Model Work

Integrated clinical decision-making: chiropractic care in lockstep with internal medicine oversight ensures complex cases are managed safely and comprehensively.
Functional medicine: systems-biology lens to address metabolic, nutritional, and gut-brain physiology that underpin resilience, mood, cravings, and energy
Rehabilitation and personal injury care: structured programs that reduce pain, restore function, and lower opioid reliance after accidents and trauma
SUD-adjacent support: non-stigmatizing care pathways, evidence-based pharmacotherapy coordination, harm reduction, and behavioral health partnerships

The Expanding Role of Nurse Practitioners in SUD Care

A Workforce Positioned for Impact

As of the latest national counts, approximately 258,000 nurse practitioners are in active practice, with projected growth of about 45% over the next decade—placing NPs among the fastest-growing healthcare professions (American Association of Nurse Practitioners, 2024). Because more than 70% of NPs practice in primary care, they occupy the front lines where SUD is first recognized and treated. This workforce expansion is reshaping access to evidence-based treatment across rural, urban, and underserved communities.
Why this matters:
Primary care is where most adults enter the health system—NPs can identify risky use early and initiate treatment
SUD prevalence intersects with chronic pain, mental health, and social determinants; NPs trained in whole-person care are built for complexity
Eliminating barriers—like the DEA X waiver for buprenorphine—means NPs can prescribe MOUD with standard DEA registration and state licensure (Substance Abuse and Mental Health Services Administration, 2023)

The NP Model Aligns with SUD Principles

Key features of NP training and philosophy mirror what SUD science shows works:
Patient autonomy, shared decision-making, and motivational interviewing
Prevention-first mindset: primary and secondary prevention integrated into routine care
Non-stigmatizing, person-centered communication that builds trust
Education and health literacy strategies that demystify neurobiology, withdrawal, and medications
Team-based care with nurse care managers and peer support to sustain engagement (Miller & Rollnick, 2023)

Prescribing Authority and Regulatory Change

Buprenorphine: X waiver eliminated—DEA-licensed clinicians, including NPs, can prescribe with standard credentials (SAMHSA, 2023)
Methadone: still dispensed via federally licensed Opioid Treatment Programs (OTPs); inpatient initiation is possible under specific regulations
State scope of practice: defines independent practice versus collaborative arrangements; our model uses physician medical direction in Texas to optimize safety and integration

Advanced Addiction Credentials

CARN-AP (Certified Addiction Registered Nurse Advanced Practice): specialty credential signaling advanced SUD expertise
PMHNP specialization: critical for managing co-occurring psychiatric disorders and integrating pharmacotherapy with counseling
Evidence-informed takeaway: expanding the NP footprint—supported by advanced credentials and integrated team models—is one of the fastest routes to closing the SUD treatment gap.
References:
NP fact sheet (AANP, 2024)
Medications for substance use disorders (SAMHSA, 2023)
Motivational interviewing: Helping people change and grow (Miller & Rollnick, 2023)

Healthcare as a Risk Environment: Why Patients Avoid Care and How We Respond

How Stigma Translates to Harm

For many people with SUD, the healthcare system feels dangerous. Stigma from clinicians—dismissive language, assumptions of drug-seeking, undertreated pain, and moral judgment—drives predictable, harmful behaviors:
Delayed care-seeking until crises
Non-disclosure of use, impairing accurate diagnosis
Minimization of pain due to fear of being labeled
Leaving care against medical advice (AMA), discontinuing lifesaving treatments
Consequences: higher morbidity and mortality, increased cost, and profound mistrust (Meurk et al., 2024). As clinicians, we must reverse this reality through trauma-informed, non-stigmatizing practices.

