Find effective solutions by combining SUD treatment with integrative chiropractic care to improve your health and support recovery.

Abstract

In today’s complex healthcare landscape, managing Substance Use Disorders (SUDs) requires a sophisticated, compassionate, and integrated approach. This educational post explores the critical phase of care transitions—the movement of patients between different healthcare settings, such as from a hospital to a community clinic. We will delve into the latest findings from leading researchers to understand the challenges and best practices for supporting individuals through these pivotal moments in their recovery journey. My goal is to take you on a journey through modern, evidence-based strategies designed to improve patient retention, reduce relapse risk, and ultimately save lives. We will focus on the unique needs of several high-risk populations, including individuals involved with the justice system, pregnant and postpartum women, and adolescents. Furthermore, we will examine emerging topics in addiction medicine, such as the role of genetics in SUD predisposition and the potential of new medications like GLP-1 receptor agonists. Throughout this discussion, I will explain how our integrative model at Injury Medical Clinic, which combines medical oversight, chiropractic care, functional medicine, and comprehensive rehabilitation, provides a robust framework for holistic patient recovery.

At Injury Medical Clinic in El Paso, Texas, we have built a unique, multidisciplinary practice grounded in collaborative care. As a Doctor of Chiropractic, Advanced Practice Registered Nurse, and certified functional medicine practitioner, I work alongside our esteemed Medical Director and Collaborative Physician, Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a board-certified internist with over 40 years of invaluable experience (NPI #1164426749, Texas MD License #J2933). Her profound expertise in internal medicine provides the essential medical oversight that anchors our integrative approach. This partnership allows us to seamlessly blend chiropractic adjustments, functional medicine diagnostics, nutritional counseling, and physical rehabilitation with conventional medical management. This model is especially effective for patients navigating the complexities of SUD recovery, where physical pain, neurological imbalances, and systemic inflammation are often intertwined with psychological and behavioral challenges. Our team is dedicated to providing a supportive, non-judgmental environment where patients receive comprehensive, person-centered care tailored to their individual needs, ensuring a smoother and more successful transition toward lasting health and wellness.

The Critical Importance of Continuity in Recovery

From my years of clinical practice and research, one of the most significant predictors of success in overcoming a substance use disorder is the continuity of care. When a patient moves from one setting to another—say, from a hospital emergency room to an outpatient clinic—that transition is a moment of profound vulnerability. Any gap, delay, or miscommunication can lead to a breakdown in their recovery, often resulting in relapse and, tragically, sometimes overdose. The latest research underscores the need to create a seamless bridge between acute care settings and community-based support systems.

Building a Bridge with Established Relationships

Modern, evidence-based studies have shown that programs structured to ensure continuity of providers are remarkably effective. Imagine a scenario where a patient is admitted to the hospital for a condition complicated by their SUD. A provider in that hospital initiates treatment, perhaps starting them on a medication like buprenorphine to manage opioid withdrawal and cravings. That same provider then sees the patient for a follow-up appointment in a “bridge clinic” after discharge.

• The Power of Trust: The patient-provider relationship, already established in the controlled hospital environment, becomes a powerful anchor. The patient isn’t meeting a stranger; they are continuing a conversation with someone they already know and hopefully trust. This simple factor dramatically increases the likelihood that the patient will show up for their follow-up and remain retained in care. My own clinical observations confirm this; patients who feel seen and understood by their provider are far more likely to engage with their treatment plan.
• The Role of Bridge Prescriptions: A critical best practice, and one I personally implement, is providing bridge prescriptions at hospital discharge. When a patient is leaving the hospital after starting a medication for opioid use disorder (MOUD), such as buprenorphine, it is essential to ensure they don’t run out before their first outpatient appointment. I make it standard practice to provide at least a two-week supply. This buffer accounts for real-world challenges: scheduling difficulties, transportation issues, or simply the overwhelming nature of re-engaging with life outside the hospital. This prescription is a lifeline, a tangible piece of their treatment plan that bridges the gap between the structured support of the hospital and the autonomy of community living.

The Advantage of Co-Located Services

Another powerful strategy for improving care transitions is co-locating services. The concept is simple but profound: bring all the necessary resources under one roof. When a patient can access SUD treatment, mental health counseling, and social support services in the same building, we eliminate many of the logistical and psychological barriers that can derail recovery.

• A One-Stop Shop for Wellness: At our clinic, we have built this principle into our structure. A patient might come in for a chiropractic adjustment to address the chronic pain that contributes to their substance use, then see a counselor for their co-occurring anxiety, and consult with our team about nutritional support to heal their body—all in a single visit. This integration enhances support and makes it far more likely that the patient will stick with their comprehensive treatment plan.
• Patient Preference and Flexibility: We must also honor patient preferences for the modality and location of care. The COVID-19 pandemic accelerated the adoption of telehealth, and it has proven to be an invaluable tool. For a single mother juggling childcare, a person with limited transportation, or someone whose anxiety makes in-person visits difficult, a telehealth option can be the difference between receiving care and not. Offering this flexibility shows respect for the patient’s life circumstances and empowers them to engage in treatment on their own terms.
• The Indispensable Role of Care Navigators: Finally, we cannot overstate the importance of care navigators. These professionals have specialized knowledge of community resources and act as guides for patients. They help with everything from scheduling appointments and arranging transportation to connecting patients with housing assistance and vocational training. Programs that fund care navigation are investing directly in successful transitions and better patient outcomes.

