Management Strategies in Opioid Abuse and Sexual Dysfunction: A Review of Opioid-Induced Androgen Deficiency

Lifestyle Medicine's Role in Common Hormonal Disorders: A Case-Based Discussion

Hormonal disorders like PCOS (Polycystic Ovary Syndrome), autoimmune thyroid disease (AITD) including Hashimoto's thyroiditis, male hypogonadism are commonly encountered in clinical practice in the US and worldwide, with rising frequency. These typically affect patients during young or middle age, compared with other common chronic illnesses like type 2 diabetes, hypertension, atherosclerotic cardiovascular disease, where onset may usually be in middle or older age. Multiple studies point to the role of disordered lifestyle health behaviors as contributory to these endocrinopathies, and conversely therapeutic lifestyle changes leading to improvement in signs, symptoms, biochemical markers, and sequelae of these conditions. This article presents 3 different real life case studies of the conditions enlisted above and documents the positive impact of lifestyle improvements on their disease condition. Therapeutic lifestyle behaviors are an extremely useful and important component of management of these familiar endocrinologic disorders, and clinicians need to routinely counsel their patients about healthy lifestyle interventions when treating these common syndromes.

The effect of sustainable low-dose sildenafil and cognitive-behavioral training on sexual function in methadone-treated men-a randomized controlled trial

BACKGROUND

Sexual dysfunction caused by opioids is one of the serious problems of drug misusers.

OBJECTIVE

This study aimed to evaluate and compare the effect of continuous low-dose sildenafil treatment alongside psychological training on the sexual function of methadone-treated patients.

METHOD

This randomized clinical trial was conducted on methadone-treated men with sexual dysfunction. Patients were randomly divided into two treatment groups: sildenafil 25 mg and psychological training. Sexual Quality of Life-Men, Sexual Self-Efficacy Scale-Erectile, and the International Index of Erectile Function were used before and 4 weeks after the end of the intervention.

RESULTS

A total of 67 couples were included in the study (34 psychological interventions vs. 33 sildenafil group). After 4 weeks of treatment, the mean of male erectile function (33.73 ± 8.114 and 27.62 ± 6.238, p = 0.003) and sexual self-efficacy score (78.36 ± 12.713 and 69.62 ± 14.940, p < 0.0001) in the sildenafil group were statistically significant compared to the psychological group, however, the sexual quality score of the two groups was not statistically significant (31.48 ± 9.216 and 31.71 ± 11.333, p = 0.342).

CONCLUSIONS

The sexual function of methadone-treated men in both groups was significantly improved, yet this difference was significantly greater in the pharmaceutical treatment group than the trainings. As a result, due to the high need for treatment, any type of intervention (medication or psychotherapy) will be effective in these patients.

Problems with opioids - beyond misuse

The U.S. is grappling with an opioid epidemic, with millions of adults on long-term opioid therapy (LTOT). Although patients often report pain relief and improved daily function with opioids, research shows no significant differences in short-term outcomes between opioid and non-opioid users, as well as no long-term opioid benefits. This scoping review aims to identify lesser-known side effects of long-term opioid use and increase awareness of them, allowing healthcare providers and patients to better assess the risks and benefits of opioid use. Our data search from PubMed and Google Scholar used keywords related to opioids, chronic pain, hypogonadism, endocrinopathies, cancer progression, cardiovascular events, renovascular events, sleep disturbances, mood disorders and others, narrowing down to English-language full articles published from January 2018 to April 2023. This review emphasizes the probable serious adverse consequences of long-term opioid use on various body systems in patients with chronic pain. Given the lack of long-term benefits and significant adverse effects, our review underscores the critical need for healthcare providers to include these risks in discussions with patients when considering the long-term use of opioid therapy.

Investigating the Impact of Kratom (Mitragyna speciosa) Use Upon Male Sexual Health

Purpose

Kratom (Mitragyna speciosa) exhibits μ-receptor agonism and is used as an opioid substitute. While opioids are known to inhibit sexual behavior, less is known regarding kratom. We conducted a pilot study to assess the subjective impact of kratom upon male sexual health including erectile and ejaculatory function.

