A look at why PTs are well-suited to help patients who have substance use disorders.
BY KEITH LORIA, APTA MAGAZINE
Recovering from substance use disorders — whether it's alcohol, opioids, or some other form of prescription or illegal drugs — is a hard road for anyone to travel. Physical therapists can play an important role in working with those who have addictions and can help get them on the road to recovery.
APTA has long championed the important role that physical therapy can play in the fight against opioid addiction. The name of the association's consumer-facing website, ChoosePT.com, began as an opioid awareness campaign in 2018 to promote physical therapy as a safer and more effective alternative to using opioids to treat chronic pain. ChoosePT since has expanded to inform consumers of all the beneficial aspects of physical therapy, but APTA continues to educate consumers, other health professionals, policymakers, and others about physical therapy's role in avoiding and treating opioid misuse.
The profession's emphasis often is on preventing opioid abuse, but that is not the only way PTs can help. Physical therapy also has a place in the treatment of addiction by providing nonpharmacological ways to increase motion and reduce pain while patients are in the process of stopping the use of opioids or other habit-forming substances.
Erica Chaconas, PT, DPT, PhD, physical therapy program director for Bellin College, worked for several years as a consultant with Advanced Therapy and Wellness, a physical therapy company that exclusively worked with patients recovering from substance use disorders.
"Those physical therapists would go to inpatient addiction recovery centers and see patients who were recovering not only from substance use disorder but also from musculoskeletal pain," he recounts. "I created a lot of the programs we would use and also the continuing education for the physical therapists in the company."
Chaconas notes that an individual often either started taking opioids after the onset of musculoskeletal pain or suffered from a substance use disorder and experienced concurrent pain. He learned that it's critical for these individuals to participate in a physical recovery program, working with a rehabilitation professional such as a physical therapist.
"We are able to address the musculoskeletal pain while they concurrently address the substance use disorder through an addiction recovery program," he says. "Physical therapists are well-suited to help these individuals because we have a modern understanding of pain along with expertise in graded exercise progressions, which really is the hallmark to this type of physical recovery. All of that, along with a psychologically informed mindset while addressing lifestyle health factors, make the physical therapist a critical member of the team to help people recover."
Kelly Sanders, PT, DPT, president of Movement for Life in San Luis Obispo, California, recently started working with recovery programs. To date, she has been working with patients in the clinics who are in recovery, helping them to address musculoskeletal pain.
"More than anything, we are working on the prevention side of substance use disorder and how to manage musculoskeletal pain conservatively versus with pharmacology," she says.
"PTs are the most qualified conservative-care providers to address musculoskeletal issues in our medical system. We need to work diligently to provide early access to PT services, ahead of any other medical intervention for conditions that can and should be managed conservatively."
Physical Therapy and Addiction Recovery
After being in private practice for 32 years in Kentucky, Holly L. Johnson, PT, DPT, started a practice that focuses on addiction recovery, developing a treatment program for substance use disorder recovery using physical therapy, pain neuroscience, and behavioral health services.
"I've seen a lot of patients who have had addiction issues, and, like a lot of PTs, I wanted to be that fork in the road to help people taper off opioids and go on with life," she says. "But you see a lot of people who don't do that well, so I wanted to take the next part of my career and take what I learned to see what I could do to help, because it's just really getting worse."
Today, Johnson treats patients — mostly women — in addiction recovery facilities and conducts research with the University of Kentucky, working to bring what she's learned about substance use disorder and physical therapy to others.
"About 87% of people who have a substance use disorder have musculoskeletal pain," she says, citing a study that appeared in the May 2016 issue of the Journal of General Internal Medicine. "A lot of people who get addicted have musculoskeletal pain that wasn't treated in physical therapy or didn't stick with their PT."
Her experience shows that those in recovery and in pain who are treated by PTs do well in tapering off opioid use. Physical therapist treatment also works to get patients to become lifelong exercisers, which prevents relapse, Johnson says.
"We found that a lot of people in recovery and in pain also have central sensitization [when the central nervous system amplifies sensory input across the body's systems], and there is also a high percentage with anxiety and depression," Johnson says. "When they have musculoskeletal pain and are treated with physical therapy, it's key that we do pain neuroscience education. It's explaining to people how their brain produces pain and how to turn off the alarm system that's overly sensitive, and then do manual therapy. We see people get better rather quickly, even when they've had chronic pain for years."
Sarah Wenger, PT, DPT, clinical professor with the Department of Physical Therapy and Rehabilitation at Drexel University in Philadelphia, teamed up with interprofessional colleagues to develop a psychoeducational group designed to help patients cope with chronic pain — and part of that includes avoiding, minimizing, and tapering opioid use.
