Opioid Induced Androgen Deficiency (OPIAD)

Discussion in 'Men's Health Forum' started by DaGeneral, Apr 7, 2006.

  1. DaGeneral

    DaGeneral Junior Member

    I have been just told by my GP during my annual check up that my blood shows low testosterone. In the words of the Dr. so low he has never seen before! (displaced-NY'er, me too). So, I've done some research on the web and one possibility is long term use of Morphine, which is me. I have a bad back and am recovering at this time from my second spinal surgury. I hope to be off the meds soon as this fusion I just had should correct the pain producing areas of my back. I have been on Oxycontin for around seven years, with Roxicodone as well, and a liquid form of oxycontin called Oxydose for quick pain releif. I am exhibiting some of the symptoms listed: Quick temper out of nowhere 9I attributed it to the meds, so I was put on Klonipin), poor errection, a disapearing Penis, as I sit up the littley guy goes down into me and I barely see the head, and who knows what else I cannot see. I am 53 yrs of age. I am wondering if anyone else here has been down this particular road as well? My GP wants me to see an endocrinologist when I am back on my feet, spinal surgery was just 16 days ago, and I am somewhat bedridden at this time. Any help will be appreciated!;)
    Last edited by a moderator: Jul 20, 2012
  2. mxim

    mxim Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    first off,
    i had a bad back,and it was only a strain so i could only imagine what you went through. you need to come off. low T is caused by ,among other things,drug use,inactivity,stress,and depression. all of which i am sure you had with something as debilitating as a bad back. start with 50mgs of clomid a day and try to do some cardio and diet/ get off the drugs asap;7 years is a hell of a long time to be on pain killers.
  3. DaGeneral

    DaGeneral Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    Thank you for your comments/advice, all those things are in my future once the incision pain passes and my med Dr. weans me off the morphine. I appreciate the candidness of your post.
  4. pmgamer18

    pmgamer18 Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    I also think that when you get your testosterone levels back up when you are off the morphine your body will start to repair a lot of damage done to your joints and muscles from low T. I pray you get your T levels back up with out having to go on T meds. Hold out as long as you can to see if your body starts to make it on it's own. I feel once a man goes on TRT it ends up most times for life.
  5. marianco

    marianco Doctor of Medicine

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    Half of men over 50 are hypogonadal due to the process of aging. And it only gets worse over time. Thus the need to consider testosterone replacement - which is probably for a lifetime since the benefits of testosterone replacement are usually better than the alternative - heart attacks, strokes, diabetes, death, and numerous other serious illnesses.

    Opiate pain medications work by activating opiate receptors to reduce pain. However, they also increase histamine levels - which can cause irritability, mood instability, manic-like behavior. They also reduce adrenal gland production - contributing to worsening of adrenal fatigue if it is present - at worse causing an Addisonian crisis - the adrenal fatigue causing mood symptoms. (see adrenal thread).
  6. DaGeneral

    DaGeneral Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    Thank you all, for your informative and kind comments. I have alot on my plate and I hope to come out of it unscathed. You never think about these type of things happening to you when you take that first pill and get some relief for difficult pain. I have alot to learn about this and will hopefully do the right things to move forward. Thanks again!
  7. jawbone

    jawbone Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    I have read that AAS (esp T) modulate our CNS to how we react to chronic pain. IOWs guys with higher T tend to tolerate chronic pain better.
    KingCahoot3627 likes this.
  8. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    This a tough nut to crack but I would defibitely think long & hard for the consequences otherwise. I have had possibly the worst pain in my life with back pain. I had a ruptured sequestrated disk at L4-5, L5-S1 in 1982. I had foot drop, paraesthesias (still to this day), and more. The procedure is banned now due to the high incidence of anaphylatic shock but for me I was fortunate. The procedure was a chemonucleolysis (papain). It decreased the pain enough for me to move around with minimal but constant pain. I have found over the years what keeeps the pain at bay the best is staying in shape and remaining flexible. Weight needs to be with a 32" waist or less; be able to do splits; and also to touch your chin to your knees. Below is some information on TRT as well as the use of buprenorphine in place of your current medications.

