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Kheirabadi D, Minhas D, Ghaderpanah R, Clauw DJ. Problems with opioids - beyond misuse. Best Pract Res Clin Rheumatol 2024; 38:101935. [PMID: 38429184 DOI: 10.1016/j.berh.2024.101935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
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.
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Affiliation(s)
- Dorna Kheirabadi
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Deeba Minhas
- Department of Internal Medicine, Division of Rheumatology, University of Michigan Medical School, 300 North Ingalls Building, Ann Arbor, MI, 48109-5422, United States.
| | - Rezvan Ghaderpanah
- Department of Physiology and Aging, College of Medicine, University of Florida, United States.
| | - Daniel J Clauw
- Departments of Anesthesiology, Medicine (Rheumatology), and Psychiatry, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, United States.
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Bradley A, Boland JW. Effects of Opioids on Immune and Endocrine Function in Patients with Cancer Pain. Curr Treat Options Oncol 2023; 24:867-879. [PMID: 37145383 PMCID: PMC10271882 DOI: 10.1007/s11864-023-01091-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/06/2023]
Abstract
OPINION STATEMENT Opioids are an important treatment in managing cancer pain. Uncontrolled pain can be detrimental to function and quality of life. Common adverse effects of opioids such as sedation, constipation and nausea are well recognised, but opioid effects on the endocrine and immune systems are less apparent. The evidence for the immunomodulatory effects of opioids suggest that some opioids might be immunosuppressive and that their use might be associated with reduced survival and increased rates of infection in patients with cancer. However, the quality of this evidence is limited. Opioid-induced endocrinopathies, in particular opioid-induced hypogonadism, may also impact cancer survival and impair quality of life. But again, evidence in patients with cancer is limited, especially with regard to their management. There are some data that different opioids influence immune and endocrine function with varying outcomes. For example, some opioids, such as tramadol and buprenorphine, demonstrate immune-sparing qualities when compared to others. However, most of this data is preclinical and without adequate clinical correlation; thus, no opioid can currently be recommended over another in this context. Higher opioid doses might have more effect on immune and endocrine function. Ultimately, it is prudent to use the lowest effective dose to control the cancer pain. Clinical presentations of opioid-induced endocrinopathies should be considered in patients with cancer and assessed for, particularly in long-term opioid users. Hormone replacement therapies may be considered where appropriate with support from endocrinology specialists.
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Affiliation(s)
- Anna Bradley
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, HU6 7RX, UK.
- Hull York Medical School, University of York, York, YO10 5DD, UK.
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Opioid-Induced Sexual Dysfunction in Cancer Patients. Cancers (Basel) 2022; 14:cancers14164046. [PMID: 36011039 PMCID: PMC9406921 DOI: 10.3390/cancers14164046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/14/2022] [Accepted: 08/17/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Sexual disorders affect up to 80% of cancer patients, depending on the type of cancer, yet they are commonly overlooked and untreated. Opioid-induced sexual dysfunction (OISD) is reported in half of opioid users. The pathophysiology of OISD—still a subject for research—may include disorders of both the endocrine and nervous systems, expressed in, among other things, erectile dysfunction and declined sexual desire, sexual arousal, orgasm, and general satisfaction with one’s sex life. The etiology of sexual dysfunction in cancer patients is usually multifactorial, so the management should be multifaceted and individualized by targeting pathophysiological factors. The treatment options for OISD are few and include testosterone replacement therapy, bupropion, opioid antagonists, phosphodiesterase type 5 inhibitors, plant-derived substances, and non-pharmacological treatments, although the evidence is insufficient. One of the treatment options may also be a choice of an opioid that is less likely to cause sexual dysfunction, yet further research is necessary. Abstract Sexual dysfunction is common in patients with advanced cancer, although it is frequently belittled, and thus consistently underdiagnosed and untreated. Opioid analgesics remain fundamental and are widely used in cancer pain treatment. However, they affect sexual functions primarily due to their action on the hypothalamus–pituitary–gonadal axis. Other mechanisms such as the impact on the central and peripheral nervous systems are also possible. The opioid-induced sexual dysfunction includes erectile dysfunction, lack of desire and arousal, orgasmic disorder, and lowered overall sexual satisfaction. Around half of the individuals taking opioids chronically may be affected by sexual dysfunction. The relative risk of sexual dysfunction in patients on chronic opioid therapy and opioid addicts increased two-fold in a large meta-analysis. Opioids differ in their potential to induce sexual dysfunctions. Partial agonists and short-acting opioids may likely cause sexual dysfunction to a lesser extent. Few pharmaceutical therapies proved effective: testosterone replacement therapy, PDE5 inhibitors, bupropion, trazodone, opioid antagonists, and plant-derived medicines such as Rosa damascena and ginseng. Non-pharmacological options, such as psychosexual or physical therapies, should also be considered. However, the evidence is scarce and projected primarily from non-cancer populations, including opioid addicts. Further research is necessary to explore the problem of sexuality in cancer patients and the role of opioids in inducing sexual dysfunction.
