Welcome back to the Healing Pain Podcast with Holly Johnson, PT, DPT

The role of the physical therapist in addiction recovery is multifaceted and it encompasses various aspects of the evaluation, the treatment of and support in recovery and addiction. At first glance, it may not seem that physical therapy fits within the addiction realm, but in fact, physical therapy and physical therapy in mental health and addiction is a perfect fit. This is a new topic for most people in our space, so we’re bringing someone who can spearhead this conversation. Holly Johnson, PT, DPT, is a specialist in the intersection between physical therapy, chronic musculoskeletal pain and addiction and mental health. In this conversation, she highlights the need for PTs to educate and train themselves on psychologically informed care so they can make a difference in the lives of people who are recovering from addiction. Tune in and get to know the nuances of care along the intersection of seemingly disparate fields of practice.

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Breaking Boundaries: Unveiling The Crucial Role Of Physical Therapists In Addiction Recovery With Holly Johnson, PT, DPT

In this episode, we are breaking boundaries and discussing the crucial role of physical therapists in addiction recovery. My guest is Dr. Holly Johnson. Dr. Johnson has been a physical therapist for many years. Her clinical experience includes orthopedics, manual physical therapy, industrial rehabilitation, women’s health, chronic pain and expertise in treating patients with addiction.

Dr. Johnson is researching physical therapy treatment programs that focus on substance abuse and addiction recovery. This may be a new episode for physical therapists as well as other healthcare professionals and maybe even members of the public alike. The role of the physical therapist in addiction recovery is multifaceted and it encompasses various aspects of the evaluation, treatment of and support in recovery and addiction.

Upon first glance, it may not seem that physical therapy fits within the addiction realm, but physical therapy and physical therapy in mental health and addiction is a perfect fit. I want to share a couple of things with you before we begin the episode that will help inform our discussion together and also give you a good outlook and see the ways in which physical therapy overlaps with mental well-being and addiction recovery.

The first one would be pain management. That’s what this entire show is all about. We know that physical therapists are skilled in the evaluation, assessment and addressing of chronic pain issues. Chronic pain has many overlaps in people with addiction and substance use, which you’ll know in the episode. The next is someone’s functional restoration or functional capacity.

Long-term addiction and long-term mental health challenges can take a toll on an individual’s physical function and their ability to interact with their activities of daily living. We know that physical therapy treatment restores someone’s physical capacity. It improves their strength, flexibility, mobility, coordination and anything that someone is struggling with. Ultimately, it enables individuals to regain a sense of independence in their daily activities. That independence is key because it could help support someone’s self-efficacy in the recovery process from addiction.

The third is exercise and physical activity. Research shows that when you embed exercise-based programs into addiction recovery, individuals are more likely to adhere to an addiction treatment program. That’s a big factor there with regard to adherence. The next is motivation and support. We know that as doctoral-trained licensed health professionals, we understand how to enhance motivation and the importance of the therapeutic alliance.

When physical therapist interacts with patients, they can help them set realistic goals, track progress, overcome any challenges that they may be facing and help them foster this more positive mindset, which helps with creating a better narrative around the recovery process and enhancing overall motivation.

The last is psychologically informed care. As physical therapists, we’re using tools and therapy such as cognitive behavioral therapy, acceptance and commitment therapy, mindfulness and pain education. All of those are important with regard to helping people not only overcome pain but also with the behavior change that’s needed when someone enters into the recovery process for addiction or substance use. Keep those topics in mind and use them as a guide as you read the interview with Holly and me. Without further ado, let’s begin and let’s welcome Dr. Holly Johnson to the show.

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Holly, thanks for joining me.

Joe, thanks for having me. I’m privileged to be here with you.

I’m excited to be speaking with you too. It’s somewhat of a novel topic for some of our colleagues, but there are others who’ve been working in this space for some time. A lot of people are starting to grow into this space and starting to fill a need here. I’m excited to talk to you about your evolution, the things that you know, some of the things you can share with us and some of your research later on in the episode that you’ll share with us. Tell us how you became interested as a physical therapist in the field of addiction medicine.

