Depression and Opioid Use: Recognizing the Need for Dual Diagnosis Treatment

Emerging research suggests that depression is playing a significant role in the opioid crisis, as people with depression disproportionately use opioids and are more likely to abuse them. Part of this is due to the fact that people with depression experience higher levels of physical pain than the general population.However, there is also a vital neurological connection between depression and opioid use that helps explain disproportionate rates of abuse. This complex relationship means that if you are struggling with co-occurring depression and opioid addiction, dual diagnosis treatment is essential to creating sustainable recovery.

As the opioid epidemic reaches a fever pitch across the United States, more and more people are beginning to wonder how exactly we reached this place of widespread addiction and overdose. What happened in the past 30 years to cause the situation we now find ourselves in? Why is this happening now?

The origins of the opioid epidemic spreading across the country are multiple, complex, and deeply intertwined. The most obvious causes are the development of more potent and more addictive opioids in the past two decades combined with increased willingness of physicians to prescribe them.

Since 1999, opioid prescriptions have more than quadrupled. But not everyone who takes these medications becomes addicted—in fact, the majority don’t. So what accounts for cases of addiction? What is different about the patients who come to develop unhealthy relationships with opioids and those who don’t? Some researchers believe that the answer lies in the relationship between depression and opioid use.


Disproportionate Opioid Use Amongst People With Depression

Opioids are designed to treat both acute and chronic physical pain and, indeed, that is the purpose of most opioid prescriptions. But there is mounting evidence that the majority opioid prescriptions are given to people who are struggling with a different kind of pain: depression and other mood disorders. “More than half of all opioid prescriptions in the United States are written for people with anxiety, depression, and other mood disorders,” says Catharine Caruso of Stat News. At the same time, people who suffer from depression are 2-3 times more likely to misuse prescription opioid medications than the general population, even if they have no prior history of drug abuse.

Many researchers now believe that depression is one of the primary causes of opioid abuse. While 5% of the general population uses prescription opioids of some kind, that number jumps to 19% amongst people with mood disorders. In raw numbers, that means over 30 million opioid prescriptions each year are being written for people with mood disorders. Dr. Brian Sites, author of a newly released study examining opioid prescribing patterns from 2011-2013, says:

If you want to come up with a social policy to address the need to decrease our out-of-control opioid prescribing, this would be the population you want to study because they’re getting the bulk of the opioids and then they are known to be at higher risk for the bad stuff.

For many, this combination of increased likelihood of receiving an opioid prescription and higher propensity for abusing that medication can have devastating consequences.

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Causes of Increased Physical Pain in People with Depression

So why are people with depression more likely to receive or seek out opioid prescriptions? The answers are not entirely clear. What we do know, however, is that depression is linked to chronic pain; people with pre-existing depression are more prone to developing chronic pain while people with pre-existing chronic pain are more likely to become depressed. Additionally, people with depression may experience pain differently—and more intensely—than people without depression.

As a study published last year in The Journal of Pain found, people with depression had lower pain thresholds and higher pain sensitivity than non-depressed subjects. This was particularly true for people whose depression had anxious features. While lifestyle factors such as poor sleep and low levels of physical activity may account for a portion of this difference, pain sensitivity, in particular, remained significantly higher in depressed subjects, even when lifestyle factors were accounted for.

Some researchers believe that the cause of this exacerbated acute and chronic pain perception arises from the neurological behavior of depression itself. “People with depression show abnormalities in the body’s release of its own, endogenous, opioid chemicals,” Olga Khazan writes in The Atlantic. In other words, your brain is not capable of alleviating pain in the same way that of a non-depressed person can via natural opioid release. Additionally, Mark Sullivan, a professor of psychiatry at the University of Washington, says, “Depressed people are in a state of alarm. They’re fearful, or frozen in place. There’s a heightened sense of threat.” Some theorize that it is precisely that heightened state of fearfulness that augments perceptions of pain.

The Neurological Connection Between Depression and Opioid Use

But the connection between depression and opioid use isn’t necessarily about physical pain at all. Research reveals that people with depression are significantly more likely to continue taking opioid medications even after their physical pain has resolved, indicating that bodily pain is not the primary motivator for opioid abuse. “If the emotional pain, the depression, is never properly diagnosed or treated, the patient might continue taking the opioid because it’s treating something,” says Jenna Goesling, assistant professor in the department of anesthesiology at the University of Michigan.

Indeed, research suggests that opioids have antidepressant properties in their own right. “There is a generally accepted hypothesis that long distance running produces a ‘runner’s high’ via the production of endorphins, one of the brain’s opioids,” writes Anna Fels for The New York Times. People who employ running as part of their depression management strategy “often experience feelings of malaise and low mood—not unlike patients who miss a day or two of their antidepressants.”

Prescription opioids can mimic this natural high by working on the brain’s opioid receptors, causing feelings of euphoria and the minimization of depressive symptoms. In fact, opioid medication buprenorphine is now being investigated for the treatment of depression that has not responded to typical antidepressant medication with promising results. For many, this comes as no surprise; “opioids have a long history of being used to treat melancholia and other psychological disorders—right up until the 1950s, when the current group of antidepressants were discovered.”

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Dual Diagnosis Treatment Offers Hope of Recovery

The fact that opioids may have antidepressant properties helps to explain the appeal they hold for people with depression. This does not mean that opioid use is positive or even benign, however, particularly when it comes in the form of substance abuse stemming from a desire to self-medicate. Uncontrolled opioid use can have significant consequences—both physically and emotionally—and contributes to the prescription opioid-related deaths of thousands of people in the United States each year. It keeps even more in a cycle of drug abuse and suffering, damaging your sense of self, your relationships, your body, and your mind.

Furthermore, such use does not address the underlying causes of your depression, nor teach you the skills you need to move toward lasting wellness. While there is still much to learn about the relationship between depression and opioid use, one thing is clear: addressing only half of the equation will leave you vulnerable to relapse for both conditions.

If you are depressed and addicted to opioids, you must recover from both conditions simultaneously via dedicated dual diagnosis treatment in order to truly heal. Dual diagnosis treatment gives you the opportunity to deeply explore the complex relationship between your depression and your opioid use to identify the obstacles standing in the way of healing and develop effective strategies for recovery.

Within a welcoming, nonjudgmental environment, you can safely detox and engage in a comprehensive array of therapies with the support of compassionate clinicians and peers who understand what you are going through. Not only will you begin to find ways of coping emotionally and behaviorally, but you can also learn invaluable techniques for addressing physical pain in healthy ways. In doing so, you can nourish yourself mind, body, and spirit to create true, sustainable relief from the pain of depression and opioid addiction.

Alta Mira is a residential opiate addiction treatment center focusing on the treatment of drug and alcohol addiction and co-occurring mental health disorders. Contact us to learn more about our renowned Bay Area programs and how we can help you or your loved one start the journey toward recovery.