In 2023, the way we approach healthcare is different than the way we did just twenty years ago. This is particularly true with regard to mental health, psychological health, emotional health, and treatment for substance use. Not long ago, all these areas of treatment were walled off from one another. Medical doctors addressed physical issues like injuries and accidents. Psychiatrists diagnosed mental health disorders, and prescribed and managed medications associated with mental health disorders. Counselors and therapists engaged in talk therapy with patients diagnosed with mental health disorders like depression, anxiety, obsessive-compulsive disorder, and post-traumatic stress disorder. Very few mental health professionals considered the impact of physical therapy on the risk of opioid use disorder.
These various areas of support represent distinct specialties and each has an important place in the overall healthcare picture. In practice, the treatment offered by providers in these specialties occurs separately. Psychiatrists have their own offices. Counselors have their own offices. Primary care providers and specialists like orthopedists or cardiologists all have their own offices.
What’s changed – or is in the process of changing – is the integration of our modes of healthcare. We now understand that to support a person completely, we need to support every aspect of their lives. That means accounting for physical health, psychological health, and emotional health. That’s what total health and wellbeing means: a thriving human on all levels.
Here’s how the World Health Organization (WHO) defines health:
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
While it’s taking time to transition, most healthcare providers understand that the time has come to remove the walls between the various specialties and subdivisions. It’s time to increase communication across disciplines. It’s time to transition to the type of integrated care that can lead to total health.
Integrating Care to Address the Opioid Crisis
With regards to addiction treatment and the ongoing opioid crisis, integration means getting all healthcare providers involved. Providers can participate in the screening process, the referral process, and the ongoing care process. The idea is that everyone – from primary care providers to mental health specialists – can play a role in supporting people who may need treatment for opioid use disorder.
That means physical therapist can use physical therapy to support people with opioid use disorder, too.
According to a recent publication in PTJ: Physical Therapy and Rehabilitation Journal called “Physical Therapist Roles During the Opioid Epidemic in Rural Appalachia: Preparing Students to Educate Communities,” healthcare professionals working in physical therapy – a specialty not typically associated with addiction treatment – can help mitigate the harm caused by the ongoing opioid crisis alongside providers like primary care specialists, psychiatrists, addiction specialists, therapists, and addiction counselors.
This publication details the formation of a model of care for doctoral candidates of physical therapy to learn and apply in practice upon completion of their training in West Virginia. The role of the physical therapist in rural areas is often enhanced, compared to more populated areas. The physical therapist (PT) may be a patient’s only source of contact or medical information following an accident, illness, or injury that requires physical therapy.
In rural, mountainous states like West Virginia, leveraging the role of the physical therapist may help mitigate the ongoing harm caused by the opioid crisis.
Before we introduce the model of care that integrates PTs into OUD prevention and treatment, let’s take a look at the latest information on the opioid crisis from a similar state: Kentucky. Like West Virginia, Kentucky is mostly rural and mountainous. Therefore, what we learn from this report on the role of PTs in West Virginia can help us support our patients in Kentucky, where we own and operate NKY Med Clinic in the town of Covington.
The Opioid Crisis in Kentucky
To understand the opioid crisis in Kentucky, it’s important to understand the nationwide crisis. The opioid crisis began in 1999, and with a small dip in overdose fatalities between 2018 and 2019, rates of fatal overdose have increased dramatically in the past two decades.
Here’s an overview of the national data.
Overdose Fatalities in the U.S. 2019-2021
- 2019: 67,697 total drug overdose fatalities (50,178 opioid-related)
- 2020: 78,056 total drug overdose fatalities (69,061 opioid-related)
- 2021: 107,306 total drug overdose fatalities (73,453 opioid-related)
The total reported for 2021 is 52 percent higher than the rate reported in 2017, and a staggering 533 percent higher than the rate reported in 1999. When we add up all the years, we discover a grim fact: the overdose epidemic has claimed the lives of over a million people in the U.S., with roughly three-quarters of those deaths attributed to opioids.
That’s one reason there’s a real need to involve everyone in the work to mitigate the harm caused by the overdose crisis, including physical therapists.
Now let’s look at the most recent overdose data from Kentucky.
