SUD Treatment Insights with Integrative Chiropractic Care

Transform your recovery with SUD treatment and integrative chiropractic care, combining traditional methods with holistic healing.

Abstract

Welcome to our comprehensive exploration of the evolving landscape of Substance Use Disorder (SUD) treatment. My name is Dr. Alex Jimenez, and I am a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), a Board-Certified Family Nurse Practitioner (FNP-BC), a Certified Functional Medicine Practitioner (CFMP), and an Institute for Functional Medicine Certified Practitioner (IFMCP). I also hold certifications in Addiction Therapy (ATN) and as a Chiropractic Clinical Science and Technology Specialist (CCST). In this educational post, I will guide you through the intricate world of SUD care, from the expanding role of nurse practitioners to the critical importance of seamless care transitions. We will explore the latest findings from leading researchers, grounded in modern, evidence-based methods, to understand the challenges and best practices for supporting patients across settings—from primary care to acute hospitals. A special focus will be placed on the unique needs of vulnerable populations, including justice-involved individuals, peripartum women, and adolescents. This discussion will explore the physiological underpinnings of addiction, the rationale behind specific treatment protocols, and the profound impact of stigma on care-seeking behaviors. A key element of this exploration is integrating multidisciplinary care. We will examine how our practice, Injury Medical Clinic PA, combines chiropractic care, functional medicine, and conventional medical oversight to provide a holistic and patient-centered treatment model. My goal is to equip you with a deep, nuanced understanding of these complex issues, empowering you to support those on their recovery journey better.

Our Multidisciplinary Team: Integrating Chiropractic and Medical Expertise

At Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, we have cultivated a unique, multidisciplinary environment dedicated to comprehensive patient care in El Paso, Texas. Our clinic is founded on the principle of integrative medicine, a philosophy that brings together the best of various healthcare disciplines to address the root causes of illness and promote holistic well-being. My diverse background spanning chiropractic, advanced practice nursing, and functional medicine has shaped my clinical approach, which is dedicated to understanding the human body as an integrated system.

I have the distinct privilege of working alongside Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933) and brings over four decades of invaluable experience as an internist to our team. She serves as our esteemed Medical Director and Collaborative Physician, providing essential medical oversight and direction that anchors our integrative model. This collaborative relationship between a Doctor of Chiropractic (DC) and a Medical Doctor (MD) is a common and highly effective structure in modern integrative and injury care clinics. Dr. Cardenas’s deep knowledge of internal medicine allows us to provide care that bridges the gap between conventional medical treatment and holistic therapies.

Together, our team integrates:

• Chiropractic Care (Dr. Jimenez): Focusing on spinal health, nervous system function, and pain management through non-invasive adjustments and therapies. My extensive training allows me to view the patient through a multifaceted lens, considering the intricate connections between the musculoskeletal system, nervous system, and overall physiological function. Chiropractic care is not just about addressing back pain; it is a holistic discipline focused on restoring proper nervous system function by correcting spinal misalignments, or subluxations. Optimizing the neuro-musculoskeletal system can profoundly affect the body’s ability to heal and regulate itself, which is particularly relevant for patients struggling with the physiological and psychological stresses of SUD.
• Medical Oversight (Dr. Cardenas): Providing diagnoses, prescribing medications when necessary, and managing complex medical conditions that often co-occur with SUDs, such as chronic pain, diabetes, and infectious diseases. This anchors our practice in rigorous medical standards.
• Functional Medicine: Investigating the underlying root causes of dysfunction, including nutritional deficiencies, hormonal imbalances, and gut health issues that can contribute to addiction and impede recovery.
• Personal Injury Care: Specializing in the treatment of injuries resulting from accidents, which are often a complicating factor for individuals with SUDs.
• Rehabilitation and Physical Therapy: Offering tailored exercise and movement programs to restore function, reduce pain, and improve overall physical resilience.
• Nutritional Counseling: Guiding diet and supplementation to support brain health, reduce inflammation, and aid in the body’s recovery process.

This integrated approach ensures that our patients receive truly comprehensive care. We don’t just treat symptoms; we address the whole person—mind, body, and spirit. By combining the strengths of chiropractic, internal medicine, functional medicine, and rehabilitation, we can create personalized, highly individualized treatment plans that support patients on their journey to recovery from SUDs and help them build a foundation for a healthier, more resilient life. In this post, I want to share insights from the forefront of SUD research, filtered through my own clinical lens and the integrative model we champion.

The Evolving Role of Nurse Practitioners in SUD Care

Hello, my name is Beth Williams. I am a nurse practitioner and an assistant professor at Oregon Health and Science University. It is a pleasure to share my insights on a topic of immense importance: care transitions and the new frontiers in the treatment of Substance Use Disorders (SUDs). In my practice and academic work, I’ve witnessed firsthand the profound impact that dedicated, well-informed healthcare providers can have on the lives of individuals struggling with addiction. Today, I want to take you on a journey through the current landscape of SUD care, focusing on the pivotal role of nurse practitioners (NPs), the best practices for patient care across different settings, and the exciting future of addiction medicine.

I have no financial disclosures to report. For clarity, I’ve prepared a list of abbreviations that we will encounter throughout our discussion:

• ACS: Addiction Consult Service
• ASAM: American Society of Addiction Medicine
• CBT: Cognitive Behavioral Therapy
• FNP-BC: Family Nurse Practitioner-Board Certified
• NP: Nurse Practitioner
• OBAT: Office-Based Addiction Treatment
• OTP: Opioid Treatment Program
• OUD: Opioid Use Disorder
• PCP: Primary Care Provider
• PCSS: Provider Clinical Support System
• SAMHSA: Substance Abuse and Mental Health Services Administration
• SUD: Substance Use Disorder

My objectives for this educational post are to:

• Discuss the unique and expanding role of nurse practitioners in SUD care.
• Review the specific aspects of different settings where patients access SUD treatment, from primary care offices to hospitals.
• Understand the best practices for managing transitions in care to ensure continuity and prevent relapse.
• Explore new research and emerging trends that are shaping the future of SUD management.

Nurse Practitioners: A Growing Force in Healthcare

The first area I want to focus on is the unique and powerful role that nurse practitioners play in delivering care for substance use disorders. The NP profession is one of the fastest-growing in the United States. We currently have around 258,000 NPs in practice, and this number is projected to grow by an astounding 45% over the next decade. This growth rate significantly outpaces that of many other professions.

What makes this growth so critical? A significant majority—more than 70%—of practicing NPs provide some form of primary care. This places us directly on the front lines of healthcare. Given how many of us practice in this setting, NPs are uniquely positioned to serve as a crucial entry point for individuals needing SUD treatment. Our presence is particularly vital in rural and underserved populations, areas that have historically lacked access to specialized medical services, including addiction care. We are often the most accessible, and sometimes the only, healthcare providers in these communities.

