A Clinical Approach to Integrative Care Essentials for OUD Treatment

Find effective strategies and insights on clinical approaches to integrative care to support recovery from opioid use disorder.

Abstract

Opioid Use Disorder (OUD) represents a significant public health challenge, rooted in a complex history of pain management, substance development, and evolving legislation. This educational post, from my perspective as Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, delves into the multifaceted nature of OUD. We will embark on a journey through the history of opioids, from their natural origins to the potent synthetic versions driving the current crisis. By examining the three distinct waves of the opioid epidemic, we will gain a clearer understanding of how we arrived at this critical juncture. A central theme of our discussion will be deconstructing pervasive myths and the corrosive impact of stigma, which remains a formidable barrier to effective care. I will present the latest findings from leading researchers, grounded in evidence-based methods, to outline the most effective treatment recommendations. This includes a detailed look at the pharmacology of medications for OUD (MOUD), such as methadone, buprenorphine, and naltrexone, and the psychological framework of motivational interviewing. We will also explore the vital role of harm reduction strategies in saving lives and promoting health. At our clinic, we bring this comprehensive approach to life through a unique integrative model. This post details how my work in chiropractic and functional medicine is seamlessly integrated with the medical oversight of our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD, to offer a holistic, patient-centered pathway to recovery.

Our Integrative Care Model: A Collaborative Approach to Healing

Hello, I’m Dr. Alex Jimenez. With a diverse background spanning chiropractic (DC), advanced practice nursing (APRN, FNP-BC), and functional medicine (CFMP, IFMCP, ATN, CCST), my career has focused on understanding the intricate connections between the body’s structure, function, and overall well-being. At Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic) here in El Paso, Texas, we have cultivated a unique environment where different medical disciplines converge to provide comprehensive, patient-centered care.

A cornerstone of our practice is our collaboration with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is Board Certified in Internal Medicine (NPI #1164426749, Texas MD License #J2933) and brings over 40 years of invaluable experience as an internist. She serves as our Medical Director and Collaborative Physician, providing the essential medical oversight that allows us to operate as a truly multidisciplinary clinic. This model is common and highly effective in integrative and injury care settings, where a medical doctor’s expertise enhances and guides the therapeutic strategies of other practitioners.

Our team integrates a wide array of services to address the whole person, not just a single symptom. This includes:

• Medical Oversight (Dr. Cardenas): Cardenas provides medical direction, oversees complex cases, manages prescription medications when necessary, and ensures our protocols adhere to the highest standards of medical care. Her internal medicine background is crucial for managing the comorbidities often associated with chronic pain and substance use disorders.
• Integrative Chiropractic Care (Dr. Jimenez): As a chiropractor, I focus on the biomechanical and neurological aspects of health. For patients with OUD, many of whom initially started using opioids for chronic pain, chiropractic care is a powerful, non-pharmacological tool. By addressing the root musculoskeletal causes of pain through spinal adjustments, soft tissue therapies, and corrective exercises, we can often reduce or eliminate the very pain that led to opioid use in the first place. This is a fundamental part of a long-term recovery strategy.
• Functional Medicine: We look beyond the symptoms to understand the “why.” Using advanced diagnostics, we investigate underlying issues like gut health, nutritional deficiencies, hormonal imbalances, and inflammation, which can all contribute to chronic pain and affect mental health and recovery from OUD.
• Rehabilitation & Personal Injury Care: We provide targeted physical rehabilitation to restore function, improve strength, and help patients regain their quality of life after an injury, which can be a critical factor in preventing the transition from acute to chronic pain.

By combining these disciplines, we create a synergistic effect. A patient struggling with OUD that began with a back injury might receive chiropractic adjustments to alleviate the structural source of their pain, functional medicine interventions to reduce systemic inflammation, medical management and counseling for the OUD itself under Dr. Cardenas’s direction, and rehabilitation to build resilience against future injury. This holistic approach empowers patients, addresses the multifaceted nature of their condition, and builds a sustainable foundation for lasting health and recovery.

A Journey Through Time: The History of Opioids

To truly grasp the complexities of the current opioid crisis, we must first travel back in time and understand the origins and evolution of these powerful substances. The story of opioids is not a recent one; it is a long and winding road that stretches back millennia, marked by discovery, medical application, and, ultimately, widespread societal impact.

From Poppy Plants to Potent Synthetics

The narrative begins with nature itself. When we discuss opioids, it’s crucial to differentiate between the various types, as their origins dictate their properties and potency.

• Natural Opioids (Opiates): These are alkaloids derived directly from the resin of the opium poppy plant, Papaver somniferum. The primary substances in this category are morphine and codeine. They are the original template from which all other opioids were developed.
• Semi-Synthetic Opioids: These are created in laboratories by chemically modifying natural opiates. Scientists synthesize these from the naturally occurring opium products to enhance certain effects, such as pain relief. This class includes some of the most well-known substances, such as heroin (synthesized from morphine), oxycodone, and hydrocodone.
• Synthetic Opioids: These are entirely artificial in a laboratory, designed to mimic the effects of natural opiates by interacting with the same receptors in the brain. This category includes therapeutic medications like methadone and the notoriously potent fentanyl.

