Middle aged men with chronic joint pain are one of the main groups of patients we see. Many of these men tell us that they use to take painkillers and anti-inflammatory medications after activities that required physical exertion, now they say, they take them before exertion as a pain preventative,and take them after, thereby doubling their dosage.
Many of these men know that they are on course for joint replacement. Their doctors have told them so. In our office we take a more proactive repair approach than masking pain symptoms with painkillers. We utilize regenerative medicine injections.
Treatment for degenerative joint disease is usually not a “magic bullet,” remedy. Treatment of degenerative joint disease usually requires a well thought out plan that goes beyond a single injection into the joint. Helping the middle aged man with chronic joint pain sometimes requires a very comprehensive treatment program that encompasses many different treatments that embrace a holistic, whole body approach. In this article we will examine the role of testosterone in joint healing.
When a man comes into our office with complaints of fatigue, weakness, or a feeling of “non-wellness,” in addition to their joint pain, we will ask during a medical history, “what type of pain medications are you taking?” Most of the time they will report simple over-the-counter medications, in some patients, they will tell us that they regularly take something, “a little stronger,” that had been prescribed by their orthopedist. Sometimes, a patient will tell us that they have noticed a problem with sexual dysfunction that is seemingly related to the intake of more medications. When this was discussed with their orthopedist, they were told that “doctors are now learning that this common side-effect.”
Opioids act on the hypothalamus, pituitary, and directly on the gonads affecting serum testosterone levels.
What is opioid-induced endocrinopathy? Endocrinopathy is commonly described as a hormone problem. It is a disorder of the endocrine gland. Among the health concerns that fall under this umbrella term are hyperthyroidism and hypothyroidism. Opioid-induced endocrinopathy is this hormone problem caused by painkillers.
Research published in the medical volume STATPEARLS (1) suggests:
“opioid-induced endocrinopathy is a condition that affects more Americans than other common comorbid conditions such as heart disease and diabetes combined. It is an important and often unrecognized cause of endocrinopathy, and can result in various clinical manifestations such as sexual dysfunction, amenorrhea, osteoporosis, fatigue, decreased muscle mass, gynecomastia, anemia, low testosterone, cortisol deficiency, and depression. It is essential to increase awareness of opioid-induced endocrinopathy and that the adverse effects of long-term opioid therapy such as opioid-induced endocrinopathy are considered and not overlooked in the treatment of chronic pain, and that benefits of chronic opioid therapy, in fact, outweigh the potential risks and side effects.”
Research published in October 2020 (2) states that “Opioids play a pivotal role in managing chronic pain with increasing prescription rates over the last few years. Hence, it is crucial to focus on the adverse effects of narcotics, and one of the lesser-known side effects is hypogonadism. Opioids act on the hypothalamus, pituitary, and directly on the gonads affecting serum testosterone levels. Narcotic-induced androgen insufficiency contributes to sexual dysfunction, infertility, hyperalgesia, and involving various body functions overall, affecting the quality of life. . . (this study) highlights the clinical significance of opioid-induced androgen deficiency and the diagnostic techniques to recognize and credible treatment alternatives, including testosterone replacement therapy.”
“Opioid-induced androgen (testosterone) deficiency is an underappreciated and underdiagnosed consequence of chronic opioid abuse.”
In October 2018, two research studies were published which offered critical advice to doctors who prescribed painkillers and what type of side effects of the medication they may expect to see in their patients.
The first study was published in the journal Sexual medicine reviews.(3)
Opioid-induced androgen deficiency can significantly impact male sexual function and quality of life.
Here is the concluding remarks from the researchers:
“”Although OPIAD (opioid-induced androgen deficiency) 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“
The last thing these men who came to visit us for help probably wanted to hear was that their pain management program was robbing them of their already diminishing levels of testosterone.
The summary of the second research concerns low testosterone in men who routinely take painkillers. It was published in the Journal of endocrinological investigation.(4)
“(opioid-induced androgen deficiency) is a common adverse effect of opioid treatment and contributes to sexual dysfunction, impairs pain relief and reduces overall quality of life. The evaluation of serum testosterone levels should be considered in male chronic opioid users and the decision to initiate testosterone treatment should be based on the clinical profile of individuals, in consultation with the patient.”
The last thing these men who came to visit us for help probably wanted to hear was that their pain management program was robbing them of their already diminishing levels of testosterone. Here at the Magaziner Center for Wellness, we treat low testosterone levels in our chronic pain patients by first getting them off their pain meds.
Four out of 5 patients, for whom opioid pain management failed demonstrated hormone abnormality
A study in the journal Postgraduate medicine (5) made a connection between failed pain management treatment and low testosterone. The study suggested that hormone levels should be tested for in patients with severe and chronic pain who fail to obtain adequate pain relief with standard pharmacologic treatment agents, including low to moderate dosages of opioids. In the study, the researchers showed four out of 5 patients, for whom opioid pain management failed, demonstrated hormone abnormality.
Pain or libido? Why are men asked to make a choice they do not have to make?
A recent article reported on in the Journal of the American Medical Association (6) tells the story of a man whose long term use of painkillers had resulted in low testosterone and a negative impact on his ability to enjoy life.
