Pain, opioids, and psychiatric care

Treating these as three separate problems for three separate clinicians is how people fall through the middle.

For high-performing professionals in Chicago and Chicagoland: This article reflects clinical evidence and direct experience. If you're in the Chicago area or Illinois, contact me to discuss your concerns.

Someone in chronic pain, taking opioids, with a mood or anxiety disorder, occupies an uncomfortable position in a system organised around single problems. Pain management, addiction medicine, and psychiatry each hold part of the picture, and the person spends considerable energy carrying information between them.

Why the intersection matters clinically

Psychiatric conditions are associated with higher rates of prescription opioid misuse, and the relationship is not simply that one causes the other. Untreated depression and anxiety make pain harder to bear, which increases the pull toward whatever provides relief. Opioids treat distress as well as nociception, which is precisely what makes them effective and what makes them risky.

The National Institute on Drug Abuse notes that mental illness and substance use disorders frequently co-occur and that treating one while ignoring the other tends to produce poor results in both.

What goes wrong in each direction

Pain clinics may reduce or stop opioids without addressing the psychiatric condition underneath, and the patient deteriorates in a way that looks like drug-seeking but is untreated depression surfacing.

Psychiatric services sometimes decline to engage until the opioid question is resolved, which leaves the person waiting for care in the exact interval where they most need it.

Both positions are defensible in isolation and produce a bad outcome together.

What integrated assessment looks like

Asking about all three domains in the same appointment rather than treating them as separate referral questions. Understanding what the medication is actually doing — controlling pain, managing anxiety, enabling sleep, or some combination — because those require different responses.

And being honest that tapering without providing something in place of what the medication was doing is not a plan.

If you are in this situation

You are not a difficult patient. You have three interacting problems in a system built to handle one at a time. It is reasonable to ask for a clinician who will look at all of it together, and reasonable to say plainly that you have been passed between services.

Related: writing on substance use, and how to think about seeking care.

Published August 2026 · Reviewed for accuracy against the sources listed above.