More than 200 million prescriptions are written annually for opioid analgesics despite limited evidence of their long-term efficacy. Opioid analgesics, or prescription-based narcotic pain killers, have long been known to reduce pain. Despite this widespread use, little is known about the risks of opioids, particularly with chronic use but reports of adverse effects and addiction continue to surface. Now, a team of investigators led by a Saint Louis University researcher has discovered a link between chronic use of pain-relieving medication and an increase in the risk of developing major depression.

 The study, which was published in the Journal of General Internal Medicine on October 31, analyzed medical record data of about 50,000 veterans who had no history of opioid use or depression but were prescribed, opioid pain killers.

 According to the findings, patients who started and continued on opioids for 180 days or longer were at a 53 percent increased risk of developing a new episode of depression and those using opioids for 90-180 days were at a 25 percent increased risk compared to patients who never took opioids for longer than 1-89 days. These findings suggest that the longer one is exposed to opioid analgesics, the greater is their risk of developing depression. 

Even though there is no clear evidence about the mechanisms by which opioids may contribute to the development of depression in a patient, there could be several factors that lead to it. Some of these include opioid-induced resetting of the brain's 'reward pathway' to a higher level, which means the chronic use of narcotic pain killers can elevate the threshold for a person's ability to experience pleasure from natural sources such as a food or sexual activity. Other factors may include body aches months and years after the use of opioids has stopped side effects such as adrenal, testosterone and vitamin D deficiencies and glucose dysregulation.

 Signs of depression can include

• Lack of interest in activities
• Depressed mood or irritability
• Changes in sleep patterns
• Changes in appetite
• Feelings of guilt or despair
• Lack of energy
• Trouble concentrating
• Suicidal thoughts

 If you’re not sure whether you’re abusing opioids, you can ask yourself the following questions

• Do you take opioids for longer or in larger amounts than your prescription?
• Have you tried to cut back your use unsuccessfully?
• Do you spend a lot of time using, obtaining, or recovering from the drug?
• Do you experience cravings to use the drug?
• Does drug use interfere with work, school, or home life?
• Do you continue consuming the drug even though it causes problems in relationships?
• Do you use the drugs in situations where it is physically hazardous to do so?
• Do you need more of the drug to create the desired effect?

  The study suggests that the higher the dose of opioid analgesics, the greater the risk of depression.

Preliminary evidence suggests that if you can keep your daily dose low, you may be at lower risk for depression. A minority of patients take these pain killers chronically which puts them at risk of developing depression that can affect their quality of life and ability to cope with chronic pain. 

Researchers think that depression may stem from how opioids cause changes in the brain’s reward and pleasure system as well as hormone levels. They also suggest that opioids are less effective if a person suffers from depression, which can lead to increased use to achieve the desired effect. Researchers recommend that physicians or other medical professionals screen patients for symptoms of depression prior to giving them an opioid prescription.

 Recent studies indicate that the use of prescription opioid analgesics has quintupled recently and that more than 200 million prescriptions were issued to patients in 2009 in the US. 

The research data suggests that opioid analgesics should be prescribed for a short duration and at the lowest effective dose and be exclusively reserved for severe pain syndromes, with as much reliance on adjuvant therapy for pain management and non-narcotic analgesics as possible. Also, advocate screening for depression and substance use disorder for all patients during opioid trials. Practitioners should consider antidepressant prophylaxis and treatment of patients entering chronic opioid treatment.

More research is needed to determine whether co-administration of anti-depressants and opioids would help to prevent incident depression in humans taking opioid analgesics.

 Treatment

Well, structured treatment is available for both depression and opioid abuse. Medications like methadone, naltrexone, and buprenorphine can help treat opioid dependence, and antidepressants can do a great deal to reduce depressive symptoms. Research shows that medication frequently is more effective when an individual seeks behavioral and counseling support. Many patients find that intensive outpatient or inpatient treatment is necessary to curb addiction and learn healthy coping methods for depression.

 When seeking treatment for opioid abuse and depression, you first may need to seek immediate medical attention to address the withdrawal symptoms of opioids, which can include nausea, vomiting, stomach pain, sweating, sleep problems, involuntary movements, nervousness, and intense cravings.

 Effective treatment programs typically include

• Peer group support for addiction and depression
• Intensive individual counseling
• Medication options for opioid replacement and depression
• A treatment plan apt as per your individual needs
• Onsite medical assistance and support
• Family psychoeducation and counseling
• Follow up support

 If you take prescription opioids or are thinking of taking them, talk to your doctor about the risks of depression and your mental health history. Non-opioids medications can be an option and your doctor can also recommend counseling along with any pain medication. If you experience chronic pain, you may be at increased risk for depression whether you take opioid medication due to the pain. 

Recovery and healing are possible, and your best chances for both are to seek immediate treatment that addresses both the drug abuse and depressive symptoms. Take that first important step today and reach out to someone who can help you move towards a fuller and healthier life.

References:

1. Saint Louis University Medical Center, Long-term use of prescription painkillers increases the risk of depression, October 31, 2013

2. Katherine Semenkovich, BA, et al, Prescription Opioid Analgesics Increase Risk of Major Depression: New Evidence, Plausible Neurobiological Mechanisms and Management to Achieve Depression Prophylaxis, MO Med. 2014 Mar-Apr; 111(2): 148–154.