Our Anti-Stigma Playbook

Person-first language: “person with SUD,” “positive screen,” “initiated MOUD”
Motivational interviewing: curiosity, empathy, reflective listening, autonomy support
Policy shifts: treat SUD as chronic medical illness; build protocols for MOUD initiation in acute settings; standardize pain control strategies for patients on MOUD
Education: train entire teams—medical, nursing, front desk—on neurobiology of addiction and harm reduction (Kelly et al., 2021)
References:
Disentangling stigma from public health (Meurk et al., 2024)
Stop talking “dirty”: Clinicians, language, and quality of care (Kelly et al., 2021)

Mapping the SUD Care Continuum: Matching Patients to the Right Level of Care

The ASAM Levels of Care

The American Society of Addiction Medicine (ASAM) Criteria provide a multidimensional, strength-based approach to match patients with the least restrictive level of care adequate to their needs (American Society of Addiction Medicine, 2023).
Level 4: Medically Managed Intensive Inpatient—24-hour medical care for severe medical/psychiatric instability
Level 3: Residential—structured 24-hour treatment in non-hospital settings
Level 2: Intensive Outpatient/Partial Hospitalization—multiple hours/day, several days/week
Level 1: Outpatient—weekly or more frequent visits for meds, counseling, and case management
Dynamic reassessment: patients move up or down as needs change.

The Full Landscape

Primary care: longitudinal hub for identification, initiation of MOUD, and life-course management
Emergency departments: initiation site for buprenorphine; crisis engagement opportunities
Hospital inpatient units: addiction consult services start treatment, link to outpatient care
Specialty programs: IOPs, PHPs, residential, OBAT clinics, OTPs
Mental health: psychiatric care and evidence-based psychotherapy coordinated with SUD treatment
Peer support: lived-experience guidance and navigation
Telehealth and bridge clinics: maintain continuity across transitions
References:
The ASAM criteria (ASAM, 2023)

Primary Care as the Foundation: How We Leverage Longitudinal Relationships

Why Primary Care Is Uniquely Powerful

In primary care, we see patients over months and years. This continuity lets us tailor interventions to readiness for change using the Transtheoretical Model—precontemplation, contemplation, preparation, action, and maintenance (Prochaska & DiClemente, 1983). It is the right place to:
Plant seeds of awareness for ambivalent patients
Use motivational interviewing to resolve ambivalence
Initiate medications, coordinate counseling, and track outcomes
Address chronic pain and mental health drivers that perpetuate use

Primary Care Crisis and SUD Access

77.2 million people live in primary care shortage areas
Only 44.5% of provider need is met; 13,364 providers needed to fill the gap (HRSA, 2025)
86.6% of patients with OUD who could benefit from MOUD do not receive it (SAMHSA, 2024)
We tackle this by embracing scalable models and telehealth.

Barriers and Solutions

Barriers:
Time constraints, reimbursement, referral scarcity
Concerns about diversion and counseling prerequisites
Lack of organizational support
Evidence-based solutions (Wakeman et al., 2023):
Pharmacotherapy access (buprenorphine, naltrexone)
Co-located psychosocial services
Integrated care pathways
Patient education and outreach
Nurse care managers as anchors
PCSS mentoring for clinicians
References:
Health workforce shortage areas (HRSA, 2025)
Key substance use and mental health indicators (SAMHSA, 2024)
Comparative effectiveness of different treatment pathways (Wakeman et al., 2023)
Provider Clinical Support System (PCSS)

Case Study: James—Re-Engaging OUD Care in Primary Care

The Patient Story

James, 52, visits our FQHC primary care clinic for type 2 diabetes and chronic pain. He previously discontinued buprenorphine and—when asked gently, directly, and without judgment—discloses a return to illicit fentanyl use driven by pain and depression. He wants to restart buprenorphine.

Our Approach

Shared decision-making: we discuss risks/benefits and agree on high-dose buprenorphine initiation to reduce withdrawal duration (Herring et al., 2021)
Co-located pharmacy: minimizes logistical barriers during withdrawal
Warm handoffs: personal introductions to onsite mental health counselor and chronic pain CBT group (Kessler et al., 2023)
Peer support: connects with lived-experience specialist
James leaves with:
Buprenorphine plan and script
Pharmacy check-in next day
Telehealth follow-up appointment
Counseling and CBT group scheduled
Peer support contact information

