Welcome back to the Healing Pain Podcast with Anne K. Swisher PT, PhD, FAPTA
We’re discussing how to train entry-level physical therapists to address the opioid epidemic. My guest is Dr. Anne Swisher. She is a Professor and Director of Scholarship for the West Virginia Division of Physical Therapy. She’s been a Board-Certified Cardiopulmonary Clinical Specialist for several years and has taught in the area of cardiopulmonary physical therapy, exercise prescription and pathophysiology. She’s also a Catherine Worthingham Fellow of the American Physical Therapy Association and has published over 80 peer reviewed publications. We focus on a paper Anne published called the Physical Therapist Roles During the Opioid Epidemic in Rural Appalachia: Preparing Students to Educate Communities.
Anne is working to address opioid misuse in what some may consider an unconventional way. She’s enhanced physical therapy instruction at West Virginia University to emphasize the physical therapist’s role in preventing and treating opioid use disorder. The reason why this is such an important topic is because the nexus of America’s opioid epidemic isn’t where most people would expect. It’s not in the big city such as New York, Chicago or Los Angeles. Instead, the hub of the epidemic is in rural states such as West Virginia. West Virginia has more than double the rate of opioid deaths in the national average and a 20% higher rate of opioid prescriptions written by providers.
On this episode, we discuss how to prepare future physical therapists to embrace advocacy roles related to opioid use disorder, the educational model and develop to guide physical therapy students regarding their roles across the spectrum of opioid use disorder. Also, how this model can serve as a guide for educating a variety of communities negatively impacted by the opioid epidemic, without further ado, let’s begin. Let’s meet Anne and learn how we can train entry-level physical therapists to address the opioid epidemic.
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Training Physical Therapists To Address The Opioid Epidemic From A Public Health Perspective With Anne K. Swisher PT, PhD, FAPTA
Anne, thanks for joining me.
It’s nice to be here. Thanks for inviting me.
As I was doing my rounds, looking at journals, there’s an early publication of a paper that you and some colleagues worked on. I wanted to invite you on the show and I’m thrilled that you accepted so we can talk about this important topic. I want to point people toward the paper first so they can read it especially if they’re a physical therapist or maybe potentially other healthcare professionals. The name of the paper, which appeared in the 2021 PT Journal is called Physical Therapist Roles During the Opioid Epidemic in Rural Appalachia: Preparing Students to Educate Communities. The paper is talking about the role of physical therapists in the opioid epidemic. There’s been a lot with regard to the prevention and how a PT plays a role on prevention. This paper went a whole lot deeper and gave lots of good direction for academics, those in clinical practice and CIs even and students going out into the field. First, tell us why you decided to take this topic and write about it.
A couple of things that probably started me off from the beginning. One is being a lifelong West Virginian and working at an institution that has deep roots within West Virginia and Appalachia. Anything that affects my state and my people gets my attention. West Virginia has unfortunately been badly affected by the opioid crisis and the epidemic. That desire to do as much as we can for the people that are affected. Even looking back historically as a cardiopulmonary clinical specialist, I’ve spent a lot of my career working with people who have cystic fibrosis. I was starting to see those patients that as they got into adulthood had pain complaints. As most adults do, your typical back pain and other kinds of things not disease-related but they were getting prescribed opioids, which, as respiratory depressants are one of the worst possible drugs that I would want those patients to be on.
Not only were they being prescribed these medications but I was also starting to see signs of addiction even in that population. That probably was the beginning of it’s like, “These drugs are problematic even in that population.” I’ve been working more with our cardiovascular surgery ICU patients and finding that addiction and the behaviors that has led to those people requiring cardiac surgeries that they didn’t before, the problems of managing their pain, if they already have addiction and then what kinds of pain medications. It became a challenge within my area of expertise. As an educator, that chance to look across all aspects of clinical practice and say, “Where are we preparing ourselves and our students as clinicians in all of these different aspects of chronic pain, the psychosocial and emotional issues of pain and how this seems to be a bad direction.” Long story short, that’s how I got started.
It’s a great story and a great way to start our episode here. Like yourself, I’m working in the State of New York. I’ve been a PT since ’96. Probably like most professionals who’ve been practicing for a couple of decades, we’ve noticed the use of opioids increase. For me, I noticed specifically after back surgery, particularly OxyContin. That was popular. You’re seeing it in cardiopulmonary, cardiovascular complications. You mentioned West Virginia, all of us as professionals, we can identify certain states, West Virginia being one of them. That was a hotbed of activity for the opioid epidemic. You noticed that yourself, was there a chatter interprofessionally in the state as to, “We’re seeing a tremendous amount of opioid use and misuse. We should start to pour some attention toward it.”
