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The number of people who have died due to drug overdose in this country is absolutely astounding…but most of us can’t relate to a number of that magnitude. Despite the common occurrence of addiction, there is still an overwhelmingly shameful stigma of substance abuse in America.
I want you to think of someone you know who has suffered because of a drug overdose.
I have a particular patient I am thinking of right now. I walked into his mother’s house (I was doing home health at the time). He had been in the hospital for months which saved his life after an overdose…but he wasn’t actually there.
His mother had already lost another son to an overdose. Yes, this was her second son who overdosed. So she brought him home with ALL of this medical equipment necessary to keep him alive. Respiratory, suction equipment, hospital bed, GI tubes, and IV lines. It was too much for one person in a hospital to manage, let alone a non-trained mother living at home by herself. His hands, knees, and feet were stuck in contractures.
It was gut wrenching.
And adding insult to injury is all the stigma of substance abuse that surrounds this experience. The additional shame that this woman and mother unnecessarily experienced as a result of something terrible that happened to her son and herself.
It turns out that depression and anxiety occur alongside addictive drug behavior. Can we say that depression and anxiety cause substance abuse? That we don’t know for sure, but there are many tools to help with anxiety and depression, which are non-medicated. It just so happens that exercise is one of the most effective options.
When recovering from substance abuse, a person may have experienced and developed several different physical impairments. These can range from muscle atrophy, lower cardiorespiratory fitness and diminished aerobic capacities. Physical therapists are in a prime position to help individuals in this phase of their recovery.
But being able to support each person with compassion and kindness is the key to creating a change in our country. By creating a safe space and environment for someone in recovery to exercise and regain their health we help to lessen the stigma of substance abuse for everyone.
Physical therapists have so much in their professional skill set to change the stigma of substance abuse. But, there is still more we can do. PT as a profession has the capacity to effectively reduce the occurrence of addiction by providing non-narcotic pain relief options which are safer, less costly, and more effective.
For the people who have already suffered from addiction, we can create a safe space for them to fully recover and get back to a life they are excited about.
Dr. Ginger Garner recently sat down with Dr. Eric Chaconas to talk more about substance abuse, stigma, and the role of physical therapy.
For those of you that prefer video, watch this discussion about prevention and wellness in orthopedic physical. You can listen to it on our podcast, Living Well.
Additionally, check out the chapter he co-wrote with Dr. Rose Pignataro “Tobacco Cessation, Substance Abuse, and Recovery” in the book, Integrative and Lifestyle Medicine in Physical Therapy.
Eric Chaconas is the Chair of Physical Therapy Programs for Bellin College in Green Bay, Wisconsin. Dr. Chaconas teaches courses on the topics of differential diagnosis, research, exercise prescription, imaging and orthopaedic manual therapy. His research interests are focused on best practices in musculoskeletal rehabilitation and he teaches continuing education seminars through the Institute of Clinical Excellence.
0:00 Dr. Ginger Garner: Hello everyone and welcome. I am here with Dr. Eric Chaconas and before we jump right in, I’d like to do a little bit of an introduction for him. Eric is the chair of the physical therapy program for Bellin College in Green Bay, Wisconsin. He teaches courses on the topics of differential diagnosis, personal favorite, research, exercise prescription, imaging, also another personal favorite, and orthopedic manual therapy. That’s a lot. His research interests are focused on best practices in musculoskeletal rehab and he teaches continuing education seminars through the Institute of Clinical Excellence. Welcome Eric.
Dr. Eric Chaconas: Thanks, Ginger.
Dr. Ginger Garner: I’m glad you’re here today. So I’d like to start out with a basic question because I’m curious and our listeners are always curious. What brought you into physical therapy? How did you get into this crazy profession?
01:02 Dr. Eric Chaconas: I always had a passion for exercise. That was kind of my thing growing up. So I found exercise science as a major in college and just thought that that made sense because it was really my passion area. And then through that, kind of, you know, how it goes, you’re in college and you work different jobs and stuff like that.