Called Power Over Pain, the focus of the group is to help participants better manage their chronic pain and thrive in their lives.
"Part of this was helping participants decrease their reliance on opioids by expanding their pain management repertoire and by providing support, education, and tools for tapering to lower doses or terminating use of opioids," says Wenger, who is a board-certified clinical specialist in orthopaedic physical therapy. "We also treat patients who have current or a history of illicit substance use, both in direct physical therapy care and in Power Over Pain."
Wenger says that, just like any other patient with pain, those with substance use disorders or challenges benefit from physical therapist interventions that expand their pain management toolkit and increase their fitness and resilience to better cope with their pain.
"For people who have a high tolerance to opioids, therefore reducing their effectiveness, and for those suffering unpleasant side effects of opioid use, having alternative tools becomes even more essential," Wenger says.
Helping Those in Recovery
PTs have the tools and knowledge to help patients in recovery from any kind of addiction. After all, improving fitness and functional mobility helps with depression, anxiety, cravings, and overall mood and wellness.
Most people with substance use disorders also have chronic pain. And most people with chronic pain have barriers to physical activity. PTs can help them navigate those barriers.
"PTs are the movement experts," Wenger says. "Improving someone's fitness, strength, or balance is not so complex when there are few barriers. But when there are multiple barriers, it takes a huge amount of skill, knowledge, creativity, and flexibility to help someone achieve mobility and functional goals without flaring pain or otherwise creating setbacks. PTs have those skills."
Chaconas notes that a 2015 study in the journal Medicine showed that individuals recovering from substance use disorder have up to a 30% reduction in aerobic capacity compared with their peers and a 15%-18% reduction in muscle strength. "So we typically see individuals who are deconditioned and we need to address that through an exercise program," explains Chaconas.
In addition to the physical aspects of the therapeutic exercises that will help improve a patient's fitness levels, helping them become more resilient, empowered, and adopt a fitness-forward lifestyle is critical to the interventions PTs provide.
"A physical therapist in this setting must practice in a psychologically informed manner. Motivational interviewing, empathy, and the mindset of a health coach is important in the addiction recovery setting," Chaconas says.
Mark Bishop, PT, PhD, associate professor and director of the Doctor of Physical Therapy program at the University of Florida, notes that PTs can manage medically supervised activity programs, monitoring patient progress and using psychologically informed principles to set appropriate goals. He collaborates with a group in south Florida who bring their physical therapist services into inpatient drug treatment programs where they previously had no activity programs or help for musculoskeletal pain.
"We are working with that program to set up some activity sequences to add to the treatment, because about 60% of those going to the treatment center indicated that they had some sort of musculoskeletal pain and were not getting treatment," Bishop says. "While they are in rehab, there are some opportunities to go to the gym or do some recreational therapy, but there is no focused activity or goal-oriented programs."
A common path to substance use is an opioid prescription for pain following an injury — for which the person ends up addicted without ever treating the underlying pain condition that started them on that cycle.
"PTs have an opportunity to screen and look at substance misuse as a pain management strategy for those who have musculoskeletal pain," Bishop says. "Once someone ends up at a treatment center, if they haven't had treatment for whatever pain they experienced, the PT can treat the musculoskeletal condition. That decreases some of the drive to get relief."
Mindful Management
When Johnson meets with a new patient, she conducts a trauma-informed PT evaluation.
"I'm asking about past traumas, adverse childhood events, things that may have caused their brains to be sensitized," she says. "We're making sure they get good counseling for anxiety and any mental health issues. Then I do a lot of manual therapy — neck, back, knee — the typical areas for musculoskeletal pain. And usually they have just detoxed, so they are not in the best condition. But we can help them get rid of their pain and get them back to life."
Johnson's sessions also include mindfulness, relaxation breathing, warmup stretches, and aerobic exercise. The program also teaches patients with substance use disorders how to incorporate these practices into their lives, bringing good habits in to replace the bad habits.
A lot of patients that Johnson works with have experienced domestic abuse, which can lead to substance use disorder. One such patient she worked with recently had neck fusion, an ACL that was torn, and some neck and back pain.
"With just six visits, along with good counseling and detox, we were able to get her pain under control, get good range of motion back, and get her out of pain," she says.
Wenger once had a patient who had nerve damage in his leg after a gunshot wound. He had chronic pain because of the nerve damage and was unable to work as a chef because he could not tolerate all the standing.
