Short communicationDepression – A major but neglected consequence contributing to the health toll from prescription opioids?
Introduction
More prescription opioid analgesics (POAs) are consumed in North America than any other international jurisdiction; moreover, the volume of POAs used has multifold increased in both the US and Canada over the past decade (Kenan et al., 2012, Manchikanti et al., 2012, Fischer et al., 2014b). In Canada, one in five adults have used an analgesic in the past year (Health Canada, 2014, Murphy et al., 2015). Importantly, these sharp increases in medical POA use have occurred alongside steeply rising levels of POA-related morbidity and mortality. For example, there have been some 16,000 POA-related overdose deaths, 366,000 emergency department and 170,000 treatment admissions annually in the US since 2010; similar rates of mortality, health care utilization and treatment at population-proportionate levels are either measured or estimated for Canada (Warner et al., 2014, Yokell et al., 2014; SAMHSA, 2014), amounting to what has been widely described as an ‘epidemic’ and acute public health crisis in North America (Manchikanti et al., 2012, Fischer and Argento, 2012, Volkow and McLellan, 2011).
Section snippets
Epidemiological evidence
While the health burden from POAs is fairly well-documented (Webster et al., 2011, King et al., 2014, Fischer et al., 2013) there is emerging evidence that POA use (including problematic use, e.g., non-medical, abuse) is associated with mental health disorders, and mainly depression. Specifically, several studies have found that individuals with current or historical mental health problems – including depression – are more likely to use POAs, and to use them chronically. For example, adjusted
Possible pathways
While potential pathways of POA misuse arising following the onset of depression (e.g., as ‘self-medication’), or co-occurring with depression as a result of shared vulnerabilities (i.e., involving common underlying mechanisms), have been reasonably well-explained (Markou et al., 1998, Goldner et al., 2014, Khantzian, 1997), a theoretical framework describing the development of depression following initiation of POA misuse has not been developed. However, there are several lines of evidence
Conclusions
The documented POA-related health toll in North America is extensive. There is now emerging epidemiological evidence that mental health problems, and specifically depression, may be an additional unintended consequence of any – not just non-medical – POA use based on the above reviewed data. While there are substantial acute research needs – especially regarding the neuro-biological pathways and processes for this link – the epidemiological evidence can be improved. Specifically, only half of
Conflict of interest
The authors have no conflicts of interest to declare.
Acknowledgments
Dr. Fischer acknowledges funding support from the Canadian Institutes of Health Research (CIHR), specifically Team Grant #SAF-94814 and the Canadian Research Initiative in Substance Misuse (CRISM) Ontario Node Team Grant #SMN-139150.
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