I graduated from the University of Kentucky in 1986 so I’ve been practicing for many years, but my first 32 years were in private practice in Appalachia. That was ground zero for the opioid crisis even before OxyContin. I didn’t get any background training for that. I worked a lot with coal miners and did general practice in women’s health, family practice, orthopedics and chronic pain. I was baptized in all that.

It was scary because I had no idea that physicians, by the early ‘90s, were saying, “Everybody should be out of pain.” Everybody was on OxyContin and I saw families getting addicted and losing patients to ODs, bad drug deals and even generational drug addiction. We were trying with my company to combat that with several clinics and did not realize what hit us. We didn’t know what we know now, the whole OxyContin epidemic and how it started with Big Pharma and affected little rural towns.

We were targeted. We are in the first Ireland in Appalachia. Eastern Kentucky, Tennessee and West Virginia towns were targeted as ground zero so I had to learn the hard way. After doing that at about 32 years, I divested in my practice. I wanted to see what else could be done because the epidemic was growing again right before COVID. Through COVID, I’m like, “This is crazy. I am sick of this.”

I begin to learn more about central sensitization and the trauma-informed care piece. I realized that we need to know more about trauma-informed care, which is why I love your show. You’ve done some great work with some neat people that we can learn a lot from. I went into an addiction recovery center called ARC, Addiction Recovery Care and said, “Could I try to see if I could treat some of your patients with musculoskeletal?” I didn’t even know if musculoskeletal pain was a problem, but I figured with a lot of my patients had gotten addicted and a lot hadn’t.

With physical therapy, they’ve not used opioids or gotten off quickly after surgery, but this is such a problem. I thought, “What can I do? I wanted to go to the source.” To me, that was the essence of early intervention for people with substance use disorder if you can get there and when they’re in detox. They let me do that years ago and I’ve been developing programs.

I work mostly with women, but I do work with men too. In the past, I have worked with both teenagers up to 65-year-olds. That’s the thing. We’re having 12-year-olds and older get addicted. There were a lot of OD deaths and a lot of people were getting Narcan and brought back after ODs. We’re seeing people after 5, 6 and 7 ODs or overdose deaths.

In developing, practicing and realizing that PT, more than 87% of people with substance use disorder report musculoskeletal pain. It might be what started their pathway or perpetuated the pathway. PTs can be effective in getting people off opioids, meth, benzos, alcohol and the whole nine yards. What I see a lot is polysubstance people. My work began with opioid addiction so my research is in that work.

Eighty-seven percent of people with a substance use disorder potentially have a pain condition or musculoskeletal pain condition, shall we say. Physical therapy can play a role in pain recovery, which we know, but also addiction medicine. I want to step back a couple of feet here because we have a global audience who follows the show.

When you mention Appalachia, I know the region you’re talking about and what that looked like as far as ground zero in the opioid epidemic. Can you paint maybe a little bit of a picture for those professionals and people who read outside of the United States who might not be so familiar with where Appalachia is? What happened in that area?

If you want to get a good documentary, the book Dopesick is a good way. There’s a series on Hulu about that and Michael Keaton goes over the details of how that happened. It’s that middle part of the Appalachian Mountains, Tennessee and West Virginia. It’s a very much coal mining area, although that’s not the only industry that was affected. Many others were to it primarily. A lot of people get injured there and had some generational chronic pain issues and disability issues too. Also, typically of high poverty and also not have a lot of medium-level physical demand jobs.

A lot of heavy physical demand-level jobs help set us up. Sometimes low education rates, although you have professionals all through those areas. You also have a population of rural a little bit less educated and a little bit more poverty, which is sometimes a setup for a great place to start a marketing process. If you wanted to pretty much put a drug in place, that might be accepted more hook, line and sinker. That was a great place to do it. That’s what Purdue Pharma did with OxyContin.

