The power of physical therapy to help prevent people from starting opioid use has been well-documented, but work now being done by physical therapists (PTs) and physical therapist assistants (PTAs) is showing that the profession also has an important role to play in the lives of those recovering from addiction. And that role has everything to do with applying the knowledge and skills PTs and PTAs already possess.

In their session "Beyond #ChoosePT: Physical Therapy and the Opioid Crisis," delivered at APTA's 2018 NEXT Conference and Exposition, presenters Mark Bishop, PT, PhD; Eric Chaconas, PT, PhD; and Ahmed Rashwan, PT, DPT, made an engaging, sometimes moving, case for why physical therapy shouldn't be thought of simply as a path for avoiding opioid addiction, but as an approach that can also help addicts achieve and maintain sobriety.

Chaconas, an associate professor at the University of St Augustine, led the discussion framing addiction as a "cunning, baffling, powerful" disease that doesn't discriminate and should not be associated with a certain class of individuals. The addict's world is, in a way, frighteningly similar to the world of the non-addicted, he said, insofar as the addict is driven to act by cravings that are beyond her or his control. "It's no different from the craving you and I have to drink when we're thirsty or eat when we're hungry."

Efforts, such as APTA's #ChoosePT opioid awareness campaign, are crucial in helping to stop opioid dependence before it begins, Chaconas said, but there's much more work to be done for the millions whose lives have already been devastated by addiction. Once good place for PTs and PTAs to start: by working with addiction treatment programs.

Bishop focused his portion of the presentation on the clinical "why" of the matter—specifically, why physical therapy is a profession uniquely suited to join the addiction treatment team. As Bishop explained, it's all about the brain and the ways in which addiction resembles many of the same brain processes as those associated with the experience of chronic pain.

"If you're comfortable working with someone who's in chronic pain you have the skill set to work with someone struggling with addiction," Bishop said. "If you accept that chronic pain is a neurocognitive disorder, then be prepared to accept that addiction is, too."

Bishop led the audience through a series of slides that not only explained the neural pathways taken by pain and the cravings experienced by an addict, but highlighted the ways in which dopamine response levels to drugs—which can sometimes be 500 times more powerful than the pleasure responses delivered by food or sex—can fuel addiction. The University of Florida professor also explained the chemical changes that take place when an individual experiences ongoing high stress levels, whether because of chronic pain or via the addiction cycle.

So how is it that physical therapy can make a difference? Bishop said the PT's ability to help reduce stress and pain are key, but perhaps just as important is the PT's own belief in the power of her or his treatments, and the ability to engage in effective motivational interviewing that helps the patient develop an expectation of improvement.

According to Bishop, studies have shown that patient faith in any treatment accounts for as much as 30% of the overall improvement experienced. In many ways, he said, the overall change patients experience "depends on what the patient thinks when they come in on day one." If the PT treating the patient with chronic pain can recognize and help to recalibrate those attitudes, improvement becomes that much more possible. "The good news is that those intervention strategies are the same for someone recovering from addiction," Bishop added.

Rashwan was all about the "how" of the issue. As chief operations officer for Advanced Therapy and Wellness, Rashwan oversees a business that places PTs in addiction treatment centers as integral elements in the treatment process.

Rashwan developed his business model partly after experiencing frustration with what he called the "hamster wheel" of outpatient physical therapy, and partly by accident. As he explained, one day at his clinic, he received a call from a treatment facility looking for PT services for a few of their patients. Rashwan was happy to take on the patients, but wondered how the facility had decided to call him. The facility staff explained that 2 other clinics had denied providing services after learning the patients were in active treatment for substance use disorder. That's all it took for Rashwan to begin thinking about how to make a difference.

According to Rashwan, PTs in his company begin working with patients as soon as they've been medically stabilized and are placed in a residential or inpatient treatment setting. Treatments are designed to address any pain-related issues the patient might have, and puts a heavy emphasis on strength training. No modalities are used, and gear is limited to portable strength training equipment, foam rollers, and yoga mats. Keeping things simple and small helps the patient understand that she or he can easily continue the exercises at home, Rashwan explained.

Rashwan echoed Bishop's emphasis on the importance of establishing a strong therapeutic alliance with each patient. Even among the most recalcitrant of patients, hearing a PT say "I want to know who you are, I want to know what makes you tick" can be a significant experience for someone whose addiction has led to estrangement from loved ones and societal rejection, Rashwan said.

How to answer the question of whether physical therapy works in the addiction setting depends on who's asking, but the short answer in any case is "yes." Rashwan explained that as PTs and PTAs well know, physical therapy reduces pain and stress, and enhances a sense of wel-lbeing. But the program is also a win for the treatment facilities, which have decreased rates of patient actions "against medical advice" by 22%, increased length-of-stay rates by 15%, and seen improvements in relapse rates and in patient involvement in counseling sessions. And, Rashwan added, there's a business angle that shouldn't be ignored: facilities with a physical therapy program can advertise a more "holistic" approach to treatment, which can increase the patient census.

Rashwan urged the audience to consider the power of physical therapy in addiction treatment.

"We're helping people recover," Rashwan said. "We're working with the entire person, not just a diagnosis, and we're planting seeds in our patients. If we can save one life, we've done something important."