25. Low Testosterone From Pain Pills

Chapter 25. Low Testosterone from Pain Pills

Above Image: Advertisement for curing morphine addiction from Overland Monthly, January 1900, courtesy of wikimedia commons.

Joe has chronic fatigue, loss of muscle strength, and erectile dysfunction. He was doing well until 10 years ago when he started pain pills after a car accident which left him with chronic back pain.

Chronic Pain Treated with Opioid Narcotics

After the car accident, Joe's family doctor prescribed Oxycontin™ pain pills, hoping the chronic back pain would eventually get better.  Unfortunately, Joe's back pain did not get better, and he still takes pain pills every day.  Even though the pain pills are no longer effective, Joe finds it nearly impossible to get off them because of the severe withdrawal effects. 

Low Testosterone Detected on Blood Tests

Joe's lab testing showed very low testosterone levels which explained the fatigue, weakness and low libido.  To remedy the low testosterone, Joe was started on bioidentical testosterone program using a topical testosterone gel, and 6 weeks later he reported that the fatigue and weakness are gone, and his wife is much happier with his renewed libido.  Joe also reported his chronic pain seemed to decrease in intensity, and he was now interested in pursuing the idea of tapering off the narcotic pain pills.(4)

Doctors Freely Prescribe Narcotic Pain Pills

When patients like Joe seek help from their doctor for a painful condition, they will be given narcotic pain tablets such as Percocet™, Oxycodone™, Roxycodone™ and Oxycontin™.  These pain pills are quite effective at relieving the painful condition.  However, they come with severe adverse side effects associated with narcotics addiction.

Adverse Effects of Long Term Pain Pills (Opiates)

Narcotic Pain Pills (opioids) are highly addictive with severe adverse effects related to drug withdrawal. Opiate containing narcotic Pain Pills are highly effective for pain, but were never intended for long term use.  Over time, these drugs cause profound suppression of the endocrine system, and in men, profound inhibition of testosterone production.  This type of testosterone suppression is quite common in our population, and yet, may go unrecognized by the busy primary care doctor. (1)

Another adverse effect of long-term use is opioid-induced hyperalgesia, which means increased sensitivity to pain.  This is a form of hypersensitivity to pain in which the original painful condition becomes worsened and magnified.  Other adverse effects include impaired cognitive function, and suppression of the immune system, rendering the patient more susceptible to common infections.(6)

 Chronic Opioid Pain Pills Lose Effectiveness Long Term

Another problem with long term use of narcotic pain pills is that they lose their effectiveness over time.  The brain and nervous system develops a "tolerance" to the drug, and higher doses are required to achieve the same result.(7)  The initial pain relief from opioid pain pills may not be sustained long term because of drug tolerance, opioid-induced hyperalgesia, and intermittent drug withdrawal effects. (7)  In other words the pills lose their effectiveness, and yet continue to produce dependence and adverse effects.

Low Testosterone Goes Largely Unrecognized

Although quite common, Opioid-induced androgen deficiency and has gone largely unrecognized by the medical profession (1).  Low testosterone is caused by opioid drug inhibition of LH (Luteinizing Hormone), a pituitary hormone involved in testosterone production, as well direct inhibition of testosterone production, itself.  Similarly, there is also inhibition of the entire endocrine system, and adrenal hormone suppression.  Symptoms of low testosterone include fatigue, depression, hot flashes, night sweats, diminished libido, erectile dysfunction, and diminished sexual arousal and satisfaction.   Men may also develop osteoporosis, anemia, and diminished muscle mass. (2)(3)  Women who consume opioid-pain pills will stop having menstrual cycles and will notice greatly diminished libido (sex drive). (5)

Testosterone Treatment Effective and Recommended by Mainstream Medicine

Administration of both topical (transdermal) testosterone and injectable testosterone has been studied and found effective for men with low testosterone on pain pills. (4) 

Our Approach to Evaluation and Treatment

For men with a chronic pain condition who have been on long-term pain pills, our evaluation includes a complete blood testing panel looking for vitamin, mineral and nutritional deficiencies.  We find these deficiencies quite commonly in this group.   In addition, evaluation includes a complete hormone panel looking at the entire endocrine system, and adrenal function.  If extensive testing shows low hormone levels, then hormone supplementation is offered.

Opiate Detoxification Program is Essential

The reality is that hormone supplementation and nutritional supplementation for the long term opiate pain pill user is only a temporary band aid.  To fully restore health, the opiate addiction must be addressed and the patient must ultimately get off the pain pills.  Drug withdrawal may be difficult because of severe drug withdrawal symptoms.  Therefore, we refer the patient to a center that specializes in narcotics detoxification, and urge the patient to strongly consider this option. (10)

For references and links, see my web site: www.bioidenticalhormones101.com

References for Chapter 25. Low Testosterone From Pain Pills

(1) http://journals.lww.com/co-endocrinology/
Abstract/2006/06000/Opioid_induced_androgen_deficiency.6.aspx
Current Opinion in Endocrinology and Diabetes: June 2006 - Volume 13 - Issue 3 - p 262-266 . Opioid-induced androgen deficiency by Daniell, Harry W.

(2) http://www.amjmed.com/article/S0002-9343(06)00614-0/fulltext American Journal of Medicine, Volume 120, Issue 9, Page 21, September 2007. Opioid-induced Androgen Deficiency Discussion in Opioid Contracts by Harry W. Daniell, MD

(3) http://www.jpain.org/article/S1526-5900(02)00032-9/abstract?refuid=S0002-9343(06)00614-0&refissn=0002-9343 Hypogonadism in men consuming sustained-action oral opioids. Presented in part at the 16th Annual Meeting of the Society for Ambulatory Anesthesia, Palm Springs, CA, May 2-5, 2001. Harry W. Daniell Volume 3, Issue 5, Pages 377-384 (October 2002)

(4) http://www.ncbi.nlm.nih.gov/pubmed/16516826 J Pain. 2006 Mar;7(3):200-10. Open-label pilot study of testosterone patch therapy in men with opioid-induced androgen deficiency. Daniell HW et al.

(5) http://www.ncbi.nlm.nih.gov/pubmed/17936076 J Pain. 2008 Jan;9(1):28-36. Epub 2007 Nov 1.
Opioid endocrinopathy in women consuming prescribed sustained-action opioids for control of nonmalignant pain. Daniell HW. 

(6) http://www.ncbi.nlm.nih.gov/pubmed/17873598 Curr Opin Anaesthesiol. 2007 Oct;20(5):451-5. An update on the role of opioids in the management of chronic pain of nonmalignant origin. Højsted J, Sjøgren P. Multidisciplinary Pain Center, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.

(7) http://www.ncbi.nlm.nih.gov/pubmed/18574357 Clin J Pain. 2008 Jul-Aug;24(6):469-78.
Efficacy of opioids for chronic pain: a review of the evidence. Ballantyne JC, Shin NS.Division of Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.

(8) http://www.viamedica.pl/gazety/gazetaE/darmowy_pdf.phtml?indeks=33&indeks_art=263 Zbigniew Zylicz, Consultant in Palliative Medicine, Dove House Hospice, Hull, United Kingdom. Opioid-induced hypogonadism: the role of androgens in the well-being and pain thresholds in men and women with advanced disease