This is a region of the United States of America that tends to be lower socioeconomic, though not all of it. It tends to have lower health literacy. The pharmaceutical giants or Big Pharma targeted this area because they felt like they could be successful, which to a certain extent, I don’t like to use the word success, but they increased the distribution of certain prescription medications so much that it impacted people’s physical health or mental health and their longevity.

Still is. That’s the sad thing. That’s what I teach at a couple of PT schools to help students understand, “You’re inheriting this. This is where it came from. You are a part of the solution.” I do feel better than ever with physical therapists because we are the low-cost musculoskeletal pain solution, especially when you add pain neuroscience to that. They are a huge part of the answer and do not get so discouraged. These patients can be hard if you don’t know the background that a lot of what your episodes provide.

Let’s talk about DPT students for a moment. I teach as well at a couple of different universities on certain topics. I’m curious as to what the feedback is from the students that you are interacting with when you come and you’re having this discussion around addiction. It’s interesting when you go to the average, let’s say, DPT program website. You see things like sports and people doing exercise. There’s the idea that we help people with physical disability, but addiction does fall or straddles the realm of both mental health as well as physical health. This must be something new for them.

Yes, it is. What I’ve found that’s so refreshing is many of them are interested because they have a family member, maybe a personal experience or a friend experience of someone that’s gotten in trouble with opioids, even if it started at a dentist appointment, an ACL repair or a family member. It’s amazing how it touches so many lives. They’re more empathetic than any generation of PTs that I’ve seen, which is neat.

They understand mental illness more because they went to PT school during COVID. They saw how anxiety and depression went way up in what we call normal populations and then people that were already struggling are struggling more. They’re open to realizing and that’s what your show shows. Some of my work shows that we do have an impact in treating anxiety and depression, especially if you can deal with the pain.

We do treat acute, subacute and chronic, but the vast majority are chronic and a lot of polytrauma with this group. They had that combination of musculoskeletal pain, which could be acute, subacute and chronic and then trauma, anxiety, depression and some bipolar schizophrenia even. It’s been a unique awakening for me, even after many years of practice.

They’re acutely aware of the problem. They’ve had family members, friends and potentially maybe colleagues or people they know that have struggled with or are currently trying to cope with an addiction. They’re interested in being part of the conversation and being part of maybe a team of professionals who are helping people recover from addiction. You mentioned psychologically informed care. Tell us the tools, strategies and interventions that physical therapists have to evaluate, treat and manage addiction.

I can tell you more about the ones I’ve been using. There are so many out there. It’s almost daunting. I did develop one that we’ve researched. It’s called the Recovery Exercise Program Index and it’s on my website. It’s a free download for anybody that wants to use it. It takes the PNE, Pain Neuroscience Plus based on Adriaan Louw’s courses. That’s more my background and it measures pain neuroscience in it, addiction and your desire to use your drug or drink of choice. Also, it has some questions about sleep.

It has the PQH and the GAD in there like built-in depression and anxiety screens. It looks at some of those things all in one place for a PT so you can see, “How am I affecting these areas?” I use that, but probably my tried and true one is I use the central sensitization inventory also to measure alongside that central sensitization and then you could use the back of the expanded versions of the anxiety and depression screenings.

I use an A score with every person I treat because I need to know upfront how high their adverse childhood events are and how high of a score. We know that if it’s three or more, you’re much more likely to develop chronic pain if you get injured and maybe use opioids. Body charts are super important. I over answered your question. You ask about mental illness, but I also work alongside counselors. If those screens show we’ve got some anxiety and depression, they’re going to be getting counseling every week.

That’s what I love about doing physical therapy and addiction recovery. Almost all quality credited places have good counseling. I encourage therapists if they don’t have that to develop those networks and help lead the team because those mental health specialists are looking for PTs. Many of their patients have musculoskeletal pain and they don’t know where to find us. Sometimes we don’t know where to find them.

