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Comorbidity With Heroin Addiction

Drug addiction is a disorder that often occurs with other mental health conditions. For example, people with heroin addiction often struggle with depression, anxiety, and PTSD.
It is not always clear which condition develops first. Some people turn to drugs to deal with difficult emotions, and others develop mental health problems as a result of their heroin abuse.
Treatment for this population is usually more complicated than for people who only have one condition. But recovery is certainly possible.

What Is Comorbidity?

Depressed patient with doctor
Comorbidity is a word used to describe 2 different disorders that occur in the same person. These illnesses can appear at the same time or in succession. The term comorbidity also implies that the illnesses interact with each other, often worsening the prognosis of both.1

People who are addicted to drugs are nearly twice as likely as the general population to have a mood or anxiety disorder, and the converse is also true.1 According to a 2014 national survey, 7.9 million people in the U.S. had both a mental health disorder and a substance use disorder.2 

Risk Factors for Comorbidity

When people abuse heroin, it can trigger emotional problems and mood disorders. It can also intensify cognitive, personality, and behavioral problems. Additionally, people struggling with mental health problems may turn to heroin as a form of self-medication.

Drug abuse and mental health disorders have many of the same contributing issues and risk factors, regardless of which condition presents first.

Factors that may influence the development of comorbid disorders include:1

  • Genetics. Traits you inherit from your parents may predispose you to both addiction and mental health problems.
  • Environmental triggers. Drug addiction and mental health issues sometimes develop after exposure to trauma, stress, and early drug use.
  • Brain abnormalities. Certain brain regions that involve stress and reward can be affected by heroin use and certain mental conditions.
  • Developmental disorders. Drug abuse and mental problems during your formative years can affect the development of the brain and increase the risk of comorbid disorders.

Other factors include:5 

  • Older age.
  • Lower socioeconomic status.
  • Living in urban areas.
  • Homelessness.
  • Incarceration.

Mental Disorders Seen With Heroin Addiction 

Heroin addiction co-occurs with many different mental health disorders, including:3,4,5

  • Depression.
  • Bipolar disorder.
  • Anxiety disorders (including panic disorders).
  • Post-traumatic stress disorder (PTSD).
  • Antisocial personality disorder.
  • Attention-deficit hyperactivity disorder (ADHD).
  • Insomnia.
  • Eating disorders.
  • Gambling disorder.

In general, women who are addicted to heroin and other drugs are more likely to have mood and anxiety disorders. Men are more likely to have antisocial personality disorder.3 

Heroin addiction also often co-occurs with other substance use disorders. In some cases, these concurrent addictions may arise from attempts to ease the symptoms of withdrawal, deal with cravings, counteract the depressive effects of heroin, or enhance heroin’s pleasurable effects.

This includes abuse of substances such as:4

  • Alcohol.
  • Marijuana.
  • Stimulants (cocaine, methamphetamine).
  • Sedatives (benzodiazepines).

Treatment for Dual Diagnoses

A dual diagnosis is when someone is diagnosed with both a substance use disorder and a mental health disorder. Programs that treat these conditions at the same time may reduce relapse risk. Unfortunately, treatment facilities for substance abuse and mental health are often separate.5

Unfortunately, less than 10% of adults with comorbid mental health and substance use disorders receive treatment for both disorders. More than 50% receive no treatment at all.6

Comorbid disorders can be difficult to diagnose. Substance withdrawal symptoms often mimic the symptoms of mental illness, and a diagnosis for a mental health condition is easier to obtain after a period of abstinence. Treatment facilities specializing in comorbid conditions can watch for signs of mental illness once the person achieves sobriety.

Therapies

The most effective treatments for comorbid disorders are integrated approaches that include behavioral therapies and medications to simultaneously address both issues.3 In behavioral therapy, the person talks with a counselor or psychologist about issues related to their mental illness and/or drug abuse. Different types of behavioral therapy can be used depending on age and illness.

