Gain a deeper understanding of the clinical approach to substance use disorder. Find methods and practices to enhance patient care.
Table of Contents
A chronic, curable illness, substance use disorder (SUD) impacts the brain, behavior, and overall body, including the musculoskeletal system. Chronic pain, injury, mental discomfort, and functional restrictions are common symptoms of SUD in many people. According to the American Medical Association [AMA], n.d.; National Institute on Drug Abuse [NIDA], n.d.; and the National Institute of Mental Health [NIMH], 2025, an integrative care model can lower risk, enhance function, and promote long-term recovery by combining evidence-based SUD screening and treatment with chiropractic care and nurse practitioner (NP)-led primary care.
This paper describes SUD, its recognition and classification, how clinicians can address it with effective processes, and how integrated chiropractic and NP treatment can address musculoskeletal sequelae and overlapping risk profiles.
SUD is a medical condition in which the use of alcohol, medications, or other substances leads to significant impairment or distress in daily life. It is not a moral failing or a lack of willpower; it is a chronic, brain? and body?based disease that is treatable (NIDA, n.d.; NIMH, 2025).
SUD exists on a spectrum from mild to severe. People with SUD may:
Use more of the substance than they planned
Try and fail to cut down or stop
Spend a lot of time obtaining, using, or recovering from the substance
Continue to use even though it harms health, work, relationships, or safety (American Psychiatric Association, 2022; NIMH, 2025)
Stigma can keep people from seeking care. Using respectful, person?first language reduces shame and supports engagement. NIDA and the AMA recommend (NIDA, n.d.; AMA, n.d.):
Say “person with a substance use disorder,” not “addict” or “drug abuser.”
Say “substance use” or “misuse,” not “abuse.”
Focus on SUD as a chronic, treatable condition.
Diagnostic criteria for SUD come from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM?5?TR) (American Psychiatric Association, 2022; NIAAA, 2025). A diagnosis is based on the number of symptoms present over 12 months.
Typical criteria include (paraphrased):
Using more or for longer than intended
Unsuccessful efforts to cut down
Spending a lot of time obtaining, using, or recovering
Cravings or strong urges
Role failures at work, school, or home
Social or interpersonal problems caused or worsened by use
Giving up important activities
Using in physically hazardous situations
Continued use despite physical or psychological problems
Tolerance
Withdrawal
Severity is determined by symptom count (American Psychiatric Association, 2022; NIAAA, 2025):
Mild: 2–3 symptoms
Moderate: 4–5 symptoms
Severe: 6 or more symptoms
Clinically, SUD is further categorized by substance type (NIDA, n.d.; NIMH, 2025):
Alcohol use disorder (AUD)
Opioid use disorder (e.g., heroin, oxycodone, hydrocodone)
Stimulant use disorder (e.g., cocaine, methamphetamine)
Sedative, hypnotic, or anxiolytic use disorder (e.g., benzodiazepines)
Cannabis, tobacco, hallucinogen, or inhalant use disorders
Each category has similar behavioral criteria but unique medical risks, withdrawal profiles, and treatment options (NIDA, n.d.; NIAAA, 2025).
For practical care, validated screening tools classify risk that guide next steps (AMA, n.d.; NIDA, n.d.; NIAAA, 2025):
Low/no risk: Negative screen or very low scores
Moderate risk: At?risk use with potential consequences (e.g., falls, crashes, future disease)
Substantial/severe risk: High scores suggest likely SUD and active harm
For example, adult risk zones using tools like AUDIT and DAST (AMA, n.d.):
Low risk/abstain: AUDIT 0–7; DAST 0–2
Moderate risk: AUDIT 8–15; DAST 3–5
Substantial/severe risk: AUDIT ?16; DAST ?6
These categories help teams decide when to give brief interventions, when to intensify care, and when to refer to specialty treatment.
National surveys show that millions of people in the United States live with SUD, yet only a fraction receive treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023). The 2022 National Survey on Drug Use and Health reported high rates of both substance use and serious mental illness, often co?occurring (SAMHSA, 2023).
Key points from recent federal data (SAMHSA, 2023; NIMH, 2025):
SUD commonly co?occurs with depression, anxiety, and other mental disorders.
