Opioid Use May Play a Part in Anxiety — Here’s What to Know

Since opioids work as sedatives, it may seem counterintuitive for them to cause anxiety, but it’s a common side effect.

Opioids reduce your level of norepinephrine, a hormone that controls alertness and blood pressure. Low norepinephrine levels can cause side effects like drowsiness and low blood pressure.

When opioids leave your system, they stop repressing norepinephrine. Your brain responds by releasing a lot of norepinephrine at once to bring your energy and blood pressure levels back to baseline. This boost can cause acute withdrawal symptoms like:

• anxiety
• jitteriness
• sleeplessness
• muscle cramps and diarrhea

If you use opioids for a long time, your body may decide this sedation is permanent. To compensate, it will keep producing norepinephrine at a higher volume, so you may start feeling anxious and jittery all the time.

You might take opioids simply to help ease your anxiety. But this can prompt your body to release even more norepinephrine, creating a self-sustaining stress spiral.

Substance-induced anxiety often involves many of the same symptoms as anxiety disorders, but 2019 research suggests it may more often manifest in certain forms, such as:

• obsessions and compulsions
• panic attacks
• free-floating anxiety
• phobias

Learn more about anxiety symptoms.

Opioids can cause anxiety even if you take them exactly as prescribed, but anxiety severity can depend on which opioids you take, the amount taken, and the amount of time you use them. You may experience anxiety for as long as you continue taking opioids.

You can also experience anxiety during opioid withdrawal. Short-acting opioids, which work quickly but only last a short while, tend to cause the most severe anxiety during withdrawal. Common short-acting opioids include codeine, oxycodone, and heroin.

Some opioids, like morphine, have both short-acting and long-acting forms. Long-acting opioids, which include extended-release opioids, tend to cause a milder but longer-lasting withdrawal.

Withdrawal anxiety can last anywhere from 5 to 14 days after you stop taking opioids.

Anxiety disorders often occur with opioid use disorder, and over 60% of people with opioid use disorder have had an anxiety-related condition at some point in life.

With opioid use disorder, you continue using opioids despite unwanted side effects, and you may be unable to stop taking them when you try.

Pre-existing anxiety may also potentially increase your chances of developing opioid use disorder.

One 2017 study included 554 people taking prescription opioids to treat chronic pain. Researchers used the Generalized Anxiety Disorder (GAD-7) scale to screen participants for anxiety and the Current Opioid Misuse Measure (COMM) to screen participants for opioid misuse.

Among those with clinically significant anxiety, 50% also misused opioids, which means they didn’t take their medication exactly as prescribed. By comparison, only 10% of those who didn’t have anxiety misused opioids.

Even after researchers controlled for social, demographic, and clinical variables, people with anxiety still remained more likely to misuse opioids than those who didn’t have anxiety.

Important

The above study didn’t specifically explore opioid use disorder risk, and opioid misuse isn’t the same thing opioid use disorder. Misusing opioids can raise your risk of this mental health condition, it’s true — but you can still develop it when taking opioids exactly as your doctor prescribed.

Chronic opioid use can contribute to depression by decreasing your sensitivity to pleasant feelings and increasing your sensitivity to unpleasant feelings.

Opioids drastically raise your dopamine levels, a hormone that helps manage your response to rewards. High dopamine levels can cause feelings of euphoria that motivate you to keep using opioids. Dopamine can also increase your brain’s sensitivity to stress, fear, and other unwanted emotions, so you may more easily get stuck in a spiral of dark or painful thoughts.

Once the opioids leave your system, your exhausted neurons produce much less dopamine than before. If you take opioids for an extended period, your brain may reset its dopamine output to a much lower level. This robs external rewards of their power, so the things that used to excite you — cake, dancing, or a really good book — may feel much less stimulating.

Learn more about depression symptoms.

Risk factors for opioid-induced depression

Unlike with anxiety, a high dose of prescription opioids may not automatically increase depression risk. The amount of time you take opioids seems to make more of a difference.

According to 2016 research, the longer you use opioids, the higher your chances of developing treatment-resistant depression (TRD), a type of depression that often doesn’t respond to antidepressants.

Compared to people who took opioids for 30 days or less, people who took opioids for 31 to 90 days had a 25% higher risk of TRD. People who used opioids for over 90 days had a 52% higher risk of TRD, researchers found.

Frequency also matters. A 2022 study examined how often people took prescribed opioids during the first 90 days of treatment and their risk of depression. People who used opioids daily, or on at least 81 of the 90 days, had a 40% higher risk of depression than people who used them only occasionally, or on less than half of the 90 days.

Can opioids ever help reduce mental health symptoms? That depends.