You can do PTSD screens. I could do back depression screens, but I don’t spend a lot of time on those. I do the shorter version screens and then send them on because I want to stay in my lane. I’m not a psychologist or a psychiatrist. I always teach my students, “You don’t want to let your patients make you that if they’re only going to want to go to one place. You’re not that person for that. You are in musculoskeletal pain, but you might be the first person whom your patient says, ‘I was sexually traumatized or I had a big trauma. I think I might have PTSD. I may be struggling with things.”

You might be the first person and taking your history, I’m finding that comes out. It’s getting them to the right place and treating them together. In my research, it has to have both of those areas trained at the same time because the brain gets all that mixed up and produces pain. Anxiety and depression can increase musculoskeletal pain and musculoskeletal pain can increase anxiety and depression. Why would we not treat them together if we want to get good low-cost and great-impact outcomes?

It’s probably a good time to introduce our readers to the types of places or the place where you work where you’re treating patients. Give us the scope of what that looks like.

I work at a place called ARC, an addiction recovery center in Kentucky. They have many centers. I work in a smaller women’s facility. I work in inpatient so people are coming there to detox their first 0 to 30 days, 30 to 60 or even up to 90 days. I follow some people up long-term. That’s one type of recovery where you go in, but then there’s also outpatient where you can keep your job and that kind of thing.

We’ve done some toolkits with the University of Kentucky and the Wisconsin University of Concordia that breaks that down because we, as PTs, didn’t know any of that stuff. I didn’t know that there are some general things in each state, but there are different ways to get treatment. As PTs, even if we’re in private practice or a hospital setting, we know if there’s a problem and how to help a patient get to the right place. That’s hard for us because it’s not anything we’re taught in school.

They’re inpatient and outpatient addiction centers. How did you approach these centers and start to develop a relationship with them?

Thankfully, I had one in my hometown and I had treated some of the people that worked there so they were open. At the time, we were seeing more MAT, which is the term that’s called Medically Assisted Treatment. What that means is they were starting to have to offer a drug to help a person get off a drug. Methadone is the old one, which is an opioid itself, but it’s a full-on agonist. You are slightly high and impaired.

The new one they’re starting to do is Suboxone or buprenorphine. That’s been around for years. There’s another one called Vivitrol, which is an injection that’s not an opioid at all. They were like, “We don’t know. The patient gets to decide what they want and you can’t give them informed consent.” The problem was all these people had musculoskeletal pain and what we were suspecting is that some of them were causing opioid-induced hyperalgesia.

People were continuing on that substance, still having pain and not ever getting PT. They might go out, relapse and add more things. We were seeing that as a problem. We thought Suboxone and buprenorphine would be the end all be all. That’s what the drug industry thought, but it’s not. In Eastern Kentucky where I work it all, it’s causing some real problems. We need research to know how important it is to get psychological care in PT and treat central sensitization. We didn’t know that there’s quite a bit of that in this population and it’s going untreated. That’s part of what is partly perpetuating our drug epidemic in the United States.

In many ways, physical therapy is in some way psychological care. Physical therapy is part of a psychological approach. There are multiple organizations. We have a catalyst group called Physical Therapy and Mental Health which I’m working on with a couple of colleagues and many people to help move that forward. I appreciate you bringing all this to light. I want to talk to some of our colleagues because I’ve heard our colleagues say things like this. We can roleplay through this. People need to be tapered or wean off their opioids or fill in the space drug first. They then can start physical therapy.

I love that you brought that up because what I’ve been learning is when physical therapists have that attitude, sometimes they’re setting their patients up for failure. Addiction is the end stage of substance use disorder. It’s a continuum. Also, I have that on the website, and that’s DSM-5. You can send somebody to get evaluated for that.