    In the 70?s, high-dose methadone was shown to depress plasma testosterone levels, and clinical studies have reported decreased sexual drive and performance in male heroin addicts. The methadone-induced suppression of testosterone levels is mediated by the inhibition of hypothalamic GnRH production as well as direct reduction of testicular testosterone secretion. Buprenorphine, a partial ?-opioid agonist, is a new drug for the pharmacotherapy of opioid dependence.

    Naturally occurring opiates (endorphins) diminish testosterone levels by inhibiting both hypothalamic gonadotrophin releasing hormone production and testicular testosterone synthesis. Heroin addicts treated with a single daily dose of methadone and nonaddicts receiving continuous intrathecal opioids quickly develop low luteinizing hormone and total testosterone levels. A similar pattern is found in men consuming commonly prescribed oral opioids.

    Approximately 90% of opioid-ingesting men who reported normal erectile function before opioid use reported severe erectile dysfunction or diminished libido after beginning their opioid therapy. Commonly prescribed opioids in sustained-action dosage forms usually produce subnormal sex hormone levels, which may contribute to a diminished quality of life for many patients with painful chronic illness.

    A 24-week open-label pilot study of testosterone (T) patch therapy in men with opioid-induced androgen deficiency (OPIAD) found androgen deficiency symptoms (ADSQ), sexual function (Watts SFQ), mood (PGWB), depression (BDI-II), and hematocrit levels to improve during treatment. The T dosage was 5 mg/day for the first 12 weeks and 7.5 mg/day for the second 12 weeks with greater improvement at the 7.5 mg/day dosage.

    Buprenorphine is a new drug for maintenance therapy of opioid dependence. Unlike methadone, a pure agonist at the ?-opioid receptor, it is a mixed agonist-antagonist opioid with low intrinsic activity and high affinity at the ?-opioid receptor and with no intrinsic activity, but high affinity, at the kappa -opioid receptor. Buprenorphine has a good safety profile and a decreased abuse potential, and it suppresses opioid withdrawal, all of which make it very suitable for the maintenance therapy of heroin addicts. Additionally, it blocks the effects of concurrently administered opioids and thereby reduces the risk of relapse in buprenorphine-maintained patients. The efficacy of buprenorphine in comparison with methadone in the therapy of opioid dependence has been firmly established.

    An investigation demonstrated that buprenorphine at a dose of 8?20 mg/d did not suppress plasma testosterone. The frequency of sexual dysfunction was significantly lower compared with that in the group treated with high-dose methadone. Buprenorphine is different from methadone insofar as it is a partial ?-opioid receptor agonist and a pure antagonist at the kappa -opioid receptor. These differing effects at ?- and kappa-opioid receptors are used to explain the unusual pharmacological effects of buprenorphine. The stimulation of kappa-opioid receptors causes a suppression of the gonadal axis. The antagonism of buprenorphine at the kappa-opioid receptor may possibly counteract the ?-opioid receptor-mediated depression of the gonadal axis.

    Buprenorphine, in contrast with high-dose methadone, seems not to suppress plasma testosterone in heroin-addicted men. Buprenorphine was less frequently related to sexual side effects. Buprenorphine might therefore be favored in the treatment of opioid dependence to prevent patients from the clinical consequences of methadone-induced hypogonadism.


    Last edited: Jul 20, 2012
    PIZZABOY, Dr JIM and Ozzy619 like this.
  9. 1cc

    1cc Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?


    My mother had a 5-6mm herniated disc at the same location. She also experienced the most horrible pain over a long period of time. She also had foot drop, which was CURED. Initially they did 2 epidural injections which eliminated the pain, but this did not eliminate the foot drop, since the disc was still touching the nerve. Fortunately by the grace of God, we found a treatment called Vax-D. This treatment claimed to be able to restore the disc back into it's original location. I did some research, and they had sample cases that provided before and after MRI's to show and prove that the disc herniations in their patients had receded. The proof was sufficient for me, and my mother started treatment. Their usual treatment is only 20 sessions, but my mother did about 60-80. Her drop foot went away. I decided to do an MRI after her treatment to make sure that the treatment had worked. The MRI showed that her disc herniation had improved and was now only 2-3mm, and obviously was not touching the nerve, since she no longer had the drop foot. You can get info about Vax-D at http://www.vax-d.com/ .

