Marc Darrow MD, JD 

Men who have a history of opioid use from chronic pain are at higher risk for testosterone or androgen deficiency. This is not an opinion, this is the cumulative research of the medical community who started to assess the collateral damage of the opioid epidemic and found a clear connection between opioid use and low testosterone levels in opioid users.

In our office we have seen many men who had a long history of opioid usage and display signs of low testosterone levels including, but not limited to, loss of muscle, fatigue, obesity and metabolic syndrome disorders such as type 2 diabetes, high cholesterol,and high blood pressure.

If you have long-term opioid use history, you will be at greater risk for testosterone deficiency.

A December 2019 study in the Journal of the American Medical Association (1) comes from the Veterans Health Administration. here researchers acknowledged that androgen (testosterone) deficiency is common among male opioid users, and opioid use has emerged as a common antecedent of testosterone treatment. (If you have long-term opioid use history, you will be at greater risk for testosterone deficiency.)

  • The study included 21,272 long-term opioid users (average age 53 years old) with low total or free testosterone levels. 14,121 (66.4%) received testosterone supplementation and 7151 (33.6%) did not.

This study found that, in the VHA system, “male long-term opioid users with testosterone deficiency who were treated with opioid and testosterone medications had significantly lower all-cause mortality and significantly lower incidence of major adverse cardiovascular events (MACE) , femoral or hip fractures, and anemia after a multiyear follow-up.”

  • In musculoskeletal health, the reduction in this study of femoral or hip fractures demonstrates that testosterone was able to positively impact bone weakening or bone mineral density loss. An important factor in helping older men especially the master athlete heal well. Bone remodeling and collagen production are key factors to joint regeneration.

Research: Screening (blood tests) for low testosterone levels is surprisingly low among prolonged opioid users

An October 2018 study (2) suggests the opioid epidemic put a lot of men in the low testerone category: “Over the last several decades, the opioid epidemic has become a national crisis, largely spurred by the spike in the use of prescription painkillers. With the epidemic came a concomitant rise in the incidence of opioid-induced androgen deficiency (OPIAD). Although OPIAD can significantly impact male sexual function and quality of life, it is an overlooked and poorly understood clinical entity that requires more attention from healthcare providers.”

Because OPIAD is an underappreciated and underdiagnosed consequence of chronic opioid abuse, healthcare providers should be particularly vigilant for signs of hypogonadism in this patient population. It is reasonable for pain specialists, urologists, and primary care physicians to closely monitor patients on prescription opioids and discuss available options for treatment of hypogonadism.

In September 2019, researchers writing in the journal Mayo Clinic proceedings. Innovations, quality & outcomes (3) suggested surprise that despite the number of men on opioids, few were screened or treated for low testosterone levels. Here is what they wrote:

“Screening for hypogonadism was surprisingly low among prolonged opioid users in our study—(within the first year only about 6% of men were tested  and 17.15% of men were tested at 5 years) —given prior studies’ estimates of opioid-induced hypogonadism, ranging as high as 90%. . . This finding suggests a widespread underscreening of opioid-induced hypogonadism during critical years of the opioid epidemic in the United States.

It is not clear what factors drove this exceedingly low rate of serum testosterone screening.

It may reflect a lack of awareness by some clinicians of the association between long-term opioid use and hypogonadism. Additionally, many clinicians—when treating patients with multimorbid disease and complex drug regimens—may be reluctant to screen for conditions that would require additional pharmacotherapy. From a patient’s perspective, it is possible that men who are struggling with chronic pain and associated conditions are less concerned than their peers about early hypogonadal symptoms, such as low libido, sexual dysfunction, increased adiposity, and decreased muscle mass. They may, therefore, be less likely to bring these symptoms to the attention of their physician or to request a hypogonadism screening test.

Finally, our observation that only 5.76% of prolonged opioid users received testosterone therapy at 5 years and only 1.50% at 1 year suggests that this condition is undertreated in the United States.”

