Case Reports

Opioid-Induced Androgen Deficiency in Veterans With Chronic Nonmalignant Pain

Fed Pract. 2015 October;32(10):26-31

References

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As this was a retrospective review, additional limitations included the inability to measure subclinical OPIAD, and the data collection related to symptoms of hypogonadism was restricted by documentation in the CPRS progress notes. The lack of data for females does not contribute to the literature on OPIAD in women. Finally, as the total daily MED does not distinguish between short-acting and long-acting opioid therapy, no differences between the impacts of short-acting vs long- acting opioid therapy on risk for  hypogonadism can be inferred. There is evidence to suggest that long-acting opioids are associated with a significantly higher risk for OPIAD compared with short-acting opioids, although the mechanism behind this is not well established.^22,23

Conclusions

The average age of the patients  on chronic opioid therapy with a  testosterone level drawn in this cohort was 58.3 years, which is younger than originally anticipated. The median age of 60 years is not significantly different from the average age, indicating that outliers did not impact this calculation. On average, the TT level was normal before starting opioids. Once opioids were started, patients were treated for an average duration of 52.5 months with an average daily dose of 126.8 mg MED. In this veteran cohort, 48.6% of patients met the criteria for TRT based on TT level alone, which is within the reported prevalence range of opioid-induced hypogonadism already published.^4,9 These results are in line with the original hypothesis that chronic opioid use can adversely impact testosterone levels and can have a poor effect on a patient’s QOL due to symptoms of low testosterone. In addition to TRT, possible and suggested (but not proven) treatment options for OPIAD include discontinuation of opioid therapy, opioid rotation, or conversion to buprenorphine.²¹ The approach used should account for multiple patient-specific factors and should be individualized.

Based on the data, there is a trend toward lower testosterone levels in veterans treated with higher MED and for longer periods with chronic opioids. Given recent data that infer that TRT carries increased CV risk as well as the VHA’s Opioid Safety Initiative, it is imperative that providers closely evaluate the appropriateness of starting TRT and/or continuing chronic opioid therapy. All patients generally should have failed non- opioid management prior to opioid therapy for chronic nonmalignant pain, and this should be documented accordingly. It is also crucial to have the “opioid talk” with patients from time to time and discuss the risks vs benefits, the potential for addiction, overdose, dependence, tolerance, constipation, and OPIAD so patients can continue to be an active and informed participants in their care.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.