Psychiatric Quarterly

, Volume 87, Issue 4, pp 585–593 | Cite as

Combined Use of Opioids and Antidepressants in the Treatment of Pain: A Review of Veterans Health Administration Data for Patients with Pain Both With and Without Co-morbid Depression

  • John J. Sellinger
  • Mehmet Sofuoglu
  • Robert D. Kerns
  • Robert A. Rosenheck
Original Paper


Musculoskeletal pain is prevalent among Veterans treated within the Veterans Health Administration (VHA). Depression is highly co-prevalent, and antidepressants are increasingly being used for psychiatric and analgesic benefit. The current study examined prescribing patterns of antidepressants and opioids in the context of musculoskeletal pain using a national VHA database. All Veterans diagnosed with musculoskeletal pain who attended at least one appointment through the VHA during Fiscal Year 2012 were dichotomized based on the presence or absence of a depression diagnosis. We compared the proportion in each group that were prescribed antidepressants to the entire sample and repeated this comparison along a continuum of the number of annual opioid prescriptions received (ranging in five categories from no opioids up to >20 scripts). Of the 5.1 million Veterans seen, 19.1 % were diagnosed with musculoskeletal pain, of whom, 27.2 % were diagnosed with major depressive disorder. Antidepressants were prescribed to 78.41 % of patients with musculoskeletal pain and depression, compared to 20.23 % of those without depression. For both groups, antidepressant use increased linearly as annual opioid fills increased. Across the categories of opioid use, patients with depression showed a 13.98 % increase in antidepressant use, compared to a 33.97 % increase in the non-depressed group. Results suggest that antidepressants are frequently prescribed to patients with musculoskeletal pain who are using opioids, consistent with multi-modal pharmacotherapy. Increasing use of antidepressants in conjunction with escalating opioid prescribing, particularly in the absence of diagnosed depression, suggests that antidepressants are being used in both groups to complement opioid therapy.


Pain management Opioids Depression Antidepressants 



This work was supported, in part, by the Veterans Affairs New England Mental Illness, Research, Education and Clinical Center (MIRECC). Research conducted with the administrative databases that were utilized in this study was approved by the Institutional Review Board.

Compliance with Ethical Standards

Conflict of interest

None of the authors involved in this work have conflicts of interest to disclose.


The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.


  1. 1.
    Bair MJ, Robinson RL, Katon W, Kroenke K.: Depression and pain comorbidity. Archives of Internal Medicine 163:2433–2445, 2003.CrossRefPubMedGoogle Scholar
  2. 2.
    Ohayon MM.: Specific characteristics of the pain/depression association in the general population. Journal of Clinical Psychiatry 65:5–9, 2004.PubMedGoogle Scholar
  3. 3.
    Arnold LM, Meyers AL, Sunderajan P, Montano CB, Kass E, Trivedi M, Wohlreich MM.: The effect of pain on outcomes in a trial of duloxetine treatment of major depressive disorder. Annals of Clinical Psychiatry 20:187–193, 2008.CrossRefPubMedGoogle Scholar
  4. 4.
    Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W.: Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care. Journal of Pain 12:964–973, 2011.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Chan HN, Fam J, Ng B.: Use of antidepressants in the treatment of chronic pain. Annals Academy of Medicine Singapore 38:974–79, 2009.Google Scholar
  6. 6.
    Mercier A, Auger-Aubin I, Lebeau J, Schuers M, Boulet P, et al.: Evidence of prescription of antidepressants for non-psychiatric conditions in primary care: An analysis of guidelines and systematic reviews. BMC Family Practice 14: 55, 2013.CrossRefGoogle Scholar
  7. 7.
    Murinson BB.: The role of Antidepressants in the Treatment of Chronic Pain. In: Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches. New York, Springer, pp. 45–51, 2013.Google Scholar
  8. 8.
    Rasu RS, Sohraby R, Cunningham L, Knell ME.: Assessing chronic pain treatment practices and evaluating adherence to chronic pain clinical guidelines in outpatient practices in the United States. Journal of Pain 14:568–578, 2013.CrossRefPubMedGoogle Scholar
  9. 9.
    Panzarino PJ.: The costs of depression: Direct and indirect; treatment versus nontreatment. Journal of Clinical Psychiatry 59:11–14, 1998.PubMedGoogle Scholar
  10. 10.
    Linton SJ, Bergbom S.: Understanding the link between depression and pain. Scandinavian Journal of Pain 2:47–54, 2011.CrossRefGoogle Scholar
  11. 11.
    Bohnert AS, Ilgen MA, Trafton JA, Kerns RD, Eisenberg A, Ganoczy D, et al.: Trends and regional variation in opioid overdose mortality among veterans health administration patients, fiscal year 2001 to 2009. Clinical Journal of Pain 30:605–612, 2009.Google Scholar
  12. 12.
    Manchikanti L, Fellows B, Ailinani H, Pampati V.: Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Physician 13:401–435, 2010.PubMedGoogle Scholar
  13. 13.
    Sites BD, Beach ML, Davis MA.: Increases in the use of prescription opioid analgesics and the lack of improvement in disability metrics among users. Regional Anesthesia and Pain Medicine 39:6–12, 2014.CrossRefGoogle Scholar
  14. 14.
    Wilson JF.: Strategies to stop abuse of prescribed opioid drugs. Annals of Internal Medicine 146:897–900, 2007.CrossRefPubMedGoogle Scholar
  15. 15.
    U.S. Department of Health and Human Services.: Results from the 2011 national survey on drug use and health: Summary of national findings (Report No. SMA 12-4713). Retrieved from, 2011.
  16. 16.
    Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K.: Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosomatic Medicine 70:890–897, 2008.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J, et al.: Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA 301:2099–2110, 2009.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Haskell SG, Heapy A, Reid MC, Papas RK, Kerns RD.: The prevalence and age-related characteristics of pain in a sample of women veterans receiving primary care. Journal of Women’s Health 15:862–869, 2006.CrossRefGoogle Scholar
  19. 19.
    Kerns RD, Otis J, Rosenberg R, Reid MC.: Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. The Journal of Rehabilitation Research and Development 40:371–380, 2003.CrossRefPubMedGoogle Scholar
  20. 20.
    Dobscha SK, Morasco BJ, Duckart JP, Macey T, Deyo RA.: Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain. Clinical Journal of Pain 29:102–108, 2013.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Gallagher RM, Rosenthal LJ.: Chronic pain and opioids: Balancing pain control and risks in long-term opioid treatment. Archives of Physical Medicine and Rehabilitation 89:S77–82, 2008.CrossRefPubMedGoogle Scholar
  22. 22.
    Staiger TO, Gaster B, Sullivan MD, Deyo RA.: Systematic review of antidepressants in the treatment of chronic low back pain. Spine 28:2540–2545, 2003.CrossRefPubMedGoogle Scholar
  23. 23.
    Kroenke K, Krebs EE, Bair MJ.: Pharmacotherapy of chronic pain: A synthesis of recommendations from systematic reviews. General Hospital Psychiatry 31:206–219, 2009.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA)  2015

Authors and Affiliations

  • John J. Sellinger
    • 1
    • 2
  • Mehmet Sofuoglu
    • 1
    • 2
    • 3
  • Robert D. Kerns
    • 1
    • 2
  • Robert A. Rosenheck
    • 1
    • 2
    • 3
  1. 1.VA Connecticut Healthcare System, Psychology Service (116B)West HavenUSA
  2. 2.Department of PsychiatryYale University School of MedicineNew HavenUSA
  3. 3.VA New England Mental Illness, Research, Education and Clinical CenterWest HavenUSA

Personalised recommendations