The Relationship Between Mental Health and Opioid Use Disorders

April 18, 2022

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Opioid overuse is a major public health problem. The opioid epidemic is the most lethal drug epidemic in US history, and those with mental health issues bear the brunt of the problem. 

More than half of the opioid prescriptions written in the United States are given to people with anxiety and depression. Anxiety disorder is present in a third and major depressive disorder in almost a quarter of people with opioid use disorder (OUD), with lifetime prevalence rates of psychiatric diagnoses as much as twice that.

In this article, we will expand on how to spot the signs of comorbid disorders and what to do when someone has both an OUD and a mental health diagnosis.

What Are Opioids?

Opioids include prescription pain medications such as morphine, codeine, methadone, oxycodone, hydrocodone, fentanyl, hydromorphone, and buprenorphine. Illicit drugs such as heroin and fentanyl analogs like carfentanil (illegally synthesized, extremely potent, and dangerous) are also opioids. 

Opioids bind to opioid receptors in the brain and periphery, reducing the sensation of pain while also causing sedation, constipation, and slowing breathing. They are also highly addictive since people can experience a short-lasting euphoria and a relief of negative mood or anxiety, which reinforces further use. 

Furthermore, if opioids are consumed daily or almost daily, stopping can induce uncomfortable withdrawal syndromes.

What Is an Opioid Use Disorder?

Opioid Use Disorder is the clinical term used to describe what happens when people start using opioids problematically. OUD is linked with poor mental health because opioid use can cause and heighten depression and anxiety. These diagnoses can also hasten the onset of OUD. 

Therefore, it is essential that both the psychiatric disorder and OUD be addressed head-on in someone who suffers from both. If that doesn’t happen, it will be much more difficult to recover from either. 

What Causes Opioid Use Disorders?

If someone experiences euphoria or relief of unpleasant emotions while on opioids, they may increase their use. Escalating frequency of use and the development of addictive behavior around opioids are rooted in psychological and neurobiological changes induced by the opioid.[1] 

Once someone starts to use them daily or almost daily, further brain changes such as tolerance and withdrawal start to set in. 

Tolerance means that the opioid receptors become less sensitive, causing the person to use more and more to achieve the same effect. Withdrawal occurs upon stopping when the person feels a variety of uncomfortable symptoms, including anxiety and low mood. In parallel, people begin to experience intense cravings and loss of control of their use.

Furthermore, the use of any opioid is associated with a high risk of developing an OUD later on. Data shows that 5% of those who misuse prescription opioids transition to heroin, and 10% of those using an opioid for chronic pain develop an OUD. 

Adolescents and young adults are particularly vulnerable since they are more likely to engage in drug experimentation than adults. In the majority of cases, adolescents obtain the initial opioids for misuse from friends or relatives.[2]

Symptoms of an Opioid Use Disorder

OUD is a clinical diagnosis, and people need to meet two of 11 criteria in the previous 12 months. This includes:

  • Spending lots of time using or searching for the drug or recovering from use
  • Continuing to use despite social and physical negative consequences
  • Intense cravings for the drug
  • Unsuccessful efforts to reduce or stop using
  • Tolerance and withdrawal symptoms 

Common signs of an opioid problem 

  • Poor performance at school or work
  • Isolating from family and friends
  • Doctor shopping
  • Exaggerating pain symptoms
  • Hiding arms in long sleeves to conceal injection marks 

To learn more about symptoms of opioid dependence and abuse, read our article on the Early Signs of Opioid Addiction

Signs of intoxication 

  • Slowed thinking
  • Tiny pupils
  • Impaired coordination
  • Nodding off 

Signs of opioid withdrawal

  • Irritability
  • Sweating
  • Shills
  • Vomiting
  • Diarrhea
  • Dilated pupils 

Opioid Use Disorder and Mental Health

Psychiatric disorders occur more frequently in people with OUD and vice versa. The list of associated disorders includes, but is not limited to, major depressive disorder, post-traumatic stress disorder (PTSD), and anxiety disorders such as generalized anxiety disorder, social phobia, panic disorder, and obsessive-compulsive disorder.[3] 

Relatedly, suicidal intentions and behaviors are pervasive in people with OUD. In one study, 39% of patients who had just overdosed reported wanting to die, and as many as a third of overdose deaths may be secondary to suicide.