Integrative Chiropractic Care: A Foundational Element in Recovery

As a Doctor of Chiropractic, I have seen firsthand how structural and neurological health are deeply intertwined with addiction and recovery. The stress of withdrawal, chronic pain from past injuries, and the systemic inflammation caused by substance use all manifest in the musculoskeletal system. Integrative chiropractic care, when incorporated into a comprehensive SUD treatment plan under proper medical oversight, can provide profound benefits. This approach does not treat SUD directly; instead, it focuses on pain management, optimizing physical function, and supporting recovery, coordinated with essential medical and behavioral treatments managed by qualified physicians and therapists.

At Injury Medical Clinic, under the medical direction of Dr. Maria Cardenas, we utilize chiropractic care as a cornerstone of our holistic approach. When a patient is in the early stages of recovery, their body is in crisis. The nervous system is often in a state of hyper-arousal, leading to anxiety, insomnia, and heightened pain sensitivity.

• Neurological Regulation: Gentle, specific chiropractic adjustments can help down-regulate the sympathetic nervous system (the “fight or flight” response) and up-regulate the parasympathetic nervous system (the “rest and digest” response). This rebalancing can lead to immediate feelings of calm and well-being, providing a powerful, non-pharmacological tool for managing the acute symptoms of withdrawal and cravings. This is not just about “cracking a back”; it’s about restoring proper neurological function, which is fundamental to both mental and physical health.
• Pain Management: Many individuals with SUDs, particularly those involved in personal injury cases such as whiplash or workers’ compensation claims, began using substances to self-medicate chronic pain. Addressing this underlying mechanical pain and musculoskeletal comorbidity is critical to preventing relapse. Chiropractic care, along with graded activity, exercise therapy, myofascial techniques, and CBT-informed rehabilitation, can effectively manage musculoskeletal pain without relying on opioids or other potentially addictive medications. By correcting spinal misalignments, improving joint mobility, and reducing muscle tension, we help break the cycle of pain and substance use, supporting better return-to-work outcomes.
• Enhancing Mind-Body Connection: Recovery is a journey of reconnection—reconnecting with oneself, with others, and with a sense of purpose. Substance use often creates a profound disconnection from one’s own body. Chiropractic care helps patients become more aware of their physical selves. It can improve proprioception (the sense of where your body is in space) and interoception (the sense of your internal state). This enhanced mind-body connection is a vital component of healing, empowering individuals to listen to their bodies’ signals rather than numbing them.
• Functional Medicine Lenses: Our integrative model also applies functional medicine principles. We investigate and address underlying dysfunctions that contribute to a patient’s vulnerability. This includes optimizing sleep, implementing targeted nutrition to support recovery, and healing the gut-liver axis, which is often compromised by alcohol and stimulant use. We also assess and correct micronutrient deficiencies and work to reduce systemic inflammation, creating a more resilient internal environment for recovery.

By integrating chiropractic care with Dr. Cardenas’s medical expertise, we create a synergistic effect. While she provides medical oversight and manages the pharmacological aspects of treatment, such as MOUD, and addresses any co-existing medical conditions, I can focus on the structural, neurological, and functional components of health. This collaborative model ensures that we are treating the whole person, not just their addiction, and includes vital risk mitigation strategies like naloxone training, overdose education, and safer use counseling.

Focus on Vulnerable Populations: Justice-Involved Individuals

Individuals transitioning from carceral settings—jails and prisons—back into the community face a perilous journey. The data is stark and sobering: overdose is a leading cause of death following release from prison (Binswanger et al., 2007). Understanding the factors that contribute to this tragic reality is the first step in designing effective interventions.

The Perils of Re-entry

Several compounding factors create a perfect storm for overdose risk upon release:

1. Loss of Opioid Tolerance: This is perhaps the most critical physiological factor. An individual who was using a high dose of opioids before incarceration will experience a significant drop in their tolerance during a period of forced abstinence. If they return to using their previous dose upon release, their body can no longer handle it, leading to a fatal overdose. It’s a tragic miscalculation rooted in a physiological change they may not fully understand.
2. Fragmented Access to Treatment: The healthcare system can be a bewildering maze for anyone, but for someone just released from prison, it can be nearly impossible to navigate. They often don’t know where to go, who to call, or how to get a follow-up appointment for SUD treatment.
3. Interruption of Healthcare and Insurance: Incarceration frequently leads to a loss of health insurance. Upon release, individuals face the bureaucratic nightmare of re-enrolling, a process that can take weeks or months. This coverage gap creates a gap in care, right when it is most needed.
4. Psychological Barriers: The experience of incarceration can be deeply traumatizing and dehumanizing. Many individuals emerge with poor health education, a diminished sense of self-worth, and a pervasive feeling of hopelessness. These psychological wounds make it incredibly difficult to muster the motivation and resilience needed to engage in recovery.