A Chronological Timeline of Opioid Development

The timeline of opioid discovery and use is not to scale. Still, it places key moments in chronological order, revealing a pattern of increasing potency and accessibility over time.

• 3400 BC: Our story begins in Mesopotamia, where the opium poppy was first cultivated. Early civilizations recognized its profound effects, often using it in religious ceremonies and for medicinal purposes.
• 1400s AD: The Greeks and Romans began to more formally document the use of opium as a potent pain reliever. Its ability to dull suffering was unparalleled at the time.
• 1500s AD: The therapeutic applications expanded. Paracelsus, a Swiss physician, created a tincture of opium called laudanum, which became a popular remedy for a wide range of ailments, including diarrhea.
• 1803: A pivotal moment occurs when a German pharmacist, Friedrich Sertürner, successfully isolates the primary active alkaloid from opium. He names it morphine, after Morpheus, the Greek god of dreams. This discovery allows for standardized dosing and marks the beginning of modern opioid pharmacology.
• 1832: French chemist Pierre-Jean Robiquet isolates another alkaloid from opium, codeine, which proves to be an effective cough suppressant.
• 1874: In a London hospital, chemist C.R. Alder Wright synthesizes heroin (diacetylmorphine) from morphine. Initially, it was marketed by the Bayer Company as a non-addictive alternative to morphine and a cough suppressant. The tragic irony of this initial marketing is now painfully clear.
• 1939: During World War II, German scientists searching for a synthetic painkiller that could be produced with readily available precursors synthesized methadone.
• 1959: Paul Janssen of Janssen Pharmaceutica develops fentanyl, a synthetic opioid estimated to be 50 to 100 times more potent than morphine. Its primary use was for managing severe pain during and after surgery.
• 1966: Scientists at a British firm discovered buprenorphine, a unique compound that would later become a cornerstone of OUD treatment due to its distinct pharmacological properties.

This historical overview shows that while the roots of opioid use are ancient, the majority of the substances that define the modern crisis were developed or discovered within the last 200 years, with a significant acceleration in the 20th century.

Understanding Opioid Potency: Morphine Milligram Equivalents (MME)

When we prescribe or discuss different opioid medications, simply comparing milligram to milligram is not only inaccurate but also dangerous. The concept of Morphine Milligram Equivalents (MME) is a crucial tool that allows healthcare providers to standardize and compare the relative potencies of different opioids. The MME calculates a dose’s equivalent strength to morphine, which serves as the benchmark.

Here is a list of common opioids, ordered by increasing potency relative to morphine. Understanding this hierarchy is essential for safe prescribing and for appreciating the risks associated with different substances.

• Tramadol: This is often considered a “weaker” opioid, but it still carries risks. Its potency is such that 1 milligram of morphine is equivalent to 10 milligrams of tramadol (an MME conversion factor of 0.1).
• Codeine: Slightly more potent than tramadol, with a conversion factor of 15.
• Hydrocodone: This is a commonly prescribed opioid for moderate pain (e.g., in products like Vicodin or Norco). It has a 1-to-1 equivalence with morphine.
• Oxycodone: Found in medications like Percocet and OxyContin, oxycodone is more potent than morphine, with a conversion factor of 5. This means 10 mg of oxycodone is equivalent to 15 mg of morphine.
• Hydromorphone (Dilaudid): This is a significantly more potent opioid, typically used for severe pain in hospital settings. Its conversion factor is 0.
• Fentanyl (Transdermal Patch): Fentanyl’s potency is in a different league altogether. It is so potent that it is measured in micrograms (mcg), not milligrams. Its MME conversion factor is 4 micrograms per hour for a transdermal patch, which is equivalent to 1 mg of oral morphine per day, but this conversion can be complex. The key takeaway is its extreme potency, which is why illicitly manufactured fentanyl has been so devastating.

From my clinical observations, the transition from a prescribed, lower-potency opioid like hydrocodone to a higher-potency one, whether prescribed or illicit, is a critical point where risk escalates dramatically. A patient accustomed to a certain dose of oxycodone may not realize that a similar-sized amount of fentanyl could be lethal. This is a vital educational point for every patient.

The Three Waves of the Opioid Crisis in the United States

The current opioid crisis did not emerge overnight. The U.S. Centers for Disease Control and Prevention (CDC) has characterized its progression in three distinct waves, each defined by the primary type of opioid driving overdose deaths.

First Wave (1999–2010): The Rise of Prescription Opioids

The crisis began in the late 1990s, fueled by a confluence of factors. There was a cultural shift in medicine to treat pain more aggressively, with pain being promoted as the “fifth vital sign.” This was coupled with the aggressive marketing of new opioid formulations, like OxyContin, which were claimed to be less addictive. The result was a dramatic increase in opioid prescribing.

• Between 1999 and 2010, prescription opioid sales quadrupled in the United States.
• Concurrently, opioid-involved overdose deaths doubled, rising from 2.9 to 6.8 deaths per 100,000 people.
• This wave laid the groundwork for the crisis by creating a large population of individuals exposed to and, in many cases, dependent on opioids.