The NP Model: A Foundation for Compassionate SUD Care

Beyond our numbers and accessibility, the NP education and practice model equips us to be highly skilled and effective providers of SUD care. Our training is rooted in a holistic and patient-centered philosophy that aligns perfectly with the needs of individuals struggling with addiction. This philosophy emphasizes several core principles:

• Valuing Patient Autonomy and Self-Determination: We are trained to see the patient as an active partner in their own healthcare journey. We respect their right to make their own decisions and work collaboratively with them to set achievable goals. This is a stark contrast to a more paternalistic model of care, and it is essential for building the trust needed to treat SUDs effectively.
• Prioritizing Prevention: A huge part of our role focuses on preventive health and wellness. In the context of SUDs, this means not only preventing the initiation of substance use but also preventing the negative consequences associated with it, such as overdose, infectious diseases, and social instability.
• Empowering Patients Through Education: We believe that an informed patient is an empowered patient. We dedicate time to educating individuals about their condition, the nature of addiction as a chronic brain disease, the available treatment options, and harm reduction strategies. This knowledge helps demystify the disease and gives them the tools to manage their health.
• Non-Judgmental and Non-Stigmatizing Communication: Our training heavily emphasizes therapeutic communication. We learn to speak with patients in a way that is respectful, empathetic, and free of judgment. Stigma is one of the biggest barriers to seeking care for SUDs, and by creating a safe and non-stigmatizing environment, we open the door for honest and productive conversations.

Motivational interviewing, a collaborative, goal-oriented communication style designed to strengthen a person’s motivation for and commitment to change, is arguably a core competency of nurse practitioner practice. It is a fundamental part of providing compassionate and effective care for patients with SUDs. We learn to listen for “change talk” and guide patients to recognize their own reasons for wanting to change, rather than simply telling them what to do.

The scope of practice for NPs, particularly regarding the prescription of controlled substances, is determined by state law. These laws dictate our level of practice autonomy and whether we need a formal practice agreement with a collaborating physician.

Breaking Down Barriers: The End of the X-Waiver

One of the most significant and positive changes in recent years has been the elimination of the X-waiver requirement for prescribing buprenorphine. Buprenorphine is a highly effective medication for Opioid Use Disorder (OUD) that reduces cravings and withdrawal symptoms, significantly lowering the risk of overdose and helping people stabilize their lives. Previously, providers had to complete special training and obtain this waiver from the Drug Enforcement Administration (DEA) to prescribe it. This created a massive bottleneck in access to care.

Now, with that barrier removed, prescribing buprenorphine is firmly within the scope of practice for primary care providers, including NPs, in a wide variety of settings. This is a game-changing development that has the potential to save countless lives by making this life-saving medication as accessible as treatments for other chronic conditions like diabetes or hypertension.

The situation with methadone, another effective medication for OUD, is different. Federal law mandates that methadone, when used for the treatment of OUD, must be dispensed from a licensed Opioid Treatment Program (OTP), often referred to as a methadone clinic. However, within these OTPs, state law again determines the NP’s scope of practice. Furthermore, in a hospital setting, NPs may oversee the initiation or dose adjustment of methadone for patients who are admitted for a different medical reason but also have a co-occurring OUD, all in accordance with their state’s scope of practice laws.

Enhancing NP Expertise in Addiction Medicine

Despite these positive developments, I must acknowledge a significant gap. In my experience, the time dedicated to learning about SUD care and treatment in many NP programs is quite limited. Curricula are packed with competing demands, and addiction medicine often doesn’t receive the focus it deserves, given the scale of the public health crisis we face.

However, established pathways exist for NPs who want advanced training and specialization in this critical field.

• Advanced Certification: A dedicated certification called the Certified Addiction Registered Nurse – Advanced Practice (CARN-AP) exists. NPs can study for and sit for this exam to obtain an advanced, nationally recognized certification in addiction care. This demonstrates a high level of expertise and commitment to the field.
• Specialty Practice: Psychiatric Mental Health Nurse Practitioners (PMHNPs) also complete advanced specialty training and board certification that explicitly includes competencies in the diagnosis and management of SUDs. Their expertise in both mental health and substance use is invaluable, as these conditions so often co-exist.

Navigating the Settings of SUD Care

When we discuss the settings where patients receive care, it is crucial first to acknowledge a harsh reality: for many people who use substances, the healthcare system is viewed as a risk environment. This is a powerful and heartbreaking concept. Instead of seeing clinics and hospitals as places of healing and safety, they see them as places where they are likely to encounter stigma, discrimination, and even punishment. They may fear legal repercussions or having their children taken away. They may mistrust providers, anticipating judgment and disrespect.

This perception has a cascade of devastatingly negative outcomes:

• Delaying Care: Patients will avoid seeking medical help until their condition becomes a dire emergency. A small, treatable infection can become life-threatening sepsis. A manageable chronic condition can spiral out of control.
• Non-Disclosure of Drug Use: Fearing judgment, patients often do not disclose their substance use to their providers. This is incredibly dangerous, as it can lead to harmful drug interactions, misdiagnosis, and inadequate management of withdrawal or pain.
• Minimizing Pain: Patients with a history of SUD may be so afraid of being labeled a “drug-seeker” that they will downplay or outright deny their pain, leading to unnecessary suffering and poorer clinical outcomes.
• Leaving Against Medical Advice: The stress, discomfort of untreated withdrawal, and perceived stigma can become so overwhelming that patients will leave the hospital or another care setting before their medical treatment is complete, often with catastrophic consequences for their health.

The ultimate result of this cycle is that instead of engaging in preventative care or addressing health issues early, patients present later with more acute and complex illnesses. This leads to increased morbidity (illness), mortality (death), and significantly higher costs to the entire healthcare system.

A Spectrum of Care Options

To meet patients where they are, we need a robust, interconnected continuum of care. Think of it as a web of services with primary care sitting at the very center, acting as the hub. From this central point, various auxiliary options radiate outwards, tailored to a patient’s specific level of need at any given time.

This ecosystem of SUD care includes:

• Hospital or Inpatient Settings: For acute medical crises, detoxification, or stabilization.
• Emergency Departments: Often the first point of contact during a crisis, with a critical need for immediate intervention and smooth transitions to ongoing care.
• Specialty SUD Treatment Facilities: These include a range of intensity levels, such as intensive outpatient programs (IOPs), which allow patients to live at home while attending structured therapy several days a week, and residential treatment facilities, which provide a 24/7 therapeutic environment.
• Peer Support Networks: These are invaluable resources, connecting individuals with others who have lived experience with addiction and recovery. Peers can offer unique empathy, practical guidance, and hope. They can provide support in the community, within healthcare settings, and during transitions.
• Dedicated Mental Health Services: Crucial for addressing co-occurring mental health conditions like depression, anxiety, and PTSD, which are often intertwined with substance use.
• Telehealth or Bridge Clinics: These innovative models use technology to provide immediate or transitional care, “bridging” the gap between an acute event (like an ER visit or hospital discharge) and engagement in long-term treatment.