Follow-Up and Stabilization

Early days: reaching moderate-severe withdrawal is challenging, but initiation resolves symptoms
Dose titration: optimize symptom control
Nurse care manager: refills, urine toxicology, coordination
Peer specialist: ongoing support
Outcome: hope, trust, and a sense of belonging to a caring team—a therapeutic factor by itself.
Reference:
High-dose buprenorphine induction in the ED (Herring et al., 2021)
Integrating behavioral health (Kessler et al., 2023)

When Primary Care Isn’t Enough: Specialty Treatment Options

Understanding the Options

IOP: 3+ hours/day, 3+ days/week; structured therapy for patients needing more than standard outpatient
PHP: 5+ hours/day, 5 days/week; step-down from inpatient or alternative to residential
Residential: 24/7 structured living environment; variable medical supervision; best for unsafe home environments
OBAT: office-based buprenorphine and counseling
OTPs: methadone dispensing with comprehensive services; regulated and often daily attendance at start

Behavioral Treatment: Valuable but Not a Prerequisite

MOUD saves lives even absent counseling. Making meds contingent on therapy blocks access and increases risk. Behavioral interventions—CBT, contingency management, 12-step facilitation—add value but should be offered collaboratively, not gatekept (SAMHSA, 2023).
Reference:
Medications for substance use disorders (SAMHSA, 2023)

Acute Care Settings as Teachable Moments: EDs and Hospitals

Why Hospitals Matter

Hospitalizations expose immediate consequences of use (infection, overdose, trauma) and create readiness for change. Respectful, non-judgmental inpatient experiences rebuild trust in healthcare (Bernstein et al., 2023).

Inpatient Addiction Consult Services: Gold Standard

Interdisciplinary teams deliver:
Medical management: withdrawal stabilization, MOUD initiation, pain co-management
Social work: ASAM assessments, MI, discharge planning
Care coordination: logistics, referrals, communication across settings
Peer support: emotional anchoring and hope from lived experience
Outcomes: fewer readmissions, higher MOUD uptake and retention, better linkage to outpatient care (Trowbridge et al., 2023).
References:
Intervention in the ED (Bernstein et al., 2023)
Addiction consultation for hospitalized patients (Trowbridge et al., 2023)

Case Study: Lisa—Inpatient Addiction Consult Service in Action

Presentation

Lisa, 32, hospitalized for left lower extremity cellulitis after injection drug use. Active fentanyl and methamphetamine use. Early withdrawal symptoms. Anxiety about her dog’s care. Known chronic hepatitis C infection, untreated.

First 24 Hours

Medical plan: begin methadone for withdrawal management; plan transition to buprenorphine once stable—leveraging methadone’s efficacy for withdrawal and buprenorphine’s safety/regulatory flexibility
Discuss harm reduction: contingency management for methamphetamine; off-label pharmacotherapies for stimulant cravings.
Social work: ASAM multidimensional assessment; MI to reduce AMA risk; discharge planning and collateral supports
Peer support: addresses dog care, provides lived-experience hope

Day Two and Beyond

Transition to buprenorphine via low-dose microinduction (Bernese method)—avoids need for severe withdrawal and reduces risk of precipitated withdrawal in the era of fentanyl (Ahmed et al., 2023)
Ongoing cellulitis treatment with IV antibiotics
Craving management for methamphetamine: contingency management, consider bupropion + naltrexone (Trivedi et al., 2021)
Harm reduction education: fentanyl contamination, nitazenes, overdose risk; naloxone; avoid using alone
Hepatitis C: referral for direct-acting antivirals—safe, effective, curative in 8–12 weeks (AASLD, 2024)
References:
Microinduction of buprenorphine/naloxone (Ahmed et al., 2023)
HCV guidance (AASLD, 2024)
Bupropion and naltrexone in methamphetamine use disorder (Trivedi et al., 2021)

Care Transitions: Managing the Most Fragile Moments

Why Transitions Are Risky

Between inpatient and outpatient care, specialty programs and community, and crisis services to ongoing management, patients face heightened risk of disengagement, relapse, and overdose—especially after abstinence-induced loss of tolerance.
Challenges:
Care silos and poor inter-team communication
Stigma and distrust
Workforce shortages and appointment delays
Resource barriers: transport, housing, technology, cost
Insurance coverage hurdles and prior authorizations