Second Wave (2010–2013): The Shift to Heroin

As awareness of prescription opioid misuse grew, regulations tightened, and it became more difficult and expensive to obtain these medications illicitly. Many individuals who had developed a dependence on prescription opioids turned to a cheaper and more accessible alternative: heroin.

• From 2010 to 2013, heroin overdose deaths surged, increasing from 1.0 to 9 per 100,000 people.
• During this period, heroin-related deaths surpassed those from prescription opioids for the first time.
• This transition marked a shift from a problem primarily involving the healthcare system to one deeply enmeshed with the illicit drug market.

Third Wave (2013–Present): The Devastation of Synthetic Opioids

The third and most lethal wave began around 2013 with the infiltration of the illicit drug supply by potent synthetic opioids, most notably illicitly manufactured fentanyl. Fentanyl is not only incredibly potent but also cheap to produce, making it a profitable adulterant for drug traffickers. It began to be mixed into heroin, cocaine, methamphetamine, and pressed into counterfeit pills made to look like legitimate prescription opioids (like Xanax or oxycodone).

• Since 2013, death rates from synthetic opioids have increased by over 1,000%, skyrocketing from 1.0 to 11.4 deaths per 100,000 people in just five years.
• A deeply concerning recent trend within this wave is the emergence of xylazine, a non-opioid animal tranquilizer, being mixed with fentanyl. This combination, known as “tranq,” increases the risk of overdose and can cause severe, necrotic skin wounds. By 2017, xylazine was found in up to 10% of fentanyl-related overdoses in some areas.

In 2017, recognizing the catastrophic scale of the problem, the U.S. Department of Health and Human Services officially declared the opioid crisis a Public Health Emergency.

The CDC graph below visually demonstrates the staggering impact of these three waves. The teal line represents the first wave of commonly prescribed opioids, showing a steady rise and then a leveling off. The blue line shows the second wave’s rise in heroin deaths starting in 2010. But it is the purple line, representing the third wave of synthetic opioids, that is most striking. It remains relatively flat until 2013 and then skyrockets exponentially, dwarfing the death tolls of the previous two waves. The sheer verticality of this line is a stark illustration of the lethality of fentanyl.

The Current Landscape of Opioid Misuse

Data from the 2021 SAMHSA National Survey on Drug Use and Health provides a snapshot of the current situation. Among people aged 12 or older in the United States:

• 9.2 million people misused opioids in the past year.
• This can be broken down further:

• • Misuse of Prescription Pain Relievers: This remains the larger issue by volume, with approximately 8.1 million people exclusively misusing pain medication.
  • Heroin Use: Approximately 0.5 million people reported using only heroin.
  • Overlap: A significant group of about 0.5 million people reported misusing both prescription pain relievers and heroin.
  • In total, about 1 million people reported using heroin.

These numbers underscore the continued importance of responsible prescribing practices for pain relievers, as this remains a primary pathway into OUD for millions of Americans.

Key Legislation and Milestones in Opioid Treatment

The legal and regulatory landscape surrounding opioids has profoundly shaped both the problem and its potential solutions. Understanding these key legislative acts provides context for why treatment is structured the way it is today.

• Harrison Narcotics Tax Act of 1914: This was one of the first federal laws to regulate and tax the production, importation, and distribution of opiates and cocaine. Crucially, it criminalized the non-medical use of opiates, framing addiction more as a legal problem than a medical one and driving it underground.
• Controlled Substances Act (CSA) of 1970: This act created the drug scheduling system (Schedules I-V) that classifies substances based on their medical use and potential for abuse. It also established the Drug Enforcement Administration (DEA) to regulate these controlled substances.
• Narcotic Addiction Treatment Act of 1974: This law specifically regulated the treatment of opioid addiction. It mandated that methadone could only be dispensed through highly regulated, federally certified programs, known as opioid treatment programs (OTPs) or “methadone clinics.” This created a siloed system, separating OUD treatment from mainstream medical care.
• Drug Addiction Treatment Act of 2000 (DATA 2000): This was a landmark piece of legislation. It created the “buprenorphine waiver” (often called the “X-waiver”), which, for the first time, allowed qualified physicians to prescribe buprenorphine—a Schedule III opioid—for the treatment of OUD in an office-based setting. This was a monumental step toward integrating addiction treatment into general medicine.
• Comprehensive Addiction and Recovery Act (CARA) of 2016: This act expanded access to treatment by allowing Nurse Practitioners (NPs) and Physician Assistants (PAs) also to obtain a waiver and prescribe buprenorphine, significantly increasing the number of potential providers.
• SUPPORT for Patients and Communities Act of 2018: This act further expanded access to care, particularly by addressing reimbursement issues within Medicare and Medicaid for OUD treatment.
• Mainstreaming Addiction Treatment (MAT) Act of 2023: This legislation marked another revolutionary change. It eliminated the buprenorphine waiver (X-waiver) requirement. Now, any prescriber with a standard DEA license who is permitted to prescribe Schedule III medications under their state license can prescribe buprenorphine for OUD. This has been a game-changer in “mainstreaming” addiction care and reducing barriers for both patients and providers.

