The Relationship Between Mental Health and Opioid Use Disorder

JESSICA THELEMAQUE, BS

Temple Lewis Katz School of Medicine

SUMMARY POINTS

• Opioid use disorder and mental health disorders are public health crises in America.

• There is a bidirectional relationship between mental health disorders and opioid use disorders.

• It’s imperative to consider mental health services as a part of a patient’s treatment regimen for opioid use disorder.

• More mental health resources and attention need to be provided to achieve the best outcome for patients with opioid use disorders.

  
  

Analysis

Background

The opioid epidemic in the United States (U.S.) is a poignant and problematic public health crisis. This can be partially attributed to the increased use and prescription of opioids in the 1990’s and early 2000’s. Lack of research on the potential side effects and comorbidities at the time led to the push, by doctors and pharmaceutical companies, for opioids to be the mainstay treatment for chronic pain. From 1999-2010 opioid prescription rates increased four-fold as well as a parallel increase in opioid use disorder, a major concern when taking opioids (1).

At the heart of the opioid epidemic, is the troubling rise in opioid use disorder. This has led the U.S. to be the country with the highest number of opioid related deaths (2). Approximately 2.1 million people have been diagnosed with opioid use disorder (3), excluding those not seeking help, thus indicating a likely underestimation. Opioid use disorder can be defined as a chronic, lifelong, and relapsing disease (3), often because of long-term prescribing. Although this disorder is challenging to overcome, research and developments in recent years have led to effective treatment options including buprenorphine, methadone, and naltrexone (4).

In addition to the various side effects of taking opioids, many comorbidities are associated with use including digestive, circulatory, and metabolic diseases (5). The most common comorbidity found among patients with opioid use disorder is mental health disorders. Historically, mental health has been downplayed in the U.S. compared to other health conditions. It wasn’t until the COVID-19 pandemic did the country see a significant demand for mental health care services. Mental health and opioid use disorders rates in the U.S. are increasing and continue to be top-of-mind public health concerns, thus it is imperative to investigate the relationship between the two for effective treatment and prevention.

Analysis

One way to examine the relationship between mental health and opioid use disorders is the likelihood of patients developing opioid disorder when comparing patients with mental health disorders to patients without. A retrospective cohort study pulling data from 2006 to 2016, looked at patients aged 11 through 25 years old who were prescribed opioids for the first time. A total of 3,278,990 patients were included, and 8,935 patients were diagnosed with opioid use disorder (2). Although this is about 0.26%, further analysis revealed that patients with mood or anxiety disorders were four times more likely to develop opioid use disorder compared to those without mental health disorder (2). This demonstrates the importance of identifying patients with mental health disorders when initiating opioid treatment.

Additionally, patients with opioid use disorder are at increased risk for developing mental health disorders. A retrospective cohort study done at St. Louis University looked at depression in this context. Researchers used data from Veterans Health Administration, Baylor Scott & White Health, and Henry Ford Health System between the years 2000-2012. They found that long term opioid use, as seen in opioid use disorder, significantly increases the risk of new onset depression (6). These findings highlight the importance of mental health services while being prescribed opioids and treating those with opioid use disorder.

Uncovering this bi-directional relationship between mental health and opioid use disorders have led to research examining the mechanism behind this. One hypothesis explaining mental health disorders increasing risk for developing opioid use disorder is that patients with depression or anxiety have increased experience of physical symptoms (7). Furthermore, chronic pain is often rated more severe in patients with mental health disorders than those without (7). Patients with mental health disorders are more likely to be prescribed opioids for their subjective severe-rated chronic pain, increasing their risk for developing opioid use disorder.

A theory to explain the reversal relationship is through neuroanatomical changes. Specifically, patients with opioid use disorder have a highly active hypothalamic-pituitary-adrenal axis, which can induce depression and anxiety (8). While these theories are limited, they enable further exploration into the mechanisms upholding this profound interplay between mental health and opioid use disorder.