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[Adverse effects of opioids, antidepressants and anticonvulsants on sex hormones : Often unnoticed but clinically relevant]. Schmerz 2022; 36:293-307. [PMID: 35831621 DOI: 10.1007/s00482-022-00655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/08/2022]
Abstract
Androgen insufficiency under treatment with opioids, antidepressants and anticonvulsants in chronic pain diseases is a side effect with a high prevalence. It can lead to clinical metabolic alterations, adynamia, stress intolerance, anemia or osteoporosis and has a significant impact on the quality of life. Opioids, antidepressants and anticonvulsants affect the hypothalamic-pituitary-gonadal axis of sex hormones. A urologist, andrologist or endocrinologist should be involved in the treatment at an early stage. The recommendation of a differential therapeutic selection of certain substances is only indicative and does not meet evidential criteria. The indications for androgen substitution must be individualized and in consideration of the risk-benefit profile. Awareness of this side effect of an otherwise lege artis medicinal pain therapy must be sharpened and compulsory included in the differential diagnostic considerations.
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Kotlińska-Lemieszek A, Żylicz Z. Less Well-Known Consequences of the Long-Term Use of Opioid Analgesics: A Comprehensive Literature Review. Drug Des Devel Ther 2022; 16:251-264. [PMID: 35082488 PMCID: PMC8784970 DOI: 10.2147/dddt.s342409] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/07/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The adverse effects of short-term opioid analgesics are well known and acknowledged; however, the spectrum of the sequelae of long-term use seems less clear. Some effects may remain undetected but still have the potential to cause harm and reduce patients' quality of life. OBJECTIVE To review the literature on the adverse effects of long-term opioid therapy. METHODS We performed a quasi-systematic search, analyzing articles published in the MEDLINE database between January 2000 and March 2021 that identified adverse effects of opioids used for chronic pain treatment. RESULTS Growing evidence indicates that there are multiple serious adverse effects of opioid treatment. Long-term opioid use may have significant effects on the endocrine, immune, cardiovascular, respiratory, gastrointestinal, and neural systems. Studies show that long-term opioid treatment increases the risk of fractures, infections, cardiovascular complications, sleep-disordered breathing, bowel dysfunction, overdose, and mortality. Opioids may potentially affect cancer development. Most consequences of the long-term use of opioids have been identified in studies of patients with non-malignant pain. CONCLUSION Studies indicate that long-term use of opioids increases the risk of drug-related events in a significant number of patients. Clinicians should be aware of these complications associated with prescribing opioids, discuss them with patients, prevent complications, if possible, and diagnose them early and manage adequately. More human studies are needed to assess the risk, including trials with individual opioids, because they have different adverse effect profiles.
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Affiliation(s)
- Aleksandra Kotlińska-Lemieszek
- Chair and Department of Palliative Medicine, Pharmacotherapy in Palliative Care Laboratory, Poznan University of Medical Sciences, Poznan, Poland.,Heliodor Święcicki University Hospital, Poznan, Poland
| | - Zbigniew Żylicz
- Institute of Medical Sciences, Medical College, University of Rzeszów, Rzeszów, Poland
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Sharp JL, Pearson T, Smith MA. Sex differences in opioid receptor mediated effects: Role of androgens. Neurosci Biobehav Rev 2022; 134:104522. [PMID: 34995646 PMCID: PMC8872632 DOI: 10.1016/j.neubiorev.2022.104522] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/19/2021] [Accepted: 01/02/2022] [Indexed: 12/26/2022]
Abstract
An abundance of data indicates there are sex differences in endogenous opioid peptides and opioid receptors, leading to functional differences in sensitivity to opioid receptor mediated behaviors between males and females. Many of these sex differences are mediated by the effects of gonadal hormones on the endogenous opioid system. Whereas much research has examined the role of ovarian hormones on opioid receptor mediated endpoints, comparatively less research has examined the role of androgens. This review describes what is currently known regarding the influence of androgens on opioid receptor mediated endpoints and how androgens may contribute to sex differences in these effects. The review also addresses the clinical implications of androgenic modulation of opioid receptor mediated behaviors and suggests future lines of research for preclinical and clinical investigators. We conclude that further investigation into androgenic modulation of opioid receptor mediated effects may lead to new options for addressing conditions such as chronic pain and substance use disorders.
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Affiliation(s)
- Jessica L Sharp
- Department of Psychology and Program in Neuroscience, Davidson College, United States
| | - Tallia Pearson
- Department of Psychology and Program in Neuroscience, Davidson College, United States
| | - Mark A Smith
- Department of Psychology and Program in Neuroscience, Davidson College, United States.