Enhancing Health Together: Embracing Multidisciplinary Evaluation and Treatment- Video

The Rationale for Treatment: A Disease That Demands a Medical Response

Opioid Use Disorder is not a moral failing; it is a chronic, relapsing brain disease. The statistics paint a sobering picture of an undertreated epidemic.

• Of the estimated 9 million adults in the United States who need treatment for OUD, only a little over 2 million (about 22%) actually receive medications for opioid use disorder (MOUD).
• In 2022, there were nearly 82,000 opioid overdose deaths.
• The economic impact is staggering, costing the nation over $193 billion annually in healthcare costs, lost productivity, and criminal justice expenses.

These numbers make it unequivocally clear that treating OUD is not just a compassionate choice; it is a medical, social, and economic necessity.

Deconstructing the Myths and Stigma Surrounding OUD Treatment

One of the greatest barriers to effective treatment is the persistent stigma that surrounds OUD and the medications used to treat it. This stigma is often rooted in deeply ingrained myths. The best way to dismantle these myths is to reframe them in the context of other chronic medical conditions.

Myth 1: “Medications for OUD (MOUD) just replace one addiction with another.”

Fact: This is perhaps the most common and damaging misconception. Let’s apply this logic to another chronic disease: diabetes. We would never say that giving a patient insulin is “replacing a sugar addiction with an insulin addiction.” We understand that insulin is a life-saving medication that corrects a physiological deficit. Similarly, medications like buprenorphine and methadone work by stabilizing the brain’s neurochemistry, which the disease of addiction has hijacked. They normalize brain function, reduce cravings, and prevent withdrawal, allowing a person to focus on recovery, hold a job, and rebuild their life. It is treatment, not a replacement.

Myth 2: “Recovery without medication is superior to recovery with medication.”

Fact: This myth creates a false hierarchy of recovery. Let’s consider a patient with hypertension. We might first recommend diet and exercise. If their blood pressure comes down, that’s a successful outcome. If another patient tries diet and exercise but their blood pressure remains dangerously high, we add medication. We would never think that the second patient’s treatment plan is “inferior.” They are simply two different patients with different physiological needs requiring different treatment plans. The goal is a healthy outcome—a stabilized patient. The same is true for OUD. For many, medication is an essential component of a successful treatment plan.

Myth 3: “MOUD is not effective.”

Fact: The evidence is overwhelmingly to the contrary. Extensive research has demonstrated that MOUD is the gold standard of care. When individuals with OUD are treated with medications like buprenorphine or methadone, their risk of fatal overdose is dramatically reduced. Studies show up to a 60% reduction in all-cause mortality among patients receiving MOUD compared to those who are not.

Myth 4: “MOUD is a crutch for weak people who can’t stop on their own.”

Fact: This statement completely misunderstands the neurobiology of addiction. OUD is a chronic disorder that profoundly alters brain circuits involved in reward, stress, and self-control. It hijacks the brain’s decision-making capacity. The intense cravings and withdrawal symptoms are not a matter of willpower; they are powerful physiological and psychological compulsions. Just as we would medically treat the pathophysiology of any other chronic organ disease, we must medically treat the pathophysiology of this brain disease.

What is a Substance Use Disorder?

The language we use to discuss these conditions has evolved. We have moved away from terms like “abuse,” “dependence,” and “addiction” in a clinical context. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), now classifies these conditions as Substance Use Disorders (SUDs).

• SUDs are defined as chronic, relapsing medical conditions that occur within the brain.
• They are diagnosed using a specific set of 11 criteria and categorized by severity (mild, moderate, or severe) based on how many criteria a person meets.
• The good news is that there are effective, evidence-based treatments

The DSM-5 Criteria for Opioid Use Disorder

To be diagnosed with OUD, a person must exhibit at least two of the following 11 criteria within 12 months. As we review these, notice how many relate to behavioral changes and life impact rather than a specific quantity of substance used. This highlights that OUD is about the loss of control and the negative consequences of use.

1. Using in larger amounts or for a longer period than intended.
2. A persistent desire or unsuccessful efforts to cut down or control use. (This is the loss of control.)
3. Spending a great deal of time obtaining, using, or recovering from the effects of the substance. (The substance becomes the central organizing principle of life.)
4. Craving, or a strong desire or urge to use.
5. Recurrent use failing to fulfill major role obligations at work, school, or home.
6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
7. Giving up or reducing important social, occupational, or recreational activities because of use.
8. Recurrent use in situations in which it is physically hazardous (e.g., driving while impaired, using non-sterile needles).
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. (The reward system overrides the brain’s self-preservation system.)
10. Tolerance: Defined by either needing markedly increased amounts of the substance to achieve the desired effect or a markedly diminished effect with continued use of the same amount.
11. Withdrawal: Manifested by either the characteristic withdrawal syndrome for the substance or using the substance (or a closely related one) to relieve or avoid withdrawal symptoms.

It is important to note that meeting only the criteria for tolerance and withdrawal (10 and 11) does not constitute an OUD diagnosis. This is because a patient taking opioids as prescribed for chronic pain can develop physiological tolerance and withdrawal without having the compulsive, life-disrupting behaviors that define the disorder. They must also meet at least one of the first nine criteria.