    I hope this helps you in some way.
  10. Paulsm

    Paulsm Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    Once I too was suffering a lot from severe chronic pain in my legs. I was undergoing many treatment, but I could not bear the pain. Then I found Thoughts Become Reality. They gave me the hypnotherapy treatment, from which I changed a lot and learnt to manage the pain.
  11. r3drang3r

    r3drang3r Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    I've been down this road as well. Been on Oxycontin for three years. Then I started to experience extreme fatigue. A blood test showed my Testosterone was quite low. My Dr a GP went straight to putting me on Testim (a testosterone replacement). She actually screwed up by doing that. The next sequence of events should have been testing to see if there is a cause for the Low T. Once you are on Testoserone for a while it shut down the Testes from making any more. Tests that should have been run are no longer possible.

    There are other ways of restoring your testosterone without shutting down your testes. First order of business is to have a good Doctor who specializes in TRT to run tests including an MRI to check the Pituitary Gland for a tumor (usually benign), or possible damage from a past accident.

    If your Testes are still able to produce testosterone there are drugs that can stimulate them to do their job more proficiently.

    Be careful of Suboxone to replace the morphone to come off of it. It can be equally addictive and the withdrawal is Hell. Don't ask me how I know.

    Good Luck.
  12. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    You do recognize that the post is from April 2006, right? Otherwise, the Suboxone note is helpful. There is another recent thread on this topic, including Suboxone use. http://forum.mesomorphosis.com/mens-health-forum/restart-something-to-consider-134286329.html
    Last edited: Mar 10, 2010
  13. r3drang3r

    r3drang3r Junior Member

  14. monkeys1954

    monkeys1954 Junior Member

    Re: Long Term Morphine user for chronic pain low testosterone Anyone?

    i have the same problems . long term opiate use after failed spinal fusion, the operation messed up my sciatic nerves. i never had any sciatica before the fusion, now it has been 24-7 for ever it seems like.i have been on morphine for years now and there is no other fix to my problem. i have suspected low t for years and now these commecials came out. i am 55 years old and wrecked my back when i as 34.
  15. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Smith HS, Elliott JA. Opioid-Induced Androgen Deficiency (OPIAD). Pain Physician 2012;15(3 Suppl):ES145-56. http://www.painphysicianjournal.com/2012/july/2012;15;ES145-ES156.pdf

    Opioid therapy is one of the most effective forms of analgesia currently in use. In the past few decades, the use of opioids as a long-term treatment for chronic pain has increased dramatically. Accompanying this upsurge in the use of long-term opioid therapy has been an increase in the occurrence of opioid associated endocrinopathy, most commonly manifested as an androgen deficiency and therefore referred to as opioid associated androgen deficiency (OPIAD). This syndrome is characterized by the presence of inappropriately low levels of gonadotropins (follicle stimulating hormone and luteinizing hormone) leading to inadequate production of sex hormones, particularly testosterone. Symptoms that may manifest in patients with OPIAD include reduced libido, erectile dysfunction, fatigue, hot flashes, and depression. Physical findings may include reduced facial and body hair, anemia, decreased muscle mass, weight gain, and osteopenia or osteoporosis. Additionally, both men and women with OPIAD may suffer from infertility. While the literature regarding OPIAD remains limited, it is apparent that OPIAD is becoming increasingly prevalent among chronic opioid consumers but often goes unrecognized. OPIAD can have a significant negative impact on the the quality of life of opioid users, and clinicians should anticipate the potential for its occurrence whenever long-term opioid prescribing is undertaken. Once diagnosed, treatment for OPIAD may be offered utilizing a number of androgen replacement therapy options including a variety of testosterone preparations and, for female patients with OPIAD, dehydroepiandrosterone (DHEA) supplementation. Follow-up evaluation of patients receiving androgen replacement therapy should include a review of any unresolved symptoms of hypogonadism, laboratory evaluation, and surveillance for potential adverse effects of androgen replacement therapy including prostate disease in males.
  16. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Opioid-Induced Hypogonadism: Why And How To Treat It