So, there happened to be a PT clinic right by campus where I was going to school in North Baltimore and worked at that PT clinic as an aide for a couple of years while in college and just learned so much from the physical therapist there. I really enjoyed it. And so, you know, having that experience and seeing firsthand what they were able to do for people really drew me to the profession. I mean, I remember within the first week of working as an aide being like, this is what I want to do. This is the career for me. Because you see this, you know, people come in with pain and all sorts of limitations and challenges. And then to see this individual help them along the way without drugs, without surgery, just using their hands, talking, communication, and education, and exercise. I thought it was really cool, and was the profession for me.
Dr. Ginger Garner: So what was the clinic? Was it musculoskeletal, outpatient? It was outpatient ortho, yeah?
02:17 Dr. Eric Chaconas: Yeah. Yeah. Ron Herbst in Towson, Maryland. And Ron was an excellent physical therapist, had a lot of strong manual therapy background. And he, I just learned so much from him and everybody there. But yeah, he would see a lot of low back pain, knee pain. He was very good with sports type ACLs and kind of stuff like that. So yeah, that was a really good experience early, early in my pre career, I guess you could say.
02:40 Dr. Ginger Garner: Yeah. Yeah. You’re making me think about my early memories of volunteering and getting hours and the first outpatient ortho clinic that I volunteered in, that’s taken me way back. You know, in reading some of the stuff that you had written, one of the phrases that you wrote, which kind of stuck with me is our country will need us more and more as problems continue to manifest like rising costs in healthcare, poor outcomes, etc. Can you expand on that a little bit?
03:15 Dr. Eric Chaconas: Yeah. I mean, that’s why I’m so excited to contribute to the lifestyle medicine book. And I think that area of practice is really where we’re needed now. And so I think that we know, right, that this retrospective approach to healthcare where we are basically treating everything as it is in a level of severity that almost is unmanageable. And so that doesn’t make any sense. It makes sense to have a preventative approach.
And so I, and who, who is going to do that and which healthcare providers are going to offer that? It’s very exciting to see physical therapists stepping up and taking on that role. And so, I mean, I just don’t, I don’t see this as sustainable. The current model, everybody knows that, everybody knows that. There’s nobody that I think would argue with you, you know, about that. The question is, how do you fix it and what’s a better model of care? And I think the physical therapists that are practicing with this lifestyle medicine approach, those are the ones that really do have some of the answers.
04:12 Dr. Ginger Garner: Yeah, absolutely. I mean, totally preaching to the choir here. For those of you who don’t know, Eric wrote the chapter on tobacco cessation, substance abuse and recovery. That’s a huge issue in our country today. I was just on with Joe Tatta. We were doing an Instagram Live just a couple of minutes ago, and we were talking about that, us being a very, perhaps over-medicated society and abusing meds in various ways. Ways that aren’t supported by the literature and that aren’t really effective. And we see that every day. I happen to, unknown to me, get thrust into one of the hardest hit areas for the opioid epidemic, and that was kind of my introduction to, you know, PT was just getting kind of slapped in the face of, holy cow, everybody coming in is on some kind of pain med. So we do have a big addiction problem, and that’s not arguable either. That’s obvious. So I think my question would be, you know, you heading up the program, it’s a new physical therapy program, right? Yeah.
05:30 Dr. Eric Chaconas: Yeah, I always say Green Bay, Wisconsin is the only city in America that has an NFL football team and no PT school. So we are really awesome. Bellin College is just a wonderful nonprofit, very small school that has historically trained nurses and sonographers and other health care providers, but never physical therapists. And so we had a fellowship program. We have a DSC program that we started a few years ago and then just recently just started our first cohort of DPT students. So we’ve got 23 of them. They’re taking a lifestyle medicine course right now. I was a guest speaker in that course yesterday talking about the opioid crisis and talking about substance use disorder and kind of how to screen for it. And we just couldn’t be more excited. We have 23 amazing people that are really working hard and they are adopting this model of care, this lifestyle medicine type of model of care. We have a very contemporary approach to our curriculum and have a lot of nutrition. You know, we’ve hired a nutrition consultant who comes into four different courses to teach nutrition topics to our students and everything that is in your book, the book that you and Joe edited, is very much in our curriculum.