Patients and Methods

Twitter and Reddit (r/Kratom) were accessed to disseminate our survey featuring validated instruments (the International Index of Erectile Function, IIEF, and the premature ejaculation diagnostic tool, PEDT). Sexual health prior to and after 4 weeks of kratom use was assessed.

Results

Most males surveyed (n = 165) were 18-40 years old (84.9%), with 95.8% of respondents using it at least weekly and 82.4% using kratom for ≥1 year. Reasons for use included treating pain (39.4%), and mental health conditions (63.6%). Kratom was associated with a positive (37.7%) and negative (20.5%) impact on sexual health. Kratom subjectively increased time to ejaculation in 104 (66.6%) patients, perceived as positive by 62 (59.6%). Seventy-eight patients answered questions about premature ejaculation. The median (with interquartile range, IQR, following;) pre-kratom and kratom use scores were 13.0; 8.0 and 6.5; 5.0, respectively (p < 0.001). Ejaculation before 5 minutes improved after kratom (51.3% vs 12.8%) (p < 0.0001). Following kratom use, patients reported lack of frustration with ejaculation prior to desire (21.8% vs 61.5%) (p < 0.001). The erectile function domain of the IIEF was statistically significantly different however - clinically similar pre-kratom use (29.0; 5.75) versus 27.0; 6.75 during kratom use (p = 0.037).

Conclusion

Clinicians treating male sexual health should be aware of kratom and its potential effect on ejaculatory and erectile function.

Evaluation the Protective Effect of Withania somnifera Extract on the Level of Sex Hormone in Morphine Addicted Female Rats

Morphine is one of the most types of phenanthrene alkaloid opioid used to soothe the acute and chronic pain via narcotic and analgesic medical employment. Increasingly constantly used of opioid in the public and medication practical important knowledge improve that. Morphine show pernicious has effects on numerous tissue for instance ovary, liver and lung morphine side effects instruct for existence of oxidative role due to generation of reactive oxygen species in the affected tissue. Last decades researchers proved that natural substance provides protective role against toxic effect. Thus, withania somnifera consider as antioxidant substance provide protective versus the toxic substance as morphine. The present study wase aimed to evaluate the protective role of withania somnifera extract on the level of sex hormone in morphine addicted female rats. In conclusion, the present study confirmed a truth evidence of a protective roles of withania somnifera  against the morphine addiction in female rats.

Sexual Dysfunction Among Patients With Chronic Kidney Disease

Sexual dysfunction (SD) in patients with chronic kidney disease is common and negatively impacts quality of life. SD is often under-appreciated because of overall low awareness. Diagnosis of SD is subjective, and manifestations can be different among men and women. Causes of SD are multifactorial, including psychological disorders, hormonal imbalances, vascular disorders, neurological disorders, and medication side effects. Non-specific approaches to improving sexual function include addressing underlying psychological disorders, promoting lifestyle modifications, optimizing dialysis care, and facilitating successful kidney transplantation, whereas treatment with phosphodiesterase type 5 inhibitor, hormone replacement, and mechanical devices can be offered to patients with specific indications.

Muscle function following testosterone replacement in men on opioid therapy for chronic non-cancer pain: A randomized controlled trial

BACKGROUND

Chronic pain and opioid treatment are associated with increased risk of male hypogonadism and subsequently decreased muscle function. A diagnosis of hypogonadism is based on the presence of low total testosterone and associated symptoms. The effect of testosterone replacement therapy on muscle function in men with chronic pain and low total testosterone remains to be investigated.

OBJECTIVES

To investigate the effects of testosterone replacement therapy on muscle function and gait performance in men treated with opioids for chronic non-cancer pain.

MATERIALS AND METHODS

A double-blind, placebo-controlled study. Forty-one men (>18 years) with opioid-treated chronic pain and serum total testosterone < 12 nmol/L were randomized to 24 weeks testosterone replacement therapy (testosterone undecanoate injection three times/6 months, n  = 20) or placebo injections (n  = 21). Muscle function was measured as leg press maximal voluntary contraction, leg extension power using the Nottingham power rig and handgrip strength using a handheld dynameter. Gait performance was measured at usual and maximal gait speed on a 10-m track. Body composition (lean body mass and fat mass) was determined by dual-energy X-ray absorptiometry. Mann-Whitney tests were performed on ∆-values (24-0 weeks) between testosterone replacement therapy and placebo.