Co?occurring conditions worsen medical outcomes and increase healthcare use.
Early identification and integrated treatment can improve function, reduce complications, and lower long?term costs.
Early, routine identification is critical. Primary care teams, NPs, and chiropractic clinics that integrate behavioral health can all play a role (AMA, n.d.; NIDA, n.d.; NIAAA, 2025).
Before asking about substance use, the team should (AMA, n.d.; NIDA, n.d.):
Explain that “we screen everyone” as part of whole?person care.
Emphasize confidentiality within legal limits.
Use a calm, nonjudgmental tone and body language.
Offer patients the option not to answer any question.
Acknowledge that stress, trauma, pain, and life pressures often contribute to substance use.
This aligns with trauma?informed care principles promoted by SAMHSA and helps patients feel safe enough to share (AMA, n.d.).
Evidence?based tools are preferred over informal questioning. Common options include (AMA, n.d.; NIDA, n.d.; NIAAA, 2025):
For adults:
AUDIT or AUDIT?C (Alcohol Use Disorders Identification Test) – screens for unhealthy alcohol use and risk of AUD.
DAST?10 (Drug Abuse Screening Test) – screens for non?alcohol drug use problems.
TAPS Tool (Tobacco, Alcohol, Prescription medication, and other Substances) – combined screen and brief assessment.
For adolescents:
CRAFFT 2.1+N – widely used for youth; captures risk behaviors and problems.
S2BI (Screening to Brief Intervention) and BSTAD – brief tools validated for ages 12–17 (NIDA, n.d.; AMA, n.d.).
For alcohol?specific quick screens:
AUDIT?C (3 questions) or full AUDIT
NIAAA Single Alcohol Screening Question (SASQ):
“How many times in the past year have you had 4 (for women) or 5 (for men) or more drinks in a day?” (NIAAA, 2025)
Results guide risk categorization and next steps.
In integrated practices, roles can be divided (AMA, n.d.):
Medical assistants or nurses
Administer pre?screens and full questionnaires.
Flag positive or concerning responses.
Nurse practitioners / primary care clinicians
Review screening results.
Deliver brief interventions using motivational interviewing.
Conduct or oversee further assessment.
Prescribe and manage pharmacotherapy for SUD when indicated.
Coordinate referrals and follow?up.
Behavioral health clinicians (on?site or virtual)
Perform biopsychosocial in-depth evaluations.
Provide psychotherapy and relapse?prevention skills.
Support motivational enhancement and family engagement.
Chiropractors and physical?medicine providers
Screen for substance misuse related to pain, function, and injury patterns.
Observe red flags (frequent lost prescriptions, inconsistent pain reports, sedation, falls).
Communicate concerns to the NP or primary medical provider.
Dr. Alexander Jimenez, DC, APRN, FNP?BC, exemplifies this dual role. As both a chiropractor and a family practice NP, he combines neuromusculoskeletal assessment with medical screening and functional medicine evaluation to identify root causes of chronic pain and unhealthy substance use patterns (Jimenez, n.d.).
Beyond formal tools, clinicians should stay alert for patterns such as (AMA, n.d.; NIMH, 2025):
Frequent injuries, falls, or motor vehicle accidents
Repeated missed appointments or poor adherence to treatment
Drowsiness, agitation, slurred speech, or odor of alcohol
Unexplained weight loss, infections, or liver abnormalities
Social and financial instability, job loss, or legal problems
In chiropractic and musculoskeletal settings, repeated injuries, delayed healing, inconsistent exam findings, or “pain behaviors” that do not match imaging or biomechanics may prompt gentle, supportive screening and medical referral.
Once a screen is positive, the next level is a more detailed assessment. This should examine substance type, frequency, amount, impact, withdrawal, mental health, physical comorbidities, and function (AMA, n.d.; NIMH, 2025).
Clinicians may use (AMA, n.d.; NIDA, n.d.; NIAAA, 2025):
Full AUDIT for alcohol
DAST?10 for general drugs
CRAFFT or GAIN for adolescents
Checklists based directly on DSM?5?TR criteria to rate symptom count and severity (NIAAA, 2025).
These tools allow classification into mild, moderate, or severe SUD and support shared decision?making regarding level of care.
