Side Effect of opioids and painkillers – low testosterone levels
Ross Hauser, MD
Many men may find themselves in a situation where they are on prolonged opioid use to manage their chronic pain. They are being pain managed until they can decide on surgery or choose to remain on painkillers to get them through their day or their job or their activities. A growing concern is what are these opioids doing to these men’s testosterone levels? The concern is well-founded.
- In this article, we will see how opioids cause joint destruction by impacting and causing reduced testosterone levels.
Research has shown that Testosterone has a direct effect on cartilage growth. If the testosterone levels are low, so is the body’s ability to regrow damaged cartilage.
Testosterone is an anabolic hormone. An anabolic hormone is a “builder upper,” its characteristics are well known as a hormone that promotes repair and growth of soft tissue, including muscle and cartilage growth.
Many people believe that testosterone is only a male hormone, research over the years shows testosterone also plays a pivotal role in the female body chemistry. Male or female, if one has a low testosterone level, then he/she will likely experience more difficulty healing.
Opioids impact serum testosterone levels
A study published in October 2020 from the California Institute of Behavioral Neurosciences & Psychology (1) describes the problems of painkillers and low testosterone levels
“it is crucial to focus on the adverse effects of narcotics, and one of the lesser-known side effects is hypogonadism (low testosterone). Opioids act on the hypothalamus, pituitary, and directly on the gonads affecting serum testosterone levels. Narcotic-induced androgen insufficiency contributes to sexual dysfunction, infertility, hyperalgesia, and involving various body functions overall, affecting the quality of life.”
In 2014, a paper with the long descriptive title: ” Long-term testosterone treatment in elderly men with hypogonadism and erectile dysfunction reduces obesity parameters and improves metabolic syndrome and health-related quality of life”, was published in the Journal of Sexual Medicine.(2)
It is a long title because the paper has a lot to say:
- This is what low-testosterone can cause in the aging male:
- erectile dysfunction (ED),
- reduced bone density and muscle strength,
- increased visceral obesity. (Belly fat)
- problems associated with insulin resistance and metabolic syndrome.
- Low levels of testosterone can also cause joint pain
Low testosterone is present among approximately 63% of male patients on chronic opioids
An April 2020 study in The Journal of Clinical Endocrinology and Metabolism (3) makes these very real observations:
- hypogonadism or testosterone deficiency is present among approximately 63% of male patients on chronic opioids
- while hypocortisolism is present in 15% to 24% of patients of both genders. In addition, hyperprolactinemia was a common feature in chronic opioid users. No definite conclusions can be drawn on the effects on the somatotropic and HPT axes.
Research: Painkillers cause erectile dysfunction – 53.3% to 81.7% of patients who were opioid-dependent (addicted) had problems with sexual dysfunction.
Men do not like to go to the doctor, this is well documented. Men will finally go to the doctor when erectile dysfunction is involved. This was documented by researchers at Brown University who wrote in the Asian Journal of Andrology (4):
“Erectile dysfunction is estimated to affect more than 30% of men between the ages of 40 and 70. As a result of an improved understanding of the disorder and improved treatment options, an increasing number of men are going to the doctor with Erectile dysfunction concerns. In fact, many of these men are visiting their health care professional for the first time with ED as their primary complaint.”
But what is causing their erectile dysfunction? While there are many causes of erectile dysfunction, this article will concentrate on the relationship between low testosterone, joint pain, and opioid or painkiller use.
A recent study from Tegore Medical College in India (5) begins with this statement: “The relationship between opioid use and sexual problems among males is a complex one, as some are using opioids to increase their sexual performance while others are suffering from sexual problems due to its use.”
The big problem is this research from Tegore Medical College is suggesting that 53.3% to 81.7% of patients who were opioid-dependent (addicted) had problems with sexual dysfunction.
But what about my daily aspirin and over-the-counter anti-inflammatories?
To be fair, there is a lot of controversy surrounding the use of Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin and the NSAIDs and aspirin’s effect on erectile dysfunction.
In July 2018, Urologists published research in the journal Medicine (6) which outlined these controversies:
- “There are various etiologies of erectile dysfunction (ED), including endothelial dysfunction (degeneration or failure of the inner lining of small arteries throughout the body including the penis), atherosclerosis (clogged arteries), and chronic inflammation.
