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Opioid Dependence and Co-occurring Disorders — Health Risks Affiliated With Opioids

Dr. Julie Craig, MD profile image
By Dr. Julie Craig, MD • Updated Aug 13, 2023

Many people who find themselves dependent on opioids have other conditions (known as “co-occurring” or “comorbid” disorders) that play a role in their addiction. Some of those conditions contribute to starting or continuing opioid use, while others are mostly a consequence of opioid use. Sometimes a condition like pain can spark opioid use, then opioid use can worsen the underlying condition. 

Co-occurring disorders can complicate recovery, and addressing these conditions can be key to the success of opioid use disorder treatment. It is important to remember that not all people use opioids due to these issues – some people come to addiction purely through recreational use, and they deserve equal access to effective treatment as people who use drugs due to depression, trauma, pain, or other disorders.

Co-occurring physical health conditions

Many “co-occurring” conditions are related to physical health. Chronic pain is a common reason for people to start and continue opioid use and can challenge sobriety if the pain is not well controlled. Long-term opioid use can also contribute to increases in baseline pain, called “opioid-induced hyperalgesia,” which causes people to be more sensitive to pain signals from minor irritations. Insomnia and sleep disorders can cause people to want to continue opioids; additionally, insomnia may be a consequence of withdrawals from short-acting opioids, which is driven by adrenaline and tends to keep people awake.

Physical consequences of illicit opioid use commonly include infectious conditions from needle use, including HIV, hepatitis C, skin infections (cellulitis and abscesses), bone infections (osteomyelitis), heart infections (endocarditis, pericarditis, etc), and sexually transmitted infections (STIs) associated with intercourse when judgment is impaired by intoxication. Opioids as a group suppress sex hormones like estrogen and testosterone, which can result in brittle bones (with long-term use), missed periods in women, and erectile dysfunction in men. In general, opioids depress the drive to breath – in overdoses, individuals stop breathing altogether, which can lead to death if not reversed in time. 

Co-occurring behavioral/mental health disorders

In addition to the physical health conditions discussed above, a variety of behavioral health conditions can contribute to opioid use and relapse. Mood disorders including depression and bipolar disorder can cause people to use opioids to numb difficult emotions. Although opioids are generally considered to be sedatives, some people experience increased energy and elevated moods when taking opioids, which can make it difficult to stop opioids. Anxiety and post-traumatic stress disorder can be causes of opioid use and may worsen during opioid withdrawal that elevates adrenaline levels in the brain.

Thought disorders (schizophrenia and bipolar disorder) are more serious conditions that include delusions, hallucinations, and other disturbances. Some substances (such as stimulants) can make mimic or worsen thought disorders. 

Finally, attention deficit disorder (ADD) is an under-appreciated contributor to substance use disorders ). Early cognitive and mental health challenges during the school years are associated with addiction and elevated rates of incarceration later in life (the so-called “school-to-prison pipeline”).

Co-occurring substance use disorders

Use of multiple substances (also called “polypharmacy” or “polysubstance abuse”) can complicate recovery from opioid addiction. Tobacco – one of the most commonly abused substances – causes more deaths than opioids overall, so it is important to offer medications and behavioral interventions to help with people quit smoking once opioid use is addressed. 

While no medications are approved to help with stimulant (cocaine, amphetamine, and methamphetamine) dependence, several medications have shown promise in helping with cravings for this class of drugs, including topiramate for cocaine, mirtazapine for methamphetamines, and others. 

The combination of alcohol, sedatives (barbiturates and benzodiazepines), and opioids are perhaps the most serious co-occurring substance addictions, because mixing these medications greatly increases the risk of overdose and death. In these cases of mixed dependence, starting buprenorphine/naloxone (Suboxone) to treat the opioid use is often an overall safety improvement, but continued use of alcohol or other sedatives with the buprenorphine/naloxone (Suboxone) remains a serious risk factor for overdose and death

MAT and co-occurring disorders

Ideally, co-occurring disorders are addressed with a holistic approach that addresses these issues simultaneously or in quick succession. For example, buprenorphine/naloxone (Suboxone) treatment sets individuals up for success in having their HIV or hepatitis treated. Someone who has a severe mental illness may benefit from an induction to buprenorphine/naloxone (Suboxone) followed quickly by psychiatric evaluation (it can be very difficult to treat mental illness in people using illicit opioids due to alternating intoxication and withdrawals; as well, it can be difficult to stay on a program if a mental illness is not recognized and treated). 

Bicycle Health focuses on opioid use disorder treatment and the immediate conditions that surround addiction. Complex cases may have best outcomes if a buprenorphine/naloxone (Suboxone) provider like Bicycle Health works together with psychiatry, primary care, and/or specialty medical care. Telehealth providers may not be optimal for all patients with complex issues, some of whom might be better served at, for example, a community health center that has primary care, substance use disorder treatment, and hepatitis C services under the same roof. If you have more complex physical or behavioral health issues, please contact our enrollment coordinators so that we can help determine whether you would benefit from our services.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Header Photo by Marco Ceschi on Unsplash

By Dr. Julie Craig, MD

Dr. Julie Craig is board certified in family medicine (2010) and addiction medicine (2015). She attended medical school at Oregon Health & Science University, then completed the Northern New Mexico Family Medicine Residency Program in Santa ... Read More


(1) Pediatrics: “Attention-Deficit/Hyperactivity Disorder and Substance Abuse.”

(2) Current Topics in Behavioral Neurosciences: “Linking ADHD, impulsivity, and drug abuse: a neuropsychological perspective.”

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