There are numerous reasons for the links between OUD and mental health problems. For one, overuse of opioids causes anxiety and depression through a variety of mechanisms, including: 

  • Exposure to hardship, trauma, and violence
  • Trouble completing school or succeeding at work
  • Resultant disappointment or financial hardship
  • Neurobiological effects of long term use leading to worsening of tolerance, repeated cycles of withdrawal, and worsening loss of control 

Additionally, certain psychiatric disorders like depression, anxiety, and post-traumatic stress disorder, predispose people who use or misuse opioids to develop OUD. This can happen through self-medication, especially if they are not getting treatment for their anxiety or depression. 

In the short term, opioids reduce a variety of unpleasant emotions that are seen in these disorders, too, like irritability, sadness, difficulty sleeping, loss of interest in life, nervousness, and nightmares. 

Furthermore, there may also be common genetic, neurobiological, medical (e.g. chronic pain), and environmental underpinnings for both sets of disorders.[4]

Treatments for Opioid Use and Mental Health Disorders

The key to recovery from OUD and prevention of overdose is to get treatment for both the OUD and the underlying mental health problem from day one of treatment. 

OUD is best treated with a combination of medications such as buprenorphine, naltrexone, or methadone plus counseling. Other useful adjuncts might include residential or intensive outpatient treatment and twelve-step meeting attendance. 

Depression, anxiety, and PTSD are all treated differently from one another, each with their own options for evidence-based treatment. However, several therapeutic modalities deserve mention here because they work across diagnoses

  • Cognitive behavior therapy, which focuses on identifying maladaptive thoughts and replacing them, is effective for mood, anxiety, chronic pain, and PTSD. 
  • Exposure therapy is effective for PTSD and phobias. 
  • Dialectical behavior therapy, which focuses on enhancing mindfulness and emotion regulation for suicidal and self-harm behavior and substance use, may prove useful for people with comorbid disorders. 
  • Selective serotonin reuptake inhibitors and their close cousins tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors are useful for the treatment of depression, anxiety, and PTSD. 

If symptoms associated with the mental health disorder don’t resolve with medication treatment of the opioid use disorder, a trial of one of these antidepressant medications may also be recommended by your doctor. 

People who misuse opioids often also misuse benzodiazepines, especially if they also have anxiety disorders. However, the combination of opioids and benzodiazepines can be lethal since benzodiazepines increase the respiratory depression caused by opioids.[5] Benzodiazepines also carry their own risk of addiction and should be avoided whenever possible.

Learn How Bicycle Health Can Help You Overcome OUD

Bicycle Health is an organization that treats opioid use disorder through telehealth, offering patients affordable and evidence-based treatment with a first-line treatment for opioid use disorder: Suboxone (buprenorphine/naloxone). Our therapists and medical personnel are excellent, well-liked by patients, and highly accessible.

Want to know more about how starting on Suboxone could interact with preexisting mental health disorders? Schedule a meeting with our experts or call us today at (844) 943-2514.

Photo by Karolina Grabowska from Pexels

Claire Wilcox, MD

Claire Wilcox, MD, is a general and addiction psychiatrist in private practice and an associate professor of translational neuroscience at the Mind Research Network in New Mexico; and has completed an addictions fellowship, psychiatry residency, and internal medicine residency. Having done extensive research in the area, she is an expert in the neuroscience of substance use disorders. Although she is interested in several topics in medicine and psychiatry, with a particular focus on substance use disorders, obesity, eating disorders, and chronic pain, her primary career goal is to help promote recovery and wellbeing for people with a range of mental health challenges.

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1. Uhl GR, Koob GF, Cable J. The neurobiology of addiction. Ann NY Acad Sci. 2019 1451(1): 5-28.

2. Hudgins JD, Porter JJ, Monuteaux MC, Bourgeois FT. Prescription opioid use and misuse among adolescents and young adults in the United States: A national survey study. PLoS Med. 2019 16(11): e1002922.

3. Hassan AN, Le Foll B, Sameerimtiaz JR. The effect of post-traumatic stress disorder on the risk of developing prescription opioid use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III Drug and Alcohol Dependence. 2017 179(1): 260-66.

4. Brady KT, Levin FR, Galanter M, Kelber HD (Eds.). Textbook of Substance Abuse Treatment (American Psychiatric Publishing Textbook of Substance Abuse Treatment), Sixth Edition. 2021. The American Psychiatric Association Publishing. Washington, DC.

5. Boyer EW. Management of Opioid Analgesic Overdose. N Engl J Med. 2012; 367:146-155

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