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Ho ST, Lin TC, Yeh CC, Cheng KI, Sun WZ, Sung CS, Wen YR, Hsieh YJ, Wang PK, Liu YC, Tsai YC. Gender Differences in Depression and Sex Hormones among Patients Receiving Long-Term Opioid Treatment for Chronic Noncancer Pain in Taiwan-A Multicenter Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157837. [PMID: 34360130 PMCID: PMC8345700 DOI: 10.3390/ijerph18157837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 01/04/2023]
Abstract
Background: Long-term use of opioids for chronic noncancer pain is associated with sex hormone disturbances. The interferences with sex hormones, sexual function, and depression were investigated in patients with chronic noncancer pain. Methods: A cross-sectional multicenter survey was conducted on 170 officially registered outpatients receiving long-term opioid treatment in nine medical centers in Taiwan between October 2018 and July 2019. Serum sex hormone levels were examined after the collection of self-administered questionnaires containing the Taiwanese version of the Brief Pain Inventory, depressive status, and sexual function interference. Results: Among 117 (68.8%) questionnaire responses from 170 enrolled outpatients, 38 women and 62 men completed the sex hormone tests, among whom only 23 (23%) had previously received blood hormone tests. Low serum total testosterone levels were detected in 34 (89.5%) women (<30 ng/dL) and 31 (50%) men (<300 ng/dL). Over 60% of women and men reported reduced sexual desire and function despite a nearly 50% reduction in pain intensity and daily function interference over the previous week after opioid treatment. Women generally had higher risks of a depression diagnosis (p = 0.034) and severe depressive symptoms (p = 0.003) and nonsignificantly lower opioid treatment duration (median 81 vs. 120 months) and morphine milligram equivalent (median 134 vs. 165 mg/day) compared with men. Conclusions: This survey demonstrated the high prevalence of depression diagnosis, low sex hormone levels, and reduced sexual function among Taiwanese patients with chronic noncancer pain receiving prolonged opioid therapy. Regular hypogonadal screenings are recommended for further management.
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Affiliation(s)
- Shung-Tai Ho
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (S.-T.H.); (K.-I.C.)
- National Defense Medical Center, Department of Anesthesiology, Tri-Service General Hospital, Taipei 11490, Taiwan;
| | - Tso-Chou Lin
- National Defense Medical Center, Department of Anesthesiology, Tri-Service General Hospital, Taipei 11490, Taiwan;
- Correspondence:
| | - Chun-Chang Yeh
- National Defense Medical Center, Department of Anesthesiology, Tri-Service General Hospital, Taipei 11490, Taiwan;
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan; (S.-T.H.); (K.-I.C.)
| | - Wei-Zen Sun
- Health Science & Wellness Center, Department of Anesthesiology, National Taiwan University Hospital, National Taiwan University, Taipei 10617, Taiwan;
| | - Chun-Sung Sung
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
| | - Yeong-Ray Wen
- Department of Anesthesiology, China Medical University Hospital, China Medical University, Taichung 40447, Taiwan;
| | - Yi-Jer Hsieh
- Department of Anesthesiology, Changhua Christian Hospital, Changhua 500209, Taiwan;
| | - Po-Kai Wang
- Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan;
| | - Yen-Chin Liu
- Department of Anesthesiology, National Cheng Kung University Hospital, National Cheng Kung University, Tainan 70403, Taiwan;
| | - Yu-Chuan Tsai
- Center of Pain Management, Department of Anesthesiology E-Da Cancer Hospital, School of Medicine, I-Shou University College of Medicine, Kaohsiung 82445, Taiwan;
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Wehbeh L, Dobs AS. Opioids and the Hypothalamic-Pituitary-Gonadal (HPG) Axis. J Clin Endocrinol Metab 2020; 105:5890030. [PMID: 32770254 DOI: 10.1210/clinem/dgaa417] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/07/2020] [Indexed: 01/22/2023]
Abstract
CONTEXT Hypogonadism is a well-established consequence of opioid use. It has been reported in both men and women, although more widely studied in men. EVIDENCE ACQUISITION PubMed was searched for articles in English until December 2019 for opioids and hypogonadism. Bibliography of retrieved articles was searched for relevant articles. EVIDENCE SYNTHESIS The prevalence of opioid-induced hypogonadism (OIH) varies between studies but was reported to be 69% in a recent systematic review. There is large heterogeneity in the studies, with different factors shown to have stronger association with hypogonadism such as specific types of opioids, higher doses, and longer durations of use. The consequences of OIH include sexual dysfunction, depression, decreased quality of life, and low bone density. There is paucity of randomized controlled trials assessing the efficacy of testosterone replacement therapy (TRT) for OIH in men, and even less studies on treating OIH in women. TRT studies in men reported varying outcomes with some studies favoring and others showing no clear benefit of TRT on different measures. CONCLUSIONS Despite the high prevalence of OIH, it remains underrecognized and undertreated with multiple endocrine and metabolic consequences. A reasonable approach in patients using opioids includes informing them of this complication and its potential consequences, screening for signs and symptoms of hypogonadism then sex hormone levels if prolonged opioid use > 3 months, and treating patients diagnosed with hypogonadism, if and when clinically indicated, with sex hormones if chronic opioids are planned to be continued for ≥ 6 months.
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Affiliation(s)
- Leen Wehbeh
- Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adrian S Dobs
- Division of Endocrinology, Diabetes & Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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