"He had been on opioids for a long time and was having difficulty tapering," she explains. "Each time he tried to taper, he experienced an increase in pain and was frightened since he was already in so much pain."
Along with the patient's physician assistant, Wenger provided education about how ineffective opioids were for long-term management, explaining how they managed pain temporarily but that other tools were needed to manage pain long term. As important, they educated him on how to taper off from the opioid use and develop a more comprehensive pain management strategy.
"He eventually stopped coming to physical therapy. A few years later he came in and gave us an update," Wenger says. "He had used all of the information we provided to taper himself completely off opioids. During his original course of physical therapy, he was undergoing some stressors at home and did not have the support he needed to engage in a taper. Once he was in a better situation, he remembered everything we taught him. He said that everything was happening just like we said it would."
One of the PTs who worked with Chaconas helped a young man during his 30-day inpatient stay and motivated the patient to change his life and exercise regularly.
"The patient was discharged, and a year later he wrote the PT the most touching letter I have ever seen," he said. "He talked about how much he trusted him and looked up to him. They worked together when this guy was at the lowest point in his life and he said that to have someone you can trust, who believes in you, and encourages you to get better during that tough time is key. He had a year of sobriety and was doing good and exercising daily. Prior to his inpatient stay, he had attempted suicide."
That's the sort of impact a PT can have on someone's life.
A Team Approach
Pain is a complex biopsychosocial issue that is best addressed with a broad range of education, tools, and treatment approaches, so PTs are especially effective when working in collaboration with other health care providers.
"We collaborate with other professionals to streamline care with a patient-centered focus," Wenger says. "Instead of having multiple goals and directives from different professionals that patients struggle to implement and prioritize, patients should have a comprehensive treatment plan that makes sense to them and for which they have the support and tools to implement at a feasible pace."
The areas where physical therapy can contribute to this plan are designing approaches to physical activity that are safe and achievable and that successfully navigate barriers and minimize flare-ups.
"We also play a role in education about pain, its physiology, and its impact, and about mechanisms for healing," Wenger says. "We have a role in building resilience, coping skills, and joy in the face of chronic pain, especially within the context of movement. My biggest take-home point here is that there is no recipe for treating chronic pain. We need to individualize care and develop our treatment plans differently for each patient as we help them navigate their stressors and barriers to build on their strengths and opportunities."
Impacting the Opioid Crisis
It's no secret that the U.S. continues to be in the midst of an opioid epidemic, with experts estimating that nearly 9.2 million Americans ages 12 and older misused opioids in the past year.
A recent multistate study of low back pain from the Workers Compensation Research Institute found that workers whose physical therapist treatment started more than 30 days post-injury were 46% more likely to receive opioid prescriptions and 47% more likely to have an MRI, compared with those who were treated by a physical therapist within three days of injury.
For PTs to make the highest impact on the nation's opioid crisis, Wenger believes they need to expand their viewpoint and understanding of chronic pain and substance use disorders.
"There has been a lot of emphasis put on understanding the neuroscience of pain and very little attention to substance use disorders in our profession," she says. "While I think understanding the neuroscientific evidence for both pain and substance use disorders is important, it is also oversimplified. Chronic pain and substance use impact immune, endocrine, and other body systems, and we need to have a more global conceptualization."
Additionally, Wenger feels a better job is needed to acknowledge the psychological and social aspects of having chronic pain and substance use disorders and the psychological and sociopolitical risk factors that influence vulnerability to developing these conditions in the first place.
"If we truly accept that pain and substance use disorders are complex biopsychosocial issues, then I think we need to envision ourselves as team members contributing our skill sets to these complex issues that benefit from having multiple professions with different skills in the mix," Wenger says. "As team members instead of independent providers, we adopt additional responsibilities for coordinating care, being good communicators, and expanding our understanding of the multisystem and biopsychosocial underpinnings of both pain and substance use disorders."
Chaconas believes working with medical providers who prescribe opioids and letting them know what the alternatives are, what PTs offer, and how they can have successful outcomes is vital for helping those with opioid addiction.
"I also think screening for substance use disorder is important," he says. "When a PT suspects that an individual might have substance use disorder, screening to identify need for referral and getting that individual the proper resources is important."
What's more, he continues, it is critical that PTs understand the brain disease model of addiction, do not judge people, and are never critical or condescending.
"People do not choose to become addicted to substances; it's a very complex disease and requires a team of health care experts to help facilitate recovery," Chaconas says.
Keith Loria is a freelance writer and frequent contributor to APTA Magazine.