It got attention on a lot of levels from physicians and pharmacists, especially in small rural communities, it impacts everything. Even our students were coming in and coming from those communities. We would teach the basics of a pharmacology or signs of addiction, if you know anybody who’s had been affected with it. Most hands on a classroom would go up. It was someone in their family, someone in their community directly affected by this. It came back to us. In the health professional realm, as we were seeing that there were a lot of initiatives for decreased prescribing and let’s monitor more closely. What was missing is what’s the alternative either to manage pain or backing up to prevent pain or backing up even further to giving individuals skills and resilience in managing their psychosocial situations. As PTs, it’s not our sole area of practice but we get into that. Finding that these initiatives were missing those pieces that I felt like we could bring.
We’re getting into it more and more. It’s a topic that we talk about on this show and others as well. The ChoosePT Campaign became quite popular. That’s an alternative. I know the work that you’ve done in the curricula and with students has started to go deeper than that than just as an alternative. Instead of the opioid, you can do physical therapy. However, I firmly believe in and I’d love to hear your thoughts. The problem that has been created is so large. That’s going to be, probably in my lifetime, we’re going to have to deal with this problem because addiction can be long and challenging. People can sometimes come in and out of it. What’s the role that you see as physical therapist in the opioid epidemic?
I love the ChoosePT Campaign. It was slickly done, nicely marketed and gave a direction to point people but I felt like it was limited to predominantly musculoskeletal. Seeing from my background with the cardiopulmonary folks, we already have these people. We can’t say prevent because they’ve already had some experience with opioids and they’re challenged with that. What can we do to help people who are struggling with their abuse problems or their overuse problems, help them get into recovery and help them stay in recovery? That’s through healthy lifestyle, finding ways through using movement and that’s our area of expertise, using the movement medicine concept of “I feel better because I’m not sedentary so much. I have feelings of accomplishment and self-esteem because I was able to get in better shape or I have skills to manage the pain that I can’t completely get away from but I’m not going to catastrophize,” and seek that escape that the opioids tend to give you.
That was the impetus for putting together the big table in that article which looks at the stage of the opioid use disorder. Prevention, what to do concurrent with management or getting out into recovery and then maintaining recovery. Breaking that down even further to look across common issues in lifespan. What are issues in children to elderly? For our own physical therapy colleagues, bringing your area of expertise. Maybe you’re a neuro-sports person and you love working with concussion. A lot of your patients have post-concussive headache. Non-pharmacologic stuff there plays a role in this whole thing. Maybe you’re a pelvic health therapist and women who are pregnant have musculoskeletal stuff and postpartum then we can help to avoid going that direction.
I’m happy you mentioned that table because as I’ve read the article, lots of great content in the paper. That table stood out to me. What you’re saying is 100% sure that ChoosePT Campaign was targeted toward musculoskeletal pain, towards traditional ortho therapists but talks to a lot of therapists in general, then you go through the paper and it’s like, “Women who were pre and postpartum may fall victim to opioid use or misuse.”
An individual who’s had a stroke and has chronic shoulder pain. What kind of alternatives? Try to think as broadly as you could.
I had a picture in my mind of all these different channels where someone could, without education and without help thinks, “This is the only solution to my problem,” and therefore become addicted or potentially misusing opioids. I thought that was powerful. Everyone can check that out in the 2021 PTJ article. The paper goes beyond prevention. You’re talking about physical therapists having a key role in opioid use disorder which hasn’t been spoken about and hasn’t been written about in the literature so much. Julia Chevan, I know you quoted her article. Your paper goes a little bit deeper than hers does.
I have a colleague from many years ago who was in practice in rural West Virginia for a long time and understood the challenges of that. He ended up working as a PT in an inpatient addiction recovery unit. Working with him as one of the collaborators here, “What are you seeing as people come in in that moment? What things could they benefit from having a physical therapist?” It’s the musculoskeletal pain but it’s also the overall deconditioning and the lack of understanding about the pain science pieces. All of that stuff that’s in contemporary curricula saying not just prevent but, “If you’re on it or you’re challenged with an unhealthy relationship with opioids, sorry. It’s too far gone.” There’s still a role for us across that spectrum.
It’s opening a conversation up because now, if you ask the physical therapist, “Can I treat addiction?” They would say, “I don’t treat addiction. That’s not within my scope of practice.” We don’t diagnose addiction. That probably belongs mostly in the mental health realm. However, we know that the body impacts the mind.
The contemporary model of PT education is working in that interprofessional team. While addressing addiction directly is probably in the mental health realm, if you talk to mental health practitioners, they will say, “I need to get my patients physically active.” That’s part of their mental health. We can go the other way. When you feel good, when you’re moving, you’re getting those endorphins released, your natural opioids. It works on the mental health as well. Going back to working with some challenging situations, one of the ones that I’ve been involved in quite heavily is working with people with cancer throughout their cancer journey. Even all of the opioid guidelines, we group out completely. “We should prescribe this.” Unless you have cancer and then anything goes. There are no guidelines in there but we know in working in the field that not everybody who has cancer needs an opioid treatment. Maybe they don’t, it’s a surgical recovery and get back to life. Maybe they do but can we minimize the usage or can we control that in some ways? That’s working together with the prescriber and managing pain even in those unique situations.