    Demaddalena C, Bellini M, Berra M, Meriggiola MC, Aloisi AM. Opioid-induced hypogonadism: why and how to treat it. Pain Physician 2012;15(3 Suppl):ES111-8. http://www.painphysicianjournal.com/2012/july/2012;15;ES111-ES118.pdf

    BACKGROUND: Gonadal hormones are critical factors in modulating the experience of pain, as suggested by the several sex differences observed: women have a greater risk of many clinical pain conditions, and postoperative and procedural pain may be more severe in them than in men. A growing body of literature demonstrates the role of estrogen in the female pain experience, whereas less attention has been given to testosterone and its functions. Nevertheless, testosterone has an appreciable role in both women and men: adequate serum levels are required in males and females for libido and sexuality; cellular growth; maintenance of muscle mass and bone; healing; blood-brain barrier; and for central nervous system maintenance. Pain therapy, and particularly opioid therapy, has been shown to affect testosterone plasma levels. Thus, the chronic administration of pain killers, such as opioids, requires the physician to be aware of both the consequences that can develop due to long-term testosterone impairment and the available means to restore and maintain physiological testosterone levels.

    OBJECTIVE: The objective is to highlight to pain physicians that the endocrine changes occurring during chronic pain therapy can participate in the body dysfunctions often present in chronic pain patients and that there are possible hormone replacement methods that can be carried out in men and women to improve their quality of life.

    STUDY DESIGN: A comprehensive review of the literature.

    METHODS: A comprehensive review of the literature relating to opioid-induced hypogonadism, as well as other very common forms of hypogonadism, its endocrine effects, and possible therapeutic actions. The literature was collected from electronic and other sources. The reviewed literature included observational studies, case reports, systematic reviews, and guidelines.

    OUTCOME MEASURES: Evaluation of the endocrine changes described in chronic pain therapy was the primary outcome measure. The secondary outcome measures were functional improvement and adverse effects of hormone replacement.

    RESULTS: The results of the survey clearly show that sex hormone determination is very rare in pain centers. Given the complexity and widespread nature of pain therapy, there is a paucity of qualitative and quantitative literature regarding its endocrine consequences. The available evidence is weak for pain relief, but is consistent for many collateral effects, possibly deriving from pain therapy, such as fatigue, depression, and neurodegenerative diseases.

    LIMITATION: This is a narrative review without application of methodological quality assessment criteria. Even so, there is a paucity of literature concerning both controlled and observational literature for the endocrine effects of most analgesic drugs.

    CONCLUSION: Testosterone replacement suffers from old prejudices about its utility and safety. With this review we illustrate the available therapeutic choices able to maintain T concentration into physiological ranges and reduce nociception with a final goal of improving patients' quality of life.
  17. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Basaria S, Travison TG, Alford D, et al. Effects of testosterone replacement in men with opioid-induced androgen deficiency: a randomized controlled trial. Pain 2015;156(2):280-8. http://www.ncbi.nlm.nih.gov/pubmed/25599449

    Symptomatic androgen deficiency is common in patients taking opioid analgesics, as these drugs potently suppress the hypothalamic-pituitary-gonadal axis. However, the efficacy of testosterone replacement in this setting remains unclear.

    The objective of this trial was to evaluate the efficacy of testosterone replacement on pain perception and other androgen-dependent outcomes in men with opioid-induced androgen deficiency. We conducted a randomized, double-blind, parallel placebo-controlled trial at an outpatient academic research center.

    Participants were men aged 18 to 64 years on opioid analgesics for chronic noncancer pain, and total testosterone levels were <350 ng/dL. Participants were randomly assigned to 14 weeks of daily transdermal gel that contained 5 g of testosterone or placebo.

    Primary outcomes were changes in self-reported clinical pain and objectively assessed pain sensitivity. Sexual function, quality of life, and body composition were also assessed.

    The mean age was 49 years. The median total and free testosterone levels at baseline were 243 ng/dL and 47 pg/mL and 251 ng/dL and 43 pg/mL in the testosterone and placebo arm, respectively. Of the 84 randomized participants, 65 had follow-up data on efficacy outcomes.