06:38 Dr. Ginger Garner: That’s fantastic. I was about to add, you know, the excitement of having a new program, the freedom and opportunity that you have there when you’re creating a new program is really exciting to me. Like in North Carolina, I believe we had nine, we have nine PT programs. I don’t know how many programs are in Wisconsin, but that is surprising that Green Bay had no PT school.
07:02 Dr. Eric Chaconas: Yeah, it’s an interesting state. Most everything is more condensed to the southern portion of the state and so around Milwaukee and then some of those other bigger kind of areas in the southern portion of state, you do have a number of PT schools. But then when you go north, there’s really nothing up there. And so we did a really pretty big survey on all the employers in the region. Northern Wisconsin, the Upper Peninsula of Michigan is very much an underserved area, very hard to retain physical therapists in that area. So our goal is to recruit kids that are from those areas who go to college or from those areas and then have them go to PT school with us and then hopefully return home to their communities, really small rural part of the state.
07:40 Dr. Ginger Garner Awesome. So that was going to be my next question. You totally answered it, which was what kind of cool, awesome things are you doing in this new program that are incorporating this way of thinking?
Dr. Eric Chaconas: Yeah, we hit the nail on the head. Or like the most fun thing I’ve ever done in my entire career, creating a new PT you can take because I was teaching for years in entry level education as well as a number of the other faculty that are in our program. But to be able to have a clean slate to hey, you can do whatever you want, create what you know, within the CAPTE standards, create whatever type of curriculum you want. And so that has been an absolute blast. We think of like, what’s the future of our profession? What are these new professionals really need to be able to do? What’s their skill set need to be? And so, you know, a lot of the old stuff that we used to teach, you know, is really not there. And it’s very much a modern, preventative. I mean, we have one course title lifestyle. It’s actually a lifestyle medicine in physical therapy practice. That’s a course. And so it’s really cool having, you know, integrate stuff like that.
So I know that you practice sonography. So like in our imaging course, we have we’re really lucky that we have a sonography program on campus. But to have our students go to the sonography lab and they get about it’s not a lot, but, you know, 20 hours worth of sonography practice. So learning MSK sonography, which we believe is a future of the profession. That’s another good example. And then the other the real game changer, I would say that we’ve been able to do is create partnerships with all the local PT clinics and then have our students one day a week for the entire first year of the program out in the clinic. So if you learn how to mobilize the shoulder joint on Monday and your orthopedics lab, you’re going to do that on a real live patient on Thursday when you go out in the clinic for your integrated clinical learning.
09:24 Dr. Ginger Garner: That’s fantastic. It’s such a different model than I went to school in 1996. So there was no training in imaging. We had nothing in prevention. In fact, it made me want to quit PT school. And I almost I seriously considered quitting PT school because there was nothing on prevention. And so instead of quitting, I ended up in the School of Public Health simultaneously as the division of physical therapy in the School of Medicine.
But it’s so awesome to be able to see this in my career in this twenty five years that have passed by to see now that this is just going to become a natural part of new programs and that existing programs, especially the big old programs like one I went to, which is UNC. So, UNC I’m telling on you a little bit. There was no prevention and health promotion. But that was probably true of so many programs, you know, in 1996. So some of the bigger older programs were bigger wheels, you know, turned slower. We’ll begin to adopt these things. It’s because it’s so incredibly important. We’re moving away from that acute care model of what physical therapy was historically built on. We’re not treating polio anymore. We’re treating chronic disease and persistent pain and these wicked problems, which brings up the issue of addiction. So tell me a little bit about, you know, what excited you about writing this chapter on substance abuse? Yeah, let’s stop. Let me start there because I’ve got like three or four questions. I don’t want to go all at once.
10:54 Dr. Eric Chaconas: Yeah. So, I mean, my background, I at one time went into and helped in an organization where we would go into addiction recovery centers and treat patients as physical therapists. And so, as you can imagine, a lot of people in inpatient recovery who are recovering from addiction to opioids or other drugs or alcohol oftentimes have musculoskeletal pain. And so we had a very kind of traditional physical therapy model of treating them, but in that setting. And so that really got me kind of in this world of learning more and more about substance use disorder and all the different ways that it’s managed.