SUD frequently co?occurs with (NIMH, 2025):
Major depressive disorder
Anxiety disorders
Posttraumatic stress disorder (PTSD)
Bipolar disorder
Attention?deficit/hyperactivity disorder
Co?occurring disorders can:
Increased risk for self?medication with substances
Worsen treatment outcomes if not recognized
Require integrated treatment plans (NIMH, 2025)
NPs, behavioral health clinicians, and chiropractors with integrative training should maintain a low threshold for mental health screening and referral.
Effective SUD care is chronic?disease care: ongoing, team?based, and tailored to readiness to change (AMA, n.d.; SAMHSA, 2023).
Key components include (AMA, n.d.; NIDA, n.d.; NIMH, 2025):
Routine screening and re?screening
Brief interventions and motivational interviewing
Harm?reduction strategies
Medications for certain SUDs (when appropriate)
Evidence?based behavioral therapies
Peer and family support
Long?term follow?up and relapse?prevention planning
For patients with low to moderate risk, brief intervention can be delivered in 5–15 minutes and often by NPs or primary care clinicians (AMA, n.d.; NIAAA, 2025). Using motivational interviewing, clinicians:
Ask open?ended questions (“What do you enjoy about drinking? What concerns you about it?”)
Reflect and summarize the patient’s own statements
Ask permission before giving advice
Help patients set realistic, patient?chosen goals (cutting down, abstaining, or seeking treatment)
This approach respects autonomy and builds internal motivation for change.
The American Society of Addiction Medicine (ASAM) describes a continuum of care (AMA, n.d.; SAMHSA, 2023):
Prevention/early intervention
Brief interventions in primary care
Self?management support and education
Outpatient services
Office?based counseling and medications for AUD or opioid use disorder (OUD)
Integrated behavioral health visits
Intensive outpatient / partial hospitalization
Several therapy sessions per week, day or evening programs
Residential/inpatient services
24?hour structured care for severe or complex cases
Medically managed intensive inpatient services
Medically supervised detoxification and stabilization
NPs and primary care teams decide the appropriate level based on risk severity, co?occurring medical and psychiatric conditions, social supports, and patient preference (AMA, n.d.; NIMH, 2025).
For some patients, medications support recovery by reducing cravings, blocking rewarding effects, or stabilizing brain function (SAMHSA, 2020; AMA, n.d.; NIAAA, 2025). Examples include:
Alcohol use disorder
Acamprosate – supports abstinence after detox
Disulfiram – creates an unpleasant reaction to alcohol, discouraging use
Naltrexone blocks the rewarding effects of alcohol
Opioid use disorder
Buprenorphine – a partial opioid agonist that reduces cravings and overdose risk; often prescribed in primary care with appropriate DEA registration
Methadone – full agonist, dispensed in specialized opioid treatment programs
Naltrexone (extended?release) – opioid antagonist that prevents relapse after detox
Overdose prevention
Naloxone – rapid opioid?overdose reversal, recommended for anyone at risk (AMA, n.d.).
NPs managing patients with SUD work within state scope?of?practice rules and in collaboration with addiction specialists where needed.
Evidence?based therapies include (AMA, n.d.; NIDA, n.d.):
Cognitive behavioral therapy (CBT)
Dialectical behavior therapy (DBT)
Motivational enhancement therapy
The Matrix Model (especially for stimulants)
Family?based therapy for adolescents
Peer support groups (Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery) can reinforce coping skills, hope, and accountability.
SUD is chronic; relapse risk can persist for years. Best practice includes (AMA, n.d.; NIMH, 2025):
Follow?up within 2 weeks after treatment initiation
Monthly to quarterly visits as patients stabilize
Peer support and care management between visits
Rapid re?engagement after any relapse or lapse
NASW, NIDA, and NIMH stress that relapse should be treated as a signal to adjust care—not as failure (NIDA, n.d.; NIMH, 2025).
SUD impacts nearly every organ system. Many effects directly or indirectly worsen neuromusculoskeletal health and pain.
