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What Co-occurring Disorders Are Common with Opioid Addiction?

Elena Hill, MD, MPH profile image
Medically Reviewed By Elena Hill, MD, MPH • Updated Aug 21, 2023 • 9 cited sources

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

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

Often, co-occurring disorders are a combination of a substance use disorder (SUD) and a mental/behavioral health condition, such as these:

  • Anxiety disorder and alcohol use disorder
  • Eating disorder and cocaine use disorder
  • Major depressive disorder and opioid use disorder

The mechanisms, symptoms, and behaviors associated with co-occurring disorders often overlap. One condition can feed into and worsen the severity of the other.

Let’s consider a few scenarios:

  • The SUD comes first. SUDs change brain chemistry and function, increasing the risk of developing a mental or behavioral condition.
  • The behavioral health issue comes first. Many people who struggle with mental illness begin to self-medicate with addictive substances, leading to a substance use disorder.

SUDs 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 substance misuse issue.

The Prevalence of Co-Occurring Disorders With Opioid Misuse 

Any substance could be part of a co-occurring condition, but opioids are particularly damaging. Researchers say people with OUDs and co-occurring conditions are more likely to require treatment for drug use than those misusing other substances, and they often need more “encounters” (or help from doctors) than those misusing other substances.[2]

Opioid misuse can alter how people feel both when they’re high and when they’re not. Symptoms include the following:[3]

  • Low motivation
  • Depression
  • Irritability
  • Insomnia (or its reverse)

For some, quitting drugs makes the problem fade away. But since OUDs are hard to address without help, many people relapse and start the cycle again. 

Of those with OUDs and past-year co-occurring disorders, less than 25% got treatment. Of those with serious OUDs and mental health issues, fewer than 30% got help.[4]

Key Facts About Co-Occurring Disorders With Opioid Misuse

  • About 3 million Americans have an OUD.[5]
  • People with a mental illness (such as depression) are more likely to develop any substance use disorder, including OUD, when compared to those who don’t have a mental illness.[6]
  • People with co-occurring disorders are more likely to be hospitalized. [7]
  • Integrated treatment models that address both issues at the same time are more effective and lead to better outcomes only address either substance misuse or mental health issue in isolation. [7]

Common Co-Occurring Disorders With Opioids 

About 9.2 million adults in the United States have a co-occurring disorder.[6] While any mental illness could exist alongside opioid misuse, some illnesses are more likely than others. 

These are some of the mental health issues that commonly appear in people with OUD:[8]


Of all potential drug/mental health combinations, OUDs and depression are the most closely linked. Depression can prompt use of substance, and conversely substance use itself can worsen the symptoms of depression. 


It’s difficult to maintain an opioid use disorder. People must find suppliers, buy drugs, and keep their misuse hidden. This can create anxiety. Conversely, patients with anxiety disorders may use substances including opioids to alleviate symptoms which can then lead to development of a substance use disorder. 

Attention Deficit Hyperactivity Disorder (ADHD)

People with ADHD can struggle with impulsivity. They may use substances like opioids to alleviate symptoms of hyperactivity or inattention. However, substance use long term can actually worsen these symptoms. 

Post-Traumatic Stress Disorder (PTSD)

Survivors of traumatic experiences can have a condition called PTSD. Sometimes, people misuse drugs to self-medicate their PTSD symptoms, and a substance use disorder can develop. 

Bipolar Disorder

Someone with bipolar disorder swings from periods of mania to periods of depression. They may use opioids during either manic episodes or depressive episodes. Opioids may worsen either depressive or manic episodes over time. Opioids also frequently interact with some of the more common medications that are used in individuals with bipolar disorder, including anti-psychotics. 

What Does a Treatment Plan Entail?

Increasingly, mental health clinics are using drug and alcohol screening questionnaires to identify people with signs of an underlying SUD. 

Identification is very important since the use of substances can worsen mental health problems and vice versa. It can also make people less likely to respond to treatments for mental health problems, like medications and evidence-based psychotherapy. 

Screening for co-occurring mental health conditions in patients with SUD can help addiction treatment centers identify people who need treatment for both disorders simultaneously. 

Behavioral Therapy

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 from CBT’s focus on discussing problems and self-reflection. DBT includes mindfulness practices, observation, and attentiveness to one’s emotions and emotions. Building skills helps to reduce intense emotions, like those associated with cravings for drugs or alcohol.
  • Assertive community treatment (ACT): A form of community-based mental health treatment, ACT emphasizes outreach by and to the community, with personalized plans for those most affected.
  • Contingency management (CM): An approach to relearning healthy behaviors and unlearning harmful or compulsive behaviors is the cornerstone of CM. Generally, whenever someone successfully overcomes a craving, avoids opioids, or makes better choices, they receive a reward, often a voucher or prize.

Medication For Addiction Treatment (MAT)

MAT is equally valuable to people with co-occurring disorders. Individuals with mental health conditions 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. It is essential to offer medications for patients with OUD. 

Suboxone is an effective medication for managing opioid use disorder.[9] Some people need additional medications to keep mental health issues controlled.

Support Groups

Support groups are often helpful for people with co-occurring disorders. Some people attend meetings made just for those with opioid use disorder, while others look for sessions that focus around mental health challenges.

Substance Free Housing

Job steadiness and housing stability are particularly difficult for many people who struggle with co-occurring disorders. 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.

Medically Reviewed By Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where ... Read More

  1. Co-Occurring Disorders. Psychology Today. July 2021. Accessed December 2022.
  2. Association of Co-Occurring Opioid or Other Substance Use Disorders with Increased Healthcare Utilization in Patients with Depression. Translational Psychology. May 2021. Accessed December 2022.
  3. Opioid Addiction With Psychiatric Comorbidities. Providers Clinical Support System. September 2021. Accessed December 2022.
  4. Co-Occurring Substance Use and Mental Disorders Among Adults with Opioid Use Disorder. Drug and Alcohol Dependence. April 2019. Accessed December 2022.
  5. Opioid Addiction. StatPearls. September 2022. Accessed December 2022.
  6. Co-Occurring Disorders and Other Health Conditions. Substance Abuse and Mental Health Services Administration. April 2022. Accessed December 2022.
  7. The Case for Screening and Treatment of Co-Occurring Disorders. Substance Abuse and Mental Health Services Administration. September 2022. Accessed December 2022.
  8. Prevalence of Mental Disorders Among People with Opioid Use Disorder: A Systematic Review and Meta-Analysis. Drug and Alcohol Dependence. July 2022. Accessed December 2022.
  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. April 2020. Accessed December 2022.
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