After laboratory workup demonstrated low testosterone levels, the patient was referred to testosterone replacement therapy. Next, this case study demonstrates the complexity of testosterone supplementation in men using opioid painkillers.
“After 6 months of testosterone therapy, the patient experienced urinary retention and therapy was discontinued. After urologic consultation, it was determined that his lower urinary tract symptoms were most likely due to opioid medication use rather than prostatic enlargement.”
The patient had good results with the testosterone supplementation, but because he reported urinary problems the treatment was stopped. Further investigation revealed that it was not the testosterone but the painkillers causing his urinary problems. So what happened?
“Discussion with his primary care physician included attempts to taper his opioid medication use, but he was still referred for management of his hypogonadism (low testosterone). In the endocrine clinic, he described a long history of fatigue, decreased libido, erectile dysfunction, and insomnia. After a detailed discussion of potential benefits and risks, he expressed a strong desire to resume testosterone therapy given his former perceived improvement in mood.”
That is the disruptive power of painkillers.
At the Magaziner Center for Wellness we do not offer a choice between painkillers and testosterone supplementation. We treat the chronic pain and make the need for painkillers irrelevant. If there is no need for painkillers there is no need to make a choice between pain management and low testosterone.
More than 19 percent of men who took high-dose opioids for at least four months also received erectile dysfunction prescriptions
Some men are stubborn, we get that. It is often the wife who comes in for treatment who tells us that their husbands will not come in and would rather “live with it.” Research has shown that erectile dysfunction gets a man to the doctor.
According to researchers at Kaiser Permanente regularly taking prescription painkillers is clearly associated with a higher risk of erectile dysfunction. The research which appeared in the medical journal Spine (7) included more than 11,000 men with back pain and examined their health records to find out if the men taking prescription painkillers were more likely to also receive prescriptions for testosterone replacement or ED medications.
More than 19 percent of men who took high-dose opioids for at least four months also received ED prescriptions while fewer than 7 percent of men who did not take opioids received ED prescriptions.
As we said above, treatment for degenerative disease is usually not a “magic bullet,” remedy. Treatment of degenerative joint disease usually requires a well thought out plan that goes beyond a single injection into the joint. It sometimes requires a very comprehensive treatment program that encompasses many different treatments embracing a holistic, whole body approach. Chronic pain and testosterone deficiency are challenging enough on their own. When a man suffers from both, you need a doctor with many years experience in handling both challenges together.
Should older men take testosterone?
There is a debate in the medical community about the safety issues concerning testosterone supplementation in older men. Those concerns surround possible increased risk of prostate cancer and heart disease in men who take testosterone. In the related articles below we go into further detail on these subjects.
More recently a January 2021 study (x) offered these guidelines to doctors and their patients considering testosterone supplementation
“Serum total and free testosterone levels in men, after reaching a peak in the second and third decade of life, decline gradually with advancing age. The trajectory of age-related decline is affected by comorbid conditions, adiposity (severe or morbid obesity), medications, and genetic factors. Testosterone treatment of older men with low testosterone levels improves overall sexual activity, sexual desire, and erectile function; improves areal and volumetric bone density, as well as estimated bone strength in the spine and the hip; corrects unexplained anemia of aging; increases skeletal muscle mass, strength and power, self-reported mobility, and some measures of physical function; and modestly improves depressive symptoms.
The long-term effects of testosterone on major cardiovascular events and prostate cancer risk remain unclear. The Endocrine Society recommends against testosterone therapy of all older men with low testosterone levels but suggests consideration of treatment on an individualized basis in men who have consistently low testosterone levels and symptoms or conditions suggestive of testosterone deficiency.”
If you would like to explore more information, please contact our office so we can start a conversation with you.
1 Medina II WA, Conermann T. Opioid-induced Endocrinopathy. 2021 Jul 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32644637.
2 Marudhai S, Patel M, Subas SV, Ghani MR, Busa V, Dardeir A, Cancarevic I. Long-term Opioids Linked to Hypogonadism and the Role of Testosterone Supplementation Therapy. Cureus. 2020 Oct;12(10).
3 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 Jul 26.
4 Coluzzi F, Billeci D, Maggi M, Corona G. Testosterone deficiency in non-cancer opioid-treated patients. J Endocrinol Invest. 2018 Dec;41(12):1377-1388. doi: 10.1007/s40618-018-0964-3. Epub 2018 Oct 20. PMID: 30343356; PMCID: PMC6244554.
5 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.
6 Murphy EN, Miranda R. Doubts about treating hypogonadism due to long-term opioid use with testosterone therapy: a teachable moment. JAMA internal medicine. 2014 Dec 1;174(12):1892-3.
7 Deyo RA, Smith DH, Johnson ES, Tillotson CJ, Donovan M, Yang X, Petrik A, Morasco BJ, Dobscha SK. Prescription opioids for back pain and use of medications for erectile dysfunction. Spine (Phila Pa 1976). 2013 May 15;38(11):909-15. doi: 10.1097/BRS.0b013e3182830482.
8. Rodrigues dos Santos M, Bhasin S. Benefits and Risks of Testosterone Treatment in Men with Age-Related Decline in Testosterone. Annual Review of Medicine. 2021 Jan 27;72:75-91.