Imagine going through opioid use disorder treatment with methadone or buprenorphine, perhaps getting a job and family and everything in your life back—except for one thing: your sex drive.
It’s an unfortunate reality that libido can be reduced by long-term opioid maintenance. This not only impacts relationships, but also presents a potential barrier to long-term engagement in these lifesaving treatments.
This unwanted effect of methadone was shown by research conducted decades ago by Jack Mendelson and colleagues,* as well as more recent studies. However, many medications can cause sexual dysfunction, so it’s important for patients and clinicians to look at the whole picture.
Dr. Alan Wartenberg, former president of the Massachusetts chapter of the American Society of Addiction Medicine, told Filter that buprenorphine can also cause sexual dysfunction, though less frequently than methadone. “I’ve seen significant amounts of both erectile dysfunction and decreased libido on buprenorphine,” he said.
“It’s extremely common with 100 milligrams or more of daily methadone,” he continued, estimating that about 30 to 40 percent of all people on methadone, and a higher percentage of people on high doses of methadone, experience sexual dysfunction. Meanwhile, “About 20 percent of buprenorphine patients experience sexual dysfunction.”
“We have something like 60 years experience with methadone, and less with buprenorphine” said Dr. Walter Ling, founding director of the Integrated Substance Abuse Programs at UCLA. “But so far we do know that buprenorphine has much less effect on the endocrine systems.”
“There were some patients that decided to end their treatment for a number of reasons, including having a lowered sex drive.”
Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, a membership organization of opioid treatment programs (OTPs, sometimes known as methadone clinics) has also known people experiencing this issue.
“I remember as an administrator at the clinic, there were some patients that decided to end their treatment for a number of reasons, including the issue of having a lowered sex drive,” he told Filter. He recalls a number of conversations with such patients. “But I do not think that this has any significant [overall] effect on retaining patients in treatment,” he added.
However, Parrino acknowledges that for an individual patient affected, lowered sex drive “is of great significance.” Because no matter what the epidemiology or the percentages say, if it’s you, it matters.
One problem with examining the prevalence of MAT-related sexual dysfunction is that it’s difficult to separate the effects of the methadone or buprenorphine from the effects of what the person was taking before, said Ling.
Ling knows—and quotes—the world’s top opioid researchers, past and present (and many would say that he is the dean of them all). David Smith, the founder of the Haight-Ashbury Free Clinic, believed that “the addict will always blame whatever he or she is feeling or experience on the last thing that he or she took,” Ling told Filter. “So it’s not surprising that everybody talks about the effects of long-term treatment with methadone and buprenorphine.”
“But if you take a step back, and ask what these people were doing before they were in treatment, they were using opioids on the street, exposing themselves to the opioid effect, including the effect on testosterone levels.”
Mendelson’s early research was fraught by problems measuring a reliable testosterone level, Ling said. The data weren’t always very good, because levels had to be taken at a certain time of day, and this didn’t always happen.
What Dr. Mary Jeanne Kreek, one of the founders of methadone treatment, would say, according to Ling, is that prior to treatment, many patients were so focused on seeking drugs—to avoid withdrawal, mainly—that central functioning wasn’t much of an issue for them. When they are in recovery, life in general becomes more of an issue—including sex life.
The best way to fix a sexual dysfunction problem is to start with a medical evaluation from a specialist.
Short-acting opioids don’t have the same effect as long-acting on testosterone, said Wartenberg, noting that most people use short-acting before they get into treatment with agonists. “The up-and-down nature doesn’t have the same effect” as methadone and buprenorphine, he said. “They know that four hours after they use heroin they can’t do anything, but six hours later, they’re good to go.”
Stimulants are another story. With methamphetamine and cocaine, “there’s great sex at first,” said Wartenberg. With tolerance and dependence, however, libido disappears.
Wartenberg noted that even in OTPs, some medical directors are not expert in addiction treatment—and most OTP patients don’t have access to physicians. “The doctor and the nurse practitioner and the physician assistant are the most expensive people in the building,” said Wartenberg. And the best way to fix a sexual dysfunction problem is to start with a medical evaluation from a specialist. “If a patient sees their psychiatrist or their PCP, most of them don’t know a lot” about sexual dysfunction, said Wartenberg.
Opioids—all opioids—lower free and available testosterone levels. Testosterone is involved in libido and orgasm—in women, as well as in men.
So who can help? Ling said that for male impotence, endocrinologists may approach the problem the way they do for all patients, with medications such as Viagra. He said there is also a fair amount of interest in testosterone replacement for MAT patients. But it’s controversial because of side effects and problems with testing.
Low testosterone can be treated via skin patches and injections, but before treatment, there needs to be an assessment by an experienced reproductive endocrinologist, said Wartenberg. “There’s a differential diagnosis, because lots of things can cause decreased libido.”
In men, this physician will measure a total testosterone level. “That’s the down and dirty way to do it,” said Wartenberg. “The problem is that the total testosterone test is only a screening test, and it may be falsely normal for people on opioids.” In other words, it may appear normal, but actually there isn’t enough testosterone. There are actually two typical tests—one for free testosterone, which is not attached to any other substance, and one for sex hormone-binding globulin.
Wartenberg believes lowered libido should be on the labeling as a possible adverse effect of long-acting opioid medications. That said, he emphasized that there are other causes of sexual dysfunction, some of which can be extremely serious, such as adrenal insufficiency. This is why it’s important for patients to have good health care.