    Compared with men assigned to the placebo arm, those assigned to testosterone replacement experienced greater improvements in pressure and mechanical hyperalgesia, sexual desire, and role limitation due to emotional problems. Testosterone administration was also associated with an improvement in body composition.

    There were no between-group differences in changes in self-reported pain. In conclusion, in men with opioid-induced androgen deficiency, testosterone administration improved pain sensitivity, sexual desire, body composition, and aspects of quality of life.
  18. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Moradi M, Mahmoodi M, Raoofi A, Ghanbari A. Chorionic morphine, naltrexone and pentoxifylline effect on hypophyso-gonadal hormones of male rats. Bratisl Lek Listy. 2015;116(4):276-9. http://www.elis.sk/index.php?page=s...ategory_id=118&option=com_virtuemart&Itemid=1

    BACKGROUND: Knowledge about harmful effects of morphine on hormone secretion seems to be necessary. The aim of the present study was to evaluate the effect of pentoxifylline on side effects derived by morphine on hypophyso-gonadal hormones of male rats.

    METHODS: 32 male rats were divided into the 4 groups of OSS: control (received 40 g Sucrose/l drinking water and intraperitoneal injection of 1 l/kg normal saline), OMS: morphine group (received 0.4 mg/l + 40 g Sucrose/l in drinking water and intraperitoneal injection of 1 l/kg normal saline), NMS: morphine+naltrexane group (received 0.4 mg/l + 40 g Sucrose/l in drinking water and IP injection dose of 10 mg/kg/ml/day Naltrexane) and PMS: morphine + pentoxifylline group (received 0.4 mg/dl + 40 g Sucrose/l in drinking water and IP injection dose of 12 mg/kg/ml/day Pentoxifylline) for 56 days, respectively.

    RESULTS: Serum levels of testosterone, LH, FSH hormones were measured. Pentoxifylline increased serum levels of testosterone, LH, FSH hormones compared to control, morphine and morphine-naltrexane groups.

    CONCLUSION: Pentoxifylline has a significant efficacy for increasing serum levels of sexual hormones. Considering that Pentoxifylline is safe and cheap, with easy application, we suggest for the usage of this drug for improving semen parameter's quality before performing ART for the treatment of morphine addicts (Fig. 1, Ref. 31).
  19. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Eichenbaum G, Gohler K, Etropolski M, Steigerwald I, Pergolizzi J, et al. Does tapentadol affect sex hormone concentrations differently from morphine and oxycodone? An initial assessment and possible implications for opioid-induced androgen deficiency. J Opioid Manag. 2015;11(3):211-27. http://pnpcsw.pnpco.com/cadmus/testvol.asp?journal=jom&year=2015

    OBJECTIVES: Opioid-induced androgen deficiency (OPIAD) affects patients treated with opioid analgesics. The norepinephrine reuptake inhibitor (NRI) and micro-opioid receptor (MOR) agonist activities of tapentadol may result in tapentadol having less effect on serum androgen concentrations than analgesics acting through the MOR alone, such as morphine and oxycodone.

    The objectives of this publication are to
    1) evaluate the effects of tapentadol (NUCYNTA and NUCYNTA extended release [ER]) on sex hormone concentrations in healthy male volunteers (vs placebo and morphine) and patients with osteoarthritis (vs placebo and oxycodone), and
    2) present a mechanistic hypothesis explaining how the combined MOR agonist and NRI activities of tapentadol may result in less impact on androgen concentrations.

    METHODS: Three clinical studies were conducted:
    study 1 (single-dose comparison study vs morphine in healthy volunteers),
    study 2 (single-dose-escalation study in healthy volunteers without an active comparator), and
    study 3 (multiple-dose study vs oxycodone in patients with osteoarthritis).

    Studies 1 and 2 were conducted at medical research centers in Germany and the United Kingdom; study 3 was conducted at primary and secondary care centers and medical research centers in the United States.

    All three studies were randomized, double blind, and placebo controlled. Concentrations of testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH; study 3 only) were evaluated at 6 and 24 hours postdose in studies 1 and 2, respectively, and at varying time points postdose in study 3.