RESULTS

At baseline, median (interquartile range) age was 55 ± 13 years and BMI was 30.7 ± 5.2 kg/m² . ∆-muscle function and ∆-gait performance were similar between testosterone replacement therapy and placebo. Median ∆-leg press maximal voluntary contraction was 174.2 ± 406.7 Newton, following testosterone replacement therapy, and 7.6 ± 419.1 Newton, after placebo, p = 0.091. ∆-lean body mass was significantly higher following testosterone replacement therapy compared to placebo, 3.6 ± 2.7 versus 0.1 ± 3.5 kg, respectively (p < 0.001).

DISCUSSION

Testosterone replacement therapy, compared to placebo, did not improve muscle function or gait performance despite increased lean body mass. Changes in body composition did not infer any changes in muscle function.

CONCLUSION

24 weeks testosterone replacement therapy in opioid-treated men with pain-related male hypogonadism did not improve muscle function.

Effects of ante-mortem use of methadone on insect succession patterns

Background

Evaluation of insect succession patterns is a scientific method to estimate the time elapsed since death. Several studies have shown that ante-mortem intake of opioids affect maggot growth rate. However, there are few published data that investigate the effect of ante-mortem opioid use on insect succession patterns.

Therefore, the main purpose of this research was to investigate the effect of methadone on the succession patterns of insects on rabbit carcasses during the spring and winter of 2019. In the present study, the H-null hypothesis represents the dissimilarity between the successional waves of species from testing and control carcasses (H0: P: 0).

Results

During this study, 15 and 13 insect species were collected from carcasses during the spring and winter, respectively. The most dominant species during the both seasons were Chrysomya albiceps and Calliphora vicina. These two species preferred to lay eggs on the control carcasses earlier than the treated carcasses. Lucilia cuprina was observed only from the remains of untreated carcasses, while Saprinus chalcites and Necrobia rufipes were recorded only from the remains of treated rabbits. Samples indicate that 11.8% of the insects were members of the Coleoptera. Permutation analyzes based on the Mantel test were 0.647 ± 0.16 (P = 0.009) and 0.693 ± 0.16 (P = 0.003) for the similarity of the species between treated and untreated carcasses in the spring and winter, respectively. Permutation analyzes for the two most dominant fly species (Ch. albiceps and C. vicina) between the treated and untreated carcasses in the spring and winter were 0.515 ± 0.15 (P = 0.05) and 0.491 ± 0.14 (P = 0.09), respectively.

Conclusion

The results revealed that the overall pattern of insect succession was similar between the treated and untreated rabbit carcasses. However, the patterns of succession of Chrysomya albiceps and Calliphora vicina differed slightly between treated and untreated carcasses, and this could have an effect on the PMI min estimate.

Low Testosterone in Male Cancer Patients and Survivors

INTRODUCTION

Hypogonadism (HG) is prevalent among patients with ongoing advanced cancer and cancer survivors. The etiology of HG in these patients is multifactorial and can be examined from cancer-related and cancer-treatment perspectives. There is evidence that HG contributes to increased morbidity in male cancer patients. Testosterone replacement therapy (TRT) for cancer survivors and advanced cancer patients is not well studied outside of prostate cancer. Here, we evaluate and summarize the current literature on HG in male cancer patients, including the role of TRT in nonprostate cancer patients.

OBJECTIVE

To summarize and present the literature for the background, etiology, clinical consequences, and treatment for HG in male cancer patients and survivors.

METHODS

A literature review was performed in MEDLINE between 1980 and 2020 using the terms hypogonadism, advanced cancer, testosterone replacement therapy, quality of life, and cancer survivors. Studies including only prostate cancer patients were excluded.