Best Practices We Use

Community partnerships: formal referral pathways between hospitals, FQHCs, OTPs, and specialty programs
Bridge prescribing: discharge prescriptions that carry patients safely to first outpatient visit
Telehealth and bridge clinics: same-day access, minimal barriers, continuity
Peer support at transitions: proactive outreach and navigation
Hot handoffs: direct introductions or calls between discharging and receiving providers
Case management: dedicated coordination across settings to prevent loss to follow-up (Wakeman et al., 2023)
Reference:
Comparative effectiveness of different treatment pathways (Wakeman et al., 2023)

New Frontiers in SUD Management: What’s Emerging and Why It Matters

Pharmacological Innovations for OUD

Extended-release injectable buprenorphine (e.g., Sublocade): eliminates daily dosing and reduces diversion; early evidence supports strong retention (Lee et al., 2023)
Extended-release injectable naltrexone (Vivitrol): blocks opioid effects; requires 7–14 days of abstinence before initiation; suitable for motivated patients
Low-dose buprenorphine microinduction: meets the fentanyl era’s challenge by avoiding precipitated withdrawal (Ahmed et al., 2023)

Stimulant Use Disorder

Contingency management: strongest behavioral evidence for reducing stimulant use and improving retention (Petry et al., 2021)
Digital CM platforms: smartphone-based verification to deliver incentives at scale
Pharmacotherapy: injectable naltrexone + oral bupropion shows promise in methamphetamine use disorder (Trivedi et al., 2021)

Harm Reduction Imperatives

Naloxone distribution: widely, proactively—saves lives
Fentanyl test strips: improve informed decision-making
Syringe service programs: reduce HIV/HCV transmission and connect users to care
Safe supply models: under study internationally; reduce overdose and harms in high-risk populations (Harm Reduction International, 2023)

Telehealth and Bridge Clinics

Telehealth MOUD delivery: equivalent or better retention vs. in-person; expands access for rural and underserved populations (Uscher-Pines et al., 2023)
Bridge clinics: walk-in, low-barrier services link patients during transitions and waiting periods—documented improvements in initiation and retention (Liebschutz et al., 2022)
References:
Comparative effectiveness of extended-release vs. buprenorphine-naloxone (Lee et al., 2023)
Contingency management treatments (Petry et al., 2021)
Treatment during COVID-19: Transition to telemedicine (Uscher-Pines et al., 2023)
Global state of harm reduction (Harm Reduction International, 2023)

Integrative Chiropractic Care in SUD Treatment: Where It Fits and Why

As a chiropractor and advanced practice nurse, I see daily how musculoskeletal, neurological, and autonomic systems interact with substance use patterns, cravings, sleep, and mood. Integrative chiropractic care is not a stand-alone treatment for SUD, but it is a powerful adjunct that supports the physiology of recovery and reduces reliance on opioids.

Chronic Pain and SUD: Breaking the Pain-Opioid Cycle

Pain is a common driver of return to use. Opioid-induced hyperalgesia (OIH) amplifies pain sensitivity through central sensitization, descending facilitation, NMDA receptor upregulation, glutamatergic excitation, and neuroinflammation—creating a vicious cycle where opioids worsen pain over time (see “Physiology” section below).
What we do:
Spinal manipulation therapy (SMT) for low back pain, neck pain, headaches, radiculopathy, and joint dysfunction
Therapeutic exercise and rehabilitation to restore function and reduce pain
Cognitive-behavioral strategies for pain reprocessing and functional gains
Non-opioid modalities synergistic with MOUD to stabilize patients in recovery
Evidence:
SMT recommended by multiple guidelines for low back pain; meta-analyses show changes in pain sensitivity and descending inhibition (Coronado et al., 2022)
Lower opioid receipt among patients engaging in chiropractic care for spinal pain (Corcoran et al., 2024)