The Pervasive Impact of Stigma on Care

Stigma is a powerful, destructive force that directly affects patient outcomes. It manifests at every level of society and creates formidable barriers to seeking and receiving care.

Public Stigma

Public stigma involves the negative attitudes and beliefs held by the general population.

• Not recognizing SUD as a chronic condition: This leads to the belief that it is a moral failing, which in turn fuels judgment and blame.
• Association with crime: People with OUD are often unfairly stereotyped as dangerous or criminal.
• Opposition to treatment access: Stigmatizing beliefs lead to “Not In My Backyard” (NIMBY) sentiment, where communities oppose the establishment of treatment facilities or harm reduction services.
• Some studies suggest that this stigma tends to increase with age.

Structural Stigma

Structural stigma is woven into the very fabric of our institutions, policies, and laws.

• Public Policy: The declaration of the “War on Drugs” in 1971 framed substance use as a criminal justice issue, not a public health one. This led to mass incarceration, disproportionately affecting racial and ethnic minorities, with very low levels of SUD treatment available within the criminal justice system.
• The Buprenorphine Waiver: The history of the X-waiver itself is an example of structural stigma. We required providers to undergo extra training and special licensing to prescribe a medication to treat OUD. At the same time, no such barriers existed for prescribing the very opioids that often caused the disorder.
• Lack of Funding and Organizational Policies: Inadequate funding for treatment and harm reduction services is a form of structural stigma. Additionally, stigmatizing policies like mandatory drug testing for employment or housing can penalize individuals in recovery and create barriers to stability.

Individual Stigma and Provider Bias

Individual stigma includes the prejudice and discrimination directed at people with OUD.

• Stereotypes: Believing that individuals with OUD are “dangerous” or “unpredictable.”
• Prejudice: Feelings of anger, fear, resentment, and moral outrage toward people with OUD.
• Discrimination: This can manifest as coercive treatment (“You must stop using completely, or I won’t treat your other conditions”) or social restrictions.
• Internalized Shame: Individuals with OUD often internalize these negative messages, leading to feelings of worthlessness and hopelessness. Some may also tell them in the recovery community that they are not “truly sober” if they are taking MOUD.

This stigma also presents as provider bias. Studies have shown that some healthcare providers hold negative attitudes toward this patient population, are worried about legal implications, or believe that SUD is a moral failing. The direct consequence is a reduced likelihood that providers will prescribe life-saving MOUD.

The Power of Language: Using Person-First Language to Reduce Stigma

One of the most powerful tools we have to combat stigma is our language. Person-first language reorients our thinking to see the person, not the disease. It is a conscious choice to use words that are objective, medically accurate, and free of judgment.

• Instead of: “addict” or “junkie” → Use: “person with a substance use disorder” or “person in recovery.”
• Instead of: “user” or “abuser” → Use: “person who uses drugs” (PWUD) or “person who injects drugs” (PWID).
• Instead of: “a baby born addicted” → Use: “a baby born with neonatal opioid withdrawal syndrome (NOWS).” A baby cannot have the compulsive behaviors that define addiction; they can, however, experience physiological withdrawal.
• Instead of: a “clean” or “dirty” urine test → Use: “negative for substance X” or “positive for substance Y.” If a patient’s A1c were high, we wouldn’t call their blood “dirty”; we would state the objective lab result. The same standard should apply here.
• Instead of: “medication-assisted treatment (MAT)” → Use: “medications for opioid use disorder (MOUD).” This subtle but important shift emphasizes that medication is not merely “assisting” treatment—medication is a primary, evidence-based treatment.
• Instead of: “abuse” → Use: “misuse” or “use.” The word “abuse” carries heavy connotations of violence and judgment. “Misuse” or “use” are more neutral and medically accurate terms.

Case Study: Putting Person-First Language into Practice

Let’s review a sample case study, first as it might be written with stigmatizing language, and then rewritten using a person-first approach.

• Original (Stigmatizing) Version:
  • Substance Use History: Patient reports abusing heroin IV from age 20 to 30. Last use of heroin was one month ago after seven years clean.
  • Treatment History: Entered recovery after an overdose. Started medication-assisted treatment.
  • Protective Factors: Regularly involved with the addict community.
  • Family History: She has a female child, nine years old, born addicted to heroin, who is healthy now.

Now, let’s see how different it reads when we apply person-first principles.

• Revised (Person-First) Version:
  • Substance Use History: The patient reports misusing heroin IV from ages 20 to 30. Last use of heroin was one month ago after seven years of no use.
  • Treatment History: She entered recovery after an overdose and started medications for opioid use disorder (MOUD).
  • Protective Factors: She is regularly involved with the recovery community.
  • Family History: She has a female child, nine years old, who was born with neonatal opioid withdrawal and is healthy now.

The second version is more respectful, medically accurate, and less judgmental. It frames the patient’s history as a medical journey rather than a series of moral failings.

Evidence-Based Treatments: A Toolkit for Recovery

Effective treatment for OUD is multifaceted, combining psychosocial support with pharmacological intervention.