Common systemic consequences include (NIDA, n.d.; NIMH, 2025; SAMHSA, 2023):
Cardiovascular disease and hypertension
Liver disease and pancreatitis (especially with alcohol)
Respiratory disease (especially with tobacco and some drugs)
Endocrine and hormonal disruption
Immune dysfunction and higher infection risk
Sleep disturbances and fatigue
Worsening of mood, anxiety, and cognitive function
These changes affect healing capacity, resilience, and the way patients perceive pain.
Substance use and SUD can influence the musculoskeletal system through several pathways:
Increased injury risk
Impaired judgment, coordination, and reaction time increase the risk of falls, motor vehicle accidents, and sports injuries.
Heavy alcohol use is associated with fractures, soft tissue injuries, and delayed healing (AMA, n.d.; SAMHSA, 2023).
Bone, joint, and muscle changes
Alcohol and some drugs can impair bone density and quality, increasing osteoporosis and fracture risk.
Nutritional deficiencies associated with SUDs weaken connective tissue and muscle function.
Sedentary behavior and deconditioning are common in people with long?standing SUD.
Chronic pain and central sensitization
Chronic alcohol or opioid use can alter pain pathways in the central nervous system, raising pain sensitivity.
Opioid?induced hyperalgesia can make pain seem worse even at stable or increasing doses.
Functional and ergonomic stress
Disrupted sleep, poor posture, and prolonged sitting or immobility (for example, in recovery environments or during unemployment) can lead to spinal stress, neck and low back pain, and muscle imbalance.
Clinically, Dr. Jimenez and similar integrative providers often see patients with combined profiles: chronic low back or neck pain, sedentary work, ergonomic strain, poor sleep, high stress, and escalating reliance on medications, including opioids or sedatives. Addressing both the mechanical and behavioral contributors can change the trajectory of pain and SUD risk (Jimenez, n.d.).
Integrative chiropractic care focuses on restoring alignment, mobility, and neuromuscular control while considering lifestyle, nutrition, sleep, and emotional stress. In the model used by Dr. Jimenez, chiropractic adjustments are combined with functional medicine strategies, targeted exercise, and collaborative medical care (Jimenez, n.d.).
For patients with or at risk of SUD, this approach offers:
Non?pharmacologic pain management
Improved movement, posture, and ergonomics
Education that empowers patients to self?manage pain
Reduced reliance on habit?forming medications
Spinal and extremity adjustments aim to:
Restore joint mobility
Reduce mechanical irritation of nerves and soft tissues
Improve segmental alignment and overall posture
Targeted exercises are prescribed to:
Strengthen deep stabilizing muscles (core, gluteal, cervical stabilizers)
Correct muscle imbalances and faulty patterns
Increase flexibility and joint range of motion
Enhance proprioception, balance, and movement control
Examples of targeted exercise strategies often used in integrative chiropractic and rehab clinics include (Jimenez, n.d.):
Lumbar stabilization and core?strengthening sequences
Hip mobility and glute activation drills for low back and sciatica?like pain
Cervical and scapular stabilization for neck and shoulder pain
Postural retraining, including ergonomic break routines for prolonged sitting
By reducing biomechanical stress and enhancing functional capacity, these interventions may decrease pain intensity, frequency, and flare?ups, which in turn can lower the drive to self?medicate with substances.
Many risk factors for SUD and for chronic musculoskeletal pain overlap, including (NIMH, 2025; NIDA, n.d.; Jimenez, n.d.):
Chronic stress and trauma
Poor sleep and circadian disruption
Sedentary lifestyle and obesity
Repetitive strain and poor ergonomics
Social isolation and low self?efficacy
Integrative chiropractic care can help shift these shared risk profiles by:
Encouraging regular physical activity and graded movement
Coaching ergonomic and postural strategies at work and home
Teaching breathing, stretching, and relaxation routines that reduce muscle tension and sympathetic overdrive
Collaborating with NPs and behavioral health clinicians to align interventions with mental health and SUD treatment plans
In Dr. Jimenez’s practice, this often includes structured flexibility, mobility, and agility programs that are adapted to age and functional status, with close monitoring to avoid over?reliance on medications, including opioids and sedatives (Jimenez, n.d.).
NPs are well-positioned to coordinate SUD care and integrate it with musculoskeletal and chiropractic treatment.