Neurophysiological Mechanisms of SMT Relevant to Recovery

Endogenous opioid release: beta-endorphins and enkephalins contribute to analgesia and may aid neurochemical rebalancing post-opioid exposure (Chu et al., 2021)
Autonomic regulation: SMT downregulates sympathetic activity, improving stress response and sleep quality (Haavik & Murphy, 2012)
Descending pain modulation: reduces central sensitization markers; helps interrupt chronic pain maintenance (Coronado et al., 2022)
HPA axis normalization: SMT may support cortisol regulation—critical in stress-linked craving (Whelan et al., 2022)

Acupuncture, Mind-Body, Functional Medicine

Acupuncture: adjunctive analgesia, withdrawal support, anxiety and depression management (Grant et al., 2023)
Mindfulness-based interventions (MBRP/MBSR): reduce craving and relapse by retraining attention and emotion regulation (Witkiewitz et al., 2024)
Functional medicine: addresses nutritional deficiencies, gut-brain axis dysbiosis, mitochondrial function, inflammation, and sleep architecture to rebuild resilience post-SUD
References:
Plausible mechanisms of chiropractic manipulation (Chu et al., 2021)
Changes in pain sensitivity following SMT (Coronado et al., 2022)
Association between chiropractic use and opioid receipt (Corcoran et al., 2024)
Acupuncture for substance use disorders (Grant et al., 2023)
Spinal manipulation, sensorimotor integration (Haavik & Murphy, 2012)
Effect of chiropractic manipulation on salivary cortisol (Whelan et al., 2022)
Mindfulness-based relapse prevention (Witkiewitz et al., 2024)

Our Integrated Model: How We Align Chiropractic, Internal Medicine, and Functional Medicine

The Clinical Architecture

Chiropractic interventions: restore joint motion, reduce nociceptive input, and modulate central processing of pain
Internal medicine oversight: diagnostics for comorbidities, medication management (including MOUD), and risk stratification
Functional medicine: targeted nutrition, gut-brain axis support, mitochondrial and anti-inflammatory strategies, sleep optimization
Rehabilitation and personal injury: structured recovery plans with documentation for medical-legal contexts
SUD-informed practice: trauma-aware, MI-based communication, harm reduction, and integrated behavioral health referrals

Examples of Integration

OUD on buprenorphine with low back pain: chiropractic plus exercise and CBT for pain while maintaining MOUD continuity; avoid opioid analgesics
Post-MVA whiplash with anxiety: SMT for cervical pain, mindfulness for stress regulation, functional nutrition to support recovery
Early recovery with musculoskeletal pain and insomnia: SMT, acupuncture, sleep hygiene counseling, possible nutraceutical support
References:
Clinical observations and integrative chiropractic insights (Jimenez, 2024)
LinkedIn professional profile (Jimenez, 2024)

Optimizing Your Wellness- Video

The Physiology of Opioid Use Disorder: A Deep Dive into Neurobiology

The Reward Circuit and Compulsivity

Addiction is a chronic, relapsing brain disorder with structural and functional changes in reward, learning, and inhibitory control systems (Koob & Volkow, 2023).
Mesolimbic dopamine: VTA to nucleus accumbens, PFC, amygdala, hippocampus
Opioids act at mu-opioid receptors (MORs): disinhibit VTA dopamine neurons → dopamine surge → intense reward
Adaptations:
MOR downregulation: tolerance
Endogenous opioid deficiency: withdrawal, dysphoria, pain sensitivity
Dopamine dysregulation: natural rewards feel blunted, drug cues drive craving
PFC dysfunction: impaired executive control → compulsive use despite harm
Why meds work: buprenorphine/methadone stabilize receptor occupancy, restoring partial homeostasis and enabling neuroplastic recovery.

The Physiology of Withdrawal

Abrupt cessation triggers locus coeruleus hyperactivity and noradrenergic surge:
Autonomic: tachycardia, hypertension, sweating, goosebumps, lacrimation, rhinorrhea, mydriasis
GI: nausea, vomiting, diarrhea, cramping
Musculoskeletal: aching, restless legs
Neuropsychiatric: anxiety, dysphoria, insomnia, intense craving
Medications:
Buprenorphine/methadone: sustained MOR agonism prevents rebound
Clonidine: alpha-2 agonist reduces noradrenergic outflow—helps autonomic/neuropsychiatric symptoms