Low testosterone is associated with an increased risk of both knee and hip replacement in overweight and obese men

In a study published in the journal Osteoarthritis Cartilage, [4] doctors in Australia confirmed that low testosterone is associated with an increased risk of both knee and hip replacement in overweight and obese men. The findings suggest that circulating sex steroids may play a role in the origins and acceleration of osteoarthritis in men.. Supporting this idea, another study lead by an international team of doctors and published by the Arab Association of Urology [5] found that restoring testosterone levels helped aging men with their joint problems, physical activity, and quality of life.

Of course these are not the only two studies to suggest that low levels of testosterone negatively impact joint pain and that providing testosterone replacement therapy may help the situation. They are however among the most recent to specifically test the theory that low testosterone levels do cause joint pain and joint pain causes low testosterone levels.

How bad are the effects of painkillers be on hormone levels?

Often we will see people who are trying to balance hormonal levels and the need to function with knee or hip pain. Many times these people have to resort to painkillers to help them get through their day. These people are in our office because they are seeking a more long-term solution to their pain issues than the daily management of pain and eventual succumbing to joint replacement surgery.

A recent study in the medical journal Pain Management suggests that even after only 30 days, patients on opioid (narcotic) medication for pain management suffer from reduced levels of testosterone.[6]

Abnormal Hormone Levels Show Painkillers Not Working Study: 80.3% of patients demonstrated hormone abnormality and pain dysfunction.

Investigators researching opioids say some patients with severe and chronic pain fail to obtain adequate pain relief with standard pharmacologic treatment agents, including low to moderate dosages of opioid. Understandably, physicians might not believe patients who claim that a standard opioid dosage is an ineffective treatment. These patients may be severely impaired, nonfunctional, and bedridden or housebound.

To help characterize these individuals and develop treatment strategies for them, a serum hormone profile consisting of adrenocorticotropin, cortisol, pregnenolone, progesterone, dehydroepiandrosterone, and testosterone was obtained on 61 chronic pain patients who failed standard treatments; 49 patients (80.3%) demonstrated hormone abnormality.(7To manage this problem the researchers suggested enhanced analgesia (more painkillers) is required and that hormone replacement may be indicated.

Years of chronic pain require a broad understanding that in many patients, pain and function problems are more than a hole in the cartilage. Hormones can be involved, weight can be an issue, lifestyle choices can be an issue. The path to healing crosses many roads.

Do you have questions? Ask Dr. Darrow about testosterone supplementation and chronic pain

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1 Jasuja GK, Ameli O, Reisman JI, Rose AJ, Miller DR, Berlowitz DR, Bhasin S. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration. JAMA Network Open. 2019 Dec 2;2(12):e1917141-.
2 Hsieh A, DiGiorgio L, Fakunle M, Sadeghi-Nejad H. Management Strategies in Opioid Abuse and Sexual Dysfunction: A Review of Opioid-Induced Androgen Deficiency. Sexual medicine reviews. 2018 Oct 1;6(4):618-23.
3 Baillargeon J, Raji MA, Urban RJ, Lopez DS, Williams SB, Westra JR, Kuo YF. Opioid-Induced Hypogonadism in the United States. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2019 Sep 1;3(3):276-84.
4 Hussain SM, Cicuttini FM, Giles GG, Graves SE, Wang Y. Relationship between circulating sex steroid hormone concentrations and incidence of total knee and hip arthroplasty due to osteoarthritis in men. Osteoarthritis Cartilage. 2016 Apr 12. pii: S1063-4584(16)30024-3. doi: 10.1016/j.joca.2016.04.008.
5. Almehmadi Y, Yassin AA, Nettleship JE, Saad F. Testosterone replacement therapy improves the health-related quality of life of men diagnosed with late-onset hypogonadism. Arab J Urol. 2016 Mar;14(1):31-6. doi: 10.1016/j.aju.2015.10.002.
6. Cepeda MS, Zhu V, Vorsanger G, Eichenbaum G. Effect of Opioids on Testosterone Levels: Cross-Sectional Study using NHANES. Pain Med. 2015 Jul 14. doi: 10.1111/pme.12843.
7 Tennant F. Hormone abnormalities in patients with severe and chronic pain who fail standard treatments. Postgrad Med. 2015 Jan;127(1):1-4. Epub 2014 Dec 15.