The ASAM Criteria: A Framework for Personalized Care

How do we determine the right level of care for a particular individual? One of the most widely used and respected models is the ASAM Levels of Care Criteria, developed by the American Society of Addiction Medicine. This is not a one-size-fits-all approach. Instead, it provides a framework for a comprehensive, multidimensional assessment that guides individualized treatment planning.

The ASAM criteria evaluate the patient across six key dimensions:

1. Acute Intoxication and/or Withdrawal Potential: What is the patient’s current state of intoxication? What is the risk and severity of potential withdrawal symptoms?
2. Biomedical Conditions and Complications: Does the patient have any co-existing medical issues that need to be managed?
3. Emotional, Behavioral, or Cognitive Conditions and Complications: Are there co-occurring psychiatric conditions like depression, anxiety, or psychosis that need to be addressed?
4. Readiness to Change: Where is the patient in their stage of change? Are they actively seeking help, or are they still contemplating it?
5. Relapse, Continued Use, or Continued Problem Potential: What is the likelihood that the patient will relapse or continue to use substances in their current environment?
6. Recovery/Living Environment: Is the patient’s living situation supportive of recovery, or is it a high-risk environment? Do they have a strong support system?

Based on this holistic assessment, the ASAM criteria define a continuum of care ranging from the most intensive to the least intensive levels:

• Level 4: Medically Managed Intensive Inpatient Services: This is the highest level of care, typically provided in a hospital setting, for patients with severe, unstable medical or psychiatric conditions.
• Level 3: Residential/Inpatient Services (with sublevels 3.1, 3.3, 3.5, 3.7): These levels provide 24-hour structured care in a residential setting, with varying degrees of clinical intensity.
• Level 2: Intensive Outpatient/Partial Hospitalization Services (with sublevels 2.1, 2.5): These programs offer a high degree of structured therapy for several hours a day, several days a week, while allowing the patient to live at home.
• Level 1: Outpatient Services: This is the most common level of care, involving regular visits to a clinic or therapist’s office, often weekly.
• Level 0.5: Early Intervention: This level provides education and support for individuals who are at risk for developing a substance use disorder but do not yet meet the diagnostic criteria.

The beauty of the ASAM criteria is that it’s a strength-based model. It doesn’t just look at a patient’s problems, needs, and liabilities. It also systematically assesses their strengths, assets, resources, and support structures. This information is then used to match the patient to the appropriate level of care on the continuum, ensuring they get the right amount of support at the right time.

Primary Care: The Front Door to SUD Treatment

I want to return to the central role of primary care because it represents our single greatest opportunity to transform how we address substance use in this country. Primary care providers (PCPs) constitute the largest clinical workforce in the United States. For most adults, their PCP is their main, and sometimes only, point of contact with the healthcare system.

This creates a unique and powerful dynamic. PCPs often have a longitudinal relationship with their patients, seeing them over months, years, and even decades. This long-term relationship allows them to build trust and meet patients with SUDs wherever they are along their personal trajectory of readiness to change their habits. The intervention a PCP provides can be tailored to the patient’s specific stage of change:

• Pre-contemplation: A patient in this stage is not yet considering change. The PCP’s role might be to gently raise the topic and plant a seed of awareness without being confrontational.
• Contemplation: A patient is now ambivalent, weighing the pros and cons of their substance use. For a patient with OUD in this stage, the PCP’s intervention might involve educating them about the health consequences of continued use and introducing harm reduction strategies, such as carrying naloxone (the opioid overdose reversal drug) and using clean needles.
• Preparation: The patient has decided to make a change and is planning how to do it. The PCP can help them create a concrete plan and explore treatment options.
• Action: The patient is actively working to change their behavior. For a patient with OUD who is ready for action, the PCP can now discuss and prescribe evidence-based medications like buprenorphine or naltrexone to support them in disrupting their use of the substance.
• Maintenance: The patient has sustained their change for a period of time and is working to prevent relapse. The PCP provides ongoing support, monitors for challenges, and celebrates their progress.

The Unmet Need: A Crisis in Primary Care

Despite primary care being the ideal setting for this kind of longitudinal, patient-centered SUD care, a stark reality prevents this vision from being fully realized. Few primary care settings in the United States currently offer a full range of SUD treatments.

The numbers are staggering. It is estimated that a shocking 86.6% of patients with Opioid Use Disorder who could benefit from life-saving medication do not receive it. Why is this happening?

To address the elephant in the room, we must acknowledge the broader crisis facing primary care in the United States. We have a massive and growing dearth of primary care providers. Looking at data projected for 2025, the picture is bleak:

• 2 million people in the U.S. live in a designated Primary Care Health Professional Shortage Area (HPSA).
• Only 5% of the need for primary care providers in these areas is actually being met.
• To close this gap, we would need to add 13,364 primary care providers to the workforce.

This profound shortage places an immense burden on existing PCPs. For these already overburdened providers, taking on the complexities of comprehensive SUD care can feel overwhelming. They face several significant barriers:

• Time Constraints: In a busy primary care practice where appointments are often scheduled in 15-minute slots, the idea of having a deep, nuanced conversation about substance use, explaining treatment options, and initiating medication can feel daunting, if not impossible.
• Low Reimbursement Rates: Historically, the reimbursement from insurance companies for the time and effort required to provide SUD care has been dismally low, creating a financial disincentive for clinics to offer these services.
• Inability to Refer to Psychosocial Support: Many PCPs feel isolated. They worry that if they start a patient on a medication like buprenorphine, they will have nowhere to refer them for the crucial counseling and psychosocial support that helps address the root causes of their addiction.
• Lack of Institutional or Managerial Support: Without support from their clinic’s leadership—in the form of protected time, additional staff, or clear protocols—providers are unlikely to take on this challenging work.
• Concerns about Medication Diversion: Some providers worry that patients will divert their buprenorphine, meaning they sell or give it to others. While diversion does happen, research shows it is often done to help others manage withdrawal or as a form of self-treatment, and the public health benefits of widespread buprenorphine access far outweigh the risks of diversion.
• Requirements for Concurrent Counseling: In some places, outdated policies may require that a patient can only receive medication for OUD if they are also actively engaged in counseling. While behavioral support is highly beneficial, making it a prerequisite for life-saving medication creates an unnecessary barrier to care and is not supported by evidence.

Best Practices for Integrating SUD Care into Primary Care

Despite these challenges, many clinics have successfully integrated SUD treatment into their primary care models. How do they do it? A systematic review that looked at twelve representative models identified four common components of successful programs:

1. Offering Pharmacologic Therapy: The cornerstone of an effective program is the ability to offer evidence-based medications like buprenorphine, naltrexone, and acamprosate on-site.
2. Offering Co-located Psychosocial Services: Successful models bring services under one roof. Having a behavioral health counselor, social worker, or therapist working in the same clinic as the PCP dramatically lowers barriers to access.
3. Integrating Care: It’s not enough to co-locate services; they must be truly integrated. This means the PCP, the counselor, and other team members communicate regularly, share treatment plans, and work together as a cohesive unit.
4. Providing Education and Outreach: These programs actively educate patients about SUDs and available treatments, and they conduct outreach to engage patients who may be hesitant to seek care.