Overdose Fatalities in Kentucky 2019-2021
- 2019: 1,380
- 32.5 deaths per 100,000 people
- 2020: 2,083 overdose deaths
- 49.2 per 100,000
- That’s a statewide increase of 51.4%
- 2021: 2,397 overdose deaths
- 56.7 per 100,000
- That’s a statewide increase of 15.2%
This data shows the rates of overdose per 100,000 people increasing, outpacing those in the rest of the country. The rate in 2019 was 5 percent higher than the national rate, and the rate in 2020 was 7.5 percent higher than the national rate. The final national rates for 2021 is not yet available. However, the rate of 56.7 deaths per 100,000 people is among the highest in the nation, as shown by preliminary statistics available here.
Again, those statistics show the need for an all-of-the-above approach to the opioid overdose crisis, as advocated by Team Kentucky: Cabinet for Health and Family Service. The paradigm for including physical therapists in the overall effort would be one component in the comprehensive state plan we describe here.
Kentucky Responds: Harm Reduction, Social Support, Education, and Treatment
- Naloxone harm reduction services that involve pharmacies, mobile units, and local treatment centers
- Support for parenting and pregnant women, including a program called Integrated Care for Pregnant and Parenting Women that connects hospitalized women with treatment services, and a Treatment Assistance Program (TAP) that provides intensive outreach and support to women and children involved in public assistance or child welfare programs
- School prevention programs, including a Positive Action Program in local recreational clubs, and various awareness and prevention programs in middle schools and elementary schools across t
- Nine KORE programs that support – and sometimes pay – for treatment needs in Kenton, including: MAT programs (including ours), residential/outpatient programs, and MAT programs in detention centers
- Recovery support services that connect people to recovery/sober housing and employment assistance in the Northern KY Workforce Development Area.
All those programs have had a positive effect on the overdose crisis in Kentucky. Now let’s take a look at how physical therapists can get involved in this all-hand-on-deck approach to the crisis.
Physical Therapy: Injury Prevention, Chronic Pain Management, and Opioid Use Disorder
The overall concept here is that physical therapists can help people across the opioid use disorder (OUD) continuum. They can target their efforts across the lifespan of patients, from infancy to old age, with specialized approaches for each stage of OUD, tailored to each phase of life.
We’ll describe these potential interventions and their potential intervention points now.
The Role of Physical Therapists in the Opioid Crisis: A New Model For Comprehensive Care
Infants
- Physical Therapy as Prevention:
- PTs can help pregnant women manage pregnancy-related pain
- Physical Therapy to Manage Chronic Pain Without Opioids:
- PTs can help pregnant women manage non-pregnancy related pain with alternative strategies
- Physical Therapy in Presence of OUD
- PTs can intervene to support infants with neonatal abstinence syndrome (NAS) and teach parents effective techniques for feeding, supportive care, and other skills for parenting infants with NAS
Children/Youth
- Physical Therapy as Prevention:
- PTs can teach children and parents techniques to prevent injury that may require pain-relief medication
- PTs can help children manage maladies like headaches or other ailments without medication
- Physical Therapy to Manage Chronic Pain Without Opioids
- PTs can teach children how to rehabilitate injuries from sports or traumatic accidents without relying on long-term opioid use that could escalate to OUD
- Physical Therapy in Presence of OUD
- For children or youth in chronic pain, PTs can help patients recover by teaching children or youth how staying active and exercising regularly can boost mood, and play a role in recovery from OUD
Young Adults
- Physical Therapy as Prevention:
- PTs can help teens – whether active in sports or not – learn healthy strategies to prevent injury and manage pain not related to injury, such as sore back muscles, etc.
- PTs can help teens with strategies to manage other types of pain, such as headaches and gastrointestinal injury, with an active lifestyle and stress-reduction techniques
- PTs can help young women manage pain associated with menstruation, pain associated with pregnancy, and pain associated with childbirth
- Physical Therapy to Manage Chronic Pain Without Opioids:
- PTs can help young adults and teens manage pain after traumatic injury due to accident, pain related to sports injuries, and acute post-surgical pain
- PTs can help young mothers manage postnatal pain related to C-sections or other birth-related physical trauma
- Physical Therapy in Presence of OUD:
- PTs can teach young adults to manage pain with exercise and therapeutic techniques as they engage in recovery from opioid use
- PTs can help young adults with manage the effects of concussion and reduce the need for opioids
- PTs can help women with OUD manage post-partum pain, which can reduce perceived need – and cravings – for opioid medication
Middle-Aged Adults
Physical Therapy as Prevention:
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- PTs can help middle-aged adults manage the early stages of age-related pain associated with arthritis, fibromyalgia, back pain, headaches, and stress.
