Opioid-induced Androgen Deficiency Discussion in Opioid Contracts

The excellent article by Arnold et al1 prompted us to suggest an addition to the text of most opioid contracts. It is our practice to improve the usefulness of these contracts to both patients and practitioners by including in them a discussion of opioid-induced androgen deficiency (OPIAD).

Strong inhibition of androgen production quickly follows the onset of sustained-action opioid use, whether the opioids are administered orally,2, 3, 4, 5 transdermally,4 or intrathecally.3, 5, 6, 7, 8 These low androgen levels result in classic symptoms of hypogonadism in a majority of opioid-consuming men, with most of them exhibiting various combinations of fatigue, depression, hot flashes, night sweats, diminished libido, erectile dysfunction, and diminished sexual arousal and satisfaction. Low androgen levels also contribute to physical changes, including osteoporosis, anemia, and diminished muscle mass. Similar changes occur in opioid-consuming premenopausal women, most of whom demonstrate amenorrhea or anovulatory menstrual cycles soon after beginning sustained-action opioid use.6, 8, 9, 10 Most premenopausal and postmenopausal women also demonstrate greatly diminished libido6, 8, 10 at this time.

Signs and symptoms of hypogonadism typically improve in men with OPIAD during replacement testosterone therapy4 and in the few women who have received hormone replacement therapy for opioid-related symptoms of hormone deficiency.6, 10

In my private practice of general internal medicine, the discussion of OPIAD in our opioid contracts includes the potential usefulness of replacement hormonal therapy and potential complications of this therapy. We have found this information to be of help in establishing the patient-physician partnership described and recommended by Arnold et al,1 which clearly is required for optimal chronic use of opioids. As part of this information exchange, we obtain sex-hormone levels in all outpatients about to begin chronic sustained-action opioid therapy and again with the development of symptoms of hypogonadism. Our contract includes discussion of testicular atrophy as a frequent complication of opioid therapy, which commonly progresses more rapidly during testosterone replacement therapy for OPIAD.4 Although this atrophy may become profound, patients are generally reassured to know that this complication is not accompanied by changes in penile size. It is our current practice to routinely document testicular size by using a Prader orchidometer before beginning chronic opioid therapy.