Motivational Interviewing: Partnering with the Patient for Change

Motivational Interviewing (MI) is a collaborative, goal-oriented communication style focused on the language of change. It is designed to strengthen a person’s own motivation for and commitment to a specific goal by eliciting and exploring their own reasons for change in an atmosphere of acceptance and compassion. It is not about confronting or persuading; it is about partnering.

The Spirit of MI

The core philosophy of MI is built on four pillars:

• Partnership: You are not the expert on the patient’s life; they are. You collaborate with them, supporting them rather than trying to persuade them.
• Evocation: The motivation for change already lies within the patient. Your job is to evoke it, to draw it out by focusing on their own perceptions, goals, and values.
• Acceptance: This involves recognizing the patient’s absolute worth, affirming their strengths, supporting their autonomy, and conveying accurate empathy.
• Compassion: The guiding principle is to act in the patient’s best interest with a non-judgmental, non-blaming, and non-shaming attitude.

The Process of MI

MI generally follows four overlapping processes:

1. Engaging: Building a strong therapeutic alliance and rapport.
2. Focusing: Collaboratively identifying a specific goal or target for change. What does the patient want to work on?
3. Evoking: Eliciting the patient’s own motivations for change. This is the heart of MI.
4. Planning: Developing a specific, concrete plan for change, exploring options, and building support.

The Tools of MI: OARS and DARN CATS

Motivational interviewing provides helpful acronyms that serve as practical guides for structuring conversations.

OARS represents the core communication skills:

• Open-ended questions: “Can you tell me a little bit about your recovery journey?” instead of “Have you been to meetings?”
• Affirmations: Recognizing and acknowledging the patient’s strengths and efforts. “That’s a really creative idea for how to avoid a situation where you might be tempted to use.”
• Reflective listening: This is the most critical skill. It involves listening carefully and reflecting the meaning of what the patient said. In good MI, the provider should be doing more reflecting than questioning.
• Summaries: Pulling together the key points of the conversation. “Let me make sure I understand… is that correct?” This shows the patient you are listening and helps to reinforce their own insights.

DARN CATS is an acronym for the different types of “change talk” you want to elicit from the patient.

DARN (The “Preparatory” Change Talk):

• Desire: “What do you hope our work together will accomplish?”
• Ability: “What do you think you might be able to change about your opioid use?”
• Reasons: “Why do you want to stop or cut back your use?” This helps connect the change to the patient’s core values (e.g., “I want to be present for my child’s graduation”).
• Need: “What needs to happen for you to feel ready to give up opioids?”

CATS (The “Mobilizing” Change Talk):

• Commitment: “I will start attending meetings.”
• Activation: “I am ready to reduce my use to two times a week.”
• Taking Steps: “I’ve already started looking up phone numbers for therapists.”

Listening for this language helps you gauge where the patient is in their readiness for change.

Understanding the Stages of Change

The Transtheoretical Model of Change provides a framework for understanding that readiness is not an all-or-nothing state. People move through different stages on their journey to change.

1. Precontemplation: The person is not currently considering change. (“I don’t think my drug use is a problem.”)
2. Contemplation: The person is ambivalent about change, seeing both pros and cons. (“I think my marriage might improve if I reduce my use, but I’m not sure I can handle the stress without it.”)
3. Preparation: The person is committed to change and is preparing to take action. (“I’ve looked up an NA meeting to attend near my house.”)
4. Action: The person is actively taking steps to change. (“I reduced the number of days per week I use drugs.” or “I initiated buprenorphine treatment.”)
5. Maintenance: The person is working to sustain the change and prevent relapse. (“I have been using medications for opioid use disorder for a year now.”)

Identifying a patient’s stage of change allows you to tailor your approach. Trying to force an action plan on someone in pre-contemplation will only create resistance. For that patient, the goal is to start a conversation about the pros and cons.

Non-Pharmacological Management: Building a Support System

Psychosocial support is a critical component of a comprehensive treatment plan. While it should not be mandatory for receiving MOUD, it greatly improves recovery outcomes.

• Behavioral Therapy: This can be one-on-one therapy with a psychologist, social worker, or licensed counselor. Recovery coaches and peer support specialists also provide invaluable one-on-one support.
• Group Therapy: Mutual support groups offer a sense of community and shared experience that can be profoundly healing. Options include:

• SMART Recovery (Self-Management and Recovery Training): Based on principles of Cognitive Behavioral Therapy (CBT) and Rational Emotive Behavior Therapy (REBT).
• Alcoholics Anonymous (AA) and Narcotics Anonymous (NA): These are 12-step programs that are widely available. While they often have a spiritual or religious component centered on a “higher power,” many groups are very welcoming to diverse beliefs.
• Secular Organizations for Sobriety (SOS): These offer a non-religious alternative for those who prefer a secular approach.

As a healthcare provider, I strongly encourage my colleagues to attend an open meeting of one of these groups. It provides invaluable insight into the supportive environment you may be recommending to your patients.

