L7: Substance Free Living

APTAs 7 population-health priority areas for PT practice

tobacco free living

preventive drug and excessive alcohol use

healthy eating

active living

mental and emotional well-being

reproductive and sexual health

injury and violence free living

what is alcohol use classified as

ages 12+ at least 1 drink in the past 30 days

overall trend of alcohol use

decrease

what is binge drinking

4+ drinks (females) or 5+ drinks (males) on one occasion

what is heavy alcohol use

binge drinking on 5+ days in the past 30 days

binge drinking trend

decrease

heavy alcohol use trend

decrease

what is underage alcohol use

ages 12-20 at least 1 drink in the past 30 days

trend of underage alcohol use

decrease

underage binge drinking trend

no significant change

underage heavy alcohol use trend

no significant change

how do underage drinking trends compare to adult drinking trends (binge/heavy drinking)

declining more slowly

cigarette use trend

decrease

nicotine vaping trend

increasing

underage cigarette use trend

no change

underage nicotine vaping trend

decreased

what are considered illicit drugs

marijuana

cocaine

heroin

hallucinogens

methamephetamine

misue of prescription drugs

illicit drug use trend

increased

adolescent marijuana trend

decreased

1 in __ people aged 12_ have used an illicit drug in 2025

4

CNS stimulants

cocaine

methamphetamine

misuse of prescription stimulants

overall trend of CNS stimulant misuse

no significant change

what CNS stimulant is misused the most to the least

cocaine

rx stimulant misuse

methamphetamine

what is substance use disorder

impairment from recurrent alcohol or drug use, per DSM-5 criteria

overall trend in substance use disorder

decreased

most to least prevalent SUD

alcohol use

any drug use

marijuana

rx pain reliever use

methamphetamine use

rx stimulant use

cocaine use

heroin use

opioid misuse trend

decreased

illegally made fentanyl trend

no sig change

most to least prevalent opioid misuse

rx pain reliever

heroin and rx misuse

heroin use

why does opioid/ illegally made fentanyl use matter to PTs

96.4% of past-year opioid misusers misused a prescription pain reliever- often one originally prescribed for pain PTs treat

-IMF (illicit fentanyl)is far more potent than prescription or heroin opioids and drives most current OD deaths)

health effects of smoking and vaping

nicotines vasoconstriction and toxin exposure directly impair tissue healing and rehab outcmes

fracture union in smokers v non-smokers

smokers: >48 wks

non: 24 wks

non-union of fracture in smokers v non-smokers

smokersL 23.6%

non: 0%

smokers likelihood of developing osteomyelitis after fracture surgery

3.7x more likely

adequate 1 month callus formation is smokers v nonsmokers

smokers: 47.3%

non: 94.5%

CP effects of smoking

reduced VO2 max and exercise tolerance limit therapeutic exercise capacity

wound healing and smoking

impaired soft-tissue microcirculation slows post-surgical wound and tendon/ligament healing

chronic cough and reduced lung function limit functional activity tolerance

vaping evidence of impacts on pulmonary system

airway inflammation

lung injury

mechanism of nicotine impairing tissue healing

nicotine causes vasoconstriction, cutting oxygen and nutrient delivery to healing bone and soft tissue

carbon monoxide reduces the blood's oxygen carrying capacity

effects of nicotine and improvement

dose-related

improve with cessation, even shortly before surgery

health effects of chronic alcohol use

directly weakens the NM and skeletals systems

muscle consequences of alcohol use

skeletal muscle maladaptation (alcoholic myopathy)

loss in skeletal muscle mass with chronic heavy use

type II fibers are selectively atrophied

what effects are most prevalent at ages 40-60 with alcohol use

proximal muscle weakness and reduced peak torque

neurologic consequences of alcohol use

peripheral neuropathy impairs balance, proprioception, and gait

bone health and alcohol use

impaired bone remodeling lowers bone density, raising fracture risk

consequence of weakness and neuropathy and intoxication (alcohol)

substantially increases fall risk

clinical considerations with alcohol use

abstinence improves strength but often does not fully normalize it- set realistic goals

screen fall risk more closely in patients who heavily drink

alcohol interacts with NSAIDs, muscle relaxants, and opioids prescribed for pain

health effects of opioid misuse

can worsen pain and function over time- central to the case of PT-led pain management

how does chronic opioid use affect B+B function

opioid induced constipation which results in more money spent on laxatives

___ morphine miligram equivalents/day (MME) markedly raises overdose risk, especially with ____

>/ 50 MME

especially with benzodiazepines

explain opioid-induced hyperalgesia and consequences

paradoxical increase in pain sensitivity with prolonged opioid exposure- pts can become more pain-sensitive