We see people in our clinics all the time and I’m not talking where I am but in normal private practice in the hospital setting and even nursing home care. People can be at that fork in the road and we can taper them off their opioids, but we’ve got to be there. If there’s musculoskeletal pain, we make such a difference. Also, if we may be the first people to figure out, “You’ve got anxiety and depression that’s not treated. If we treat that, your taper is going to be so much easier.”

PTs, I feel like can be the leader of the team by saying, “There’s musculoskeletal pain and I can treat that with good pain neuroscience, manual therapy exercise and all that, but we need to be treating these mental health issues too at the same time.” That makes the taper so much easier. To say to somebody, “You’ve got to get off your opioids before I treat you,” it’s setting them up for failure.

In my work, what I’m finding is they do so much better if they get the education first and you get to treat them for a couple of weeks and get the pain. Let them see those personal victories. They can get the pain under control and then they’re much less afraid. They’re much more open because it has to be their decision or it’s not happening. That’s the one thing I’ve learned about motivational interviewing and stages of change. You’re planting seeds. They’re not ready until they’re ready.

Here’s a second scenario. As a physical therapist, I cannot treat a person who is currently taking a certain drug under the influence or may be impaired. It’s contraindicated or will impact the outcomes of the treatment.

It will impact the outcomes of the treatment, that’s for sure. We have to be so much more careful if they are impaired. Being in Eastern Kentucky, I had those times at my private practice when people came impaired. I had to say, “You’re not driving home. If you do drive home, I’m calling the state police because you’re not safe to be on the road.” I am a proponent of tough love, first of all.

I had a lot of interventional meetings with families and family members of so-and-so. “Joe, you have a problem. We care about you. We’ve seen a personality change.” Patients sometimes are ready to get something done and some aren’t. However, I’ve also had the patient that we had to stick with plant seeds. They would finally get to the point of saying like, “Do I really have a problem?”

That’s what we do with the toolkits of the University of Kentucky and the University of Concordia in Wisconsin. We have 15 lessons for physical therapists that they can download and do for 10 minutes. Sometimes they can’t hear it the first time. They can hear it for the tenth time. They have homework pages and all that stuff. There are fifteen different ways to explain how we slide through substance use disorder and can get to the point of being in trouble.

There is also a time when you have to say, “Patient, this is all I can do until you’re willing to address these,” especially when it’s high levels like benzos, alcohol, opioids and high levels of drugs. They get to the point where they’ve plateaued. It is fine to say, “We’ve done all we can do for now. I encourage you to get some help. Can we talk to your provider?” Sometimes the provider is the problem. They are the pill. That’s tough. We have a toolkit for that too.

What’s hard is helping either educate the doctor, which you can do with these tools or help the patient move if they’re ready or not ready. A lot of times, it’s very co-dependent relationships between patients and providers. They want customers. They want to keep their customers and they don’t necessarily care about the damage that they’re doing. A patient is okay with it. I caused that. Still, more people are getting opioids for back pain than in other care. PT comes in second and patients like it. There’s still a high satisfaction rate. It’s because, in the United States, we’re a wealthy nation. Our insurances pay for it. We feel like we have the right to be out of pain and we love to take a pill.

Final question before you move on to your research. This question could be coming from a physical therapist. It could also be coming from a mental health provider who is listening to this episode and the question often goes something like this. I can see how physical therapists can use psychological strategies to treat pain, but I don’t see how physical therapists are trained to treat addiction.

What I do in my work is a neuro pain science lecture and a substance use disorder neuroscience lecture.

It’s a pain education lecture.

In it, I have combined pain neuroscience and addiction recovery science. It’s very important to my patients. I’ve learned that they understand how their dopamine reward system got hijacked because that’s the why behind how I rebuild my brain and how I retrain my brain to turn off the pain and reset my alarm system.