The most successful primary care models almost always employ team-based approaches. For instance, they might utilize nurse care managers as the primary point of contact for patients on buprenorphine. These nurses can handle follow-up calls, coordinate refills, manage urine toxicology screening, and provide ongoing support, freeing up the PCP to handle more complex medical decisions.

Additionally, supporting providers and empowering SUD champions within the clinic is essential. This means providing ongoing education, mentorship, and protected administrative time for the providers who are leading the charge in delivering this care.

Excellent resources are available to support PCPs in this work. One I particularly want to highlight is the Provider Clinical Support System (PCSS). This is a program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) specifically designed to support clinicians in treating OUD. One of PCSS’s most valuable features is its clinical mentoring program, where any primary care clinician can sign up and be paired with an experienced mentor to consult on challenging cases, such as how best to manage a complex buprenorphine induction.

A Case Study in Integrated Primary Care: The Story of James

Let’s walk through a case study that beautifully demonstrates these best practices in action.

James is a 52-year-old man who has an appointment with his primary care nurse practitioner at a federally qualified health center (FQHC). The official purpose of the visit is to discuss his diabetes and chronic pain management. James has a known history of Opioid Use Disorder.

During the visit, the NP doesn’t just focus on his blood sugar and pain scores. She skillfully uses open-ended, non-judgmental questions to assess his overall well-being. She specifically inquires if he has been having any cravings to use opioids, especially given his ongoing struggle with chronic pain.

This safe and empathetic approach works. James feels comfortable enough to disclose that he has recently returned to using illicit fentanyl. He explains that the main drivers of his use are his unmanaged pain and his underlying depression. James had been on buprenorphine previously but stopped taking it because he thought he didn’t need it anymore. He tells his NP, “I thought I could do it without support.” Now, he is asking for help and wants to restart the medication.

The NP’s Response:

• Shared Decision-Making: The NP immediately validates his request and begins discussing the options for restarting buprenorphine. They have a collaborative conversation about the risks and benefits and the various approaches to initiating the medication. They jointly decide to use a high-dose initiation strategy (also known as macro-dosing), a newer protocol that can get patients stabilized more quickly.
• Co-located Services: The NP sends the buprenorphine prescription to the co-located pharmacy in the same building as the clinic. This eliminates the barrier of James having to travel to a different location, where he might face stigma or logistical challenges.
• Treating the Whole Person: The NP and James then discuss other supportive options to address the root drivers of his use—his depression and pain. They agree to submit referrals to a mental health counselor and a Cognitive Behavioral Therapy (CBT) group focused on chronic pain management. Crucially, both of these services are also offered on-site within the same clinic.
• The Warm Handoff: The visit doesn’t end with a paper referral. The NP walks James down the hall and personally introduces him to the mental health counselor he will be meeting. This “warm handoff” is an incredibly powerful intervention. It demystifies the process, lowers anxiety, and dramatically increases the likelihood that the patient will follow through with the referral.

As we can see, this model of co-located services and warm handoffs creates a seamless and supportive experience. James is more likely to engage in these multiple services because he feels that everyone involved in his care is working together as a team.

After the Visit:

By the time James leaves the clinic that day, he has a concrete plan in place:

• He has his buprenorphine prescription in hand and clear instructions on how to start it.
• He has a planned pharmacy check-in for the next day and a telehealth follow-up appointment with his NP.
• He already has appointments scheduled for both the mental health counselor and the chronic pain group.

Over the coming weeks, James successfully transitions back onto buprenorphine. For patients undergoing a high-dose initiation, it’s recommended to have very frequent, short-interval follow-ups. James can have these check-ins by telephone with both his NP and the pharmacist, allowing them to address any questions or concerns in real time.

During a follow-up visit with his NP, James reports that getting to the point where he was in moderate to severe withdrawal—which is necessary before starting a high dose of buprenorphine to avoid precipitated withdrawal—was very challenging. But he says that once he was able to start the medication, he felt much, much better. He and the NP work together to increase his dose slightly to optimize its effectiveness. They also review the plan for his ongoing care, which will involve regular check-ins with the clinic’s nurse care manager. He is also introduced by phone to a peer support specialist, who can provide an extra layer of support and encouragement as he moves forward in his recovery.

At the end of the call, James feels hopeful. He feels that he has a team he can trust and turn to for help if he struggles in the future. He also feels a profound sense of pride that he has not used fentanyl in two days.

In the future, James has regular visits with the nurse care manager, who coordinates his buprenorphine refills and urine toxicology testing. He begins to dig into the roots of his substance use by actively participating in treatment for his depression and learning new CBT skills for managing his chronic pain. He is no longer just treating the symptom (opioid use); he is healing the whole person.

I want to pause and acknowledge that this case represents an optimal situation. To many of you, especially those working in under-resourced or rural settings, this may feel aspirational. The various services that James was able to access—the co-located pharmacy, the on-site mental health counselor, the nurse care manager, the peer specialist—may not be available in one place, or even at all, in the settings where you work.

But I believe this case is incredibly important to reflect on because it highlights the power of treating the whole person. This is something that we as nurse practitioners are especially trained and uniquely positioned to do.

Another important caveat is that for some patients, even this high level of integrated primary care may not provide sufficient support to help them disrupt their illicit substance use. For this reason, it is essential to know your local referral resources and be ready to refer patients to a higher level of care, such as a specialty SUD treatment facility, when needed.

Specialty SUD Treatment and Acute Care Settings

When a patient’s treatment needs cannot be fully met within a primary care setting, a variety of specialty SUD treatment options exist. These programs offer a more intensive level of care and structure. Examples include:

• Intensive Outpatient Treatment (IOP): As mentioned, these programs provide several hours of structured therapy and group sessions, multiple days per week.
• Residential or Inpatient Rehab: These programs provide a 24/7 therapeutic environment, removing the patient from high-risk environments and providing intensive clinical services.
• Office-Based Addiction Treatment (OBAT): This term often refers to specialty outpatient clinics that focus primarily on addiction medicine, often with a team of addiction specialists.
• Opioid Treatment Programs (OTPs): These are the federally regulated clinics where patients can receive methadone for the treatment of OUD. Many OTPs are also expanding to offer buprenorphine and other services.

It is critically important to note, especially given the limited access to specialty treatment in most areas, that participation in a behavioral program should not be a prerequisite for a patient to receive medical treatment for an SUD. While behavioral interventions like counseling and therapy are a mainstay of treatment and are highly beneficial, they should not be used as a gatekeeper for life-saving medications. A patient should be able to be started on buprenorphine or naltrexone for OUD without needing to take part in counseling simultaneously. The evidence is clear: these medications save lives on their own, and adding barriers to them is counterproductive and harmful.

The Teachable Moment: SUD Care in Acute Settings

Acute care settings, like hospitals and emergency departments, represent a profound opportunity for patients to initiate SUD care. A medical crisis—an overdose, a serious infection, a traumatic injury—often serves as a “teachable moment.” This is a point in time when an individual is forced to confront the consequences of their substance use, reevaluate their life and goals, and may be more willing to accept help and try treatment than at any other time.