-easily mistaken for undertreated pain, prompting further dose escalation

-no LT functional advantage of opioids over non-opioid care for most chronic pain

other systemic effects of opioid misuse

tolerance and physical dependence with escalating dose

sedation, cognitive impairment, and fall risk

endocrine dysfunction (Suppressed testosterone/cortisol)

reduced physical function and QOL despite continued use

substance use and mental health

7% of adults had co-occurring any mental illness and SUD in 2025

trend of co-occurring any mental illness and substance use disorder

no sig change

adolescents and depression with SUD

2.5% had co-occurring

trend of adolescents having co-occurring major depressive episode and SUD

decrease

why does substance use disorder and mental health matter

co-occurring mental illness and SUB is common enough that PTs will regularly treat pts navigating both

unmanaged anxiety or depression can reduce adherence to exercise programs and pain self-management strategies

adolescents with depression and substance use need coordinated, no siloed, care- a PT POC is one touchpoint among many

what screening tools could be used mental health to determine if someone needs a referral

AUDIT-C or NDIA quick screen

substance use need vs received treatment

45.2 M needed treatment

only 15.7% received any treatment

most common treatment setting for substance use

outpatient

recovery from substance use

30.6 M perceived ever having a substance use problem

22.3M (73%) consider themselves recovered or in recovery

trend of recovery from substance use

no significant change

drug overdose death trends

decline

-third consecutive annual decrease since 2022 peak

overdose death trends in each state

falling in nearly every state

-out west is experiencing the greatest change

what demographics are more likely to have nonfatal drug overdoses treated in the ER

males

35-44 years old

fatal overdose demographics

male

white

35-44

explain the 3 waves of opioid overdose deaths

wave 1: rise in prescription opioid overdose deaths (started in 1990s)

wave 2: rise in heroin overdose deaths (started in 2010)

wave 3: rise in synthetic opioid overdose deaths (started in 2013)

what do most drug overdose deaths involve

at least one opioid (81.4%) or at least one stimulant (61.8%)

most common opioid for OD deaths

illegally-made fentanyl

most common stimulant for OD death

cocaine

efficacy limitations of opioid usage for pain management

no LT advantage of opioids over non-opioid medications for chronic pain

benefits typically fade while risks accumulate with continued use

risks of opioids for pain management

tolerance: pts need higher doses for same effect

dependence and addiction: risk rises with dose and duration

OD risk: especially >/ 50 MME/day or combined with benzodiazepines

side effects of opioids

constipation

sedation

endocrine dysfx

impaired cognition

opioid impact on function

do not improve physical fx or QOL

function restoration- the core of PT care- targets what opioids alone cannot fix

CDC guidelines for opioid prescribing

1. start cautiously (use opioids only if expected benefits outweigh risks; prioritize non-opioids first)

2. choose immediate release: avoid starting with long-acting/extended release formulas

3. use lowest dose: prescribe min effective dose and avoid unneccessary escalation

4. limit duration: for acute pain, prescribe only the shortest effective course

5. reassess early and often: re-eval within 1-4 wks of starting/changing, then at least every 3 months

6. mitigate risk: check the prescription drug monitoring program, consider urine drug testing, avoid benzodiazepine co-prescribing, offer naloxone if indicated

7. monitor ongoing therapy: continue only if benefits persist; taper gradually if risks outweigh benefits

8. individualize care: shared decision making, pt specific goals, avoid rigid cutoffs or abrupt discontinuation

pain management alternatives

PT and related approaches

psychological therapies

mind-body practices

neuromodulation

XR (extended reality)

placebo and expectation mangement

how doe pain management alternatives work

act on the NS through neuromodulation, endogenous neuropeptides, neural activity, inflammatory markers, and muscle strengthening

