When Pain, Anxiety, and Opioid Use Overlap: Why Treating Only One Problem Can Backfire

By Your Health Magazine Contributor

Your Health Magazine Contributor

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When Pain, Anxiety, and Opioid Use Overlap: Why Treating Only One Problem Can Backfire

A person may start taking an opioid because of back surgery, a serious injury, or years of chronic pain. Months later, the situation may no longer be only about pain.

Poor sleep can increase anxiety. Anxiety can make pain feel harder to manage. Depression may reduce activity and rehabilitation. Some people begin relying on medication not only for physical discomfort, but also because they feel calmer or temporarily detached from emotional distress.

This does not mean everyone who takes opioids for pain will develop opioid use disorder, or OUD. It does mean that pain, mental health, and opioid use can become closely connected.

When that happens, focusing on the opioid alone may leave the forces driving the problem untreated.

Pain and Emotional Distress Can Feed Each Other

Chronic pain affects much more than the part of the body that hurts.

It can interfere with sleep, work, relationships, exercise, and independence. Over time, frustration and uncertainty may contribute to anxiety or depression. Mental distress can then make coping with pain more difficult.

Rab Nawaz, M.D., an expert contributor to MyOpioidRecoveryTeam, has described why chronic pain often needs more than one treatment approach:

“Chronic pain requires multimodal treatment that addresses biological, psychological, and functional dimensions simultaneously.”

That distinction matters when opioids are involved. A medication may reduce part of the physical pain without addressing insomnia, fear of movement, anxiety, depression, or loss of function.

A multimodal plan may include nonopioid medication, rehabilitation, behavioral treatment, exercise, interventional procedures, sleep treatment, or mental health care depending on the cause of the pain and the individual’s needs.

Sometimes Substance Use Is a Clue to Another Problem

Patients may hesitate to tell their doctor exactly how they are using opioids, alcohol, cannabis, or other substances.

Fear of judgment is one reason. Another is the belief that substance use is separate from other health problems.

Raquel K. Zemtsov, M.D., M.P.H., a family medicine physician and Director of Addiction Services at UPMC Matilda Theiss Health Center, has explained that people sometimes use substances in an attempt to manage another problem:

“Be it anxiety, depression or pain.”

Knowing why someone is using a substance can completely change the clinical conversation. Dr. Zemtsov has described situations in which identifying anxiety behind daily substance use allowed treatment to focus on the underlying mental health problem instead.

That is why an honest discussion about opioid use should not be treated as a confession. It is medical information.

Physical Dependence Is Still Not the Same as OUD

Someone taking an opioid regularly can develop physical dependence even when the medication is taken exactly as prescribed.

Physical dependence means the body has adapted to the opioid. If the dose is suddenly stopped or reduced too rapidly, withdrawal symptoms may develop.

OUD is different. It involves a problematic pattern of opioid use that causes clinically significant impairment or distress.

A person may therefore have chronic pain, anxiety, and physical opioid dependence without having OUD.

On the other hand, warning signs such as repeatedly taking more than intended, strong cravings, unsuccessful efforts to control use, or continuing opioid use despite significant harm should prompt an assessment for OUD.

The distinction matters because treatment is different.

Replacing an Opioid With Another Sedating Drug Is Not Automatically Safer

When anxiety, insomnia, or nerve pain occurs alongside opioid treatment, clinicians may consider nonopioid medicines.

But “nonopioid” does not automatically mean risk-free.

Shernell Surratt-Gary, D.O., a physician and clinical adviser at Aura Recovery Center, has discussed the increasing use of gabapentin for anxiety:

“Gabapentin’s popularity in treating anxiety largely stems from clinical pragmatism rather than robust scientific support.”

She notes that gabapentin may sometimes help when anxiety occurs alongside neuropathic pain or insomnia, but individual responses vary and the evidence for anxiety treatment is limited.

There is another reason for caution when opioids are involved.

The FDA warns that gabapentin and pregabalin can cause serious breathing problems in people with respiratory risk factors, including those taking opioid pain medicines or other central nervous system depressants.

This does not mean gabapentin should never be used with an opioid. It means the complete medication list matters.

Benzodiazepines Deserve Particular Attention

Anxiety may also be treated with benzodiazepines such as alprazolam, lorazepam, clonazepam, or diazepam.

Combining a benzodiazepine with an opioid can increase sedation and respiratory depression. CDC guidance recommends particular caution when these medicines are prescribed together.

Patients should not abruptly stop a benzodiazepine they have been taking regularly, because withdrawal can be serious.

Instead, clinicians may consider whether the medication remains necessary, whether another treatment could be appropriate, and whether gradual changes are needed.

Alcohol and other sedating substances should also be part of the conversation because their effects can add to opioid-related respiratory depression.

Good Treatment Begins With Listening

When several problems overlap, patients may receive fragmented care.

One clinician manages pain. Another treats anxiety. A third may prescribe medication for OUD. If those parts of treatment are not connected, important information can be missed.

David Wolff, M.D., M.P.H., a psychiatrist and addiction medicine physician, summarizes his patient-centered approach with three requests:

“Listen to me. Try to understand me. Talk to me and work with me to explore solutions.”

That approach is especially relevant when opioid use, pain, and mental health symptoms intersect.

A person may be afraid that admitting anxiety will make a clinician dismiss their pain. Someone with OUD may worry that reporting severe pain will be interpreted as drug-seeking. Another person may hide taking extra opioid doses because they fear losing access to care.

Trust can make the difference between discovering those problems early and finding them only after a crisis.

OUD Treatment Should Not Wait Until Every Other Problem Is Solved

If someone meets criteria for opioid use disorder, evidence-based medications include buprenorphine, methadone, and naltrexone.

Mental health treatment can be extremely valuable alongside OUD care, especially when anxiety, depression, trauma, or other psychiatric conditions are present.

But medication treatment for OUD should not be delayed simply because counseling is unavailable or because the person is not yet ready to participate in psychotherapy. CDC guidance specifically states that declining psychosocial treatment should not prevent or delay medication for OUD.

SAMHSA recommends integrated treatment for people with co-occurring mental health and substance use disorders, meaning both conditions are addressed rather than forcing someone to finish treatment for one before receiving help for the other.

Naloxone Can Be Part of the Safety Plan

People taking opioids may benefit from discussing naloxone with their clinician, particularly when additional overdose risks are present.

CDC recommends offering naloxone especially to people with a history of substance use disorder or overdose, higher opioid doses, sleep-disordered breathing, concurrent benzodiazepine use, or reduced tolerance after a period without opioids.

A suspected opioid overdose is a medical emergency.

If someone cannot be awakened or has very slow or stopped breathing, emergency medical services should be contacted immediately and naloxone should be administered when available.

The Better Question Is Often “What Is the Opioid Doing for You?”

That question can reveal more than asking how many tablets someone takes.

Is the medication treating physical pain? Is the person also using it to sleep? Does it temporarily calm anxiety? Has fear of withdrawal become part of why the medication continues? Are depression or trauma making pain harder to manage?

The answers can point toward very different treatment plans.

For some people, opioids may continue to have an appropriate role in pain care. Others may benefit from a gradual, medically supervised reduction. Someone with OUD may need buprenorphine or methadone. Anxiety or depression may require its own treatment.

The goal is not to force every problem into the same diagnosis.

It is to understand how pain, emotions, medications, and opioid use are interacting, then treat the person rather than only the prescription.