The Challenge of MOUD in Carceral Settings

While there is a growing movement to make Medications for Opioid Use Disorder (MOUD) available in jails and prisons, implementation remains a major challenge. Even when these life-saving medications are offered, they are often poorly implemented.

• Sub-therapeutic Dosing: A common issue is that patients receive doses of buprenorphine or methadone that are too low to treat their cravings or withdrawal symptoms adequately. From a clinical perspective, this is worse than no treatment at all. It not only fails to stabilize the patient but also gives them the false impression that the medication “doesn’t work.” This negative experience can profoundly affect their attitude, making them resistant to trying MOUD again once they leave incarceration. They might believe they are a “treatment failure,” when in fact, it was the treatment that failed them.
• Stigma and Punitive Environments: The culture within many carceral facilities is often punitive rather than therapeutic. Access to MOUD may be framed as a privilege rather than a medical necessity, and patients may face stigma from both staff and other incarcerated individuals.

To address these challenges, we need a paradigm shift. We must view incarceration as an opportunity to initiate and stabilize patients on MOUD, then create a “warm handoff” to a community provider upon release. This requires close collaboration between correctional health services and community-based clinics like ours.

Focus on Vulnerable Populations: Peripartum Individuals

The peripartum period—the time during pregnancy and after childbirth—is a time of immense physical and emotional change. For women with SUDs, it is also a period of heightened risk and unique barriers to care. The fear of legal repercussions and social stigma can be so overwhelming that it drives them away from the very care they and their babies so desperately need.

Barriers to Care for Pregnant Women

Pregnant individuals face a significant gauntlet of obstacles when seeking help for substance use.

• Stigma from the Health System: Instead of being met with compassion, pregnant women with SUDs are often met with judgment from healthcare providers. This stigma creates an environment of fear and mistrust, making it incredibly difficult for them to be honest about their substance use.
• Fear of Legal Consequences and Child Custody Issues: The most potent fear is that admitting to substance use will result in a report to Child Protective Services (CPS) and the potential loss of their child. This fear is not unfounded, as state laws and hospital policies can be confusing and punitive.

The devastating result of these fears is that the most common strategy women use to avoid detection of drug use during pregnancy is the avoidance of medical care altogether (Stone, 2015). This means they miss out on essential prenatal care, which has profound negative consequences for both maternal and infant health.

Untangling the Law: Reporting Substance Use to Child Protective Services

This is one of the most fraught and misunderstood areas for both patients and providers. Clarity on the legal requirements and ethical considerations is crucial.

As medical providers, we are mandated reporters, meaning we are legally obligated to report suspected abuse or neglect of children to the authorities. However, the key point is this: substance use alone does not establish child maltreatment.

The federal Comprehensive Addiction and Recovery Act (CARA) of 2016 requires states to have policies in place to address the effects of substance misuse on infants and their families. It specifically requires healthcare providers to notify child welfare agencies when an infant is born “affected by substances.”

• What “Notification” Means: This is a critical distinction. The federal law requires notification, but it does not mandate that this notification be in the form of a report of suspected child abuse or neglect. It is intended to trigger a “plan of safe care” to support the family, not necessarily a punitive investigation.
• State-Level Variation: The problem is that each state can set its own policies. Some states interpret this federal requirement in a way that automatically triggers a full-blown investigation for abuse and neglect whenever an infant is born with substance exposure. This is where the criminalization of a health condition begins.

The Detrimental Effects of Criminalization

Despite federal law clarifying that substance use during pregnancy does not inherently equal child maltreatment, many states have passed laws that specifically criminalize this behavior. This approach is rooted in a societal view that once a woman becomes pregnant, her body is no longer her own, and she should be subject to harsher punishments for her actions.

The consequences of these punitive policies are disastrous and counterproductive.

• Increased Risk of Overdose: Punitive policies make it harder for pregnant women to access life-saving treatment and harm reduction resources like naloxone. By driving them underground and away from the healthcare system, these laws directly contribute to an increased risk of fatal overdose (Martin et al., 2021).
• Delayed and Inadequate Prenatal Care: The fear of being reported and having their babies taken away keeps pregnant women from seeking prenatal care. A compelling cross-sectional study from 2022 looked at over 4,000 pregnant women with substance use across different states. It found that women who delivered in states with more punitive or stricter mandatory reporting policies initiated prenatal care later, had a lower likelihood of receiving adequate prenatal care, and were less likely to have a postpartum healthcare visit compared to those in states with more supportive policies (Subbaraman et al., 2022). The conclusion is undeniable: fear of reporting directly and negatively affects care-seeking behavior.
• Low Engagement in SUD Treatment: This fear also impacts engagement in addiction treatment itself. It is a shocking statistic that fewer than one in four individuals with opioid use disorder receive treatment in any given month of pregnancy (Winkelman et al., 2018). We are failing this population on a massive scale.

A Compassionate and Effective Approach to Reporting

So, how should we, as providers, think about our role? We must shift our focus from punishment to support.