Opioid-Induced Hyperalgesia (OIH)

Mechanisms:
Central sensitization: NMDA receptor upregulation, glutamate excitation
Descending facilitation: amplified spinal pain signaling
Neuroinflammation: glial activation, pro-inflammatory cytokines
Clinical implications:
Opioids may worsen pain over time
Treat with multimodal, non-opioid strategies: SMT, exercise, CBT for pain, MOUD where indicated, and anti-inflammatory support

Stress Systems: HPA Axis and Allostatic Load

Chronic SUD produces allostatic overload—hyperactive stress response:
Elevated cortisol baseline and sensitized reactivity
Immunosuppression → infection vulnerability
Metabolic dysfunction: insulin resistance, dyslipidemia
Sleep disruption: impaired circadian cortisol rhythm and architecture
Craving risk: stress triggers are powerful relapse drivers
Interventions:
SMT and acupuncture for autonomic balance
Mindfulness and exercise to recalibrate HPA axis
Functional nutrition to restore metabolic resilience
References:
Neurobiology of addiction (Koob & Volkow, 2023)

Functional Medicine Foundations in SUD Recovery

Why Functional Medicine Adds Value

A systems-biology approach addresses the physiological terrain that either supports or undermines recovery.
Nutritional repletion: B vitamins (alcohol), magnesium, zinc; amino acids for neurotransmitter precursors (L-tyrosine, L-tryptophan/5-HTP)
Gut-brain axis: microbiome dysbiosis influences inflammation, neurotransmitter production, and mood; restore with probiotics, diet, prebiotics (Hillemacher et al., 2023)
Mitochondrial support: CoQ10, alpha-lipoic acid, NAC, magnesium, B-complex
NAC: modulates glutamatergic signaling in nucleus accumbens; evidence for craving reduction in cannabis, cocaine, methamphetamine (McClure et al., 2023)
Anti-inflammatory strategies: omega-3s, curcumin, resveratrol; dietary patterns that lower neuroinflammation
Sleep optimization: behavioral therapy for insomnia, sleep hygiene, targeted supplementation (when appropriate)
References:
Alcohol, microbiome, brain and behavior (Hillemacher et al., 2023)
N-acetylcysteine as candidate treatment (McClure et al., 2023)

Locating SUD Treatment Resources: Practical Tools

SAMHSA Treatment Locator: findtreatment.gov — search by location, service type, payment options
SAMHSA Buprenorphine Prescriber Locator — find experienced prescribers
PCSS (Provider Clinical Support System): pcssnow.org — education and clinical mentoring for clinicians on MOUD and integration

Precision and Future Directions: Genetics, Pharmacotherapy Targets, Psychedelics

Precision Medicine and Pharmacogenomics

Genetic variability influences vulnerability and treatment response (e.g., OPRM1, CYP2D6/CYP3A4)
As sequencing becomes accessible, pharmacogenomics may tailor MOUD choices and dosing.
Current clinical use is limited by ethical, predictive, and trial constraints; robust family history remains valuable.

Novel Pharmacologic Targets

Kappa-opioid receptor (KOR) antagonists: potential for dysphoria/stress-induced relapse reduction
Orexin/hypocretin modulators: reduce craving and reinstatement
Cannabidiol (CBD): early evidence for reducing cue-induced craving/anxiety (Hurd et al., 2019)

Psychedelic-Assisted Therapies

Psilocybin-assisted therapy: striking early efficacy for alcohol and tobacco use disorders via profound shifts in psychological flexibility and values (Johnson et al., 2022)
Ketamine-assisted psychotherapy: promising for alcohol and cocaine; robust antidepressant effects relevant to co-occurring depression
MDMA-assisted psychotherapy: primary PTSD focus, relevant to high trauma prevalence in SUD populations
References:
Cannabidiol for cue-induced craving (Hurd et al., 2019)
Pilot study of psilocybin in tobacco addiction (Johnson et al., 2022)

Specialized Populations: Justice-Involved Individuals, Peripartum Women, and Adolescents