Patient with therapist
For adolescents, therapies include:3

  • Multisystemic therapy (MST). This approach targets factors that contribute to antisocial behavior in adolescent drug abusers, including attitudes and issues at home and school.
  • Brief strategic family therapy (BSFT). This approach focuses on family interactions. Family patterns that enable or exacerbate drug use and problem behaviors are evaluated.
  • Cognitive behavioral therapy (CBT). This is a form of talk therapy that helps adolescents modify harmful thoughts and behaviors.

For adults, therapies include:3,7

  • Cognitive behavioral therapy (CBT). During CBT, therapists help people identify and change unhealthy thought patterns that may cause self-destructive behaviors, such as drug use.
  • Therapeutic communities (TCs). TCs focus on re-socializing individuals into healthy, sober communities of their peers. They are well-suited for vulnerable populations, such as those with legal trouble or unsafe living situations.
  • Assertive community treatment (ACT). ACT programs are a form of case management designed for people with severe mental disorders and co-occurring substance abuse problems.
  • Dialectical behavior therapy (DBT). DBT is a type of talk therapy often used for patients with borderline personality disorder. It involves identifying self-destructive thought patterns and validating difficult emotions.
  • Exposure therapy. Exposure therapy is a common treatment option for people with PTSD and specific phobias. It involves gradual exposure to triggers.
  • Integrated group therapy (IGT). This is a new approach developed specifically for people with comorbid bipolar disorder and drug addiction.

Medications

Treatment for comorbid heroin addiction and mental illness may involve one or more medications. Medication often plays an important role in managing withdrawal and cravings. It is also a fundamental part of treating many mental illnesses.

Common medications include:3,5,8,9

  • Methadone. This is a long-acting opioid taken to prevent the symptoms of withdrawal and reduce cravings. It can also block the effects of heroin. Research shows that methadone is more effective when combined with individual or group counseling. It is only available in specially licensed programs.
  • Buprenorphine. As a partial opioid receptor agonist, this medication does not produce the same high that heroin does, but it can lessen the effects of withdrawal. Qualified physicians can prescribe it.
  • Naltrexone. This is an opioid antagonist, which means it blocks the effects of opioids to minimize the likelihood of relapse. There is an intramuscular injectable version that can be administered once per month.
  • Suboxone. This is a newer medication that contains both buprenorphine and naloxone. It can block the effects of heroin, and the user will have withdrawal symptoms if they try to inject Suboxone.
  • Antipsychotics. These drugs play an important role in treating schizophrenia and other psychotic disorders.
  • Antidepressants. These medications influence the activity of several brain signaling chemicals known as neurotransmitters. The widely used serotonin reuptake inhibitors (SSRIs) alter serotonin neurotransmission, and a drug called bupropion works on the norepinephrine and dopamine systems. They can help people with depression, anxiety, and PTSD.
  • Lithium. This drug is primarily used to treat bipolar disorder and episodes of mania.

Some of these medications work well together, but others do not. In particular, methadone can interact adversely with many medications, including some SSRIs.5

Support groups are a great resource for people struggling with comorbid conditions. Self-help groups that may be beneficial include:

Sources

  1. National Institute on Drug Abuse. (2011). Comorbidity: Addiction and Other Mental Disorders.
  2. National Alliance on Mental Illness. (2017). Dual Diagnosis.
  3. National Institute on Drug Abuse. (2010). Comorbidity: Addiction and Other Mental Illnesses.
  4. American Psychiatric Association. (2015). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  5. Substance Abuse and Mental Health Services Administration. (2005). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Chapter 12.
  6. National Institute on Drug Abuse. (2017). Study Highlights Unmet Treatment Needs Among Adults with Mental Health and Substance Use Disorders.
  7. National Alliance on Mental Illness. (N.D.). Psychotherapy.
  8. National Alliance on Mental Illness. (2017). Mental Health Medications.
  9. National Institute on Drug Abuse. (2018). Opioid Addiction.

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