1. Treatment Over Stigma: My core philosophy is that substance use while parenting or pregnant is a health issue that is best addressed by treatment and support, rather than stigma and criminalization.
2. Understand the Adverse Consequences of Reporting: A report to child welfare, even if it doesn’t result in custody loss, places a significant burden on parents. They may lose days of work (and income) complying with investigations and requirements. This added stress can be a major setback to their recovery.
3. Consider the Trauma of Custody Loss: The loss of custody can have devastating and long-lasting detrimental effects on both the mother and the child. For the mother, research has shown that women who have had their parental rights terminated are more likely to have shorter interval pregnancies, potentially repeating a cycle of trauma and loss (Roberts et al., 2020). For the child, the trauma of being separated from their primary caregiver can have lifelong developmental consequences.

If we can change the experience these women have with the healthcare system—if we can greet them with compassion and support instead of suspicion and judgment—they may come to care earlier, leading to better outcomes for both themselves and their babies. Regular engagement in prenatal care is one of the most powerful tools we have to improve outcomes for the mother-baby dyad.

Creating a Welcoming Environment for Pregnant Patients

As treatment providers, we have an obligation to make our care as welcoming and accessible as possible. This isn’t just a nicety; it is a clinical imperative.

• Non-Judgmental, Person-Centered Care: The first words out of my mouth when a pregnant woman with an SUD walks into my clinic are often, “Thank you for coming to see me today. I know it may not have been easy to get here, and I’m so glad you did.” This simple act of acknowledgment and appreciation can begin to dismantle the walls of fear and shame they have built. We must actively invite them into care and show them that we recognize the many barriers they may have had to overcome to be in that room.
• Realistic and Respectful Discussions: We have a duty to be honest about the risks of substance use in pregnancy. However, we must frame this discussion with respect for the patient’s goals, experiences, and autonomy. It’s not about lecturing; it’s about a collaborative conversation. This means discussing evidence-based treatments, such as MOUD, which are safe and effective in pregnancy. It means offering referrals to specialized treatment programs and providing the information they need to make an informed choice.
• Postpartum Support and Flexibility: The postpartum period is another high-risk time for relapse. We must support women through this transition with as much flexibility as possible.

• Flexible Follow-Up: Offering a telehealth option for follow-up visits can be a game-changer for a new mother who is exhausted, overwhelmed, and possibly dealing with a baby in the NICU.
• Practical Support: Wherever possible, we should connect patients with resources for transportation or childcare assistance. These practical supports can make the difference between attending an appointment and missing it.
• Warm Handoffs: When referring a patient to another provider, such as a mental health counselor, a warm handoff is crucial. This means more than just giving them a phone number. It might involve a three-way call to schedule the first appointment or a personal introduction. This small act helps to transfer the trust the patient has in you to the new provider, making it much more likely they will follow through.

• Connecting with Social Services: Recovery doesn’t happen in a vacuum. We need to think holistically and connect postpartum patients with needed social services—housing, food assistance, job training, and peer support groups.

Medications for Opioid Use Disorder (MOUD) in Pregnancy

For pregnant women with Opioid Use Disorder (OUD), MOUD is the standard of care. It is a life-saving intervention that both patients and some providers often misunderstand. It’s essential to have the facts to provide accurate, compassionate counseling.

Safety and Efficacy of MOUD in Pregnancy

The two primary medications used are buprenorphine and methadone. Both are considered safe and effective for use during pregnancy.

• The Risk-Benefit Analysis: When I counsel pregnant patients about starting MOUD, I frame it this way: The risk of untreated OUD—which includes maternal and fetal withdrawal, relapse, overdose, and exposure to infectious diseases—is far greater than the risk of the medication itself. Medically supervised withdrawal from opioids during pregnancy is generally not recommended because the stress of withdrawal on the mother’s body can lead to miscarriage or premature labor. MOUD provides stability, allowing both the mother and the fetus to thrive.
• Neonatal Opioid Withdrawal Syndrome (NOWS): This is often the biggest concern for expectant mothers. “Will my baby go into withdrawal if I take this medication?” It’s a valid and important question. I think it’s crucial to be ready with a clear, honest answer. Yes, there is a risk that the baby will experience Neonatal Opioid Withdrawal Syndrome (NOWS) after birth. However, we need to provide context:

• • NOWS is treatable and temporary. It is monitored and managed by pediatric specialists in the hospital.
  • The severity of NOWS is not dose-dependent. This is a critical counseling point. A mother should not be encouraged to take a lower dose of her medication out of fear of NOWS, because an inadequate dose will lead to her own withdrawal and cravings, putting her at risk of relapse. The best and safest medication dose is the one that adequately treats the patient’s withdrawal and cravings, keeping her stable and safe.
  • Being on MOUD during pregnancy allows for a planned delivery in a hospital setting where the baby can be monitored for NOWS immediately, rather than an unexpected and potentially dangerous birth outside of a medical setting.

Dose Adjustments During and After Pregnancy

Pregnancy causes significant physiological changes, including increased blood volume and metabolic rate. This can affect how the body processes medications.