Justice-Involved Individuals

Post-release overdose is a leading cause of death due to loss of tolerance, fragmented care, and limited access to properly dosed MOUD. During incarceration, sub-therapeutic dosing erodes confidence in medications. Post-carceral stress dysregulates the HPA axis and elevates relapse risk.
Our strategy:
Immediate, low-barrier access to care
Chiropractic for autonomic regulation and musculoskeletal stabilization
Proper MOUD initiation and titration under internal medicine oversight
Functional medicine repletion to rebuild physiological resilience
Peer navigation for insurance re-enrollment, housing, and follow-up

Peripartum Substance Use

Stigma, fear of CPS, and punitive policies drive avoidance of prenatal care. Federal CARA mandates notification—not necessarily abuse/neglect reports—when infants are affected by substances; states vary in implementation. Punitive laws correlate with delayed or inadequate prenatal care and reduced postpartum visits.
Evidence-based approach:
Treat SUD as chronic illness; prioritize MOUD and non-judgmental support
Discuss Neonatal Opioid Withdrawal Syndrome (NOWS) honestly:
Risk exists but is manageable; NICU skilled in care
Not clearly dose-dependent; aim for maternal dose that prevents cravings/withdrawal
Dosing considerations:
Late pregnancy: increased dose often needed
Postpartum: metabolism normalizes over 3–12 weeks; gradual dose reduction to avoid sedation
Flexible follow-up: telehealth, co-located services, warm handoffs
Chiropractic care: relieve pregnancy-related musculoskeletal pain and regulate stress
Functional medicine: nutritional and gut-brain support through pregnancy and postpartum

Case: Liz—Postpartum MOUD Continuity

On buprenorphine 32 mg/day at delivery
Post-discharge plan:
Assess mother-baby dyad: housing, transport, social supports
Telehealth follow-up within first week; frequent check-ins
Gradual dose reductions over 3–12 weeks guided by sedation/craving balance
Engage social work, peer supports, mental health, and practical resources

Adolescents

Modern risks:
Mental health crisis: anxiety, depression, stress
Misuse of prescriptions: low awareness of fentanyl in counterfeit pills
Education prevents harm—targeted information reduces intent to misuse
Clinical realities:
Developing brain: heightened reward sensitivity, immature executive control
Drivers: low self-esteem, peer pressure, self-medication
Polysubstance use and low retention in programs
Consent laws vary; providers must know state rules and encourage family involvement when safe
MOUD considerations:
Buprenorphine: FDA-approved 16+, used off-label down to younger ages when risk warrants
Naltrexone/methadone: 18+ approvals
For non-dependent episodic users: discuss sedation risks at 8 mg and pursue shared decision-making
Wraparound care: medical, mental health, educational, family support
Harm reduction: universal naloxone distribution and training for teens and families

Building Therapeutic Alliance: The Most Powerful Non-Specific Treatment Factor

Outcome drivers:
Trust, empathy, reliability, shared goals
Consistent presence through crises and transitions
Unconditional positive regard and genuine curiosity about the whole person
Practical steps:
Validate effort and courage in seeking care
Respect autonomy and lived experience
Be transparent about risks and benefits
Prioritize warm and hot handoffs over passive referrals

Clinical Observations: How Integrated Care Changes Trajectories

My observations from chiropractic and functional medicine practice include:
Patients stabilized on MOUD often achieve faster pain reduction and functional gains when non-opioid musculoskeletal therapies are integrated early
Autonomic regulation via SMT and acupuncture reduces stress-linked craving cycles and improves sleep continuity
Targeted nutritional repletion and gut-brain support reduce fatigue and mood lability, improving treatment adherence
Mindfulness and reconditioning programs build daily coping skills that are protective during transitions
References:
Clinical observations and integrative chiropractic insights (Jimenez, 2024)
LinkedIn professional profile (Jimenez, 2024)