- PTs can help middle-aged women manage chronic pelvic pain
- Physical Therapy to Manage Chronic Pain Without Opioids
- PTs can help middle-aged adults understand the importance of attending and fully completing their prescribed physical therapy after injury or accident. This can facilitate faster healing. It can prevent acute pain from becoming chronic pain. This can prevent the initiation of opioid use for pain, which could escalate to opioid misuse
- PTs can help middle-aged adults recover from age-related surgery – e.g. transplants, cardiac surgery – without the need for strong pain medication
- Physical Therapy in Presence of OUD
- For people with OUD who have chronic pain, or experience accident, injury, or other physical trauma, a PT can help them manage chronic pain and direct the rehabilitation process. This can help reduce pain, perceived pain, and perceived need for opioid medication
- For patients in recovery in a critical care situation, PTs can help reintroduce physical activity that can both relieve chronic pain and improve mood, thereby reducing need or perceived need for opioid medication
Older Adults
- Physical Therapy as Prevention:
- As people age, maintaining an active lifestyle to prevent chronic pain from age-related issues – arthritis, etc. – becomes paramount. PTs can help older adults adapt exercise routines for their age and capabilities. They can help reduce the rate of accidents and falls in general. This can reduce likelihood of injury and the need for any opioid medication with the potential for misuse
- PTs can help older people manage pain related to stroke, diabetic neuropathy, and the effects of chemotherapy
- PTs can help older people manage pain associated with age-related surgeries, such as chest pain following open heart surgery
- Physical Therapy to Manage Chronic Pain Without Opioids
- PTs can help older people in recovery from age-related surgeries like hip or knee replacement.
- PTs can help people manage pain associated with typical arthritis, rheumatoid arthritis, and other rheumatologic diseases
- For cancer patients, PTs can help the management of chronic pain in the palliative care or hospice milieu
- Physical Therapy in Presence of OUD
- For older people with chronic pain and OUD, PTs can teach skills to help manage age-related musculoskeletal pain. This can decrease the need or perceived need for opioid pain medication
This model accounts for the role of the physical therapist at all phases of potential opioid use or misuse. Their role in injury prevention can reduce the need for pain medication. Their role in pain management can reduce the need for opioid pain medication that could lead to misuse and disordered use. And their role for people already diagnosed with OUD cannot be overstated. They can help prevent relapse to opioids due to pain by teaching patients evidence-based, effective strategies for managing pain without the need for opioids.
The Community Connection: How Providers Can Integrate and Cooperate
This new paradigm for the role of physical therapists in reducing overall risk of opioid use disorder among rural patients takes elements from general health care, mental health care, and treatment for substance use disorder and combines them into a logical, coherent whole.
Many of the concepts are familiar, but what makes them innovative is the place and timing of their application. For instance, a primary care provider may discuss the importance of physical activity in general. A physical therapist can offer specific exercises and activities at a level of detail a primary care provider might not. They can also connect the dots about how exercise and physical activity supports mental health and wellbeing. And that mental health and wellbeing, in turn, support successful recovery and reduce risk of relapse.
That’s one small example that provides insight into the concept of community cooperation and integration. If healthcare providers see themselves as part of the community, they can work with other healthcare providers across a continuum of care. They can intervene at any point in the care process and care continuum and offer the necessary support.
This integrated, all-of-the-above approach works – and we have data to support it. The state of West Virginia introduced a comprehensive, integrated approach to the opioid crisis, and the results are paying off. Here’s the latest CDC data on overdose in Kentucky:
- For August 2021 – August 2022, there were 2,299 reported overdose deaths
- For August 2020 – August 2021, there were 2,341 reported overdose deaths
That’s an increase of just 1.8%.
That’s progress. It’s a not the reduction we hope for. However, compared to the 50 percent increase from 2019-2020, and the overall increase of 15 percent between 2020 and 2021*, it’s real progress. It shows that when a state coordinates all its resources – including innovative approaches like including providers across the treatment continuum – it can make a significant impact. It can change lives for the better.
*A surge in overdose deaths at the end of 2021 and the beginning of 2022 was followed by a steady reduction in overdose deaths between February and August 2022*