Pharmacological Management: Medications for Opioid Use Disorder (MOUD)

To understand how MOUD works, we must first review the basic pharmacology of the opioid receptor. The primary target for opioids is the mu-opioid receptor in the brain. Different substances interact with this receptor in different ways.

• Full Agonists: These substances bind to and fully activate the mu-opioid receptor. This produces the full opioid effect, including euphoria and, at higher doses, dangerous respiratory depression. Examples include heroin, fentanyl, morphine, and methadone.
• Partial Agonists: These substances bind to the mu-opioid receptor but activate it only partially. This produces a limited opioid effect that is sufficient to prevent withdrawal and reduce cravings. Still, it has a “ceiling effect,” meaning that beyond a certain dose, the effects do not increase. Buprenorphine is the primary example.
• Antagonists: These substances bind to the mu-opioid receptor but do not activate it. Instead, they block the receptor, preventing any agonist from binding and having an effect. Naloxone and naltrexone are pure antagonists.

The key takeaway is buprenorphine’s ceiling effect. This property is what makes it a much safer medication for OUD treatment than a full agonist.

Methadone

• Mechanism: Methadone is a long-acting full mu-opioid agonist.
• Regulation: It is a Schedule II controlled substance that, for OUD treatment, can only be dispensed through federally certified Opioid Treatment Programs (OTPs).
• Side Effects: Common opioid side effects include constipation, sedation, dizziness, and sweating.
• Serious Side Effects: The most significant serious side effect is QTC prolongation, an electrical disturbance in the heart that can lead to fatal arrhythmias. This risk increases at higher doses (generally over 100 mg/day). As a full agonist, it also carries a significant risk of respiratory depression.
• Contraindications: Acute or severe asthma (due to respiratory risk) and GI obstruction (due to its effect of slowing the gut).

Buprenorphine

• Mechanism: Buprenorphine is a partial mu-opioid agonist and a kappa-opioid antagonist. It has a very high affinity (strong binding) for the mu-receptor but low intrinsic activity (it only partially activates it).
• Key Properties:

• • Its high affinity means it can displace full agonists like heroin or fentanyl from the receptor. This is why initiating it requires the patient to be in a state of moderate withdrawal. If given when a person has a full agonist in their system, it will “bump off” the full agonist and rapidly lower receptor activation, causing a severe, abrupt withdrawal known as precipitated withdrawal.
  • Conversely, if a person is already in withdrawal (low receptor activation), buprenorphine will bind and bring the activation up to its ceiling level, relieving withdrawal symptoms.
  • It reduces cravings but does not provide the intense euphoria of full agonists due to its ceiling effect.

• Side Effects: Headache, constipation, nausea, oral hypoesthesia (numbness in the mouth from sublingual formulations).
• Serious Side Effects: While much lower than with full agonists, there is still a risk of respiratory depression, especially when combined with other central nervous system depressants like benzodiazepines or alcohol. Other rare but serious effects include hepatotoxicity.
• Drug Interactions:

• • Benzodiazepines: This combination increases the risk of respiratory depression. However, the FDA has issued guidance stating that the benefits of treating OUD with buprenorphine in a patient taking benzodiazepines outweigh the risks of withholding it, as the alternative (illicit fentanyl use) carries a much higher risk of overdose. Patients should be counseled on the risks and monitored closely.
  • CYP3A4 Inhibitors (e.g., erythromycin, grapefruit juice): These will slow the metabolism of buprenorphine, increasing its concentration.
  • CYP3A4 Inducers (e.g., rifampin, St. John’s wort): These will speed up the metabolism of buprenorphine, decreasing its concentration.

Naloxone

• Mechanism: Naloxone is a pure opioid antagonist. It is the primary medication used to reverse an opioid overdose.
• Use in Combination Products: You will often see buprenorphine formulated in combination with naloxone (e.g., Suboxone). The purpose of the naloxone in this oral formulation is as a deterrent to misuse. When taken sublingually as directed, the naloxone has very poor bioavailability and has no effect. However, if a person were to crush and inject the tablet, the naloxone would be bioavailable. It would block the opioid receptors, preventing the buprenorphine from working and potentially causing withdrawal.
• Use in Overdose Reversal: Naloxone has a shorter half-life than most opioids. This is critically important. When you administer naloxone to someone who has overdosed on fentanyl, the naloxone will knock the fentanyl off the receptors and reverse the respiratory depression. However, the naloxone will wear off in 30-90 minutes, while the fentanyl is still present in the body. When the naloxone is gone, the fentanyl can re-bind to the receptors and cause the overdose to resume. This is why it is essential to call 911 and seek emergency medical care even after naloxone has been administered.
• Side Effects: If given to someone with opioids in their system, it will induce an acute opioid withdrawal syndrome (tachycardia, irritability, fever, nausea, vomiting, diarrhea). If given to someone without opioids in their system, it has no effect.
• Formulations:

• • Intranasal: Commonly known by the brand name NARCAN, it is available as a 4 mg/0.1 mL nasal spray. Education should include giving one dose in one nostril, waiting 2-3 minutes, and if there is no response, giving the second dose (from the second device in the box) in the other nostril.
  • Injectable: Often used by EMS personnel.

