Should People With Depression Take Prescription Painkillers?

A recent report shows 51% of people with opioid prescriptions distributed in the U.S. are also suffering from depression or another mood disorder. While it comes as no surprise that so many people with depression are in need of pain relief, it is of concern that the drugs are landing in the hands of people who are at greater risk for misusing them.

Prescription painkillers can be addictive, and they’re being prescribed to a population with a strong need to self-medicate. Research shows that one in three adults who struggle with drug or alcohol abuse also suffers from depression.

Are patients depressed because they're in pain and taking pain medicine, or are they taking pain medicine because they're depressed? The two are fellow travelers because if you have chronic pain, you're going to be more likely to get depressed.

Four Ways Depression and Opioids Intersect

Many people start taking opioid painkillers because they are in pain, continue because the drugs lighten residual pain, and perhaps also find along the way they helped improve their mood. There is not one over-arching reason for the high incidence of depression in opioid users. There are several issues to consider:

1. Chronic pain contributes to depression. Chronic pain can affect mood, outlook, ability to function in day-to-day life, sexual function, sleep and appetite. It is not unusual for people who have pain issues to become depressed, or to have some of the same symptoms that they would have if they were depressed. And some research suggests opioids can lead to depression. In a study of over 49,000 patients who were prescribed opioids for common ailments such as headaches, back pain and arthritis, the risk of depression increased the longer they were on the drug. They did not have a prior history of depression.
2. Antidepressants may be used to treat pain. Some antidepressants, particularly the ones that affect norepinephrine, inhibit pain signals going to the brain. So mixed SNRIs or SRIs may be used as part of adjunctive treatment for the pain syndrome because they inhibit the pain signals from getting to the cortex. Studies show they are especially used for neuropathic pain and they seem effective because pain and depression appear to share some common biochemical mechanisms.
3. People self-medicate symptoms of depression. People with depression may try to improve their mood by taking excessive or even regular doses of pain medicine. Narcotic analgesics can have mood-elevating effects, and some people continue to take pain medication because it lifts their mood ― not because they are necessarily experiencing pain. Research shows that in the early part of dependency, people continue to take the drugs because they stimulate the brain’s reward system. However, as the compulsion grows, the pleasurable effects wane and all that is left is dependency and tolerance, as well as the depression. Studies find this is because the continued drug use changes the brain and “hijacks” the reward circuit, leaving the person in discord.
4. Prescription drug abuse can lead to depression. Major depressive disorder is common in those who abuse drugs. Although depression can be part of the underlying problem that motivates people to attempt to self-soothe with drugs, opioids can cause depression symptoms in users with no prior history of depression. Prescription opioids can be a gateway to heroin, which is easier to obtain and is also strongly associated with depression.

Identifying Your Risk

Because of the association between pain and mood, it’s important to take steps to proactively prevent painkiller abuse and addiction.

1. Don’t automatically say yes to pain medicine. Opioids are prescribed by busy physicians on the front lines of family and emergency medicine. There is often no preliminary conversation about a patient’s general mental state. If you know you have a mood disorder, discuss this with your physician so that they can prescribe the least risky medicines and doses for a limited time period.
2. Assess physical versus mental pain. Depression can cause a physical manifestation of pain and also exacerbate existing pain. If the cause of the physical pain is not obvious – an accident, surgery or a traumatic injury – consider seeking psychological care in addition to medical treatment.
3. Educate yourself on the signs of dependency. Prescription opioids can turn from helpful temporary pain relief to a drug dependency. There is no negating that people sometimes need pain medicine but when you find yourself craving the drug, not being able to function without it or using the medicine for mood control, it’s time to seek help. Knowing the signs may also help you nip it in the bud.
4. Seek psychopharmacological treatment. There is some evidence that people with mood disorders may be using pain medicines to elevate their mood because they're not responding to their other treatment. If this is the case, it is important to find the correct psychopharmacological support. If opioids are being used for psychological benefits, find a specialist who is apprised of all options for mood disorders and their interactions with other prescriptions.
5. Be aware of the rebound effect. While some people take opioid painkillers to improve mood, many drugs have a rebound effect. This means that they boost mood immediately and within a short period lead back to, or increase, depression, requiring more of the drug for mood elevation. If you are not aware of this issue, you may stay stuck in a cycle of continuing with the medicine or increasing the dose without ever finding a real solution.

Prescription painkillers have an important place in medicine, but caution is needed when they’re prescribed to populations at high risk of addiction. Even medicine that is prescribed in good faith can lead to a problem requiring specialized dual diagnosis treatment that is designed to address both depression and addiction at the same time.

David Sack, MD, is board certified in psychiatry, addiction psychiatry and addiction medicine. As chief medical officer of Elements Behavioral Health, he oversees a network of drug rehabs and depression treatment centers that includes The Ranch depression rehab and Lucida mental health retreat in Florida.