Summary and Conclusion: A Compassionate, Integrated Path Forward

Key takeaways:
Substance use disorder is a chronic, neurobiological illness—our care must be comprehensive, sustained, and humane
Primary care, EDs, inpatient units, and specialty programs each play crucial roles
Care transitions are high-risk; proactive bridge prescribing, telehealth, peer support, and care coordination save lives
Integrative chiropractic care, functional medicine, and mind-body interventions help break the pain-opioid cycle and restore autonomic and stress physiology.
Collaboration between chiropractic, advanced practice nursing, and internal medicine—like our El Paso model—delivers safer, more complete care.
Specialized populations require tailored approaches informed by legal context, physiology, and social determinants.
New frontiers—extended-release MOUD, microinductions, contingency management, telehealth, digital therapeutics, GLP-1 agonists, genetics, and psychedelics—are reshaping the landscape.
At Injury Medical Clinic PA, Dr. Cardenas and I work every day to embody these principles—science-driven, patient-centered, integrated care that treats the whole person and builds lasting recovery.

References

• NP fact sheet (American Association of Nurse Practitioners, 2024)
• Medications for substance use disorders (Substance Abuse and Mental Health Services Administration, 2023)
• Motivational interviewing: Helping people change and grow (Miller & Rollnick, 2023)
• Disentangling stigma from public health: An exploration of attitudes toward people with alcohol disorders (Meurk et al., 2024)
• Stop talking “dirty”: Clinicians, language, and quality of care for the leading cause of preventable death in the United States (Kelly et al., 2021)
• The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions (American Society of Addiction Medicine, 2023)
• Stages and processes of self-change of smoking: Toward an integrative model of change (Prochaska & DiClemente, 1983)
• Health workforce shortage areas (Health Resources & Services Administration, 2025)
• Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (SAMHSA, 2024)
• Comparative effectiveness of different treatment pathways for opioid use disorder (Wakeman et al., 2023)
• High-dose buprenorphine induction in the emergency department for treatment of opioid use disorder (Herring et al., 2021)
• The problem of integrating behavioral health in the primary care medical home and the questions it leads to (Kessler et al., 2023)
• Intervention in the emergency department for alcohol and other drug use disorders (Bernstein et al., 2023)
• Addiction consultation for patients hospitalized with drug use-related infections: Implications for antibiotic stewardship (Trowbridge et al., 2023)
• Microinduction of buprenorphine/naloxone: A review of the literature (Ahmed et al., 2023)
• HCV guidance: Recommendations for testing, managing, and treating hepatitis C (American Association for the Study of Liver Diseases, 2024)
• Bupropion and naltrexone in methamphetamine use disorder (Trivedi et al., 2021)
• Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (Lee et al., 2023)
• Contingency management treatments: Reinforcing abstinence from multiple substances (Petry et al., 2021)
• Global state of harm reduction 2023 (Harm Reduction International, 2023)
• Treatment of opioid use disorder during COVID-19: Experiences of clinicians transitioning to telemedicine (Uscher-Pines et al., 2023)
• Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial (Liebschutz et al., 2022)
• Plausible mechanisms of chiropractic manipulation in musculoskeletal and beyond: A narrative review (Chu et al., 2021)
• Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis (Coronado et al., 2022)
• Association between chiropractic use and opioid receipt among patients with spinal pain (Corcoran et al., 2024)
• The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control (Haavik & Murphy, 2012)
• The effect of chiropractic manipulation on salivary cortisol levels (Whelan et al., 2022)
• Acupuncture for substance use disorders: A systematic review and meta-analysis (Grant et al., 2023)
• Retraining the addicted brain: A review of hypothesized neurobiological mechanisms of mindfulness-based relapse prevention (Witkiewitz et al., 2024)
• Neurobiology of addiction: A neurocircuitry analysis (Koob & Volkow, 2023)
• Alcohol, microbiome, and their interaction on brain and behavior (Hillemacher et al., 2023)
• N-acetylcysteine as a candidate pharmacological treatment for cannabis use disorder (McClure et al., 2023)
• Cannabidiol for the reduction of cue-induced craving and anxiety in drug-abstinent individuals with heroin use disorder (Hurd et al., 2019)
• Pilot study of the 5-HT2AR agonist psilocybin in the treatment of tobacco addiction (Johnson et al., 2022)
• Clinical observations and integrative chiropractic insights (Jimenez, 2024)
• LinkedIn professional profile (Jimenez, 2024)

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