APTA beyond opioids: policy recs

1. public awareness: federal campaign for providers, payers, regulators, employers, and the public on pain assessment and management options

2. benefit design: health plans should support early access to non-pharmacological interventions, including PT for primary pain care

3. remove cost barriers: reduce or eliminate pt out of pocket costs for person-centered, non-pharmacalogical pain treatment

4. provide education: educate PCPs on value of non-pharmacological interventions and how to assess, treat, and refer pts with pain

5. finance effective models: federal and state policymakers should fund replication of effective pain-management care, including bundled payment for multidisciplinary programs

6. workforce initiatives: student loan repayment programs should incentivize PTs and other providers to work in communities hit hardest by the opioid crisis

PT as first line care outcomes

early PT is associated with reduced opioid use

PT as first-line treatment is associated with decreased healthcare costs

PTs role in opioid crisis

1. overcome stigma

2. screen routinely

3. track function, not just pain

4. lead with functional restoration

5. educate on risk

6. coordinate care

7. encourage evidence based OUD treatment

how can PTs overcome stigma of opioid crisis

treat opioid misuse as a medical condition, not a moral failing- approach every patient without judgment

routine screening as a PT

screen for opioid misuse and RF as part of standard history, not only when a red flag appears

track fx, not just pain as PTs

link pain and fx to opioid use over time, watch for opioid-induced hyperalgesia- worsening pain despite dose increases

PTs lead with functional restoration

offer exercise-based, active care as the Choose-PT evidence first-line alternative, dosed to the pts tolerance and goals

PT education on risk for pts

explain tolerance, dependence, OD risk, and constipation/sedation effects in plain language

coordinate care as PTs

communicate fx and pain trends to the prescriber the support CDC guideline based tapering decisions

how to encourage evidence-based OUD treatment as PTs

support and refer to medication for opioid use disorder and counseling- do not let stigma block referral

PT screen/assess role for alcohol use

-ask about alcohol use as part of every standard health history, not only when injury seems alcohol-related

-use AUDIT-C brief screening tool to flag risky or heavy use

-assess fall risk more closely given alcohol's effects on muscle strength, neuropathy and balance

PT role in adapting POC with alcohol use

-set realistic strength and fx goals- myopathy from heavy use may not fully resolve with abstinence alone

-modify exercise prescription and fall-prevention strategies for reduced proprioception and type II fiber weakness

-flag interactions btwn alcohol and prescribed NSAIDs, muscle relaxants, or opioids

PT role in education and refer with alcohol use

-explain how alcohol slows healing and rehab progress in terms tied to the pts own goals

-refer pts who screen positive to PCP or counseling- mirror the referral step used for opioids

-track alchol use and fx togeteher at follow-up visits

AUDIT-C questions

AUDIT-C scoring and interpretation

PT role with AUDIT-C

Pt role in ask/screen with tobacco and nicotine vaping

ask every pt about cigarette use and nicotine vaping at intake, not just pre-surgical patients

-a single question status check (current, former, never) takes seconds and id who needs counseling

PT role and setting realistic expectations for tobacco and nicotine vaping

-for smokers, plan around slower bone and ST healing

-coordinate with surgeon or physician on a pre-operative cessation window- even brief cessation before surgery improves healing

-explain that vaping LT MSK effects are still being studied, so caution is still warranted

PT role in advising and referring for tobacco and nicotine vapoing

-give brief, direct cessation advice- even a short compensation increases quit attempts

-refer to a tobacco quitline or cessation program

-reinforce progress at follow-up visits alongside fx gains

5As for tobacco use

ask: inquire about tobacco/nicotine use

advise: encourage quitting and link to their health and fx goals

assess: determine readiness to quit

assist: refer to appropriate cessation resources and providers

arrange: reassess at future visits and reinforce referrals

5Rs for pts not ready to quit tobacco and nicotine vaping

relevance: explore how quitting fits their goals

risk: share key health and fx risks

rewards: discuss potential benefits that matter to them

roadblocks: ask about barriers and refer as needed

repetition: revisit the conversation overtime