But, yeah, I mean, the number one issue that we have is really that it’s one of the most under-treated diseases in our country. So if you look at the percentage of people who suffer from substance use disorder, but actually go to treatment, it’s a very, very small percentage. And so unlike most other diseases like diabetes or heart disease, which obviously get treated. Substance use disorder goes untreated. There’s a stigma around it. So it prevents people from talking about it, prevents them from seeking treatment or help. And so because of that, really, it’s a severity thing, right? It typically gets treated when it’s in its most severe state and when somebody’s basically gotten into legal trouble. And so the criminal justice system is the primary referral source for substance use disorder treatment, not the health care system. I mean, 99 percent of all cases of substance use disorder treatment come through our legal system in the United States.
12:25 Dr. Ginger Garner: So that our reactivity as a health care system just makes you hang your head, right? Because that’s what we’re doing. That’s what you’re describing is chronic reactivity and knee jerk reactions that happen only after something is full blown and then very, very hard to treat.
So, let’s say we have a clean slate, you know, in recreating what our health care system looks like. How do you see us moving from a place of reactivity to one of proactivity? Because that is a lot of what’s included in your chapters, things on screening and things like that. So in your ideal universe, what do we do to go from reactivity to proactivity?
13:05 Dr. Eric Chaconas: I think first and foremost, providers have to really get good at reducing the stigma. And so in our own lives and our own personal thoughts, you know, understanding the brain disease model of addiction, understanding that good people, bad disease, right? Because I think a lot of people look at somebody who’s had trouble with alcohol or substance use disorder as a bad person. Right. And like, so that’s not obviously not true. Good people, bad disease is what we usually say. And so the symptoms of that disease are oftentimes bad behavior. And so the stigma is really important to address that and to create a safe space in our clinics where we can talk with individuals about substance use disorder openly and make them feel comfortable.
Trust is one of the most important things when it comes to this, because so many people who do suffer from addiction or substance use disorder, they do have a history, right? They have a history of maybe trust issues or legal trouble. Or there’s all sorts of, you know, everybody’s worried about losing their job and losing their family if they talk about their problem. And so I think creating a safe space is probably priority number one.
But, yeah, the screening component to it and making good referrals, because not everybody needs to go away to a 30 day inpatient rehab facility. Right. Sometimes it’s a simple thing as a physical therapist having a relationship with a local treatment center and getting people in the right hands for treatment, because it is a complex condition and really does require, you know, multidisciplinary approach. And so having those relationships and those referral patterns is really important.
14:42 Dr. Ginger Garner: Yeah, absolutely. To repeat what you said, because I think that everybody needs to hear this everywhere is good people, bad disease. If it doesn’t take much of digging into the literature to realize that a lot of people with addiction issues also suffered from adverse childhood experiences or ACEs. Can you talk about how you’ve you know, you’ve run into that in your work that you’re doing and how we can be prepared? Now, of course, in our book, we have a book chapter on psych informed physical therapy, because that’s part of it. But tell me a little bit about your experience in working with people with addiction and ACEs.
15:21 Dr. Eric Chaconas: I don’t think I’ve ever met anyone in that facility that doesn’t have some type of history of trauma and shot. Yeah, like you said, you know, the childhood experiences that we have that influence so much of this mental health. I mean, when you look at the literature, the correlation with mental health, various mental health conditions and substance use disorder is very strong. One thing that we know is that the younger that you abuse, even even things like alcohol, tobacco and marijuana, the younger that you use, the more likely you are to have substance use disorder as an adult. And so all of those things definitely impact, you know, the outcome and impact people in their adult lives and how they suffer from these different conditions.
16:09 Dr. Ginger Garner: And I’ve also. In reading literature, we know that the earlier people suffer those childhood experiences, so the earlier the trauma and the more frequent the trauma, which makes sense, totally makes sense. But the earlier they experience a trauma, the more likely they are to go on to have problems, which means if it was very early, they may not they may not have, you know, memories or recollection of that. And then it begins to be very hard because you can’t just say here, here’s an ACE inventory, fill it out and let’s see what happens.