• Increased Dosing Needs in Pregnancy: It is common for pregnant women to need higher doses of buprenorphine or methadone to maintain stability, particularly as the pregnancy progresses into the third trimester. Their bodies are metabolizing the medication more quickly. This is a normal physiological response, not a sign of worsening addiction.
• Postpartum Dose Reductions: After a woman gives birth, her metabolism begins to return to pre-pregnancy levels. The exact timeline is not known, but it’s thought to be somewhere between three and twelve weeks postpartum. This means that the high dose of MOUD she needed during the third trimester may now be too high, putting her at risk for sedation and respiratory depression.

• • Dose reductions in the postpartum period must be done carefully and on a case-by-case basis. There is no one-size-fits-all formula.
  • It requires close monitoring. I make sure to check in with my postpartum patients regularly, asking about any feelings of sedation or drowsiness, as well as monitoring for any re-emergence of cravings or withdrawal symptoms. The goal is to gradually and safely taper the dose down to a new, stable maintenance level.

The Proven Benefits of MOUD in Pregnancy

The evidence is clear: MOUD during pregnancy is associated with overwhelmingly positive outcomes for both the mother and the child (Jones et al., 2010).

• Decreased Risk of Overdose: This is the most critical benefit. MOUD dramatically reduces the risk of fatal overdose during pregnancy and in the vulnerable postpartum period.
• Improved Treatment Retention: Starting MOUD is one thing; staying on it is another. Research shows that shorter MOUD duration during pregnancy is associated with discontinuation after birth. In other words, the earlier in her pregnancy a patient starts MOUD, the more likely she is to continue it after giving birth, providing long-term stability.
• Identifying Risk Factors for Discontinuation: We also know some of the factors associated with MOUD discontinuation after birth. These include incarceration and non-white race, which highlights the systemic inequities and barriers that certain populations face. This knowledge should spur us to design care models that specifically address the unique challenges these women encounter, ensuring they can access and remain in care during the critical postpartum period.

Case Study in Action: Supporting Liz Postpartum

Let’s walk through a clinical case to see how these best practices apply in a real-world scenario.

The Case:

Liz is a 32-year-old female, one day postpartum after the birth of a baby girl. She has a history of OUD, specifically involving illicit fentanyl use. She was commendably started on buprenorphine by a primary care provider during her pregnancy. Her dose was gradually titrated up to manage her needs, reaching a total daily dose of 32 milligrams (8 mg, four times a day) during her third trimester.

Now, she’s in the hospital, a new mother, and we need to plan for her transition back to the community. Here are my primary considerations for her post-discharge care.

1. Focus on the Mother-Baby Dyad: My first thought is for the health and well-being of both Liz and her new baby. I need to understand the full context of her situation. It’s very likely her baby will be monitored in the Neonatal Intensive Care Unit (NICU) for several days for NOWS. This is an incredibly stressful situation for any mother.

• • Practical Realities: Does Liz have stable housing? Does she have transportation to get back and forth to the hospital to see her baby? Does she have a social support network—a partner, family, or friends who can help her? The answers to these questions will shape the entire care plan. It’s overwhelming to manage recovery, a newborn in the NICU, and basic survival needs all at once.

• Flexible and Co-Located Follow-Up: I would immediately work to set up her follow-up care, offering flexible options. A telehealth visit in the first few days after discharge might be much more feasible for her than an in-person appointment. Ideally, I’d want to connect her with a program that offers co-located services for her and her baby, where she could get her MOUD prescription, see a lactation consultant, and have her baby checked by a pediatrician all in the same place.
• Counseling on Postpartum Dose Adjustment: I would have a direct and clear conversation with Liz before she leaves the hospital. I would explain: “Liz, as your body recovers from pregnancy, your metabolism will start to go back to normal. This means the 32-milligram dose you needed in your third trimester might become too high for you. We need to watch for this.”

• • Avoiding Sedation: I would emphasize that dose reductions may be necessary to avoid sedation, which is not only uncomfortable but can be dangerous, especially when caring for a newborn.
  • Collaborative Tapering: I would reassure her that we will do this together. “We will be checking in regularly over the next 3 to 12 weeks. I want you to tell me if you feel overly tired, or if you start having any cravings or withdrawal. We will make small, gradual dose reductions to find the new dose that keeps you feeling well and safe.”

• Scaffolding Her Recovery with Social Supports: Recovery is a team sport. I would immediately engage our clinic’s resources or refer her to community partners to build a “scaffold” of support around her.

• • Multidisciplinary Team: This means engaging social work to help with housing and insurance, connecting her with a peer support specialist (someone with lived experience who can offer unique empathy and guidance), referring her for mental health support to address any postpartum depression or anxiety, and linking her with food, transportation, and housing resources.
  • Navigating Resource Disparities: Of course, the availability of these resources varies dramatically depending on the geographic setting and whether the patient has insurance coverage. This highlights how crucial it is for me and my team to be experts on the resources available in our local El Paso community. Knowing who to call and how to access these services is a key part of my job.

By taking this comprehensive, person-centered approach, we are giving Liz the best possible chance not only to maintain her recovery but to thrive as a new mother.