Naltrexone

• Mechanism: Naltrexone is a mu and kappa opioid receptor antagonist. It completely blocks the opioid pathway. It is also used for Alcohol Use Disorder.
• Use in OUD: It reduces cravings and, by blocking the receptors, prevents a person from feeling any effect if they do use opioids.
• Important Consideration: A patient must be completely opioid-free for 7-10 days before starting naltrexone. If given sooner, it will precipitate a severe withdrawal. Patients also need to understand that if they are on naltrexone, standard opioid pain relief will not work in an emergency or surgical situation.
• Side Effects: Headache, nausea, diarrhea, and injection-site reactions with the long-acting formulation.
• Serious Side Effects: Rare but serious risks include acute hepatitis, eosinophilic pneumonia, and depression. Liver enzymes should be monitored.
• Formulations:

• • Injectable (Vivitrol): A 380 mg extended-release injectable suspension given as a deep IM gluteal injection once a month.
  • Oral (PO): Typically dosed at 50 mg daily.

Harm Reduction: A Pragmatic and Life-Saving Approach

Harm reduction is a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use. It is a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. It is about meeting people where they are, without judgment.

• Naloxone Co-prescribing: I make it a practice to co-prescribe naloxone to any patient who uses drugs (not just opioids) or is on prescription opioids for chronic pain. The illicit drug supply is so contaminated that even people who think they are using cocaine or methamphetamine are at risk of a fatal fentanyl overdose. Their family and friends must be trained on how to use it.
• Fentanyl Test Strips: These are small, inexpensive strips of paper that can detect the presence of fentanyl in a drug supply. Providing these to patients allows them to test their drugs before using them. Discovering that their supply is contaminated with fentanyl can be a powerful motivator to change their use or seek treatment.
• Never Use Alone Hotline: This is a service where a person can call a confidential hotline before they use drugs. They provide their location, and an operator stays on the line. If the person becomes unresponsive, the operator calls emergency services to that location.
• Clean Needle Exchanges (Syringe Service Programs): These programs provide sterile syringes and other injection equipment to people who inject drugs. They are proven to dramatically reduce the transmission of bloodborne pathogens like HIV and Hepatitis C, and they also serve as vital access points to connect people with treatment and other health services.
• Urine Drug Screens (UDS): A UDS should not be used as a punitive tool. It is a therapeutic tool. A patient may tell you, “I don’t use fentanyl,” and genuinely believe it. When their UDS comes back positive for fentanyl, it opens the door for a non-judgmental conversation: “It looks like your heroin supply might have fentanyl in it. That’s incredibly dangerous. Let’s talk about how to keep you safe.”
• Prescription Drug Monitoring Programs (PDMPs): These state-level electronic databases track controlled-substance prescribing. They are an essential tool for providers to ensure coordinated, safe care and to identify patients who may be receiving prescriptions from multiple sources.
• Motivational Interviewing: As discussed, MI is itself a form of harm reduction. It prioritizes the patient’s own goals, which may not be immediate abstinence but could be a smaller step like “not sharing needles” or “using less frequently.”

In my own practice, integrating these harm reduction strategies with chiropractic care and functional medicine is key. By reducing a patient’s pain through manual therapies, we reduce their reason to seek out opioids. By optimizing their nutrition and gut health, we improve their mental clarity and resilience. This holistic approach, guided by Dr. Cardenas’s medical expertise, embodies the principle of meeting patients where they are and offering every available tool to move toward a healthier life.

Conclusion: A Path Forward

The history of opioids provides a crucial context for understanding the modern OUD crisis. It is a story of medical innovation intertwined with profound social and legal consequences. Stigma remains one of the most significant and damaging barriers to care. Still, we can actively combat it through our language and our commitment to treating OUD as the chronic medical condition it is.

Fortunately, we have a growing arsenal of effective, evidence-based treatments. These include life-saving medications for opioid use disorder (MOUD), powerful psychosocial tools like motivational interviewing, and pragmatic, life-affirming harm reduction techniques.

At Injury Medical Clinic, our multidisciplinary approach embraces this complexity. By weaving together the diagnostic acumen of internal medicine, the biomechanical focus of chiropractic care, the systems-based approach of functional medicine, and a deep commitment to evidence-based OUD treatment, we can offer our patients a comprehensive and compassionate path to recovery.

If you have any questions, please feel free to reach out. Thank you for taking the time to engage with this important topic.

References and Further Reading

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://www.psychiatry.org/psychiatrists/practice/dsm
• Centers for Disease Control and Prevention. (2021). Understanding the epidemic. U.S. Department of Health and Human Services. https://www.cdc.gov/opioids/basics/epidemic.html
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). The Guilford Press. https://motivationalinterviewing.org/motivational-interviewing-helping-people-change
• National Institute on Drug Abuse. (2022). Opioid overdose crisis. https://nida.nih.gov/drug-topics/opioids/opioid-overdose-crisis
• Substance Abuse and Mental Health Services Administration. (2022). National survey on drug use and health. https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report
• Substance Abuse and Mental Health Services Administration. (2023). Medications for substance use disorders. https://www.samhsa.gov/medications-substance-use-disorders

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