Address the Opioid Use Crisis by Treating Depression

I have written extensively about the linkage between depression and opioid use and addiction. In these commentaries, I have stressed the causal importance of this linkage, and the role that appropriate treatment of depression can play in addressing our national opioid crisis. Here, I would like to provide a summary of the evidence documenting this linkage, evidence on treatment for these co-occurring conditions, and some recommended actions and next steps. Co-occurring depression and opioid use/addiction The following evidence supporting this linkage: Persons with depression are often at greater risk for developing problems associated with long-term opioid dependence, although it is not entirely clear why this is so.[i] Having depression is a significant predictor of opioid use.[ii] Persons with depression are more likely to use long-acting opioids, and had higher oral morphine equivalency doses, than non-depressed persons.[iii] In one study, persons on chronic opiate therapy with moderate and severe depression were found to be two to three times more likely to misuse their opioid medication.[iv] Depression may be an important factor associated with the risk of non-fatal drug overdose.[v] Survey data support that among persons taking opioids for non-cancer pain, those who were depressed were more likely to misuse opioids.[vi] Among adults with depression in the U.S, nearly 19% are opioid users, compared with only 5% among those without mental health disorders.[vii] Treatment for co-occurring depression and opioid use/addiction Evidence also exists that the critical linkage between depression and opioid use/addiction does not play any significant role in in the treatment provided for opioid use and addiction, even though joint treatment for co-occurring disorders is recommended: Despite treatment guidelines, less than 10% of adults with co-occurring mental health and substance use disorders receive treatment for both disorders.[viii] The authors attributed low perceived need and barriers to care access for both disorders as likely to contribute to the low treatment rates. According to the American Psychiatric Association, a comprehensive psychiatric evaluation is essential in evaluating a person with a suspected or confirmed substance use disorder.[ix] Per the American Society for Addiction Medicine treatment guidelines, assessment for a psychiatric disorder should occur at the onset of treatment for opioid dependence and a detailed reassessment should occur after the person is stabilized.[x] The National Alliance of Healthcare Purchaser Coalitions, serving 12,000 purchasers and 45 million Americans, similarly highlighted this issue and recommended that Patient-Centered Medical Home (PCMH) and/or Accountable Care Organizations (ACOs) should require the use of screening tools and documentation that would lead to better managing the mental health needs of persons receiving care (measurement-based care).[xi] Recommended actions To improve this situation, the following actions are recommended: Screening and treatment for depression should occur prior to initiating opioid treatment, during treatment with opioids, and whenever opioid use or dependence is encountered. For those with depression, access to mental healthcare and appropriate interventions, including medications, are critical. This means that a healthcare provider must be able to prescribe – and the person must be able to obtain – a medication that most appropriately meets that person’s needs. Clearly, both federal legislative and program action will be necessary to build the infrastructure to accomplish effective co-occurring treatment for depression and opioid use/addiction. We must start this now if we are to get ahead of the opioid crisis now engulfing us. [i]. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010;105(10):1776-1782. [ii]. Sullivan MD, Edlund MJ, Steffick D, Unützer J. Regular use of prescribed opioids: association with common psychiatric disorders. Pain. 2005;119(1-3):95-103. [iii] Goesling J, Henry MJ, Moser SE, et al. Symptoms of depression are associated with opioid use regardless of pain severity and physical functioning among treatment-seeking patients with chronic pain. J Pain. 2015;16(9):844-851 [iv]. Feingold D, Brill S, Goor-Aryeh I, Delayahu Y, Lev-Ran S. The association between severity of depression and prescription opioid misuse among chronic pain patients with and without anxiety: A cross-sectional study. J Affect Disord. 2018;235:293-302. [v]. Bartoli F, Carrà G, Brambilla G, et al. Association between depression and non-fatal overdoses among drug users: a systematic review and meta-analysis. Drug Alcohol Depend. 2014;134:12-21. [vi] Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med. 2012;10(4):304-311. [vii] Davis MA; Lin LA; Liu H; Sites BD. Prescription Opioid Use among Adults with Mental Health Disorders in the United States. Journal of the American Board of Family Medicine: 30(4):407-417, 2017 Jul-Aug. [viii] Han B, Compton WM, Blanco C, Colpe LJ. Prevalence, treatment, and unmet treatment needs of US adults with mental health and substance use disorders. Health Aff (Millwood). 2017;36(10):1739-1747. [ix]. Kleber HD, Weiss RD, Anton RF, et al. Practice Guideline for the Treatment of Patients with Substance Use Disorders, 2nd edition. Washington, DC: American Psychiatric Association; 2006. [x]. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) national practice guideline for the use of medications in the treatment of addiction involving opioid use. J Addict Med. 2015; 9(5): 358–367. [xi] National Alliance of Healthcare Purchaser Coalitions. Achieving value in mental health support: A deep dive powered by eValue8. August. 2018. https://www.nationalalliancehealth.org/www/initiatives/initiatives-national/workplace-mental-health/evalue8-deepdive