So it kind of begs for us all to be trauma informed in what we’re doing, and to be psych informed in what we’re doing and to be really sensitive, I think, in like you mentioned, creating safe space in order to even get to the point where you can screen and ask about alcohol or tobacco or any, you know, street drug use or anything like that.
So if you were going to pull one thing out of the chapter, one kind of clinical pearl, I guess, if you will, what would it be?
17:27 Dr. Eric Chaconas: Well, I love the treatment side, because that’s really what we did when we would go into those facilities is provide treatment. And so, you know, we have just we saw so much success with these exercise based programs, helping people reduce their symptoms, but then exercise based programs that was just so complementary to the recovery program. And so, you know, we’re improving sleep, we’re improving abstinence. People are eating better. They’re feeling better. And it’s such a hard thing when you get after detox, you know, usually the first few days of being an inpatient rehabilitation, there’s a period of detox. And then after that, it’s a pretty rough road of withdrawal for the next two weeks. And you’re trying to learn this new normal and learn and, you know, develop the strategies and skills and really take an inventory. I mean, they’re addressing a lot of things. It’s very complex and it’s very multi-disciplinary. There’s all sorts of different providers all kind of chiming in.
But exercise plays a critical role in all of that. And it really is a variable that can’t be skipped. And so I think if I’m a physical therapist and I have a practice and I’m, you know, growing that practice and I’m looking for opportunities, first thing I would do is reach out to the local recovery center and see if they need help. You know, is there anything that I can do for your patients? Can I? And sometimes it’s not going in and providing physical therapy. Sometimes, it’s group exercise. Sometimes, it’s not a traditional physical therapy type of model. Sometimes we have to put our strength coach hat on or, you know, our exercise hat on. And sometimes it’s just getting everybody moved. But having that expert physical therapist doing that is really helpful because it’s not, you know, when somebody has an ache or pain in class, being able to go and screen them and look at them. And it’s not like you’re teaching a kickboxing class for a group of healthy 45 year olds. Right. This is a more challenging population. And so having that health care provider, that physical therapist in that role is really important.
19:25 Dr. Ginger Garner: Yeah. Because, you know, the mental health piece of that, if they’re struggling with, you know, anxiety, depression, or a number of things is related to their sleep quality, is related to what they’re eating and their gut health. Since a lot of the serotonin is produced in the gut, we think about, you know, supporting that through healthy nutrition. So there’s multifactors. Right. Or that same physical therapist could be teaching mindfulness based movement or just seated chair based mindfulness period to change that stress response.
So that brings up another question that I was thinking of while you were talking about these things, because you mentioned multidisciplinary and between the two of us, we’ve kind of listed all the facets of lifestyle medicine and then throwing the mindfulness piece in there of integrative medicine. So in working in those facilities, what kind of brought you into integrative and lifestyle medicine or what was your entry point into that? Where you are like, we can’t not address sleep. You know, we must address nutrition. Where did that come in your career?
20:33 Dr. Eric Chaconas: I think I think like most people, I’ve kind of noticed this trend lately. And so, you know, I’ll be at a conference and I remember hearing Joe do a presentation at an APTA conference not too long ago, a couple of years ago. And that kind of piques my interest. And you hear other people that are kind of working in this space hear about it. And so, yeah, by no means did I graduate PT school thinking about this. And, you know, I think I probably am a late adopter like most people. But you’re absolutely right. I’ve seen in really high quality facilities this comprehensive multidisciplinary approach with a nutritionist. Obviously, there’s lots of counselors and people doing the same thing.
There’s lots of people doing 12 step work and stuff like that. Psychologists, psychiatrists, physician, physical therapist. You know, we have even even a yoga instructor. And then we would have all sorts of other providers come in and provide care like acupuncturists, you know, alternative medicine. So, so, yeah, no, that was maybe five, six years ago. And I would say that’s around the time that I probably started noticing all this trend in the profession. You’d have to be asleep right now to not notice it. I mean, every journal, you know, I mean, it is really popular now. And so I think I’ve kind of I’ve evolved along with that trend in what we see in our profession.