For patients who have long avoided the healthcare system due to past experiences with stigma, a positive and compassionate engagement during a hospitalization can be transformative. It can begin to repair their trust in the medical system and open the door to ongoing care.

The gold standard for providing addiction care in the inpatient hospital setting is the inpatient addiction consult service. These services have been shown to dramatically improve patient outcomes, including reducing hospital readmissions and increasing the number of patients who not only start but also continue taking medications for Opioid Use Disorder after they are discharged.

A Deeper Look at Addiction Consult Services (ACS)

So, what exactly is an addiction consult service? An ACS is an inpatient, interdisciplinary team composed of experts in substance use disorder treatment. The exact composition of the team may vary by hospital, but it typically consists of:

• A Medical Provider: This could be an addiction medicine physician, a psychiatrist, or an advanced practice provider like an NP or a PA with specialized training in addiction.
• A Social Worker: This team member is skilled in psychosocial assessments, counseling, and discharge planning.
• Care Coordination Personnel: A dedicated person, often a nurse or case manager, who focuses on the complex logistics of linking patients to post-discharge care.
• A Peer Support Specialist: Often the heart of the team. A peer is an individual with their own lived experience of addiction and recovery. They can provide a unique form of empathy and emotional support, help the patient navigate the confusing and often intimidating hospital system, and serve as a powerful role model of hope.

An ACS offers comprehensive SUD care during the hospital stay and, critically, establishes post-discharge linkages to ensure a warm handoff to community-based treatment. The services they provide include:

• Initiating Medications: Starting patients on medications like buprenorphine or methadone while they are in the controlled environment of the hospital.
• Pain Management Expertise: Providing expert consultation on how to manage acute or chronic pain for patients with SUDs, a notoriously complex clinical challenge.
• Therapeutic Interventions: Offering motivational interviewing, brief counseling, and other therapeutic support to patients while they are hospitalized.

Beyond direct patient care, addiction consult services also drive system-wide change across the hospital system. They achieve this by:

• Improving Hospital Policies: Working with hospital administration to revise policies to be more patient-centered and evidence-based for patients with SUDs (e.g., policies around withdrawal management, naloxone distribution at discharge, etc.).
• Leading Quality Improvement Initiatives: Using data to identify gaps in care and implementing projects to improve the quality, safety, and effectiveness of SUD treatment within the hospital.
• Providing Provider Education: Giving lectures, grand rounds, and in-service trainings to staff across the institution—including physicians, nurses, pharmacists, and social workers—on best practices in addiction care. They work to dismantle stigma and build capacity for compassionate care on every unit of the hospital.

A Case Study in Acute Care: The Story of Lisa

Let’s examine how an interdisciplinary addiction consult service might engage a patient in the hospital.

Lisa is a 32-year-old woman who presents to the emergency department. She reports seven days of increasing swelling, redness, and warmth in her left lower leg. She openly tells the care team that she has been using both intravenous and inhaled fentanyl, as well as methamphetamines, daily. She needs immediate withdrawal management, stating that her last use was about six hours ago and she is already starting to feel sick.

As the team begins to talk with her, she says she is very worried about her dog, which she left in the care of a friend. She’s not sure how long her friend can keep the dog, and this is a major source of stress for her.

A review of her chart reveals that she has previously tested positive for active, untreated hepatitis C. When asked about it, she says, “Yeah, I think someone told me I had that a while back, but I haven’t gotten around to getting it treated.”

The ACS Team in Action:

Within the first 24 hours of Lisa’s hospital stay, the addiction consult service is paged.

1. The Medical Assessment: An ACS medical provider meets with Lisa and performs a thorough assessment. After taking a detailed history, the provider determines that Lisa meets the diagnostic criteria for severe Opioid Use Disorder and severe Stimulant Use Disorder. The provider immediately begins a collaborative discussion with Lisa about her options for managing her opioid withdrawal and treating her OUD. After a conversation about the risks and benefits of each medication, Lisa and the provider decide to start methadone for her immediate withdrawal management, with a plan to transition her to buprenorphine once she is more stable. The provider also discusses harm reduction strategies and the available options for treating her methamphetamine use.
2. The Social Worker’s Role: Next, the ACS social worker meets with Lisa. The social worker completes a comprehensive ASAM assessment to evaluate all six dimensions of her life and determine the appropriate level of care she will need upon discharge. With Lisa’s permission and a signed release of information, the social worker might also reach out to her family or friends to gather helpful collateral information and enlist their support. The social worker utilizes motivational interviewing techniques to help Lisa feel supported and to encourage her to stay in the hospital to complete her medical treatment. This is crucial, as hospital stays can be very distressing for patients with SUDs, and the temptation to leave against medical advice is often high. The social worker helps to prevent this by building rapport and addressing Lisa’s anxieties. They also discuss Lisa’s personal goals and begin the process of securing referrals for post-discharge treatment, such as a residential treatment program or an intensive outpatient program.
3. The Peer Specialist’s Support: An ACS peer specialist then meets with Lisa. The peer provides support through active listening and validates her concerns about her dog. This is not a small thing; for many patients, a pet is their primary source of emotional support, and worrying about their safety is a major barrier to engaging in care. The peer can provide Lisa with a cell phone and help her navigate the logistics of securing alternative care for her pet. This practical support can make all the difference in allowing Lisa to focus on her own health.

Two Days Later:

With the ACS team’s intensive engagement, Lisa’s situation has stabilized significantly.

• Her opioid withdrawal is now well-managed with a stable, titrated dose of methadone. The team and Lisa have decided to proceed with a plan to transition her to buprenorphine using a low-dose initiation strategy (also known as microdosing or the “Bernese method”), which allows for a smoother transition without needing to experience severe withdrawal.
• She has been officially diagnosed with left lower extremity cellulitis and has been started on IV antibiotics.
• Her active, untreated chronic hepatitis C has been confirmed, and a referral for outpatient treatment has been placed.
• She continues to voice significant cravings to use methamphetamines.

As Lisa continues her hospital stay, the ACS team continues to support her and help her prepare for discharge.

• For her cellulitis, the ACS team helps coordinate a connection to a primary care provider for follow-up who they know is experienced and comfortable caring for patients with SUDs.
• For her stimulant use disorder, they discuss treatment options, including contingency management, an evidence-based behavioral therapy where patients earn incentives for providing stimulant-negative urine samples. They might also discuss starting certain off-label medications that have shown some promise in reducing cravings for methamphetamines.
• For general education, the team provides crucial harm reduction counseling. They educate her about the increasing contamination of the drug supply, explaining that even if she thinks she is only using methamphetamines, it may be contaminated with fentanyl, putting her at high risk of an accidental opioid overdose. They emphasize the critical importance of carrying naloxone and avoiding using substances alone. They also provide education about the risk of transmitting infectious diseases like HIV and hepatitis C by sharing any paraphernalia used to prepare or use substances.

