More than half of those who overdose from opioids struggled with mental illness or chronic pain.

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The opioid crisis sweeping America has brought record-high overdose rates, and a new study shows that those who live with depression, anxiety, or chronic pain may be most at risk.

According to a new report published in the American Journal of Psychiatry, more than half of those who have died from opioid overdose lived with chronic pain. Similarly high rates of depression and anxiety were found by an analysis of data collected from the U.S. Centers for Disease Control and Prevention (CDC).

The data included medical backgrounds from more than 13,000 men and women who died from an opioid overdose between 2001 and 2007.

“The frequent occurrence of treated chronic pain and mental health conditions among overdose decedents underscores the importance of offering substance use treatment services in clinics that treat patients with chronic pain and mental health problems,” said lead investigator Dr. Mark Olfson, a professor of psychiatry at Columbia University Medical Center.

“Such a strategy,” said Olfson in a news release, “might increase early clinical intervention in patients who are at high risk for fatal opioid overdose.”

The researchers note that the number of Americans who died from an opioid overdose more than quadrupled between 1999 to 2015, according to the CDC’s data.

For the study, the researchers specifically focused on Medicaid enrollees who had died after an overdose. They found that more than half of the 13,000 people identified in the data had been previously diagnosed with a chronic pain issue within the year before their death. Approximately a third had been diagnosed with a drug use disorder.

Worryingly, more than half had filled prescriptions for either opioids or benzodiazepines within 30 days of their death. Many sought both types of medication, which can be extremely dangerous when used together. The combination of these drugs can lead to life-threateningly shallow breathing called “respiratory depression,” the researchers explained.

Despite these issues, less than five percent of people had been specifically diagnosed with an opioid use disorder during the last month of their life. This led the team to believe “that dropout from drug treatment is common before fatal opioid overdose.”

“Improving treatment retention, with contingency management or other effective behavioral interventions, might help lower the risk of fatal overdose in these patients,” Olfson concluded.

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