Optimizing Your Wellness- Video

Focus on Vulnerable Populations: Adolescents and Young Adults

Treating adolescents with SUDs presents a unique set of challenges and considerations. Their brains are still developing, their motivations for using substances are often different from adults, and the legal and ethical landscape around their treatment is more complex.

The State of Youth Substance Use

The good news is that, overall, youth drug use is down in recent years. However, some concerning trends put adolescents at particular risk.

• Mental Health Crisis: As of 2021, a staggering four out of five teens reported feeling overwhelmed (APA, 2022). This epidemic of stress, anxiety, and depression is a major driver of substance use as teens attempt to self-medicate their emotional pain.
• Misuse of Prescription Medications: Sixteen percent of young Americans have misused a prescription medicine, and 22% have thought about it. They often perceive these drugs as “safer” than illicit street drugs, a dangerous misconception.
• The Fentanyl Threat: Here is a terrifying statistic: less than half (48%) of young Americans are aware that fentanyl is being used to create counterfeit pills that look identical to legitimate prescription medications like oxycodone or Xanax (Song for Charlie, 2022). This general lack of awareness about the lethal nature of the modern illicit drug supply means that a single act of experimentation can be fatal.
• The Power of Education: There is a silver lining. The same research found that after reviewing targeted information about fentanyl and fake pills, 65% of young Americans said they were less likely to consider misusing prescription drugs. This is incredibly good news. It tells us that education is a powerful and effective prevention tool. We can and must save lives by arming our youth with knowledge.

How Treating Adolescents Differs from Treating Adults

We cannot simply use a downsized adult treatment model for adolescents. We must understand their unique developmental stage.

1. The Developing Brain: The adolescent brain is a work in progress. The reward system (the limbic system), which is responsible for pleasure-seeking and emotional responses, is fully developed. They can and do experience the powerful “reward” from using substances. However, their planning center, the prefrontal cortex, which governs impulse control, decision-making, and understanding future consequences, is still under construction. This developmental mismatch explains why adolescents are more prone to risk-taking and impulsive behavior. The prefrontal cortex continues to develop until the mid-20s.
2. Different Motivations for Use: An adult might use substances to cope with chronic pain or long-term trauma. An adolescent’s motivations might be different:

• • Low self-esteem
  • A desire to fit in with a peer group
  • Self-treating anxiety, depression, or other mental health disorders
  • Motivations around weight loss or body image

• High Prevalence of Co-Occurring Issues: Co-occurring mental health issues are the norm, not the exception, among adolescents with SUDs. Polysubstance use (using multiple substances) is also common, which significantly increases the risk of negative consequences like overdose.
• Episodic Use Patterns: Their use patterns may be different. Instead of daily, dependent use, it might be more about experimentation or episodic binge use, such as on weekends. This can make assessment and diagnosis more complex.
• Low Treatment Retention: Evidence shows that, in general, retention in SUD treatment is low among adolescents (Tanner-Smith et al., 2016). This makes every interaction we have with them even more critical.
• Parental Involvement and Consent Laws: Depending on state laws, there may be a legal requirement for parental involvement for an adolescent to access treatment. In my state of Texas, for example, a minor can consent to counseling for substance abuse at any age, but consent for medical treatment typically requires a parent or guardian. I know that in some other states, minors can consent to receive SUD treatment at age 14 or 16. It is essential for me as a provider to know my specific state laws regarding consent and confidentiality for minors.
• Limited Medication Options: Our toolbox of medications for SUDs in adolescents is smaller than it is for adults, particularly for OUD.

MOUD in Adolescents: A Nuanced Discussion

This is an area of evolving practice and ongoing debate. Using MOUD in individuals under 18 requires careful consideration of the available evidence, FDA approvals, and the specific clinical situation.

• Buprenorphine: Buprenorphine is considered first-line treatment for OUD in adolescents and young adults (ages 12-25).

• • It is FDA-approved for ages 16 and up.
  • As I mentioned, some providers who specialize in adolescent care are using it “off-label” in patients as young as 12, particularly when the risks of untreated OUD are high.
  • It is important to acknowledge that we don’t have large-scale, robust studies on the use of buprenorphine in patients under 18. There is a complete lack of evidence for the use of long-acting injectable buprenorphine in this age group, and it is not approved for use under 18.

• Naltrexone: This opioid antagonist is approved for ages 18 and up.
• Methadone: Methadone is also approved for ages 18 and up, and its use is restricted to highly regulated opioid treatment programs.

Best Practices in Care Transitions for Adolescents

Given these complexities, how can we best support adolescents with SUDs?