What I’ve found is those two things go together. When a physical therapist understands how the brain gets hijacked, the dopamine reward system gets hijacked. It’s any type of substance use disorder and how that has to reset as you taper medication. If they’re doing physical therapy, increasing aerobic exercise and decreasing the reasons that their brain is producing pain, they get better so much faster. If they have central sensitization, it gets better quicker.

Why would we not hit all those things at one time? Why would not fire on all cylinders? That’s with counseling. I want to be very clear about that. That’s not the PT doing that by themselves. They still need counseling for their trauma. There’s a reason why they’re using. Remember, it’s very helpful. When people have anxiety and depression, even though opioids can incite depression, they can make it worse. PTSD too.

Opioids feel like it’s treating them because it’s numbing the pain for a little while. It’s quieting their pain, anxiety and depression for a little while until the reward pathway gets again hijacked and those receptors want more. You have to give more, and there’s the whole dope sick thing that happens. Patients initially are like, “I’m desperate. Nobody’s treating this mental illness issue. These medications are making me feel better.”

It’s an important point. I had this in one of the emails that I sent out a couple of days ago. The pathways that create chronic pain and the pathways for addiction overlap and are very similar in some ways. Sometimes pain can become an addiction.

You add the cortisol dump in there. That’s increased with depression, anxiety, chronic pain and stress. That’s why some people can hang out on opioids for a little while at a certain level and be in that mid-range of substance use disorder, but then when you add the right life stressors, in other words, a reason for anxiety and depression to go up, all of a sudden, it’s not. Pain goes up too and the frontal lobe says, “We need more medication.”

If a physical therapist is there at that moment to say, “No, let me problem solve. Why? What are the triggers here? Let’s get counseling at the same time,” that’s the real treatment for the problem. That doesn’t mean that you don’t need some SSRIs or SNRIs. They can be super helpful, but there are some drugs for some people that are terrible. They get ahold of the wrong drugs or the prescriber’s not paying attention. I believe PT, behavioral health and primary care make such a great team. That’s what every person deserves to have if there’s a mental illness, musculoskeletal pain and substance use disorder.

You’ve done some research on this. Can you share some of the information that you have?

The study is done. We’ve crunched all the numbers, but we’re in the peer review process of finishing the write-up and submitting so we hope to be published in the summer of 2023. The exciting thing is what I said. First of all, my setting is women in Appalachia. I have about 90-some people in my study and they have high levels of central sensitization. We did not know that was even a thing.

There are very high levels of anxiety and depression in the 90th percentile so that’s amazing. Also, musculoskeletal pain. I did not realize that was so prevalent in that combination of musculoskeletal pain and mental illness. I’m not even counting the schizophrenias and the bipolar. I’m talking about a garnered variety of clinical depression, anxiety and substance use disorders. That’s all admittedly and it’s polysubstance. It can be alcohol but also opioids and the whole nine yards.

What we found is if they get in early for their musculoskeletal pain and they get off all their drugs and we help them taper their medically assisted treatment or get on the right one that is not an opioid or the lowest level, they do well. That’s a combination of physical therapy and standard care. Addiction recovery is also counseling and group activities.

What we found is the number needed to treat is somewhere in the range of if you treat three people as a physical therapist in that room, you’re going to get a home run. You’re going to get people from high levels of central sensitization down to either no central sensitization or very low in maybe 1 month to 2 months’ time of treatment. I’m giving you general ranges here like 4 to 6 visits. It’s so much faster than what I saw in my regular PT world of many years of practice. That blows my mind. That’s exciting to me.

Some of the research on central sensitization, we aware of it in the world of pain, but there are some overlaps and some evidence of central sensitization occurring in anxiety, depression and PTSD. It’s interesting how these systems try to peg these conditions into one category or the other. We’re starting to see that these are diverse human conditions that overflow and overlap with other conditions. With that, it makes our scopes and how we approach things somewhat permeable in some way.

