When we see men who have had years, even decades of chronic pain, we often find ourselves having to convince some of them that because their joint decay or erosion is so significant, that our regenerative injection treatment to help reverse this damage and help them their pain, mobility, and activity levels will need to take some time. Many of these middle age men are very active. They have sought out our treatments because they have reached a point where they are being advised by their orthopedist that the next treatment will be a knee or hip replacement surgery. That option has little appeal for some as the rehabilitation and recovery time can stretch into many months, possible more than a year away from their favorite pastime, if they can return at all.
Middle aged men with chronic joint pain are one of the main groups of patients we see. These men will complain about about muscle weakness, fatigue, and not feeling well overall. Some will simply say, “I feel old.” They want to know what we can do with their knee or hip. If we can help them avoid replacement.
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. 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 has been prescribed by their orthopedist.
We may ask next, “how is your sexual function?” Sometimes the man will say, “that works okay, it is my knee that is the problem”
But why would we ask about sexual function?
There has been a tremendous amount of research in the last few years that have identified painkillers as causing rapid and accelerated testosterone loss in men.
The summary of research and concerns about low testosterone in men who routinely take painkillers can be seen in October 2018 research published in the Journal of endocrinological investigation.(1)
“OPIAD (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.
But weaning patients off of painkillers is sometimes a challenge as seen by the recent acknowledgement that we are in an Opioid Crisis. Patients can be shown research that Vicodin, OxyContin, Percocet, et al, have a number of adverse effects including hormonal imbalances that hinder successful treatment and recovery from joint disease, yet the need for and possible addiction to the painkillers is tough to overcome. (2)
Four out of 5 patients, for whom opioid pain management failed demonstrated hormone abnormality
A study in the journal Postgraduate medicine 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.(3)
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 (4) 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.
Painkiller usage is clearly associated with a higher risk of erectile dysfunction
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 (5) 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.
If you would like to explore more information, please contact our office so we can start a conversation with you.
1 Coluzzi F, Billeci D, Maggi M, Corona G. Testosterone deficiency in non-cancer opioid-treated patients. J Endocrinol Invest. 2018;41(12):1377-1388.
2. Bawor M, Bami H, Dennis BB, et al. Testosterone suppression in opioid users: a systematic review and meta-analysis. Drug Alcohol Depend. 2015 Apr 1;149:1-9. doi: 10.1016/j.drugalcdep.2015.01.
3. 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.
4. 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.
5. 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.