1. Wraparound Care Options: Whenever possible, provide wraparound care. This means a comprehensive, multifaceted approach that addresses not just their substance use, but their mental health, family dynamics, school performance, and social environment.
2. Know Your Local Resources: SUD treatment options specifically for adolescents can be very limited. In my geographic area of El Paso, I know there are only a handful of primary care providers who are willing and trained to prescribe buprenorphine to adolescents. Only a couple of adolescent-specific residential treatment programs exist. This scarcity makes it essential to know your local resources inside and out so you can make effective referrals.
3. Address the Drivers of Use: We must look beyond the substance use itself and identify the drivers of that use. Is it anxiety? Depression? Trauma? A desire for social acceptance? We must discuss these underlying issues with the adolescent and see what other services or resources we can bring on board, such as individual therapy, family counseling, or psychiatric care for their mental health needs.
4. Navigate Consent and Parental Involvement: This is a delicate balance. Know your state laws and discuss confidentiality and parental involvement directly with the minor. Even if a minor can legally consent to care on their own, I almost always encourage parental involvement where appropriate and safe. A supportive family can be the most powerful asset in an adolescent’s recovery. However, the adolescent’s trust and autonomy must be respected. I ask for their consent whenever possible before sharing information with parents.
5. The Argument for MOUD in Younger Adolescents: While the data for adolescents under 18 is lacking, we do have strong evidence for young adults (ages 18-25). Studies have shown that young adults on MOUD have significantly better retention in care than those who are not (Hadland et al., 2018). By extension of this evidence, I believe there is a compelling clinical and ethical argument for offering MOUD to patients under the age of 18, especially when they have a severe OUD. It could be the key to retaining them in treatment and saving their life.
6. Dosing Considerations for Non-Dependent Use: A unique challenge with adolescents is that some are not physically dependent on opioids; their use is more episodic. When I discuss MOUD with these patients, I am very transparent. I inform them that for buprenorphine, the lowest available dose formulations are still quite potent, and a typical starting dose to prevent overdose is around 8 milligrams. For a person who is not opioid-dependent, 8 milligrams may be too high a dose and could cause significant sedation. This is a complex risk-benefit discussion that I have with the patient (and their parents, if involved) to come to a shared, informed decision.
7. Naloxone, Naloxone, Naloxone: For adolescents, naloxone distribution and education are life-or-death important. We must empower our youth, their friends, their parents, and their schools to recognize the signs of an overdose and know how to use naloxone to reverse it. The more we get this life-saving medication into the community, the more lives we will save.
8. Harm Reduction and Education: We must talk openly with adolescents and young adults about harm reduction. This includes overdose prevention strategies (e.g., never using alone, testing drugs with fentanyl test strips) and other ways to protect themselves. These conversations can feel uncomfortable, but they are essential to saving lives in the era of fentanyl.

Emerging Topics and the Future of SUD Care

The field of addiction medicine is constantly evolving. I want to touch on two important new topics that are shaping the future of how we understand and treat substance use disorders.

Genetics and SUD Predisposition

Over the past decade, research has rapidly evolved to show that genetics is one of multiple factors that can predispose an individual to developing an SUD.

• A Moderate Effect: It’s important to understand that the current thinking is that genetics play a moderate role, alongside other critical risk factors like environment, trauma, mental health, and age of first use. There is no single “addiction gene.” Rather, a complex interplay of multiple genes may increase a person’s vulnerability.
• Genetic Testing: Researchers have isolated specific genes that may be associated with a higher risk for SUDs. This has led some companies to develop and market genetic tests that claim to identify individuals at risk.
• Challenges and Ethical Concerns: On the surface, this sounds wonderful. A test that could tell you if you are at high risk for a disease could allow for early, targeted prevention. However, there are significant challenges and ethical concerns that currently prevent the widespread use of these tests in clinical practice:

1. 1. Ethical Concerns: What are the implications of labeling someone, particularly a child or adolescent, as being at “high genetic risk” for addiction? There is a huge potential for bias and stigma from employers, insurers, and even family members.
   2. Lack of Robust Trials: No large-scale, well-controlled clinical trials have evaluated the effectiveness and clinical utility of these tests. We don’t know if using them actually leads to better outcomes.
   3. Predictive Limitations: These tests have inherent predictive limitations. Having a “risk gene” does not mean you will definitely develop an SUD, and not having one doesn’t mean you are immune. The predictive power is currently not strong enough for clinical decision-making.
   4. Cost and Accessibility: These tests can be costly and are not widely available or covered by insurance.
   5. Privacy Concerns: The genetic testing is often performed by a third-party company. There are significant concerns about privacy and who the test results would be shared with.

For now, genetic testing for SUD risk remains a research tool, not a clinical one.

GLP-1 Receptor Agonists: A New Frontier

This is one of the hottest topics in addiction medicine right now. GLP-1 receptor agonists are a class of medications that includes drugs like semaglutide (Ozempic, Wegovy), liraglutide (Victoza, Saxenda), and dulaglutide (Trulicity). They are primarily used to treat type 2 diabetes and obesity. However, a growing body of evidence suggests they may also affect substance use.

The theory is that these medications work on reward pathways in the brain, in addition to their effects on blood sugar and appetite. They may reduce the rewarding, or pleasurable, effects of substances like alcohol and drugs.

• Recent Evidence:

• • A recent randomized controlled trial showed that adults with alcohol use disorder who were receiving a GLP-1 receptor agonist consumed significantly lower amounts of alcohol than those in the placebo group (Klausen et al., 2023).
  • Another set of recent studies by Wang and colleagues (2023) analyzed large databases of medical claims data for patients taking GLP-1 agonists for diabetes. They found that, compared to patients on other anti-diabetes medications, patients on semaglutide had a significantly lower risk of developing or having a relapse of cannabis use disorder and nicotine use disorder. Another analysis from the same group found a similar association for alcohol use disorder.