RESULTS

The main outcome measure was to complete a review of peer-reviewed literature. HG is not only prevalent among male cancer patients and survivors but also clinically reduces quality of life and increases morbidity. The etiology of HG in male cancer patients and survivors is multifactorial. There are few studies examining the benefit of TRT in these patient populations. The results of randomized controlled trials show potential benefit for TRT in hypogonadal male cancer survivors and those with advanced cancer.

CONCLUSION

HG affects many male cancer patients and survivors because of a multifactorial etiology. HG in these patients contributes to increased morbidity and reduced quality of life. Treatment of HG in male cancer patients is not well studied, and further studies are needed to elucidate the role of TRT. Xu P, Choi E, White K, et al. Low Testosterone in Male Cancer Patients and Survivors. Sex Med 2021;9:133-142.

The role of testosterone in mu-opioid receptor expression in the trigeminal ganglia of opioid-tolerant rats

Although tolerance serves as a major limitation in the long-term clinical use of opioids in patients with chronic severe pain, mechanisms of opioid tolerance are poorly understood. In this study, a morphine tolerance model was established by subcutaneously injecting male rats with morphine (10 mg/kg) twice a day for 10 consecutive days. In addition, a subset of morphine-tolerant rats underwent testosterone replacement therapy. The levels of mu-opioid receptor (MOR) mRNA and protein in the trigeminal ganglia (TGs) of morphine-tolerant versus control rats and of morphine-tolerant rats with vs. without testosterone replacement therapy were measured. We found that testosterone levels were significantly lower in morphine-tolerant rats than in the controls (1.248 ± 0.231 ng/ml vs. 2.223 ± 0.153 ng/ ml, respectively; p = 0.008). Furthermore, chronic morphine exposure led to a downregulation in the levels of MOR mRNA to 79.3%, and of MOR protein to 68.9%. Testosterone replacement therapy restored MOR mRNA and protein levels specifically in rats who had developed a tolerance to morphine, thereby suggesting a potential role of testosterone in the opioid-receptor response to chronic morphine exposure. In summary, our study provides evidence for the involvement of testosterone in the proper regulation of the peripheral MOR system in rats following prolonged morphine exposure. We also suggest that analgesic therapeutic measures should take into account the testosterone levels of patients who have built up a tolerance to morphine.

Pomegranate Seeds Extract Possesses a Protective Effect against Tramadol-Induced Testicular Toxicity in Experimental Rats

Tramadol is a centrally acting opioid analgesic that is extensively used. The chronic exposure to tramadol induces oxidative stress and toxicity especially for patients consuming it several times a day. Previously, we and others reported that tramadol induces testicular damage in rats. This study was conducted to investigate the possible protective effect of pomegranate seed extract (PgSE) against tramadol-induced testicular damage in adult and adolescent rats. Male rats were orally treated with tramadol or in a combination with PgSE for three weeks. Testes were then dissected and analyzed. Histological and ultrastructural examinations indicated that tramadol induced many structural changes in the testes of adult and adolescent rats including hemorrhage of blood vessels, intercellular spaces, interstitial vacuoles, exfoliation of germ cells in lumen, cell apoptosis, chromatin degeneration of elongated spermatids, and malformation of sperm axonemes. Interestingly, these abnormalities were not observed in tramadol/PgSE cotreated rats. The morphometric analysis revealed that tramadol disrupted collagen metabolism by elevating testicular levels of collagen fibers but that was protected in tramadol/PgSE cotreatment at both ages. In addition, DNA ploidy revealed that S phase of the cell cycle was diminished when adult and adolescent rats were treated with tramadol. However, the S phase had a normal cell population in the cotreated adult rats, but adolescent rats had a lower population than controls. Furthermore, the phytochemistry of PgSE revealed a high content of total polyphenols and total flavonoids within this extract; besides, the DPPH free radical scavenging activity was high. In conclusion, this study indicated that PgSE has a prophylactic effect against tramadol-induced testicular damage in both adult and adolescent ages, although the tramadol toxicity was higher in adolescent age to be completely protected. This prophylactic effect might be due to the high antioxidant compounds within the pomegranate seeds.

Efficacy and harms of long-term opioid therapy in chronic non-cancer pain: Systematic review and meta-analysis of open-label extension trials with a study duration ≥26 weeks

BACKGROUND AND OBJECTIVE

This updated systematic review evaluated the efficacy, acceptability and safety of long-term opioid therapy (LTOT) for chronic non-cancer pain (CNCP).

