What Co-occurring Disorders Are Common with Opioid Addiction?

April 19, 2022

Table of Contents

People with opioid use disorder are at higher risk for many mental health conditions, especially anxiety and depression.

Co-occurring disorders occur when a mental health condition and a substance use disorder are present in the same person at the same time. The conditions require simultaneous treatment. 

What Are Co-Occurring Disorders? 

The term co-occurring disorders refers to two or more chronic conditions that exist and need treatment at the same time.[1] Most often, co-occurring disorders are a combination of a mental/behavioral health condition and substance use disorder (SUD), such as anxiety disorder and alcohol use disorder (AUD), an eating disorder and cocaine use disorder, or major depressive disorder and opioid use disorder (OUD). 

The mechanisms, symptoms and behaviors associated with co-occurring disorders often overlap. One disorder can feed into and worsen the severity of another disorder. SUD can increase the risk of and severity of mental health problems, and the reverse is true as well, in that people with mental health problems are often at greater risk of developing a SUD.  

Substance use disorders change brain chemistry and, over time, can change brain function and neurochemistry in a more long-standing way. This increases the risk of developing a mental or behavioral condition. 

On the other hand, many people who struggle with mental illness begin to self-medicate their depression and anxiety symptoms with addictive substances like alcohol, opioids, or crystal meth, which leads to loss of control of use of the substance and emotional dysregulation more quickly. In the case of opioids, studies show that physical and emotional pain may register similarly in the brain, so taking an analgesic drug like an opioid might ease that pain.[2] 

The Prevalence of Co-Occurring Disorders With Opioid Abuse

As of 2018, about 7.7 million American adults reportedly have a co-occurring mental health and substance use disorder.[3] By 2020, that number had gone up in recent polling to 17 million U.S. adults with co-occurring disorders.[4] 

Symptoms of one may begin before symptoms of the other. Ultimately, it is important to diagnose all co-occurring conditions and treat them concurrently. If one condition, like SUD, is treated while other conditions are not treated, there is a higher risk of relapse back into compulsive patterns. 

Here are some stats on co-occurring disorders:[3]

  • Over 20 million U.S. adults have received a SUD diagnosis. About 37.9% of those adults have a co-occurring mental or behavioral condition.
  • More than 42 million U.S. adults have a diagnosed mental health condition. About 18.2% of those individuals have a diagnosed co-occurring substance use disorder.
  • Over 9% of those with co-occurring disorders got the treatment they needed, while 52.5% did not receive any treatment.

Increasingly, mental health clinics are using drug and alcohol screening questionnaires to identify people who also have signs of an underlying SUD. This is very important since use of substances can worsen mental health problems and make people less likely to respond to treatments for mental health problems, like medications and evidence-based psychotherapy. Similarly, these questionnaires can help addiction treatment centers identify people who use more than one substance to excess since people often have more than one substance use disorder at a time.  

Information gathered from the 2015–2017 National Surveys on Drug Use and Health (NSDUH) found that people with opioid use disorders also had higher rates of several co-occurring conditions.[5] 

  • 26.4% had an alcohol use disorder 
  • 10.6% had a methamphetamine use disorder
  • 64.3% reported a mental illness in the past year
  • 26.9% reported a serious mental illness in the past year

Another report found that about 43% of people in treatment for prescription opioid use disorder have either symptoms of or a diagnosis of another mental health condition, particularly depression and anxiety.[6] 

Common Co-Occurring Disorders 

These are common mental health problems that people with opioid use disorder struggle with: 

  • Anxiety disorders
  • Depression 
  • Attention deficit hyperactivity disorder (ADHD)
  • Bipolar disorder
  • Post-traumatic stress disorder (PTSD)
  • Schizophrenia
  • Eating disorders
  • Personality disorders
  • Conduct disorders[7]

Common substances of abuse associated with mental health issues include the following: 

  • Alcohol
  • Opioids
  • Tobacco
  • Stimulants
  • Marijuana
  • Hallucinogens
  • Other prescription drugs like Ambien or Xanax[8]

People who struggle with co-occurring disorders are also at higher risk of contracting diseases or developing chronic medical illnesses. Here are some of these conditions: 

  • Hepatitis, especially hepatitis C
  • Sexually transmitted infections (STIs)
  • Heart disease
  • Lung problems
  • Liver failure
  • Digestive issues

What Would a Treatment Plan for Co-Occurring Disorders Look Like?

There are several ways that a person with co-occurring disorders receives a diagnosis. 

