By Lyndzie Jackson, PT, DPT

One of the most troubling aspects of this decade has been the worsening state of the opioid epidemic in the United States. Therefore, treating opioid addiction is a major concern. Overdose deaths are increasing and leaving families reeling from both a pandemic and an opioid epidemic. The start of the COVID-19 pandemic in 2020 saw a record number of people dying of overdose—nearly 92,000—according to the National Center for Health Statistics. At the time that was a record, with 21,000 more deaths than any other year. Sadly, 2021 brought new record-breaking numbers from the NCHS. Nearly 108,000 died from drug-related overdoses last year, an increase of 15%. 

The increase in deaths from opioids and other drugs is a stark warning for addiction professionals that they must do more. Everyone in addiction treatment must find ways to better treat the causes of opioid addiction. As a physical therapist for an intensive outpatient program treating addiction, general mental health issues, as well as chronic pain, I am continually exposed to people seeking treatment for opioid addiction and I am constantly thinking about physical therapy’s role in this epidemic. Physical therapy as a tool for treating opioid addiction is sadly underutilized, despite the fact that it can be essential to the recovery of many people dealing with opioid addiction and should be used more often.

Chronic Pain and PT’s Role in Treating Opioid Addiction

For many people, opioid abuse begins as a way to manage chronic pain. According to the National Institute of Health, “roughly 21% to 29% of patients prescribed opioids for chronic pain misuse them” and “Between 8% and 12% of people using an opioid for chronic pain develop an opioid use disorder.” If chronic pain is one of the major factors that leads to opioid abuse, then it is our job as physical therapists to step in and offer alternative options for treating opioid addiction. 

Physical therapy is a pain management solution that can actually address the underlying causes of chronic pain as opposed to just masking said pain. Those who are dealing with chronic pain, more often than not, also experience some level of stress, anxiety, and/or depression. Opioids diminish these issues for a brief period of time but, in the long term, they can actually increase the levels of pain, anxiety, and depression a person experiences. Someone who is dependent on opioids because of chronic pain is often significantly limited in their daily activities and becomes fearful of movement (fear avoidance), which leads to a lack of movement that therefore can further increase their pain and use of opioids. This approach to managing their pain often causes depression related to an inability to perform simple tasks and engage in activities that once gave them purpose. 

From a physical therapy perspective, the most beneficial approach to help someone suffering from chronic pain feel better is to first calm down their central nervous system and then slowly reintroduce movement in a safe and methodical manner. The longer a patient lives in this cycle of pain, decreased movement, anxiety, and depression, the more their nervous system stays ramped up in what is called “fight or flight” mode. As physical therapists, we can help patients calm their nervous system down by teaching them techniques such as diaphragmatic breathing and helping them develop an overall better awareness of their body. The biggest barrier for many people is a mental one. They feel like they are unable to move and exercise because either the pain is too great or they will hurt themselves if they do so. Physical therapy can be the tool to help them overcome that fear by slowly showing people struggling with addiction and chronic pain that it is safe to move.

Breathing to Ease the Mind

Diaphragmatic breathing is a great first step for physical therapists to take with new chronic pain patients dealing with addiction, since it is critical to wean their nervous system off that fight-or-flight mentality. The way we breathe is an important signal to the brain that tells it how we are feeling. “Fight or flight,” controlled by the sympathetic nervous system, is designed for protection; any time our body perceives danger of any sort, whether it be physical or emotional, our body puts us in this mode so that we can be ready for whatever comes next. This mode is usually associated with quick shallow breathing or prolonged periods of not breathing. Living in a constant state of “fight or flight” can lead to racing thoughts, hypersensitivity, increased tension throughout the body, elevated blood pressure, increased stress hormone production, digestive issues, and inability to sleep. 

According to the National Institute of Health, “over 75% of people with opioid abuse disorder have sleep problems.” Teaching a patient the proper breathing techniques helps them understand that they can relax their bodies and, more importantly, better understand the cues their bodies are giving them. Deep breathing, or diaphragmatic breathing, not only helps to focus the mind and bring more oxygen into the body, but on a physiological level, it triggers the vagus nerve to directly signal the nervous system to transition into “rest and digest” mode, controlled by the parasympathetic nervous system. 

The parasympathetic nervous system mode is where we should be spending the majority of our time as humans; it is the optimal mode for rest, healing, digestion, sleep, and all other essential bodily functions. Before we can safely get a patient dealing with chronic pain moving, it is imperative to bring their nervous system out of the “fight or flight”, hypersensitive, protective mode into “rest and digest” mode so that their body is more receptive to this new movement and does not perceive it as potential danger. Diaphragmatic breathing is also essential for managing the stress, anxiety, and depression that comes along with pain and addiction. Utilizing these breathing techniques along with other relaxation strategies will benefit the mind and body of someone recovering from addiction.