I had a couple of interviews about mental health in rural communities. I had a chat with Dr. Lilian Dindo. Everyone can go back and read her episode. She does small group act in the community in rural communities. After the show, her and I were chatting. She said, “We don’t have enough mental health professionals in rural areas to treat patients.” It’s a little bit idealistic that we’re always going to have an interprofessional team because sometimes that’s not there in rural health or it’s not there based on insurance reimbursement. A PT who’s seeing the patient may be their only access to effective pain care. The work that you have laid out in the article helps a PT realize, “There’s a lot that I can do without having to ‘diagnose the person’ as having an opioid use disorder and help them on the road to recovery.” That’s powerful in your paper.
PTs, for a long time, are used to working with pain medications, not just opioids but any of them. Imagine after surgery, it’s like, “You need it now. You need that tomorrow. I need to go down on your dosage.” Those kinds of things as your body recovers. Especially the emphasis now on educating our entry-level colleagues on some basic pain science, that needs to be in every PT program curriculum or strategies of motivation. While we’ll apply them to movement, they’re not unique to movement. If people can learn some of these skills to manage their movement or their physical activity, they may find that, “That also helps me set goals for a healthy diet or set goals for healthy relationships.” We’re not going to go outside our scope. A lot of the skills, once you learn the skills of resilience, goal setting and those kinds of things, apply across a lot of different issues.
Any physical therapist, we’re getting better at it but we don’t realize the cognitive behavioral skills that we have. We can generalize that not just to pain but to other lifestyle conditions. Addiction in some ways may be a lifestyle condition for some people. You mentioned the curricula a number of times. You’re a University Professor for a long time now. I did a little bit of research before looking at CAPTE, the Commission on Accreditation in PT Education, going on their form which is public. If you go in there and you put in keywords opioids, addiction, opioid use disorder, nothing comes up.
I’m not surprised.
I figured you wouldn’t be surprised because you’ve done some research on this. If I type in the word pharmacology, it does come up as one of the seven key elements of PT education practice, which is key. When I looked at it, it was written within the context of almost pharmacokinetics. There was nothing under tests and measures so screening for opioid use disorder, which sounds there’s a bit of that in your paper. I’m wondering, we don’t have a whole bunch with regard to pain education in CAPTE. It’s there but it’s minimal. Do we need to include some information with regard to opioid use disorder in CAPTE regulations?
You always run into a challenge with accreditation guidelines. Not being able to stay as current as you might be in practice. For example, there’s not going to be anything in CAPTE guidelines about Telehealth but we got thrown into it. As an educational program, you have to balance meeting those criteria that the whole profession has decided that’s minimum, we need to meet those. Also, responding to what’s going on in your environment, in your society at that time. When a polio epidemic came out then everybody learned everything about polio. Now, maybe even not so much of an emphasis anymore but we have to go with those trends.
One of the things that our group tried to do in the paper was to say you don’t need to create a new class on opioid use disorder because you’re teaching elements of this throughout the curriculum by meeting certain CAPTE standards. That was my message to other educators. If you want to pull this together, don’t worry about having to teach a whole new thing but providing this framework. You say, “Trace this through and then find opportunities where you can use case examples, discussions, guest lectures or something to pull that stuff together.” Instead of saying, “We need to teach a whole new content and create another course or curricula. We’re dealing with the challenges of the time that it takes to be a DPT.”
Lots of content in there and always challenging to pull something old out and put something new in. One of the refreshing parts of your paper is you put this into clinical practice. Your students went out into the field and did some outreach projects. I believe that was part of their affiliation, their internship. Can you talk us about that and maybe tell us those projects that stand out that were well received by the student physical therapist as well as their CIs?
We are the West Virginia University so we’re funded by the people of West Virginia. One of their full-time clinical rotations has to be in a rural community. That had been established for a long time. They also had a requirement of doing some community education project. We pulled what was existing and not creating a new thing that students had to do. Let’s take what you already have to do and see if we can match with your interest and your community’s needs to say what piece of this puzzle might fit for where you are in your community and your interest level. Unfortunately, the rollout of this coincided with COVID but our students and their clinical instructors are creative. A lot of this happened virtually as opposed to go to the senior center and talk to a group of 30 people about fall prevention.
If you don’t fall, you don’t have injuries, you don’t have pain, you don’t get on opioids. It became a little more creative to try to do that. They were able to put some information on a clinic social media site. There was a lot of interest in some of the unique pieces like a prenatal exercise class for teaching moms not only exercise safely now but how to manage your babies, so they don’t have pains. Early mobility programs, a more critically-ill population or in ICU survivors how to use movement as pain prevention. They’re a creative bunch. With the guidance of clinical instructors living in those rural communities and knowing what some of those challenges are, they’re putting together some nice projects. We have to see. That’s still ongoing.