They may attend a doctor’s appointment for an unrelated ailment, but their doctor flags potential substance misuse or mental health struggles in a routine questionnaire. They may have struggled with SUD for years and entered treatment, and then received an associated mental health diagnosis. Or, they may have entered therapy to treat a mental health condition, and then discussed their substance consumption with their therapist. 

The overall SUD treatment process typically involves: 

  • Rehabilitation with group therapy, often training in use of coping skills, relapse prevention, and emotion regulation. This can occur in the residential or outpatient setting, depending on individual needs.
  • Psychotherapy that lasts at least the duration of the rehabilitation program, with a recommendation for ongoing mutual support groups afterward.
  • Medication for Addiction Treatment (MAT), especially for OUD.
  • Supportive housing and employment training, if needed.

Both substance use disorder and mental health treatments utilize behavioral therapy, ideally with an evidence-based intervention. These include the following: 

  • Cognitive Behavioral Therapy (CBT): This well-known and commonly used form of talk therapy focuses on challenging irrational thoughts and unhelpful thought patterns to help participants better cope with difficult situations in the future. 
  • Dialectical Behavior Therapy (DBT): This therapeutic method grew out of CBT’s focus on talking through problems and self-reflection. DBT has added mindfulness practices along with observation and attentiveness to one’s current emotions and emotional state. There are also skills that help reduce intense emotions, like those associated with cravings for drugs or alcohol. 
  • Assertive Community Treatment (ACT): This is a form of community-based mental health treatment that emphasizes outreach by the community and to the community, with personalized treatment for those most affected. 
  • Contingency Management (CM): This is an approach to re-learning healthy behaviors and unlearning harmful or compulsive behaviors. Generally, whenever someone successfully overcomes a craving, avoids opioids, or makes healthier choices, they receive a reward, often in the form of a voucher or prize.
  • Therapeutic Communities (TC): For many people who struggle with co-occurring disorders, job steadiness and housing stability are particularly difficult. Entering a drug-free therapeutic community ensures stable housing, the ability to focus on treatment, and support with other needs, including finding work or getting job retraining. 

Medication for Addiction Treatment & Co-Occurring Disorders

Suboxone is an effective medication to manage opioid use disorder.[9] MAT is one of the most important advances in addiction science, helping many people, especially those overcoming opioid use disorder, avoid harmful withdrawal symptoms and focus on recovery. 

Medication for Addiction Treatment (MAT) is equally valuable to people with co-occurring disorders. Individuals with mental health struggles are at risk of misusing or stopping their prescription medications, so it’s important to work with a physician and support staff throughout treatment. 

Access to MAT has helped more people overcome OUD than ever before. As a result, it is important to provide this option while also treating underlying mental illness.

Medically Reviewed By 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. Co-Occurring Disorders. Psychology Today. http://www.psychologytoday.com/us/conditions/co-occurring-disorders. Accessed December 2021. 
  2. Nummenmaa L, Tuominen L. Opioid system and human emotions. British Journal of Pharmacology. 2018;175(14):2737-2749. doi:10.1111/bph.13812. 
  3. Comorbidity: Substance Use and Other Mental Disorders. National Institute on Drug Abuse (NIDA). https://www.drugabuse.gov/drug-topics/trends-statistics/infographics/comorbidity-substance-use-other-mental-disorders. August 2018. Accessed December 2021. 
  4. Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend. 2019;197:78-82. doi:10.1016/j.drugalcdep.2018.12.030. 
  5. Common Comorbidities with Substance Use Disorders Research Report, Part 1: The Connection Between Substance Use Disorders and Mental Illness. National Institute on Drug Abuse (NIDA). https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness. April 2020. Accessed December 2021. 
  6. Substance Use Disorders. National Alliance on Mental Illness (NAMI). https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Substance-Use-Disorders. May 2020. Accessed December 2021. 
  7. Substance Use and Co-Occurring Mental Health Disorders. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health. March 2021. Accessed December 2021. 
  8. Co-Occurring Disorders and Other Health Conditions. Substance Use and Mental Health Services Administration (SAMHSA). https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/co-occurring-disorders. November 2021. Accessed December 2021. 
  9. Common Comorbidities with Substance Use Disorders Research Report, Part 4: Barriers to Comprehensive Treatment for Individuals with Co-Occurring Disorders. National Institute on Drug Abuse (NIDA). https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-4-barriers-to-comprehensive-treatment-individuals-co-occurring-disorders. April 2020. Accessed December 2021.

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