Creating an Open Posture

Once a patient’s central nervous system is in a state of “rest and digest,” a physical therapist can focus on a patient’s exercises and movements. Treatment of patients with chronic pain and addiction should be slow and deliberate with a focus on exercises that promote safety in the system as well as an open posture. Along with the way we breathe, posture is another signal to the nervous system that tells it how we are feeling. A forward flexed, rounded shoulder, arms and legs crossed posture is protective in nature and tells the brain we are not feeling safe, therefore keeping us in a state of “fight or flight.” The alternative, shoulders back and upright/open posture, tells the brain that we are feeling safe and can help to bring us more into “rest and digest” mode. A chronic pain patient dealing with opioid abuse initially feels like every movement is unsafe. This is why teaching them safety within movement by incorporating small, non-threatening movements into their treatment plan is essential. Slowly introducing these movements builds confidence in the patient as they relearn a full range of motion.

Addiction and chronic pain, for many people, means their brain is in a constant state of panic, that movement will hurt, and only opioids can numb that pain. A physical therapy treatment plan is key for anyone dealing with addiction and chronic pain. Physical therapy retrains the brain and lets the patient know they can still do things without pain. When they slowly see they can do these movements, it gradually gives the patient more control over their life, which was previously controlled by addiction, pain, and fear. If a patient believes they can do these movements, they will start to believe they can do more things like going on a hike, making a gym plan, and playing with their kids.

If patients feel they can move without pain, we can teach them to live without opioids. Teaching their bodies to move again helps them—physically, mentally, and emotionally. Addressing the physiological reasons for addiction is just as important as addressing the mental reasons for addiction. We want to avoid having a revolving door of chronic pain patients who do a few sessions of treatment and then return because of relapse. Using physical therapy as one discipline in a broader treatment plan puts everything into a bigger picture that benefits the patient as a whole.

Setting Realistic Expectations

Physical therapy can be a huge boon for patients struggling with addiction and chronic pain, and should be a focus in many treatment plans. However, it should not be the only treatment plan. Behavioral health professionals and treatment modalities must be included in any addiction treatment plan. Physical therapists must also look at their jobs from a multi-faceted lens. We are not behavioral health professionals, but having a basic understanding of behavioral health’s role in chronic pain treatment makes us better physical therapists. It is important for us to understand that there are other ways besides manual techniques to make people feel better. Using these different treatment modalities will give our patients a more active role in their recovery, leading to long-term success.

It is important that physical therapists get away from the mentality of being the “savior,” thinking that one technique or treatment will make patients better. We are just one important cog in a long multidisciplinary treatment plan.

Lastly, it is important that we be mindful of our patients’ limitations. Physical therapists have a tendency to push our patients, and many times that can be a beneficial thing. However, when it comes to chronic pain and addiction, we should avoid the “no pain, no gain” mindset. Pain is a warning signal and instead of blowing past it or ignoring it, we want to slowly increase patients’ tolerance level in order to avoid regression that might lead them to medicate with opioids.  

The record-breaking increase in overdose deaths over the last two years is an extreme concern to addiction professionals. Everyone who works in the industry must do everything they can to create comprehensive and multifaceted plans for treating opioid addiction. Chronic pain is a leading cause of opioid addiction, so we must do everything we can to address a patient’s chronic pain. 

Physical therapy as a profession is in a great position to help addiction professionals treat the underlying causes of addiction. By exposing people dealing with chronic pain and addiction to physical therapy, we can help them manage the pain that leads them to opioid addiction. Physical therapists working in conjunction with behavioral health professionals can help patients get past the mental block that makes them feel like they can’t get up and get moving. We can play an essential role in improving the lives of patients and diminishing their reliance on opioids.

Lyndzie Jackson PT, DPT is the Director of Physical Therapy at Recovia. They are a non-interventional pain clinic and behavioral health center specializing in treatments for chronic pain, general mental health, and addiction. The programs offer an integrated outpatient approach to address prescription medication dependency, chronic pain, and substance abuse. All programs are based on an interdisciplinary model, combining medical, behavioral, and holistic treatment modalities. Recovia is one of the fastest-growing pain management and behavioral health centers in Arizona with 5 locations in Phoenix, Tempe, and Mesa with plans to open 2 more locations in Tucson. Recovia also offers all programs virtually via Recovia Virtual Care.