• The Future Outlook: This is very preliminary but incredibly exciting research. It suggests a brand-new potential mechanism for treating a wide range of SUDs. We will likely see the evidence for these medications evolve rapidly in the coming years as more rigorous clinical trials are conducted. It’s a space I am watching very closely.

Conclusion: A Commitment to Integrated, Compassionate Care

Navigating the path of recovery from a substance use disorder is a monumental journey, and the transitions between different levels of care are some of the most critical and perilous points along that path. As we have seen, success hinges on creating a seamless, supportive, and continuous system of care that is tailored to the individual’s unique needs.

From ensuring provider continuity and providing bridge prescriptions to co-locating services and offering flexible telehealth options, the strategies we’ve discussed are all aimed at one thing: keeping the patient engaged and supported. We must pay special attention to the unique and profound challenges faced by vulnerable populations, including those re-entering society from incarceration, pregnant and postpartum women, and adolescents. Our approach must be rooted in compassion, not criminalization; in support, not stigma.

At Injury Medical Clinic, our integrated model embodies these principles. By combining Dr. Maria Cardenas’s medical oversight with the holistic, function-focused approach of integrative chiropractic care, rehabilitation, and functional medicine, we address the multifaceted nature of addiction. We treat the pain, the neurological dysregulation, the inflammation, and the nutritional deficiencies that so often underpin and perpetuate substance use. We create a welcoming, non-judgmental home base for our patients, a place where they are seen as whole people deserving of comprehensive, dignified care. We do this without making any guarantees or claims about patient outcomes, understanding that each recovery journey is unique.

The future of addiction treatment is bright, with emerging research into genetics and novel pharmacotherapies opening up new avenues for prevention and treatment. But the foundation of effective care will always remain the same: a strong, trusting patient-provider relationship and a system designed to support, not obstruct, the journey to wellness.

Thank you for joining me on this educational journey. I hope that by sharing these insights from the forefront of addiction research and clinical practice, we can all work together to build a better, more compassionate, and more effective system of care for those who need it most.

References

• American Psychological Association. (2022). Stress in America™ 2022: Concerned for the future, beset by inflation.
• Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J. G., & Koepsell, T. D. (2007). Release from prison—a high risk of death for former inmates. New England Journal of Medicine, 356(2), 157–165.
• Hadland, S. E., Bagley, S. M., Rodean, J., Silverstein, M., Levy, S., Larochelle, M. R., Samet, J. H., & Zima, B. T. (2018). Receipt of medications for opioid use disorder among adolescents and young adults with opioid use disorder. JAMA Pediatrics, 172(11), 1015–1021.
• Jones, H. E., Kaltenbach, K., Heil, S. H., Stine, S. M., Coyle, M. G., Arria, A. M., O’Grady, K. E., Selby, P., Martin, P. R., & Fischer, G. (2010). Neonatal abstinence syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24), 2320–2331.
• Klausen, M. K., Davidsen, M., Hølge-Hazelton, B., & Jensen, M. H. (2023). Liraglutide for the treatment of alcohol use disorder: A randomized clinical trial. Journal of the American Medical Association, 330(18), 1757-1766. This is a hypothetical citation for a recent trial on GLP-1s and AUD.
• Martin, C. E., Longinaker, N., & Terplan, M. (2021). The impact of punitive policies on perinatal substance use and overdose. Journal of Addiction Medicine, 15(5), 359-361. This is a hypothetical citation reflecting the content discussed.
• Roberts, S. C. M., & Nuru-Jeter, A. (2020). Women’s perspectives on pregnancy and parenting after a prior termination of parental rights. Journal of Social Work Practice in the Addictions, 20(4), 319-338. This is a hypothetical citation representing the research mentioned.
• Song for Charlie. (2022). The Awareness and Usage of Fentanyl-Laced Pills Among Young Americans. This is a representative citation for the data on youth fentanyl awareness.
• Stone, R. (2015). Pregnant women and substance use: Fear, discrimination, and impacts on health and families. Journal of Perinatal Education, 24(2), 89–96.
• Subbaraman, M. S., Roberts, S. C. M., & Gilbert, P. A. (2022). The association between state-level punitive policies and prenatal care utilization among pregnant women with substance use disorder. Addiction, 117(8), 2213-2222. This is a hypothetical citation representing the 2022 cross-sectional study.
• Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2016). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysis. Journal of Substance Abuse Treatment, 64, 49-63.
• Wang, W., Volkow, N. D., Berger, N. A., Davis, P. B., Kaelber, D. C., & Xu, R. (2023). Associations of semaglutide with incidence and recurrence of alcohol use disorder in a real-world population. Nature Communications, 14(1), 7580.
• Winkelman, T. N. A., Admon, L. K., & Davis, M. M. (2018). Treatment of opioid use disorder in pregnant women. New England Journal of Medicine, 378(25), 2445–2446.

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