- Aspirin has a protective role against endothelial dysfunction and atherosclerosis, whereas all non-steroidal anti-inflammatory drugs (NSAIDs) are known for their anti-inflammatory properties.
- However, the association between the use of aspirin or non-aspirin NSAIDs and ED is controversial.”
Comment: On the surface, it would appear that NSAIDs would help ED as an anti-inflammatory and aspirin would help ED as it may help clear clogged arteries. So why the controversy? Because many researchers think the opposite. This is the concluding statement from this research:
- “Most clinical trials indicated an association between aspirin or non-aspirin NSAIDs and ED, but other studies reported inconstant results, ranging from beneficial effects to marginal/moderate risk. These diverse clinical consequences may come from various study designs, population samples, dosages, or medical indications.”
Aspirin and NSAIDs while shown to cause erectile dysfunction – may help others with their ED. The evidence according to this research team is inconclusive.
Painkillers are causing Erectile Dysfunction. Now men are taking medicine for their pain and asking for prescriptions for their erectile dysfunction
Listen to what researchers in the Journal of Sex Medicine (7) had to say. “Long-term opioid therapy has been found to have a strong impact on the hypothalamic-pituitary-gonadal axis that can be manifested clinically by sexual dysfunction. This event is rarely reported and thus unnoticed and undertreated.”
- So a man goes into the doctor’s office. He has chronic joint or back pain but desires to have the ability to be able to sexually perform. He is given painkillers.
- A man goes back to the doctor and says, his problem now is that he cannot perform sexually NOT because of pain, he cannot perform sexually because he is on painkillers. Now he gets a prescription for erectile dysfunction.
- The man and his doctor are not aware of this usually unnoticed connection between painkillers and erectile dysfunction.
The management of male patients with pain should include a review of their sexual health history
In a second study, published in February 2017 (8) by the same team of researchers, this time appearing in the journal Clinical Medicine, made these findings:
- Erectile dysfunction was observed in 27.6% of patients on opioids.
- Treatment for Erectile Dysfunction:
- After 6 months, 42% of those patients showed a significant improvement after being treated with iPDE5 – Viagra (48.5%) and/or testosterone gel (81.8%).
- Erectile function and quality of sexual life, as well as anxiety, improved in patients treated chronically with opioids after administering andrological (testosterone) treatment. The management of patients with pain should include a review of their sexual health history given the significant emotional impact posed to the patient, the impact on their overall quality of life, and its good clinical response to an interdisciplinary treatment.
The use of testosterone gel should be discussed with your health care provider.
Testosterone does repair joint damage.
- An Australian study published in the Annals of the Rheumatic Diseases examined the role of low circulating testosterone in men facing total knee replacement found that low testosterone impacted cartilage tissue loss and bone loss.(9)
- In this study, 28 men (average age 52) had a knee MRI. Then two years later they had another MRI of the same knee. Measuring testosterone levels and examining the MRIs, the researchers found a reduction in tibial cartilage (shin bone). This tibial cartilage loss was associated with serum-free testosterone levels.
- In one landmark study from St Bartholomew’s Hospital Medical College in London, doctors showed how testosterone reversed cartilage damage and reduced proteoglycan (the stuff of connective tissue) loss. It was suggested that testosterone replacement therapy in patients with low testosterone levels may help prevent joint damage and disability.(10)
- Doctors of the Research Program in Men’s Health: Aging and Metabolism, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston University School of Public Health, and the University of Pittsburgh School of Medicine found that men with androgen deficiency (low testosterone) brought on by overuse of painkillers and other pain medications, showed improvements in pain, sexual desire, body composition, and aspects of quality of life when put on a testosterone replacement program.(11)
The answer is not a balance of painkillers and erectile dysfunction medications: the answer is to fix the joint and get rid of the painkillers and the need for erectile dysfunction medications
The summary of research and concerns about low testosterone in men who routinely take painkillers can be seen in October 2018 research published in the Journal of Endocrinological Investigation.(12)
“Opioid-induced androgen deficiency is a common adverse effect of opioid treatment and contributes to sexual dysfunction, impairs pain relief, and reduces overall quality of life. The evaluation of serum testosterone levels should be considered in male chronic opioid users and the decision to initiate testosterone treatment should be based on the clinical profile of individuals, in consultation with the patient.”
The answer is not a balance of painkillers and erectile dysfunction medications: the answer is to fix the joint and get rid of the painkillers and the need for Viagra.