21:48 Dr. Ginger Garner: Yeah, I always love to hear people’s kind of origin stories of that because we get pulled into it in so many different ways.
21:59 Dr. Eric Chaconas: Yeah, I might be. I mean, I’m a pretty traditional musculoskeletal orthopedic, you know, PT who’s kind of been in that world all the time. But I pay attention to the pulse of the profession and what’s going on. And when you see people having success and also talking to people with private practice who integrate, you know, who have this type of practice, a lifestyle medicine practice, you start noticing and you say, you know, wow, this is, there’s something here, I need to be better. I need to be more well rounded and I need to learn this approach.
22:23 Dr. Ginger Garner: Yeah. And when we experience it ourselves, so, you know, anyone listening has had a crappy night of sleep and then how did you feel the next day? Were you mentally foggy? You know, how did you feel it worked? Could you really focus, et cetera? So I don’t think it, we don’t have to throw that stone very far to like hit something that, you know, really sticks and lands for someone because we felt it ourselves, we, you know, what, we know what it’s like, that’s for sure.
So what do you think, obviously integrating this into physical therapy practice, it’s not an if, it’s a when, and it’s an urgently, you know, kind of, it’s an urgent situation because of what we’re facing in the United States, where we have the most expensive health care system in the world, but the worst outcomes, unless you’re incredibly wealthy and even then it might not matter. We still have questionable outcomes. So obviously we have a system that’s not well aligned to integrate this into it because reimbursement models, you know, pay, et cetera. So in your experience, you, you’re a clinician, you’re an educator, you’re a researcher, what do you see is, you know, the, one of the biggest challenges that we face as we move forward?
23:44 Dr. Eric Chaconas: I mean, I think you said it – reimbursement. I think payment, payment dictates practice. I heard somebody say that once. I thought, well, that’s pretty smart. And so until we have a model where the, the third party payers understand the benefit, right. And, and believe that this is a worthwhile investment. I can’t picture it changing. I mean, outside of the cash pay model or the direct to employer model, which is a really effective model that you see, there’s lots of examples of that. And so those are probably the solutions in my experiences that I’ve had with the Florida physical therapy association, where I was very involved in advocacy and payment reform and stuff like that.
That is one of the most frustrating things you can ever imagine is trying to negotiate or work with an insurance company who doesn’t see anything other than the bottom line. And so, yeah, I don’t have a lot of a positive feeling about that. You probably know better than I do. And I, and I, but I do think this trend of the cash pay model and this trend of this direct to employer model, maybe that forces the hand of some, you know, the system, I don’t know, but that’s what you, what you hope.
24:59 Dr. Ginger Garner: Yeah. You bring up a really important point about corporations changing the flow of things because they can, they carry that much power. Apple or Microsoft or whomever it may be can decide, Hey, integrative and lifestyle medicine, you know, that’s our new MO, that’s our status quo, and we’re going to build our programs around that. And that can definitely, you know, hold heavy weight because when the corporation weighs in, everybody pays attention. So I think that’s a really important point to, to hang onto whether you’re a consumer, you know, if you’re, whether you’re just a person looking for a job, or you’re a physical therapist also looking for a job, or you’re a new PT looking about, you know, where your opportunities are.
25:41 Dr. Eric Chaconas: Yeah. You know, when I go around, I teach, I was for a number of years teaching continuing education, live in-person courses. Now I just do stuff online, but for you, it was amazing. You travel these, I’d go to California and I remember going to a course out there. All these PTs that are taking the course, they’re like, yeah, I work at Google. I’m a physical therapist at Google. Like I’m hired by them. I was like, that’s amazing. And you just get people in these big companies, Nike and Boeing and all these companies that have in-house physical therapists, they realize how much money they’re saving and how much better and healthier their employees are when they have that model.
