The Role of Mental Health Symptomatology in Opioid Overdoses: Implications for Social Work Intervention

Background/Purpose:Drug overdose is the leading cause of accidental death in the US and most of these overdose deaths involve opioids such as heroin. The lethal epidemic is growing exponentially; the incidence of opioid overdose has quadrupled in the past decade and a half.  While medical interventions like Nalaxone are critical, a true harm reduction strategy should be informed by an understanding of the factors that increase the risk for overdose to begin with.  A limited body of literature identifies elevated psychiatric symptoms and particularly depression as risk factors for opioid overdose. Building on these prior findings, we employed a unique data set of substance dependent individuals enrolled in a treatment study where recent overdose history was systematically assessed.  We tested the following hypothesis: Heroin/opioid users who have recently overdosed are more likely to experience severe mental health symptoms than heroin/opioid users who have not recently overdosed.

Methods:We performed secondary data analysis of the Addiction Health Evaluation and Disease (AHEAD) Management Study, which was a treatment study of 563 participants with alcohol and/or other drug dependence. The study occurred in Boston, Massachusetts and collected data from 2006 to 2010. For our analyses, we relied exclusively on the study’s baseline questionnaire data. We identified 283 participants (50.3% of the sample) who self-reported heroin or another opioid as their only, primary, or secondary substance problem at baseline. We performed descriptive analyses related to overdose, heroin/opioid use, depressive symptoms, and suicide.

We employed logistic regression to compare heroin/opioid users who had experienced a recent overdose to heroin/opioid users who had not experienced a recent overdose. We investigated the relationship between PTSD (based on MINI scores), severe depression (based on the PHQ9, using a cutoff of 20 and above), psychosis (based on the BASIS 24), and overdose among heroin/opioid users controlling for age, education, race, and gender.  

Results: Descriptive analyses revealed that 45 (15.9%) of the 283 heroin/opioid users in the sample reported a recent (past 3-month) overdose experience. Among those 45 participants, five (11.1%) indicated that their most recent overdose was a suicide attempt. Adjusting for background covariates, the logistic regression model suggests that heroin/opioid users with PTSD (OR 2.6; 95% CI 1.2, 5.4), those with severe depression (OR 2.1; 95% CI 1.0, 4.4), and those with psychosis (OR 2.2; 95% CI 1.0, 4.7) had significantly increased risk for reporting a recent overdose.  Having a high school diploma also increased overdose risk (OR 4.96; 95%CI 1.60,15.36).  Follow-up analyses suggest that those reporting recent overdose were significantly more likely to report ongoing suicidal thoughts compared to other opioid users (X²= 12.42; p <.01).

Conclusions and Implications:  Whether the elevated and severe mental health symptoms we found are precursors, correlates or consequences of overdose, these data suggest that the immediate life-saving impact of medical overdose interventions such as Nalaxone may be short-lived without connections to essential behavioral health treatment services.  To effectively address longer-term mental health risk in overdose, social workers need to partner with medical providers to foster connections needed services.