Opioid Abuse and Depression: A Bi-Directional Relationship in Need of Better Attention

Ron Manderscheid

Ron Manderscheid, PhD
Executive Director, National Association of County Behavioral Health and Developmental Disability Directors and the National Association of Rural Mental Health

It’s no secret that opioid abuse remains a growing problem in the US, notwithstanding increased attention by policymakers, law enforcement and health care professionals from Main Street to the halls of the US Congress. Despite expressions of concern and promises of funding, little has improved the situation.  Indeed, as many as 2.4  million American today abuse painkillers; nearly 500,000 more abuse heroin. Only 1 in 5 get specialty treatment and, perhaps not surprisingly, two-thirds of drug overdose deaths in 2016 were from opioids.   According to new CDC data, the number of Americans with opioid overdoses who turn up in emergency rooms has risen sharply in recent years, up 30% between July 2016 and September 2017 alone.

While the White House continues to focus nearly all of its attention on interdiction and penalties for opiate dealers, the US Department of Health and Human Services (HHS) is implementing a 5-point plan that more significantly addresses prevention, treatment, and recovery from opioid abuse.  The plan is designed to (1) strengthen public health surveillance,  (2) advance pain management,  (3) improve access to treatment and recovery services, (4) target the availability and distribution of overdose-reversing drugs, and (5) support cutting-edge research.

Yet what the White House and HHS fail to address is the significant interrelationship among opioid abuse and depression (and other mental problems as well) and physical ailments. Instead, the HHS plan proposes to do battle against opioid abuse in a treatment vacuum, despite the evidence-based recognition that behavioral health and physical health can no longer be siloed when it comes to prevention, treatment and recovery.  Ironically, the HHS plan seems to fly in the face of the Department’s clear and increasing emphasis on integrated care in both grants and program directions.

At the level of the person, just as in the larger policy landscape, all too often, opioid abuse is only part of the picture, only part of a larger problem that may need to be addressed across behavioral and physical health.  Put simply, opioid abuse may well be complicated by depression.  And both may be complicated by a physical ailment for which the opioids were prescribed in the first place.  Under any of these circumstances, sustained recovery from opioid abuse is likely to be difficult unless co-occurring mental or physical conditions also are addressed.  Critically, the relationships among opioid abuse, depression, and physical illnesses are bi-directional: any one of the health conditions may give rise to one or more of the others.

Decades of research have disclosed that people with depression or anxiety disorders have a greater than average risk for opioid abuse. In many cases, individuals with depression or an anxiety disorder engage in drug use to self-medicate their mental condition.  Similarly, research has evidenced that physical health problems, such as hip fracture, arthritis, or severe back pain, can give rise to depression and, with the increasing use of opioids to manage the pain and the depression, also can lead to opioid abuse. A St. Louis University study reports that some 10% of more than 100,000 patients who were prescribed opioids developed depression after using the medications for over a month. These patients were taking the medication for ailments such as back pain, headaches, arthritis, etc., and had not received a diagnosis of depression prior to treatment.

These clear interrelationships between and among mental health conditions, opioid abuse, and physical ailments pose interesting implications for prevention, treatment, and recovery. To begin, these interrelationships underscore the requisite for healthcare professionals—whatever their discipline or specialty—to recognize and respond to these co-occurring problems in an integrated approach to treatment. That means it is time to end siloed treatment immediately, both in practice and in policy.  Health needs to be considered across mind and body; all aspects of illness need to be addressed concurrently if treatment is to be successful and recovery is to endure.  Preventive interventions and treatments that integrate care, increasingly part of a person-centered rather than ailment-centered health system, can help reduce the bi-directional relationship among opioid abuse and other physical and behavioral issues.

The opioid crisis we face is more multifaceted than most policymakers imagine. It is time for us to step up to educate about evidence-based connections across opioids, mood disorders, and physical illnesses that not only affect the trajectory of the opioid crisis, but also the health of the nation as a whole.

Your Turn

  • What steps might we take to better unify care of mind and body when addiction is involved?
  • Describe your vision of care that addresses mental and physical health simultaneously.

Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors. The association represents county and local authorities in Washington, DC, and provides a national program of technical assistance and support. Concurrently, he is Adjunct Professor at the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University. He has served in several federal leadership roles in the U.S. Department of Health and Human Services. Dr. Manderscheid is particularly noted for his work with the peer and family communities and for introducing consumer participation in federal workgroups and consumer assessments of mental health care.

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