So I think that trend, perhaps that trend continues. And then those physical therapists realize I can do a lot more outside of traditional orthopedic rehab, if I integrate this lifestyle medicine approach to the company, to what I’m doing with these employees. And so that’s pretty cool. And then I can think of a number of physical therapists who have businesses where all they do is contract with medium to smaller sized companies, go and provide that same service.
So the company isn’t actually employing the physical therapist, but the physical therapist is a contractor with the company to go out and provide care. Right. And I think that it’s part of our future. It’s part of our future and it’s, it’s jobs and opportunities in places that you and I, you know, would have never dreamed about when we first started out, you know, in physical therapy. So it’s very exciting for the students, you know, coming out now. They can think about opportunities that, that didn’t exist before. I think that we’re going to continue to have challenges with reimbursement. We’re going to continue to have challenges with pay.
And I think that’s part of the growing pains too of I remember I was the first master’s degree class at Chapel Hill. And now, you know, Whoa, it’s a, it’s whiplash, right? Things have changed so much. Everything is, you know, doctoral based and everyone’s doctorally prepared now, but there’s a lot of catch up that still needs to do around that, including educating the public about what we do and also expanding practice rights where it’s very well warranted, like in the areas of imaging, being able to order imaging, being able to do and in North Carolina, we’re pretty fortunate. We have, you know, dry needling rights and we’re, you know, discussing imaging now and things like that, like many other States are. So I think there’s a lot of, um, hopeful conversation to be had.
There’s a lot of potential. I say all that to attract, um, awesome, you know, college grads who are looking or considering whether or not they’re going to, um, join us in physical therapy. I think there’s, um, there’s a lot of reasons to be hopeful about that.
Taking an exhale and just taking a moment. You talked about, the clinical pearls from your chapter. Is there anything for the therapist, um, or person who is listening that would be easy for them to, cause you talked about treatment and screening. If you were talking to a physical therapist now, what would you suggest that they do? What’s the, what’s the most, um, you know, best evidence way to intervene? Um, I have an idea about what you might say this on the literature, but tell me about that and then on the other, and the other piece to that is, you know, a first step towards change for them.
Um, because we’re talking about patient care, but we’re also talking about us as people and with addiction being such a big problem, um, I think that’s a valuable question for everyone. So that was two parts, let me repeat that one more time. One is screening for the PTs who are out there who are like, how do I do this? I’m a little bit nervous about doing this. Where do I start? And then too, okay, I’ve gotten through that part. Now what? What’s, what’s the best thing to do first? Either if I’m a person with addiction or if I’m a practitioner treating a person with addiction.
29:49 Dr. Eric Chaconas Yeah. And we, and what we integrate in the book is, you know, the DSM-5 as a screening tool. So there are definitely specific screening tools that can be used.
I would say as an aside, I would advocate that this is something that occurs when you have a relationship with the person that you’re working with. So, you know, like we talked about before, trust is so critically important. I’m probably not breaking out the DSM-5 in the first five minutes of my eval or, you know, Hey, do you have a drinking problem? Like, do you want me to like, that’s not going to go well. Right. So, so there’s a relationship there. And I think, you know, a lot of physical therapists, this is the one thing that drew me to the profession. You probably have all the different healthcare providers, this individual has, you probably have the best relationship with them, like you are probably the, you spend more time with them than most people, you’re very close with them and so they trust you. And so that really gives the physical therapist a leg up on being the appropriate person to kind of have this conversation. And so it starts with a relationship. It starts with trust and then it, and then there’s, you know, conversations. I think motivational interviewing is a critical component to it. But, you know, you’re not going to talk somebody out of abusing alcohol or abusing substances. It’s a complete lifestyle shift. And really this is a complex condition. And so with the DSM-5, you have it sort of a three, you know, if you have three of the criteria, your diagnosis, having a substance use disorder, four to five is a moderate and then six or more is severe. So when you think of moderate and severe substance use disorder, that really does require some type of professional treatment from a multidisciplinary team that sometimes involves medical providers, sometimes involves counselors, but definitely more people than just the physical therapist.