NP responsibilities typically include (AMA, n.d.; NIMH, 2025; NIAAA, 2025):
Conducting and interpreting SUD screening and risk stratification
Performing physical exams and ordering labs or imaging
Diagnosing SUD and co?occurring conditions
Prescribing non?addictive pain strategies and medications where indicated
Managing or co?managing medications for AUD or OUD (per training and regulations)
Monitoring for drug–drug and drug–disease interactions
Coordinating with behavioral health and community resources
In integrative settings like Dr. Jimenez’s clinic, the NP role is blended with functional medicine principles, looking at nutrition, metabolic health, hormonal balance, and inflammation that influence both pain and SUD risk (Jimenez, n.d.).
NPs also provide individualized counseling on:
Workplace ergonomics (desk height, chair support, screen position)
Safe lifting strategies and body mechanics
Activity pacing and graded return to work or sport
Sleep hygiene and circadian rhythm support
Nutrition strategies that support musculoskeletal healing and brain health
These interventions lower the mechanical load on the spine and joints, reduce fatigue, and increase a patient’s sense of control—all of which help reduce triggers for substance use and relapse.
NPs often serve as the central coordinator who (AMA, n.d.; NIMH, 2025):
Ensures all team members (chiropractor, physical therapist, behavioral health, addiction medicine, primary care, or specialty providers) share a coherent plan
Tracks progress on pain, function, substance use, mood, and quality of life
Adjusts the plan as conditions change
Supports families and caregivers in understanding both SUD and musculoskeletal needs
In a model like Dr. Jimenez’s, this may involve regular case conferences, shared EHR notes, and integrated treatment plans that align spinal rehabilitation with SUD recovery goals (Jimenez, n.d.).
For clinics that combine chiropractic and NP services, a practical, stepwise pathway for patients with possible SUD and musculoskeletal complaints can look like this (AMA, n.d.; NIDA, n.d.; NIAAA, 2025; NIMH, 2025; Jimenez, n.d.):
Intake includes questions on pain, function, injuries, sleep, mood, and substance use.
Staff administer brief tools (for example, AUDIT?C and DAST?10 for adults, CRAFFT for adolescents).
The chiropractor documents neuromusculoskeletal findings; the NP reviews medical and behavioral health risks.
Negative or low?risk screens ? brief positive health message and reinforcement of low?risk behavior.
Moderate risk ? NP provides brief intervention, motivational interviewing, and a follow?up plan.
Substantial or severe risk ? NP initiates comprehensive assessment, safety planning, and possible referral to specialized services.
The team crafts a unified plan that may include:
Spinal adjustments and targeted exercises to correct alignment and biomechanics
Gradual increase in physical activity with pain?sensitive pacing
Non?pharmacologic pain strategies (manual therapy, exercise therapy, education)
Behavioral health referral for CBT, trauma?informed treatment, or other modalities
Consideration of medications for AUD or OUD, if indicated
Harm?reduction measures (for example, naloxone prescription for those at overdose risk)
NP and chiropractor jointly review workplace and home ergonomics, posture, and activity patterns.
Patients learn micro?break routines, stretching, and strengthening sequences for high?risk tasks (for example, lifting or prolonged sitting).
Nutrition, stress?management, and sleep interventions are introduced or refined.
Regular follow?up visits evaluate:
Pain levels and functional capacity
Substance use patterns and cravings
Mood, sleep, and quality of life
Adherence to exercise and ergonomic plans
The team updates the treatment plan to respond to progress, setbacks, or new diagnoses.
Patients are coached to view flare-ups or lapses as opportunities to learn and adjust, not as failures.
This kind of coordinated, integrative approach can reduce repeated injuries, unnecessary imaging or surgeries, and long?term dependence on medications, including opioids.
Although each practice is unique, Dr. Alexander Jimenez’s clinic illustrates several principles that can guide others (Jimenez, n.d.):
Whole?person assessment: History taking includes injuries, lifestyle, trauma, nutrition, environment, and psychosocial stressors.
Functional movement focus: Care plans emphasize flexibility, mobility, agility, and strength to restore capacity rather than just relieve symptoms.
Non?invasive first: Chiropractic adjustments, functional exercise, and lifestyle interventions are prioritized before invasive procedures or long?term controlled substances.