DATABASES AND DATA TREATMENT

Clinicaltrials.gov, CENTRAL and MEDLINE until June 2019. We included open-label extension trials with a study duration ≥26 weeks of RCTs with ≥2 weeks duration. Pooled estimates of event rates of categorical data and standardized mean differences (SMD) of continuous variables were calculated using a random effects model.

RESULTS

We added four new studies with 1,154 participants for a total of 15 studies with 3,590 participants. Study duration ranged between 26 and 156 weeks. Studies included patients with low back, osteoarthritis and neuropathic pain. The quality of evidence for every outcome was very low. 31.1% (95% Confidence interval [CI] 23.0%-40.7%) of patients randomized at baseline finished the open label period. 14.1% (95% CI 10.9%-19.4%) of patients dropped out to due adverse events. In 6.3% (95 CI 3.9%-10.1%) of patients serious adverse events and in 2.7% (95% CI 1.5%-4.7%) aberrant drug behaviour were noted. 0.5% (95% CI 0.2%-1.4%) of patients died.

CONCLUSIONS

Within the context of open-label extension studies, opioids maintain reduction of pain and disability and are rather well tolerated and safe. LTOT can be considered in carefully selected and monitored patients with low back, osteoarthritis and neuropathic pain who experience a clinically meaningful pain reduction with at least tolerable adverse events in short-term opioid therapy.

SIGNIFICANCE

There is very low quality evidence of the long-term efficacy, tolerability and safety of opioids for chronic low back, osteoarthritis and diabetic polyneuropathic pain within the context of open-label extension studies of randomized controlled trials. Drop out rate due to adverse events and deaths increase with study duration. One-third of patients profit from LTOT. Long-term opioid therapy can be considered in some carefully selected and monitored patients.

Substance Abuse and Male Hypogonadism

Progressive deterioration of male reproductive function is occurring in Western countries. Environmental factors and unhealthy lifestyles have been implicated in the decline of testosterone levels and sperm production observed in the last fifty years. Among unhealthy lifestyles, substance and drug abuse is a recognized cause of possible alterations of steroidogenesis and spermatogenesis. Alcohol, opioids and anabolic-androgenic steroids are capable to reduce testosterone production in male interfering with testicular and/or hypothalamic-pituitary function. Other substances such as nicotine, cannabis, and amphetamines alter spermatogenesis inducing oxidative stress and subsequent apoptosis in testicular tissue. Substance and drug abuse is a potentially reversible cause of hypogonadism, defined as the failure of the testis to produce physiological concentrations of testosterone and/or a normal number of spermatozoa. The identification of the abuse is important because the withdrawal of substance intake can reverse the clinical syndrome. This review summarizes the most important clinical and experimental evidence on the effect of substance abuse on testosterone and sperm production.

Supraphysiologic-dose anabolic-androgenic steroid use: A risk factor for dementia?

Supraphysiologic-dose anabolic-androgenic steroid (AAS) use is associated with physiologic, cognitive, and brain abnormalities similar to those found in people at risk for developing Alzheimer's Disease and its related dementias (AD/ADRD), which are associated with high brain β-amyloid (Aβ) and hyperphosphorylated tau (tau-P) protein levels. Supraphysiologic-dose AAS induces androgen abnormalities and excess oxidative stress, which have been linked to increased and decreased expression or activity of proteins that synthesize and eliminate, respectively, Aβ and tau-P. Aβ and tau-P accumulation may begin soon after initiating supraphysiologic-dose AAS use, which typically occurs in the early 20s, and their accumulation may be accelerated by other psychoactive substance use, which is common among non-medical AAS users. Accordingly, the widespread use of supraphysiologic-dose AAS may increase the numbers of people who develop dementia. Early diagnosis and correction of sex-steroid level abnormalities and excess oxidative stress could attenuate risk for developing AD/ADRD in supraphysiologic-dose AAS users, in people with other substance use disorders, and in people with low sex-steroid levels or excess oxidative stress associated with aging.