It was great to see that in the paper that you’re taking that from the academic setting and it’s going right into their clinical internship, which is great. I would love to even talk to one of them on the show and see what their experience is with bringing that to the clinic knowing that it’s something new yet it’s something probably meaningful and important to them as citizens of West Virginia. It’s great work. That’s why I wanted to invite you on. It’s been great talking with you. I’d love to hear any plans of what you plan on doing with this work in the future, more papers, more studies or deeper studies. Let people know how they can continue to follow your work.
We’ve been fortunate that the work we’ve done so far has been funded as part of the State Opioid Response Grant, which every state received some degree of federal money to help rollout, address this problem. Our State Health Department solicited projects and they thought this was a unique one predominantly because we were about the only ones addressing prevention. That’s a hook to get in there and to get more PT colleagues at the table with those discussions. Some of the challenges that we’ll have coming out of this is figuring out how to document whether we’re effective or not. How do you document prevention of opioid use? That’s a little more challenging but you can look at things like, “Are you driving any traffic and direct access to local clinics? Are people hearing about this? Are PTs then being represented on various teams that are looking at addressing the opioid problem in communities?” That’s yet to be seen.
As we look at the feedback from our students who’ve rolled out this first stage of the project and see how they were received, what kinds of audiences seem to be receptive to this or not receptive to this and what kinds of formats, hopefully we’ll at least be able to put out some of those examples of projects that our students had been doing with that? Everybody’s focus got diverted to the pandemic, what is COVID and what’s happening with us. As we began to see a light at the end of the tunnel of that and coming out of this epidemic, I’m unfortunately thinking that the opioid use epidemic is going to be even worse than it was before.
The social isolation is a big issue. If you start with individuals who are dealing with emotional pain and that’s why they have a tendency to seek the escape that they can get, that unfortunately may be even more of a challenge. I’ve seen literature showing that somewhere between 10% and 20% of COVID survivors who went home were on opioids and we’re continuing to be on opioids long-term. There’s even an issue potentially there in that population. That’s beyond where we were putting the model together is looking at a whole new population that can use as we help them recover their physical function, mobility, decrease their pain, anxiety and all those things that we can do.
The awareness that has been raised around the COVID pandemic and opioids both prescription and illegal drug use with regard to it. It’s there and the research is building. We’re well poised and we have some experience based on some literature you’ve done, some of the work all of us have done in the practice that we can say, “Before this gets out of control, let’s intervene with effective pain education, physical therapy, the promotion of physical activity and healthy lifestyle for those to recover.” If they have to be long copers of COVID, which some people are then we have a place at the table for that without a doubt. Like previous pandemics, physical therapists were there and enforced to help people. They’re all wonderful points. As your work develops, please come back and update us on it both here on the show and share with me. I’m always sharing interesting things on social media that people click on and link to. It’s been great chatting with you. How can people reach out to you in the future?
If anyone is interested, they can reach me at West Virginia University. My email there is, [email protected]. People can reach out to me if they’re interested in learning more about what we’re doing or continuing that conversation.
Make sure to check out the paper in the 2021 Physical Therapy Journal. The title of the article is called Physical Therapist Roles During the Opioid Epidemic in Rural Appalachia: Preparing Students to Educate Communities. At the end of every show, I ask you to share this information with your friends and family on social media. It could be LinkedIn, Facebook, Twitter. It could be a Facebook group, wherever anyone is talking about the effective and safe treatment of chronic pain, opioids and opioid use disorder. Thanks so much for being here with us.
Important Links:
- Dr. Anne Swisher
- ChoosePT Campaign
- Dr. Lilian Dindo – Past episode
- Commission on Accreditation in PT Education
- [email protected]
- https://WVUToday.WVU.edu/stories/2021/04/08/-pain-is-always-a-perception-physical-therapy-can-help-prevent-treat-opioid-use-disorder
- https://Academic.OUP.com/ptj/article/101/2/pzaa215/6044309
About Anne Swisher
Anne K. Swisher PT, PhD, FAPTA is Professor and Director of Scholarship for the WVU Division of Physical Therapy. She has been a board certified Cardiovascular and Pulmonary clinical specialist for 20 years and has taught in the area of cardiopulmonary physical therapy, exercise prescription and pathophysiology for 26 years. She has practiced and consulted in critical care, acute care and oncology settings. She is a Catherine Worthingham Fellow of the APTA and has over 80 peer reviewed publications. She has twice been awarded Fulbright scholarships for her research and teaching. She is the past Editor-in-Chief of the Cardiopulmonary Physical Therapy Journal.
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