Strengthen and stabilizing joints with Prolotherapy injections
The knee is one of the most common joints treated with Prolotherapy at Caring Medical. We use a comprehensive Prolotherapy approach that stimulates the natural repair of connective tissue. Prolotherapy research shows significant improvement in selected patients with knee osteoarthritis. Treating the whole knee joint as opposed to selective parts of the knee is more effective in alleviating knee pain and healing the damage.
Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle. This research can be found at our article: The evidence for Prolotherapy Injections for knee osteoarthritis and as an option to knee surgery
As briefly demonstrated in this graphic. Prolotherapy injections share many of the healing characteristics of testosterone. We mention that both Prolotherapy and testosterone help fibroblasts (a connective tissue cell that produces collagen and other fibers to proliferate and subsequently produce strong ligament strength.
Do you have a question about this article? You can get help and information from our Caring Medical Staff
1 Marudhai S, Patel M, Subas SV, Ghani MR, Busa V, Dardeir A, Cancarevic I. Long-term Opioids Linked to Hypogonadism and the Role of Testosterone Supplementation Therapy. Cureus. 2020 Oct;12(10). [Google Scholar]
2 Yassin DJ, Doros G, Hammerer PG, Yassin AA. Long‐term testosterone treatment in elderly men with hypogonadism and erectile dysfunction reduces obesity parameters and improves metabolic syndrome and health‐related quality of life. The journal of sexual medicine. 2014 Jun;11(6):1567-76. [Google Scholar]
3 de Vries F, Bruin M, Lobatto DJ, Dekkers OM, Schoones JW, van Furth WR, Pereira AM, Karavitaki N, Biermasz NR, Zamanipoor Najafabadi AH. Opioids and Their Endocrine Effects: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab. 2020 Mar 1;105(3):1020–9. [Google Scholar]
4 Miner M, Kim ED. Cardiovascular disease and male sexual dysfunction. Asian Journal of Andrology. 2015 Jan;17(1):3. [Google Scholar]
5 Aggarwal N, Kherada S, Gocher S, Sohu M. A study of assessment of sexual dysfunction in male subjects with opioid dependence. Asian journal of psychiatry. 2016 Oct;23:17. [Google Scholar]
6 Li T, Wu C, Fu F, Qin F, Wei Q, Yuan J. Association between use of aspirin or non-aspirin non-steroidal anti-inflammatory drugs and erectile dysfunction: A systematic review. Medicine. 2018 Jul;97(28). [Google Scholar]
7 Ajo R, Segura A, Inda MM, Planelles B, Martínez L, Ferrández G, Sánchez A, Margarit C, Peiró AM. Opioids increase sexual dysfunction in patients with non-cancer pain. The journal of sexual medicine. 2016 Sep 1;13(9):1377-86. [Google Scholar]
8 Ajo R, Segura A, Margarit C, Ballester P, Martínez E, Ferrández G, Sánchez-Barbie Á, Peiró AM. Erectile dysfunction in patients with chronic pain treated with opioids. Medicina Clínica (English Edition). 2017 Jul 21;149(2):49-54. [Google Scholar]
9 Hanna F, Ebeling PR, Wang Y, O’Sullivan R, Davis S, Wluka AE, Cicuttini FM. Factors influencing longitudinal change in knee cartilage volume measured from magnetic resonance imaging in healthy men. Ann Rheum Dis. 2005 Jul;64(7):1038-42. [Google Scholar]
10 Da Silva JA, Larbre JP, Spector TD, Perry LA, Scott DL, Willoughby DA. Protective effect of androgens against inflammation induced cartilage degradation in male rodents. Ann Rheum Dis. 1993 Apr;52(4):285-91. [Google Scholar]
11 Basaria S, Travison TG, Alford D, Knapp PE, Teeter K, Cahalan C, Eder R, Lakshman K, Bachman E, Mensing G, Martel MO, Le D, Stroh H, Bhasin S, Wasan AD, Edwards RR. Effects of testosterone replacement in men with opioid-induced androgen deficiency: a randomized controlled trial. Pain. 2015 Feb;156(2):280-8.[Google Scholar]
12 Coluzzi F, Billeci D, Maggi M, Corona G. Testosterone deficiency in non-cancer opioid-treated patients. J Endocrinol Invest. 2018;41(12):1377-1388. [Google Scholar]