Challenges and Best Practices in Care Transitions

One of the most critical and often most difficult aspects of SUD care is the care transition. A care transition is any time a patient who is engaged in treatment needs to move between different settings or levels of care. This could mean transitioning from an inpatient hospital stay to an outpatient clinic, moving to a more intensive option like residential treatment, or stepping down to an intensive outpatient program.

These transitions are notoriously challenging and represent points of high vulnerability where people often “fall through the cracks.” There are many reasons for this, including:

• Care Silos: Different healthcare systems often operate in silos with poor communication, meaning medical records don’t transfer and the receiving provider has little information about the patient.
• Stigma: Patients with SUDs continue to face stigma when trying to access new levels of care, which can be discouraging.
• Lack of Staff and Community Providers: Community-based treatment programs often have limited slots, leading to long waitlists.
• Lack of Patient Resources: Patients may lack resources like transportation, a phone, or stable housing.
• Insurance Barriers: Navigating insurance authorizations and ensuring coverage can be a bureaucratic nightmare.

A scoping review that specifically looked at transitions from acute to community-based settings identified several best practices (Krawczyk, Picher, & Feder, 2017). Most importantly, we must leverage existing community partnerships and proactively establish clear lines of communication between different treatment agencies. We cannot wait until a crisis to build these bridges.

The Critical Importance of Continuity in SUD Treatment

Research consistently shows that fragmentation in the care journey is a major predictor of relapse and disengagement. One of the most powerful tools for improving patient retention is ensuring continuity of care with the same providers. Let me illustrate with a clinical scenario. A patient is admitted to the hospital with a condition complicated by an Opioid Use Disorder (OUD). During their stay, a provider initiates buprenorphine.

• The In-Hospital Connection: This initial interaction begins a therapeutic alliance. The provider builds rapport, educates the patient, and addresses their fears.
• The Post-Discharge Bridge: If that same provider is also available to see the patient for a follow-up at a “bridge clinic” after discharge, the likelihood of that patient continuing treatment increases dramatically. The patient is not starting over with a stranger; they are continuing a journey with a trusted guide. That established patient-provider relationship becomes a lifeline.

In my own APRN practice, I have found that providing “bridge prescriptions” at hospital discharge is indispensable. The gap between discharge and the first outpatient visit is a period of extreme vulnerability. Cravings and withdrawal can quickly return. Therefore, the standard of care should be to provide at least a two-week supply of their medication, such as buprenorphine, upon discharge. This simple act provides a crucial buffer, giving the patient time to connect with outpatient resources without the pressure of impending withdrawal. It’s a practical, compassionate measure that directly supports retention in care.

Co-Locating Services and the Power of Care Navigators

Another powerful strategy, supported by a growing body of evidence, is co-locating services. The principle is simple: make it as easy as possible for patients to access comprehensive care. Integrated care hubs where a patient can see their buprenorphine provider, attend a therapy session, and meet with a case manager all in one place dramatically reduce barriers. Furthermore, we must offer flexibility in care modality, such as telehealth, to honor patient preference and acknowledge real-world constraints.

Finally, the role of care navigators cannot be overstated. These individuals have specialized knowledge of community resources and act as guides and advocates for the patient. A care navigator can help a patient schedule appointments, understand insurance benefits, and connect them with transportation and support groups. They provide the “warm handoff” that is so crucial for building trust. Programs that fund and integrate care navigation are an essential investment in the human side of healthcare.

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Addressing the Unique Challenges of Justice-Involved Individuals

When we consider care transitions, we must focus on populations that face extraordinary barriers, such as justice-involved individuals transitioning from carceral settings—jails or prisons—back into the community. This period is fraught with peril.

We know from stark and tragic data that overdose is a leading cause of death following release from prison (Suen, Lalehparast, & Binswanger, 2020). The reasons are both physiological and systemic.

• Loss of Opioid Tolerance: One of the most significant physiological factors is the loss of opioid tolerance. An individual who was using a certain amount of opioids before incarceration may abstain while inside. Upon release, if they return to using the same amount, their body can no longer handle it. Their tolerance has diminished, and what was once a typical dose can now be a fatal one, especially with the illicit drug supply contaminated with fentanyl.
• Systemic Barriers to Care: These individuals also face a mountain of systemic obstacles. Incarceration often leads to a loss of health insurance. Upon release, a person may find themselves without coverage, making it nearly impossible to access medical care. The experience of incarceration itself can lead to poor education about health resources and a profound lack of self-worth, undermining a person’s motivation to seek help.

The Inconsistency of MOUD in Carceral Settings

Another critical challenge is the availability and implementation of Medications for Opioid Use Disorder (MOUD) within jail and prison systems. While providing MOUD (like buprenorphine or methadone) in these settings is a life-saving intervention (National Academies of Sciences, Engineering, and Medicine, 2019), its implementation is often inconsistent.

• Underdosing and Ineffective Treatment: In some facilities, patients may be given doses that are too low to treat their cravings or withdrawal adequately. This has a doubly negative effect. First, the patient continues to suffer. Second, it can negatively shape their attitude towards these medications. They may leave incarceration believing that “buprenorphine doesn’t work for me,” when in reality, they were never on a therapeutic dose.

To make these transitions safer, we need a concerted effort to bridge the gap between the carceral system and community-based care, ensuring that individuals are released with insurance in place, a scheduled appointment, and a supply of any necessary medications.

The High-Stakes World of Peripartum Substance Use

Another population at extremely high risk for negative outcomes, including fatal overdose, is peripartum individuals—those who are pregnant, have recently given birth, or are parenting young children. For these women, the journey of substance use is entangled with stigma and fear.

Pregnant women who use substances often face intense judgment. Their primary fear is that their substance use will be discovered and lead to legal repercussions and affect their child custody. This fear is so potent that it drives dangerous behavior: avoiding medical care. Studies have shown that the most common strategy women use to hide their drug use during pregnancy is to avoid prenatal care altogether (Roberts & Nuru-Jeter, 2010).

The Complex Issue of Reporting to Child Protective Services

This fear is not unfounded and is intertwined with reporting to Child Protective Services (CPS). As healthcare providers, we are mandated reporters. However, there is a great deal of confusion about what this means. It is a common misconception that any substance use by a pregnant woman must be reported as suspected maltreatment.

• Substance Use vs. Child Maltreatment: According to federal law, substance use alone does not establish child maltreatment. A parent can have an SUD without being abusive or neglectful.
• The CARA Law: The federal Comprehensive Addiction and Recovery Act (CARA) of 2016 requires states to have policies to ensure providers notify child welfare agencies when an infant is born “affected by” substances. The law intends to facilitate early identification and intervention, not necessarily to trigger an abuse investigation. This notification does not have to be a report of suspected abuse (Substance Abuse and Mental Health Services Administration, 2018).

However, the federal law gives states authority to determine their own policies, and many have taken legislative steps to criminalize this behavior specifically for pregnant women.