Opioids and anxiety

Technically, yes. Opioids do have a sedative effect that can ease anxiety. That said, you’d be hard-pressed to find a doctor or psychiatrist who recommends treating anxiety with opioids. That’s because you have a range of options for safer anti-anxiety medications that pose less risk of dependence or opioid use disorder.

In addition, not all opioids affect anxiety. Opioids work via one of two chemical pathways: the β-arrestin path or the G-protein path. According to animal research, opioids that use the β-arrestin path may reduce anxiety but they can also cause serious side effects like shallow breathing, dependence, or addiction.

Thus, many doctors prefer to prescribe opioids that use the G-protein path. These medications are safer, but they also have little effect on anxiety.

Opioids and depression

Preliminary research suggests the opioid buprenorphine may have benefits as a treatment for depression, particularly the treatment-resistant type.

Buprenorphine is typically used to treat opioid use disorder since it has a much weaker effect on nerve receptors than other opioids. While it stimulates your nerves enough to prevent withdrawal, buprenorphine generally won’t cause euphoria or cravings.

Researchers believe buprenorphine treats depression by restoring your dopamine to its typical levels, which may help you feel pleasure after happy events and increase your attachment to people around you.

The Food and Drug Administration (FDA) hasn’t approved buprenorphine as a depression treatment yet, citing the need for more human research. That means you can only try buprenorphine for depression if you join a clinical trial.

Find more treatments for depression here.

If you have been using opioids for a long time or taking more than your prescribed dose, you may need extra support to stop taking them.

Treatment for opioid use often involves a combination of psychotherapy and medication-assisted treatment (MAT). If you have a co-occurring mental health issue, like anxiety or depression, experts highly recommend treating it at the same time.

Many people leave treatment early due to the emotional stress of anxiety and depression during withdrawal, but support from a mental health professional can help you cope with these symptoms during opioid use disorder treatment and recovery.

Medication

You can safely take most antidepressants during MAT. Some research suggests that during MAT, older tricyclic antidepressants (TCAs) may prove more effective than selective serotonin reuptake inhibitors (SSRIs).

Benzodiazepines, used to treat anxiety, are more difficult to integrate into MAT.

The MAT drug methadone may interact with:

• diazepam (Valium)
• alprazolam (Xanax)
• lorazepam (Ativan)

These drugs also pose a high risk of dependence and substance use disorder, so they may not be ideal during opioid use disorder treatment.

Clonazepam (Klonopin) appears to be a safer option to treat anxiety or panic attacks, since it’s slower acting than other benzodiazepines.

Psychotherapy

During opioid use disorder treatment, psychotherapy is the go-to intervention for treating anxiety or depression.

Antidepressants can absolutely make a difference for symptoms that affect your quality of life, but more evidence supports the effectiveness of therapy. Also, medication can’t address the underlying triggers, or causes, of anxiety and depression.

One treatment that may prove particularly helpful is integrated cognitive behavioral therapy (I-CBT). Experts designed this form of CBT specifically to treat co-occurring anxiety and opioid use disorder. With this approach, you’ll learn helpful ways to cope with anxiety and practice them under the guidance of a therapist.

I-CBT typically involves 12 hour-long sessions once a week. I-CBT is intended to supplement, not replace, MAT, so you’ll most likely do both interventions simultaneously.

Another often-recommended intervention is acceptance and commitment therapy (ACT), which helps you find new ways to commit to your life. In the context of opioid treatment, ACT tends to work best for co-occurring depression, although people with anxiety may benefit, too.

Many people use opioids to treat chronic pain. If you live with chronic pain, you might experience feelings of emotional exhaustion or depression, due to the limits pain has placed on your life. You may use opioids not just to numb your pain, but also to dull your emotions around said pain.

ACT, however, can help you acknowledge the challenges of chronic pain and work to build a fulfilling life around those obstacles.

Opioid use can cause feelings of anxiety and depression. These mood symptoms may then play a part in continued opioid use, which could increase your chances of opioid use disorder.

Even if you don’t experience major mood symptoms while taking opioids, these drugs still pose a high risk of dependence, tolerance, and opioid use disorder. Anxiety and depression can also complicate treatment, so it’s important to get support sooner rather than later.

Using opioids only as your doctor directs, for the amount of time they recommend, can help minimize your risk of opioid use disorder. If you’re finding it difficult to stop opioid use on your own, a mental health professional specializing in recovery can help.

Emily Swaim is a freelance health writer and editor who specializes in psychology. She has a BA in English from Kenyon College and an MFA in writing from California College of the Arts. In 2021, she received her Board of Editors in Life Sciences (BELS) certification. You can find more of her work on GoodTherapy, Verywell, Investopedia, Vox, and Insider. Find her on Twitter and LinkedIn.