To the central sensitization syndrome, the people that have IBS, TMJ, whiplash-associated disorder, chronic low back, that’s what I see. There’s so much of that addiction recovery because they’ve gone undiagnosed and the psychological issues have gone undiagnosed too. When PTs get in there and make a difference, think of the cost savings that there are and the quality of life changes we’re making in people who have destroyed their lives or whose lives have been destroyed seeking care.

We call it drug and drink their emotional and musculoskeletal pain. That’s exciting but also sad to me because there’s such a shortage of physical therapists and only 10% of people get to PT that need to get to PT. That’s why I’m encouraging PTs to do this in their private practice, hospital settings and nursing homes. It can be done anywhere. Thinking about even going onsite in an addiction recovery facility or having them bring their patients to you can be done so many different ways.

It’s hoping that PTs, as they get educated, can know that they can make a difference. If you could have a good pain neuroscience background and you’re a good manual therapist and creative with exercise, you can’t mess up unless you’re going to be judgmental and as long as you have compassion for people and realize that it is a brain disease.

In addition to pain education, I’d add to that. Mindfulness skills help. Cognitive behavioral skills are important. Motivational interviewing skills are important when you’re working with a group. It’s not just pain education that’s going to move the needle. It’s a combination of all the psychologically informed skills that become part of the treatment plan.

You need to use it with every patient every day in every way. In this population, you’re going to see even better results with people’s lives who have been screwed up and that’s fun. They are so appreciative because they’ve been waiting for this for 5, 10, 15 and 20 years. They’ve hit rock bottom so they are very willing and ready in most cases to go.

I see people that if I had seen in my clinic many years ago, it might’ve taken me two years to get them better, if at all or they would never have finally tapered off their Lyrica or Lortab. They would’ve lived on it. They’ve wrecked their lives and have gotten to detox, they’re like, “I didn’t know I could live without this stuff.” That’s pretty fun for me, having seen what I saw for many years.

Physical therapy builds their confidence and agency in having some control of their pain, body, physical sensation, thoughts and emotions. All of that folds into the mix there.

They can get a job. That’s what’s so important. They can go back and either do their job without the pain that would cause them to use, get a new job or go back to school.

I love that point because so often, we’re so focused on pain. We want to decrease, eliminate or control pain, which is how many of these people wound up in trouble in the first place. What we should be doing as all licensed healthcare practitioners is we want the pain to decrease, but more importantly, we want to engage people in a process where they can then be reintegrated into the community and have some type of meaning and purpose in their life.

We know that that decreases relapse. They’re much less likely and become productive. They’re wonderful. By and large, they’re so glad. They can make great employees. I call it lines on elephants. Once they address the elephant of addiction and they don’t feed that line anymore, if you feed it, it can always grow again. It’s the same thing with the line of central sensitization. We got to get that down to a cub level. Once they learn those coping skills, they are so grateful. They work hard in their recovery. They’re so much more self-aware.

Sometimes our regular patients would be. It’s fun too when somebody comes into your office and says, “I’m in recovery.” They’re getting ready to have surgery. Prehab is so important for them because they can’t take opioids on the other end. I had a lady in my study that had a bilateral mastectomy and only used 800-milligram ibuprofen. Can you imagine? They’re doing those kinds of procedures like hip procedures, knee surgeries or orthopedic surgeries on 800 milligrams 3 times a day of ibuprofen. They’re being put to sleep the typical way, but it’s the aftercare. There’s accountability because you’re like, “I’ve worked too hard. I’m not relapsing over this.”

That’s an interesting point right there because I’ve had patients who have been in recovery for a number of years. They then wind up having a knee replacement or hip replacement, back surgery or whatever it is. It could even be an abdominal surgery or something that’s not musculoskeletal related. They’re prescribed and told that opioids are safe for them.

As professionals, we have to walk that fine line between the patient and the provider. We try to advocate for them and mention that this might not be the best prescription medication for this patient at this time, considering that they have struggled with pain and addiction in the past. That message has not been shared throughout the pain, musculoskeletal, psychiatry and addiction world effectively.