The Criminalization of Pregnancy and Its Devastating Effects

The consequences of this criminalization are not just unjust; they are actively harmful.

• Increased Risk of Overdose: Punitive policies, rather than encouraging women to seek help, do the exact opposite. They make treatment harder to access. When women fear being arrested or losing their children, they go into hiding, use substances alone, and are cut off from life-saving harm reduction services.
• Fear and Avoidance of Prenatal Care: The fear of babies being taken away directly leads pregnant women to avoid prenatal care, ironically harming the fetus the laws are intended to protect.

A compelling cross-sectional study published in 2022 found that women in states with more punitive 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. The conclusion is inescapable: fear of reporting directly and negatively affects care-seeking behavior. This fear also impacts SUD treatment engagement. Data show that fewer than one in four pregnant individuals with OUD receive treatment in any given month (Terplan, Longinaker, & Appel, 2015).

A Call for a More Compassionate Approach

Substance use during pregnancy is best addressed with treatment and support, not with stigma and criminalization. Reporting can have severe adverse consequences, including a complete disengagement from the health system. We must also consider the profound and lasting trauma of custody loss. Research has shown that mothers who have their parental rights terminated experience devastating consequences, including shorter intervals between pregnancies, suggesting a cycle of unresolved trauma.

As treatment providers, we must offer nonjudgmental, person-centered words to a woman who has overcome immense fear to see us; they should be: “Thank you for coming to see me today. I know it wasn’t easy to get here, and I appreciate you trusting me with your care.” We must have realistic discussions of the risks while honoring the patient’s goals. The postpartum period is another time of high vulnerability. We need to offer flexibility in follow-up, provide resources for transportation or childcare, and use warm handoffs to other providers. We should also proactively connect patients with needed social services.

Medications for Opioid Use Disorder (MOUD) in Pregnancy

For women with OUD who are pregnant, MOUD is a life-saving, evidence-based intervention. The two primary medications are buprenorphine and methadone. The most important point is that both buprenorphine and methadone are safe and recommended in pregnancy.

Weighing the Risks and Benefits

For both the mother and the fetus, the risk of untreated opioid use and repeated cycles of withdrawal is far greater than the risk of the medication’s effects. Untreated OUD in pregnancy is associated with poor fetal growth, placental abruption, preterm labor, and fetal death. MOUD stabilizes this system, allowing the mother to disengage from the chaotic cycle of illicit drug use and focus on her health.

Neonatal Opioid Withdrawal Syndrome (NOWS)

One of the most common concerns is Neonatal Opioid Withdrawal Syndrome (NOWS). It’s important to be transparent and explain that yes, there is a risk the baby may experience NOWS, a treatable condition where the newborn experiences withdrawal symptoms (Patrick, Barfield, & Poindexter, 2020). However, the benefits of the mother being on a stable dose of medication far outweigh these risks.

A crucial counseling point is that the risk and severity of NOWS are not directly correlated with the mother’s dose of buprenorphine or methadone. The best and safest medication dose is the one that adequately treats the patient’s withdrawal and cravings. Reducing a woman’s dose during pregnancy out of a misguided fear of NOWS can be dangerous, as it may lead to relapse.

Dose Adjustments During and After Pregnancy

Pregnancy causes significant physiological changes, and women often require higher doses of buprenorphine or methadone to maintain stability, particularly in the third trimester. After a woman gives birth, her metabolism begins to return to its pre-pregnancy state, likely between three to twelve weeks postpartum. This means a dose that was therapeutic during pregnancy may become too high, potentially leading to oversedation.

• Case-by-Case Reductions: Postpartum dose reductions should be made carefully and on a case-by-case basis.
• Close Monitoring: Postpartum women on MOUD must be monitored closely for signs of sedation and respiratory depression.

The evidence is unequivocal: MOUD during pregnancy is associated with positive outcomes for both the mother and the child, including a significantly decreased risk of overdose.

Case Study: Applying Best Practices for Post-Discharge Care

Let’s walk through a case. Liz is a 32-year-old woman who is one day postpartum. She has a history of OUD (fentanyl use) and was started on buprenorphine during pregnancy, reaching a dose of 32 mg daily in her third trimester.

Considerations for Post-Discharge Care Transitions:

1. Focus on the Mother-Baby Dyad: My first thought is for the well-being of the unit. The baby may be in the NICU for NOWS. Does Liz have stable housing? Transportation? Social support? These are clinical questions.
2. Offer Flexible Follow-Up Options: I would immediately develop a plan with flexible options like telehealth and connecting her with co-located services.
3. Patient Counseling on Dose Reduction: I would have a compassionate conversation with Liz about her dose, explaining that reductions may be necessary postpartum to avoid sedation.
4. Regular Check-ins and Gradual Tapering: The plan would involve regular check-ins by phone or telehealth to ask about cravings and sedation, with small, gradual dose reductions over the 3-to-12-week postpartum period.
5. Scaffolding Her Recovery with Social Supports: Recovery is about rebuilding a life. I would work to connect her with social work, peer support, mental health support, and practical resources like food banks and housing assistance. The availability of these resources varies, highlighting the importance of every clinician knowing the resources in their local area.

Navigating the Complexities of Adolescent Substance Use

The final special population I want to discuss is adolescents. The landscape of youth drug use is evolving, and our approach must evolve with it. The good news is that, overall, youth drug use is down. However, this is overshadowed by deeply concerning statistics.

• Mental Health Challenges: As of 2021, a staggering four out of five teens reported feeling overwhelmed. Mental health challenges are rampant, and for many, substance use becomes self-medication.
• Misuse of Prescription Drugs: Sixteen percent of young Americans have misused a prescription medicine.
• Lack of Awareness about Fentanyl: This is perhaps the most alarming: less than half (48%) of young Americans are aware that fentanyl is being used to create counterfeit pills. They may think they are taking a Xanax or Percocet but are actually ingesting a lethal dose of fentanyl.
• The Power of Education: On a more hopeful note, research shows that after reviewing targeted information, 65% of young Americans are less likely to consider misusing prescription drugs. Education is life-saving (Volkow & Blanco, 2020).

How Treating Adolescents Differs from Treating Adults

Treating adolescents requires a fundamentally different approach, rooted in neurobiology and psychology.

1. The Developing Brain: The adolescent reward system (limbic system) is fully developed, making them highly sensitive to the rewarding effects of substances. However, their planning center, the prefrontal cortex, is still developing until the mid-twenties. This mismatch means adolescents experience the “reward” but lack the mature brain architecture to consistently “put on the brakes.”
2. Different Motivations for Use: Motivations can include low self-esteem, the desire to fit in, or self-treating anxiety or depression.
3. High Prevalence of Co-occurring Issues: It is the rule that adolescents with SUDs also have co-occurring mental health issues. Polysubstance use is also common.
4. Different Use Patterns: Use may be experimental or episodic rather than daily and dependent.
5. Low Treatment Retention: In general, retention in SUD treatment is low among adolescents.
6. The Need for Parental Involvement (and Consent Laws): Depending on state laws, parental involvement may be required. The age at which an adolescent can consent to their own treatment varies by state. Providers must know their state laws.
7. Limited Medication Options: For OUD, FDA approvals are generally for older adolescents. Buprenorphine is considered first-line and is FDA-approved for age 16 and up. Naltrexone and methadone are approved for ages 18 and up.