So I think having that team, that’s another key takeaway. Do you have a team, do you have a team of people, relationships across town where you can lean on them and share with them and refer between each other to approach this as a team, because it really does need to be a team approach. So I think that’s another really critical takeaway.
And then the last critical takeaway is really just when somebody is going through treatment, making sure that we are addressing this part of their, you know, their experience, which is musculoskeletal health, pain. We know that pain is a really tricky thing when it comes to substance use disorder recovery, especially think of people who are addicted to opioids. So the physical therapist needs to be involved in that component of it. And then all the other components of lifestyle, medicine, nutrition, diet, exercise that really need to be integrated into treatment.
32:22 Dr. Ginger Garner Yeah, that first half of that answer on what PTs can do is very rooted in having a sense of self-efficacy that you can do that. And you can ask those questions because you already have that relationship that is probably deeper and built on more trust than another practitioner that does not have the time. They don’t have the luxury of time to spend with them than we do. So I think that if you are listening and you’re a physical therapist, take confidence in that, that you have the ability to ask those hard questions because you have that trust. So feel good about that. And then the other thing..
33:03 Dr. Eric Chaconas: Just to add to that, I mean, who’s better providing a subjective history than a physical, like we are so good at that and everything that we do in the way that we ask questions and the way that he’s paralleling and connect, I mean, it’s really well done. So yeah, I would never hesitate to have a physical therapist screen and have these conversations about substance use disorder. I would never hesitate.
33:23 Dr. Ginger Garner Yeah. And I think that to build on what you said on the second part of that question about, you know, what to do, having that network is incredibly important. And I think that the other thing that the literature really presses, what it did for me, like my big takeaway on studying this was and learning more about this and writing about it was repeated, just asking those short, those brief interventional moments where you’re only spending a few minutes seem to exact more impact than if you tried to spend 10 or 15 minutes at a time. And then the other piece of that was we’re not trying to convince them to stop. The more effective way is to ask them questions that would have them come up with the reason of why it might be a good idea to consider, you know, changing.
34:13 Dr. Eric Chaconas: I love the little conversations, the small, you never know what the impact of that can have on people. You have no idea at the time. You can’t tell the way they’re taking it or not, but they might just reflect on that later and you never know. There’s a lot of conversations that occur, very short conversations that occur that make a huge difference to people because, you know, it’s just, they trust you. And then to go back later and think about it, reflect on that conversation. I think that does make a difference. It’s like, I’ve heard people use this analogy of waves and like eroding away, slowly eroding away on a beach, right? And just like that repetitive, infrequent, small dose, right? It’s not like you’re not overpowering them all at once with one huge 20 minute lecture. I think that is really important.
35:00 Dr. Ginger Garner: And they don’t feel preached to the way I would feel about that if someone just dropped those little questions every once in a while is that, oh, this person actually cares. They care about the fact that I’m struggling with that. They’re not making some, they’re not reinforcing the stigma. You’re kind of chiseling away at that. Like, hey, that’s all right. Let’s so many people have these issues. You’re validating their experience. Um, so yeah, I think that’s a good, that’s a good finishing point because, um, I want PTs out there to feel confident as you do about your skillset and talking to people about their addiction. We want our patients to feel confident and trust us and know that we’re asking you those questions, not to badger you, not to create stigma around it, but to deconstruct barriers to your success to let you know that we do care.
35:53 Dr. Eric Chaconas: Absolutely. And I think if people are wondering, like, how do I get started? I just think Googling in your local area recovery centers. So, alcohol and drug abuse recovery centers and talking to them and saying, Hey, who do you use? Who’s a great outpatient counselor in town that you just start developing that network is a really key takeaway.
36:16 Dr. Ginger Garner: Yeah. And don’t be afraid to ask your friendly local physical therapist about resources because we should all have that list of resources. And if you’re a PT listening, this is a good chance. It’s a little bit of homework is to do the same thing. Go Google that and start to build your list of resources so that you can have that interdisciplinary approach in your area.
All right, Dr. Chaconas, thank you so much for joining me today. I really appreciate your time.
All right, guys, until next time, keep living well out there.
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