Occupational Therapy and the Opioid Epidemic: Recognizing the Need to Address Mental Health Comorbidities in Resolving Opioid Substance Abuse

Opioid Abuse and Mental Health Comorbidities

Comorbidity “…describes two or more disorders or illnesses occurring in the same person. They can occur at the same time or one after the other. Comorbidity also implies interactions between the illnesses that can worsen the course of both” [16]. However, this combination does not suggest the unpretentious existence of two disparate syndromes. On the contrary, the interactive nature of two or more (comorbid) syndromes tends to create a more unique disorder-one that likely presents with an increase in the number and complexity of symptoms while demonstrating an increased resistance to standard treatment protocols [17]. As a result, comorbidities have the tendency to become chronic or long-term in duration. Moreover, because of the limited focus of most healthcare evaluation protocols, one of a client’s comorbid conditions is likely to be ignored or go undetected and not fully addressed.

Research on opioid use, opioid substance abuse, and opioid addiction has demonstrated a robust relationship between those behavioral engagements and a diverse assortment of analogous mental health syndromes, i.e., mental health comorbidities. For example, Davis, et al. [18] found that over half of all opioid prescriptions are consumed by those adults with mental health disorders, even though they represent only one-sixth of the US population.

Mood and anxiety disorders have repeatedly been shown to coincide with opioid dependence/addiction disorders [19, 20, 21, 22]. Utilizing a process incorporating negative binomial generalized estimating equations, Foley, et al. [23] confirmed an association between percent of state populations reporting depression diagnoses and number of opioid analgesic-related deaths. Specifically, they found that “A one percent point increase in state-level depression diagnoses was associated with a twenty-six percent increase in opioid analgesic-related deaths.” Likewise, Seal, et al. [20] found that among US veterans of military campaigns in Iraq and Afghanistan, those veterans with aberrant pain diagnoses and with specific mental health diagnoses, e.g., depression, anxiety, or PTSD, were significantly more likely to receive opioids, present with high-risk opioid use, and experience adverse clinical outcomes than those with no mental health diagnoses. In addition, those veterans with PTSD were more likely to receive higher-dose opioids, use two or more opioids concurrently, and readily obtain early opioid refills [20].

Desai, et al. [24] determined that among elderly breast cancer survivors using adjuvant endocrine therapy (AET) regimens, opioid use was significantly higher for those women diagnosed with mental health comorbidity, especially those presenting with depression and anxiety. Similarly, Brooks, et al. [25] found that older adults with severe depressive symptoms were considerably more likely to be taking high‐potency opioid medications than those older adults not presenting with such symptoms.

A comorbid relationship between mental health disorders and opioid abuse has also been found among adolescents. Quinn, et al. [26] for example, found that: “Adolescents with a range of prior mental health conditions and treatments had substantially higher rates of transitioning from initial opioid receipt to long-term opioid therapy…Long-term opioid therapy rates were low among commercially insured adolescent opioid recipients overall but were substantially higher among those with preexisting mental health conditions and treatments” [26].

Consequently, response to and treatment of opioid abuse patently requires more than the historically singular approach focusing on pain management; it requires focus on and address of acknowledged comorbidities, particularly mental health syndromes and disorders [27, 28, 29]. Unfortunately, such comorbidities, while greatly impacting opioid substance use and abuse, tend to be overlooked and/or not attended to. As Sartorious, et al. [17] realistically asserts: “Specialists in disciplines other than psychiatry and general practitioners avoid making a diagnosis of mental illness – partly because of their uncertainty about the diagnosis and treatment of psychiatric disorders and partly because they would like to avoid the perceived stigmatization of their patients that occurs when they are labeled as ‘mentally ill’.”

Occupational Therapy, Opioid Substance Abuse, and Mental Health Comorbidities

The roots of occupational therapy lie in mental health as do the profession’s early practice models [30, 31, 32]. Moreover, given national accreditation standards in the United States requiring occupational therapy and occupational therapy assistant educational programs to provide instruction specific to an understanding of mental and cognitive functioning as well as training in responsive therapeutic intervention strategies, graduating practitioners possess a foundational background in these key opioid “comorbid areas”.

Occupational Therapy’s importance in the treatment of opioid abuse and addiction is highlighted in its inclusion in the 2018 “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” passed by the US Congress [33]. Sadly, this act tends to over-emphasize the management of pain by healthcare professionals as the primary treatment regimen in the care of those suffering from opioid substance abuse. An occupational therapy approach to substance abuse, on the other hand, is one that would include a focus on pain management when applicable, but one which by professional definition more expectantly examines routines, habits and behaviors, especially those which in some way involve the abuse behavior as well as the perceived or admitted physical and psychological desire for the addictive substance, along with the incorporation of a unique client-centered approach [34, 35]. Moreover, an occupational therapy approach is one that assists in filling any “void” that results if the addictive substance is removed immediately or slowly reduced in amount, concentration, and/or frequency thereby creating a void or vacuum in the individual’s life. However, in mounting an effective response to the basic substance abuse, it is critical for occupational therapy practitioners to take into consideration all components germane to the addiction: the initial reason(s) for use of the substance; current access to targeted opioid substances; determination of any on-going motives promoting the abuse; the physical addiction itself; existence of pain and need for pain management; and, importantly, the prospective co-diagnosis of any mental health disorder(s). Moreover, because of the documented association between opioid abuse and mental health disorders, occupational therapy clients known to be or suspected of abusing opioids should be concurrently screened for presence of such disorders, principally for symptoms of depression, anxiety, and/or other mood disorders [18, 20].

An occupational therapy approach should be one that in addition to the aforementioned components does include an enhanced focus on address and treatment of any mental health co-morbidities given the profession’s foundational roots in that area as well as the extensive array of research evidence confirming co-symptomatology of substance abuse/addiction disorders and assorted mental health syndromes. Yet, while such occupational therapy approaches do exist and have received significant support in the professional literature, practicing therapists, including those in mental health practice settings, tend not to regularly adopt such approaches [36]. Therapists all too often fail to provide equal weight of focus toward address of mental health comorbidities as they do toward the management of pain and/or other more traditional or contemporary occupational therapy physical/bodily directives.

Sadly, when choosing to concentrate primarily or exclusively on pain management and/or other non- mental health function areas, occupational therapists and occupational therapy assistants not only demonstrate regression from their historic and professional roots in mental health, but blatantly disregard complete utilization of any/all occupational therapy treatment stratagems which hold the potential to more effectively resolve a client’s opioid abuse disorder by co-addressing physical and mental health comorbidities. This is especially the case given that those individuals abusing opioid substances tend to disproportionately present with recognizable mental health disorders [22].

Occupational therapists, particularly those practicing in acute care and rehabilitation hospitals, subacute facilities, outpatient, and/or mental health settings, are not only likely to have a fifty percent or greater probability of having one or more clients who they know for certain are abusing opioids and/or who they strongly suspect of abusing opioids, but also have a one in five probability of having a client overdose on an opioid substance and likely to do so in their presence [37]. Tragically, clients abusing opioids are not regularly screened for suicidal ideation, even though opioid abuse has been demonstrated to account for an increased risk of committing suicide and demonstrated to be a likely causal agent in the suicidal action [38, 39]. This relationship alone highlights the need to acknowledge and address the complex co-relationship between opioid substance abuse and associated mental health comorbidities in designing effective occupational therapy and non-occupational therapy treatment interventions.