Best Practices in Care Transitions for Adolescents

• Wraparound Care Options: Aim for wraparound care, a model that surrounds the adolescent and their family with a comprehensive, integrated team of services.
• Know Your Local Resources: SUD treatment options for adolescents can be limited. It is imperative to know your area’s resources.
• Address the Drivers of Use: Identify and address the underlying mental health needs.
• Involve Parents and Family (with Consent): While honoring an adolescent’s right to consent, encourage parental or family involvement whenever safe and appropriate.
• The Argument for MOUD in Younger Adolescents: Research on young adults (18-25) shows MOUD improves retention. By extension, offering MOUD to patients under 18 could save their lives. This requires a careful risk-benefit discussion.
• A Nuanced Approach to Prescribing Buprenorphine: I am transparent with adolescents that, for buprenorphine to prevent overdose, a dose of around 8 mg is often the minimum needed. For an adolescent with episodic use, this may be too high and cause oversedation. This requires a nuanced conversation to empower them to make an informed decision.
• Naloxone, Naloxone, Naloxone: Naloxone distribution and education are extremely important. We must empower youth, their families, and school personnel to recognize and reverse an overdose.
• Harm Reduction is Life-Saving: We must have open, nonjudgmental conversations about prevention, the dangers of fentanyl, and never using alone.

New and Evolving Topics in SUD Care

The field of addiction medicine is constantly evolving. Two important topics are at the forefront of this evolution.

The Role of Genetics in SUDs

Research has identified genetics as one of multiple factors that predispose individuals to developing SUDs. Genetics is thought to play a moderate role, interacting with environmental and social risk factors.

• Gene Identification and Genetic Testing: Studies have isolated specific genes, and some companies now advertise direct-to-consumer genetic tests.
• Challenges and Ethical Concerns: Significant challenges prevent the widespread use of these tests.

• • Ethical Concerns: Major concerns include bias and the potential for stigma.
  • Lack of Evidence: No large-scale clinical trials have evaluated the efficacy of these tests (Hser, Nosyk, & Saxon, 2017).
  • Predictive Limitations: The tests cannot account for the complex interplay of non-genetic factors.
  • Cost and Accessibility: These tests can be costly and are not widely available.
  • Privacy Concerns: There are legitimate concerns about data privacy.

While genetic research will deepen our understanding, we are not yet at a point where genetic testing is a clinically useful or ethically sound tool.

GLP-1 Receptor Agonists: A New Frontier?

A hot topic is the potential use of GLP-1 receptor agonists to treat SUDs. This class includes drugs like semaglutide (Ozempic), liraglutide (Victoza), and dulaglutide (Trulicity), which are used for type 2 diabetes and weight management. GLP-1 receptors are also found in the brain’s reward system, and the theory is that these medications might reduce the rewarding effects of substances.

The evidence is early but intriguing:

• Alcohol Use Disorder: A recent randomized controlled trial showed that adults with alcohol use disorder receiving a GLP-1 receptor agonist consumed significantly less alcohol than those on a placebo.
• Other SUDs: Recent studies analyzing large databases found that patients taking semaglutide for diabetes had a significantly lower risk of having medical encounters for tobacco, cannabis, and opioid use disorder compared to patients on other anti-diabetes medications (Wang, Volkow, & Berger, 2023).

This is correlational data, not proof of cause and effect, but it is a strong signal. We are likely to see more research on these medications for SUDs in the coming years.

In Closing

Navigating the world of substance use disorders is a complex and deeply human endeavor. From ensuring seamless care transitions to providing compassionate, evidence-based care to special populations, our work as clinicians requires a commitment to lifelong learning and a holistic, patient-centered perspective.

Here at Injury Medical Clinic PA, our integrative model, which brings together the expertise of chiropractic, functional medicine, and the vital medical oversight of Dr. Maria Cardenas, is built on this very foundation. We believe that by addressing the structural, biochemical, and psychosocial aspects of health, we can offer our patients a more comprehensive and effective path to recovery and wellness.

Thank you for joining me on this educational journey. I hope that these insights will be valuable in your own practice and in your efforts to support those affected by substance use disorders.

Finding SUD Treatment Resources

I want to highlight a couple of excellent resources that can help you and your patients locate SUD treatment in your area.

• The first is the SAMHSA Behavioral Health Treatment Services Locator. This website allows you to search for treatment agencies by location and filter by the type of care provided.
• The second is a resource list of buprenorphine prescribers. Now that the X-waiver has been eliminated, it should theoretically be easier to find someone who prescribes buprenorphine. However, this list can still be a valuable tool for connecting you with addiction experts in your area.

References

1. American Society of Addiction Medicine. (n.d.). The ASAM criteria.
2. Hser, Y. I., Nosyk, B., & Saxon, A. J. (2017). Treatment of substance use disorders: The Dodo bird verdict is out. JAMA Psychiatry, 74(4), 317–318.
3. Krawczyk, N., Picher, C. E., & Feder, K. A. (2017). The overdose crisis in the USA: The need for a focus on care transitions. Addiction, 112(11), 1909–1911.
4. National Academies of Sciences, Engineering, and Medicine. (2019). Medications for opioid use disorder save lives. The National Academies Press.
5. Patrick, S. W., Barfield, W. D., & Poindexter, B. B. (2020). Neonatal opioid withdrawal syndrome. Pediatrics, 146(5), e20200290.
6. Roberts, S. C. M., & Nuru-Jeter, A. (2010). Women’s perspectives on screening for alcohol and drug use in prenatal care. Women’s Studies International Forum, 33(4), 347–356.
7. Substance Abuse and Mental Health Services Administration. (2018). Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants.
8. Substance Abuse and Mental Health Services Administration. (n.d.). Buprenorphine practitioner locator.
9. Substance Abuse and Mental Health Services Administration. (n.d.). Find treatment for substance abuse/addiction.
10. Substance Abuse and Mental Health Services Administration. (n.d.). Provider Clinical Support System (PCSS).
11. Suen, L. W., Lalehparast, A., & Binswanger, I. A. (2020). Overdose prevention and response in carceral settings: A call to action. JAMA Internal Medicine, 180(7), 925–926.
12. Terplan, M., Longinaker, N., & Appel, L. (2015). Women’s experiences with prenatal care and child protective services in the context of substance use and pregnancy. Journal of Addiction Medicine, 9(5), 382–387.
13. Volkow, N. D., & Blanco, C. (2020). The changing landscape of adolescent substance use in the United States. New England Journal of Medicine, 382(12), 1089–1091.
14. Wang, W., Volkow, N. D., & Berger, N. A. (2023). Associations of semaglutide with incidence and recurrence of alcohol use disorder in a real-world population. Nature Communications, 14(1), 8196.

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