Discussion

Unfortunately, patients with opioid use disorder who have mental health comorbidities are at higher risk for morbidity and mortality (9). In 2016, the CDC Guideline for Prescribing Opioids for Chronic Pain — United States was created, which includes 12 Recommendations when prescribing opioids. After this guideline was released, there was a drop in high-risk prescribing (1), thus decreasing the chance of patients developing opioid use disorders. However, despite the release of these guidelines, rates of opioid use disorders remain high, which points towards the lack of effective treatment. As mentioned previously, opioid use disorders are commonly treated with medications such as buprenorphine, methadone, and naltrexone. Since there is a bi-directional relationship between mental health and opioid use disorders, treating patients with opioid agonist medications, seems to be treating only one aspect of this disease. It has been proven that treating patients with medication in addition to implementing mental health services, reduces opioid misuse and increases retention during treatment (10). Yet in a study using data between 2015-2018, 43% of patients with opioid use disorders did not receive any mental health treatment (11).

Providers play a vital role in addressing this strong association between mental health and opioid use disorders. As such, recommendation #7 of the 2016 CDC Guidelines recommends additional caution and monitoring in patients with depression (1), and implementing comprehensive training for providers on mental health and substance misuse (9). In addition to effective mental health screening prior to prescribing, providers should advocate for patients with opioid use disorders to receive supplemental psychiatric care. There is certainly more research that must be done, but acknowledging the relationship between mental health and opioid use disorders could provide better recovery outcomes and decreased rates of opioid use disorder in the U.S.

REFERENCES

1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022;71(3):1-95. Published 2022 November 4. doi:10.15585/mmwr.rr7103a1. Accessed June 26, 2023.

2. Hadland SE, Bagley SM, Gai MJ, et al. Opioid use disorder and overdose among youth following an initial opioid prescription. Addiction. 2021;116(10):2790-2800. doi:10.1111/add.15487. Accessed June 26, 2023.

3. Patterson, David A, and Mark Gold. “Treatment Resistant Opioid Use Disorder (TROUD): Definition, Rationale, and Recommendations.” Journal of the Neurological Sciences, U.S. National Library of Medicine, 15 Apr. 2020, pubmed.ncbi.nlm.nih.gov/32078842/. 

4. NIDA. Effective Treatments for Opioid Addiction. National Institute on Drug Abuse website. November 1, 2016, https://nida.nih.gov/publications/effective-treatments-opioid-addiction. Accessed June 26, 2023.

5. Acevedo A, Rodriguez Borja I, Alarcon Falconi TM, Carzo N, Naumova E. Hospitalizations for Alcohol and Opioid Use Disorders in Older Adults: Trends, Comorbidities, and Differences by Gender, Race, and Ethnicity. Substance Abuse. 2022; 16:11782218221116733. Published 2022 Aug 10. doi:10.1177/11782218221116733. Accessed June 26, 2023.

6. Scherrer, Jeffrey F., et al. “Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations.” Annals of Family Medicine, The Annals of Family Medicine, 1 Jan. 2016, www.annfammed.org/content/14/1/54. Accessed 26 June 2023.

7. Sullivan, Mark D. “Association between Mental Health Disorders, Problem Drug Use, and Regular Prescription Opioid Use.” Archives of Internal Medicine, JAMA Network, 23 Oct. 2006, jamanetwork.com/journals/jamainternalmedicine/article-abstract/411106. Accessed 26 June 2023.

8. Lingford-Hughes, Anne, and Katherine Herlinger. “Opioid Use Disorder and the Brain: A Clinical Perspective.” Addiction (Abingdon, England), U.S. National Library of Medicine, 6 July 2021, pubmed.ncbi.nlm.nih.gov/34228373/. Accessed 26 June 2023.

9. Jones, Christopher M, and Elinore F McCance-Katz. “Co-occurring substance use and mental disorders among adults with opioid use disorder.” Drug and alcohol dependence vol. 197 (2019): 78-82. doi:10.1016/j.drugalcdep.2018.12.030. Accessed 26 June 2023.

10. Amato, Laura et al. “Psychosocial and Pharmacological Treatments versus Pharmacological Treatments for Opioid Detoxification.” The Cochrane Database of Systematic Reviews, U.S. National Library of Medicine, 7 Sept. 2011, pubmed.ncbi.nlm.nih.gov/21901695/. Accessed 26 June 2023.

11. Ali, Mir M, and Joel Dubenitz. “Suicidal behavior, opioid use disorder, and behavioral health treatment: Prevalence and correlates among adults in the United States 2015-2018.” Journal of substance abuse treatment vol. 130 (2021): 108413. doi:10.1016/j.jsat.2021.108413