I agree. However, we do have patients that can take 1 or 2 opioids, but they have to give them to somebody else. It has to be a person that understands. Be honest with your doctor. A lot of my patients will say, “I have an allergic reaction to opioids.” It’s okay to say that, but go ahead and tell them you’re in recovery and you were addicted at one point. If they’re open to doing that, that shows you how strong they are in their recovery.

Some people do get to that desperate point where they want to relapse and create a musculoskeletal pain process because life has gotten tough and they’re having cravings. That happened a lot during COVID. Even OxyContin use went back up. People went back to their old ways. Some people had to rinse, repeat and start over. I saw a lot of those patients, but some people can take 1 or 2 and be fine.

It depends on their brains and if there is anxiety, addiction and all the other things. Are they being treated under control? Are they in a supportive work environment? You’re right. It’s not a one size fits all, but it is important for patients. Even in my REP Index, I even measure self-efficacy because if that’s not going up and how they manage their pain, we are not doing a good enough job. If somebody wants to find something, they will find it, whether it’s by prescription or off the street.

Holly, it’s been great speaking with you about the intersection between physical therapy, chronic musculoskeletal pain and addiction and mental health. Let the readers know how they can learn more about you and follow your work.

I have a website. It’s JohnsonPTConsulting.com. Everything on there is free to download like all the forms that I use. I do teach courses. If PTs want to learn how to do this in their setting or consult with PTs on setting up these programs, whether it’s big hospital settings, nursing home settings, private practice or teaching electives, if I can be helpful at all, that’s what I wanted to do, empower PTs to be comfortable and have their self-advocacy in doing this type of work.

It’s not that hard. If you’re a good PT, it takes about an eight-hour training. I would also encourage these toolkits that the schools are doing because it supports their chapters, which is great. It’s students that have combed through the research after having my course. They produce some nice tools. The University of Kentucky, a PT Kentucky chapter has a good toolkit that you can purchase. Concordia Wisconsin University also. Those are the two that are out there.

They’re very good. They all have 15 and 20 lessons on how to explain this. Also, 15 frequently asked questions like, “How do I improve sleep after addiction recovery? How do I improve my nutrition? How do I not relapse,” and all those things. I cover that in my course. For anybody that wants to reach out, it’s great work. It needs to be done all over the United States and the world. It could be done internationally too.

I want to thank Holly for joining us on the show. If you are a professional who works in physical medicine rehabilitation, maybe you work in mental health or addiction medicine or maybe you’re someone who has a friend or a family member who is struggling with pain or addiction, make sure to share this episode with them on your favorite social media handle so we can share the message that pain recovery and addiction recovery go hand in hand. It is possible and there’s hope out there for the millions of people who struggle with both pain as well as addiction. It’s been a pleasure spending this time with you. I’ll see you next time.

Important Links

• Dr. Holly Johnson
• Dopesick
• Recovery Exercise Program Index
• ARC
• DSM-5

About Holly Johnson PT, DPT Cert.MDT

Holly Johnson PT, DPT Cert.MDT graduated from University of Kentucky PT Program in 1986 and received her doctoral degree in PT from AT Still University in 2005. She has recently retired from a 32-year practice at PT Pros in Kentucky. She currently owns Johnson PT consulting LLC. Her PT management and clinical experiences include orthopedics, manual PT, industrial rehab, women’s health, with expertise in chronic pain management, and treating patients in addiction and other underserved populations globally.

She is currently developing and researching PT treatment programs focusing on substance abuse and addiction recovery utilizing PT, pain neuroscience and behavioral health services. She has served as the Kentucky Chapter Payment Policy Committee Chairmen since 2008, and on the PPS Payment Policy Committee since 2013. She has been a frequent speaker at PPS annual conference, and APTA Combined Sections Meeting representing PPS on alternative payment model programs.