Long-term high-dose opioids for pain can result in ED

Men using long-term, high dose prescription opioids for back pain were about 50% more likely to be using medications for erectile dysfunction than men with back pain who were not using opioids, according to a study published in a recent issue of Spine.

In a 2004 cross-sectional examination of electronic medical records and pharmacy records for males with back pain in a large integrated HMO, researchers considered relevant prescriptions for 6 months before and after the index visit. There were 11,327 males with a diagnosis of back pain. The men who received medications for erectile dysfunction or testosterone replacement (n=909) were significantly older than those who did not and had greater comorbidity, depression, smoking, and use of sedative-hypnotics.

In logistic regressions, long-term opioids use was associated with greater use of medications for erectile dysfunction or testosterone replacement compared with no opioid use (odds ratio, 1.45; 95% CI, 1.12–1.87; P<.01). Age, comorbidity, depression, and use of sedative-hypnotics were also independently associated with the use of medications for erectile dysfunction or testosterone replacement. Patients prescribed daily opioid doses of 120 mg of morphine-equivalents or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (odds ratio, 1.58; 95% CI, 1.03–2.43), even with adjustment for the duration of opioid therapy.

“This was true even after adjusting for other important correlates of erectile dysfunction such as age, comorbid illness, depression, and other medications,” said study lead author Richard Deyo, MD, MPH, Oregon Health and Science University (OHSU) professor and the Kaiser-Permanente endowed professor of evidence-based medicine in the department of family medicine at OHSU, Portland, Ore.

“Men should be aware that erectile dysfunction is a potential side effect of long-term, high dose opioid therapy,” Dr Deyo told Formulary. “Doctors and patients should be aware of this when considering options for chronic pain management, especially because non-pharmacologic treatments-such as rigorous exercise and cognitive-behavioral therapy-may be at least as effective. This should be part of a shared decision-making process regarding management of chronic pain.”

This is a side effect that’s familiar to many pain physicians, but many primary care physicians and patients may be less aware, according to Dr Deyo.

“This goes a step beyond measuring testosterone levels alone to examine a marker of actual sexual dysfunction, which is only loosely associated with hormone levels,” he said. “Erectile dysfunction has been studied with questionnaires among illicit drug users and methadone maintenance programs, but less often in patients using prescription opioids for pain management, or making use of pharmacy records to identify drugs for erectile dysfunction. Finally, we highlight other factors-age, depression, use of sedative-hypnotics-that are also risk factors  for erectile dysfunction in men with chronic pain.”