Integrated roles: As both DC and FNP?BC, Dr. Jimenez unifies neuromusculoskeletal, primary care, and functional medicine perspectives in a single, coordinated plan.
Patient empowerment: Education, coaching, and accessible care options help patients take a proactive role in maintaining spinal health and reducing SUD risk.
This model aligns with national guidance on behavioral health integration and SUD management in medical settings while adding the musculoskeletal and ergonomic expertise of chiropractic care (AMA, n.d.; NIDA, n.d.; NIMH, 2025).
SUD is a chronic, treatable medical condition that often co?occurs with mental disorders and chronic pain.
Validated screening tools and non?stigmatizing, trauma?informed communication are core to early identification.
Risk and severity categories (mild, moderate, severe) guide brief intervention, level of care, and referral decisions.
SUD significantly affects the body, including bone health, soft tissue integrity, injury risk, and chronic pain pathways.
Integrative chiropractic care—with spinal adjustments, targeted exercises, and ergonomic guidance—can reduce pain, improve function, and lower overlapping risk factors for SUD.
Nurse practitioners provide comprehensive SUD management, coordinate care, and deliver ergonomic and lifestyle counseling that complements chiropractic treatment.
A collaborative, long?term, patient?centered model—such as the one exemplified by Dr. Alexander Jimenez—offers a promising pathway to healthier spines, healthier brains, and healthier lives.
As a complicated medical issue, substance use disorder needs evidence-based screening, compassion, and interdisciplinary coordination of treatment. Whether they are primary care physicians, chiropractors, nurse practitioners, or behavioral health specialists, the first step in identifying and helping patients with SUD is for healthcare professionals to understand what it is, how to recognize it, and how to respond with respect and evidence-based interventions.
For patients who suffer from both chronic pain and drug abuse, the combination of chiropractic therapy with nurse practitioner-led primary care provides a unique benefit. Patients who have had a job injury, a car accident, or years of bad ergonomics may not disclose that they are also struggling with amphetamine use, alcoholism, or prescription opioid abuse. However, these issues often coexist. The musculoskeletal system is burdened by poor healing, muscular atrophy, elevated pain sensitivity, and a higher risk of fractures. Both the neurological system and the mind are impacted equally, and mood swings, disturbed sleep, and diminished stress tolerance exacerbate the cycle of pain and drug abuse.
This loop may be broken by clinics and practices that include screening, short intervention, and coordinated therapy. Mechanical function is restored with spinal modifications. Proprioception and strength are restored via targeted activities. Re-injury is prevented via ergonomic coaching. In addition to coordinating medication, nurse practitioners also keep an eye out for drug interactions and provide lifestyle advice that promotes spinal health and SUD recovery. Peer support, treatment, and relapse prevention are all offered by behavioral health professionals. This team works together to address underlying problems rather than simply symptoms.
As shown by the clinical paradigm offered by clinicians such as Dr. Alexander Jimenez, a single clinician with dual expertise—chiropractic and family practice nurse practitioner credentials—can effortlessly weave these threads into a cohesive, patient-centered strategy. Patients gain from consistency, goal alignment, and a clinician who is knowledgeable about the neurology of addiction as well as the biomechanics of a herniated disc. With intentional team communication, collaborative decision-making, and a dedication to trauma-informed, non-stigmatizing treatment, larger practices may get comparable outcomes.
Early identification improves outcomes and saves lives, as the research abundantly demonstrates. Accurate and fast screening technologies are validated. Motivational interviewing and short-term therapies are effective. Opioid and alcohol use disorder medications are safe and effective when used as directed. Physical activity, manual treatment, stress reduction, and social support are all effective but often overlooked non-pharmacologic methods. Additionally, patients who get musculoskeletal and behavioral health treatment simultaneously recover more quickly, resume their normal activities sooner, and have a much lower chance of relapsing into drug abuse.
Healthcare teams that are prepared to go beyond isolated complaints—beyond “just” worry or “just” back pain—will reap the benefits in the form of patients who regain their sense of purpose, relationships, and health. This is the promise of evidence-based, integrated, team-based treatment for musculoskeletal disorders and drug use disorders.
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The information herein on "Clinical Approach Strategies for Substance Use Disorder" is not intended to replace a one-on-one relationship with a qualified health care professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional.
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