    RESULTS: In study 1, mean serum total testosterone concentrations in healthy male volunteers were similar at baseline for all treatment periods; 6 hours after dosing, mean concentrations were comparable between placebo (8.6 nmol/L) and tapentadol immediate release (IR; 43 mg, 8.8 nmol/L; 86 mg, 9.3 nmol/L), but were lower following administration of morphine IR 30 mg (5.4 nmol/L).

    In study 2, there were no or minimal changes in testosterone in the therapeutic dose range with tapentadol IR (75-100 mg), and there was a modest decrease that appeared to level off in the supratherapeutic range (125-175 mg); mean testosterone and LH concentrations with all doses remained within normal ranges (testosterone, 4.56-28.2 nmol/L; LH, 2.9-4.6 U/L).

    In study 3, the decrease in the mean [standard deviation] testosterone concentration from baseline to endpoint for male patients receiving tapentadol ER (100 mg, -1.9 [0.71] nmol/L; 200 mg, -2.1 [0.93] nmol/L) was numerically smaller compared to oxycodone CR (20 mg, -2.7 [0.93] nmol/L), but higher compared to placebo (-0.3 [1.62] nmol/L).

    CONCLUSIONS: These results suggest that tapentadol, which has combined MOR and NRI activities, may have a lower impact on sex hormone concentrations than pure opioid analgesics, such as morphine or oxycodone.

    The data and mechanistic rationale presented herein provide a justification for conducting additional hypothesis testing studies, and are not intended to be used as a basis for clinical decision making. Future studies may help elucidate whether the observed trends are clinically significant and would translate into a reduced incidence of OPIAD.
  20. Michael Scally MD

    Michael Scally MD Doctor of Medicine

    Plasma testosterone and Sexual Function in Methadone and Buprenorphine Maintenance Treatment

    BACKGROUND: Methadone has been recognized as an effective maintenance treatment for opioid dependence. However, its use is associated with several complications, including sexual dysfunction in men. AIM: To assess plasma testosterone and sexual function in Southeast Asian men on methadone maintenance treatment (MMT) or buprenorphine maintenance treatment (BMT).

    METHODS: 76 sexually active men on MMT (mean age = 43.30 +/- 10.32 years) and 31 men on BMT (mean age = 41.87 +/- 9.76 years) from a Southeast Asian community were evaluated using plasma total testosterone (TT) and prolactin levels, body mass index, social demographics, substance use measures, and depression severity scale.

    OUTCOMES: Prevalence and associated factors of TT level lower than the reference range in men on MMT or BMT.

    RESULTS: More than 1 third of men (40.8%, n = 31) on MMT had TT levels lower than the reference range, whereas 1 fourth of men (22.6%, n = 7) on BMT did.

    At univariate analysis, MMT vs BMT (beta = 0.298, adjusted R(2) = 0.08, P = .02) and body mass index (beta = -0.23, adjusted R(2) = 0.12, P = .02) were associated with changes in TT after stepwise regression.

    There were no significant associations with age; Opiate Treatment Index Q scores for alcohol, heroin, stimulant, tobacco, or cannabis use and social functioning domain; education levels; hepatitis C status; and severity of depression. Prolactin level did not differ between the MMT and BMT groups.

    CLINICAL IMPLICATIONS: The sex hormonal assay should be used regularly to check men on MMT.

    STRENGTHS AND LIMITATIONS: This is the first study conducted in the Southeast Asian community. Our study was limited by the lack of a healthy group as the reference for serum levels of testosterone and prolactin.

    CONCLUSIONS: The findings showed that plasma testosterone levels are lower in MMT than in BMT users. Hence, men who are receiving MMT should be screened for hypogonadism routinely in the clinical setting.

    Yee A, Loh HS, Danaee M, Riahi S, Ng CG, Sulaiman AH. Plasma Testosterone and Sexual Function in Southeast Asian Men Receiving Methadone and Buprenorphine Maintenance Treatment. J Sex Med 2017. http://www.jsm.jsexmed.org/article/S1743-6095(17)31853-2/abstract