However, sexual dysfunction is a “quality of life” issue, and the easiest and least expensive way to treat it is often with testosterone, said Wartenberg. “I have treated women with testosterone, but much lower doses—usually with skin patches,” he said. Shots are difficult to give because of the viscosity of the testosterone, he said, adding that the VA had an injection clinic with nurses who knew how to give them.
To get more of a sense of how these issues apply on the ground, I spoke with Dr. Adam C. Lake, a Pennsylvania family physician with a concentration in HIV and addiction medicine. Lake has some transgender patients, some of whom he is also treating for substance use disorder, so he is familiar with hormone testing.
In his experience, naltrexone—an opioid blocker approved for treatment for alcohol and opioid use disorder—has resulted in most problems for patients. “In general, naltrexone can produce anhedonia, which means that we don’t enjoy things as much that we usually enjoy,” Lake told Filter. He has two patients who were on oral naltrexone for alcohol use disorder, who reported both general anhedonia and “decreased interest in sex in general.”
Regarding methadone and buprenorphine, he recalls one male patient—a chronic pain patient who was on methadone and “having prostate issues”—for whom testosterone was undetectable on testing. “He was having all the symptoms of low testosterone,” Lake said. Another male chronic pain patient switched to buprenorphine and “all along had erectile dysfunction and low sex drive. There was a lot of chaos in this situation.”
However, Lake hasn’t encountered many problems with women in terms of treatment with buprenorphine and sex drive, he said.
Research in the area of sexual dysfunction should be taken more seriously.
For patients who do need testosterone, Lake recommends the gel. “But sometimes it’s depression, so I may [also] use Wellbutrin,” he added. He hasn’t yet given testosterone to any cis women, but has started one trans woman (who was not affected by opioid issues) on testosterone.
Lake, whose trans practice grew out of his HIV practice, said that research in the area of sexual dysfunction should be taken more seriously. “We can look at the success of erectile dysfunction drugs, because this is what people care about, but we also need to talk about dyspareunia [painful intercourse],” he said. “I bring this up as a routine issue with my trans patients.”
There’s an unpleasant feedback loop when it comes to sexual performance, because once there is a physical problem, there is typically also a psychological problem with performance anxiety and phobic-avoidant behavior, said Wartenberg. When someone avoids sex because of fear of performance, this has an adverse effect on a relationship. This is why counseling with a professional who has experience dealing with sexual issues in couples is important, he said.
Individuals are unique, and circumstances like sexual trauma throw further complications into the mix. Elizabeth Brico recently wrote for Filter about women with traumatic histories who found that heroin use improved their sexual function, but that they lost interest in sex while on MAT.
Brico said that she was only on methadone for about a year, including the taper, and that for most of that time she was pregnant. “I’ve seen women in forums discussing the dampening effect of methadone on sex drive, but I didn’t experience that myself,” she told me.
However, she did feel a lack of libido when she was on buprenorphine. “I don’t know if it was the buprenorphine itself, or no longer having my trauma masked, or the birth control implant that ruined me in so many ways I am still recovering from,” she said. “Probably a combination of the three, I would guess. It was like the sexual part of me was erased completely.”
Loss of libido in women is much more complex to assess and treat.
In men, symptoms of sexual dysfunction, at least, can be easily described: erectile dysfunction and impotence. If they have problems with libido, it’s still difficult to ascertain the cause, but erectile dysfunction is a “good proxy for low testosterone levels,” said Dr. Steve Straubing., an obstetrician/gynecologist and medical director for a facility of Meridian Behavioral Healthcare, which has opioid treatment programs (OTPs) with methadone as well as buprenorphine/Vivitrol clinics in north central Florida.
“Low testosterone is easy to diagnose with blood levels and treat accordingly with testosterone,” he told Filter.
But loss of libido in women, as Brico’s experience suggests, is much more complex to assess and treat. Straubing described loss of libido as “very difficult to assess and quantitate” in women. For women, he continued, “an analog of erectile dysfunction is decreased vaginal lubrication as well as anorgasmia, but both of those can be related to many [non-opioid] medications as well as medico-psycho-social dysfunctions.”
And while decreased testosterone can be responsible for low sex drive in women as in men, “testosterone levels in women are not standardized,” said Straubing, adding that testosterone supplementation comes with “severe side effects.”
It’s also impossible to assume that the methadone or buprenorphine is causing sexual dysfunction, Straubing notes. “Libido changes in both men and women can be due to a whole host of things like depression, bad relationship, stress, opioids, anger…and the list goes on,” he said. “As a result, in women it’s very difficult to ascribe it to one thing. Hypoactive sexual desire disorder is the ‘low back pain’ of gynecologists. It’s very difficult to get to the root of the cause and even more difficult to treat.”
Women have a better “signal” for endocrine problems than men—their menstrual cycle—said Ling. “But we still don’t have a lot of data.” Typically, when menstrual cycles are off, endocrinologists check prolactin level and thyroid, he said.
In men, Straubing will usually ask if their low libido is accompanied by erectile dysfunction.” If it’s not, most of the time testosterone levels are normal, and then we have to look elsewhere.”
For men, if a patient says “’I have good libido but I can’t keep the erection up,’” the cause may be vascular, diabetes, or many other things—but the mostly likely cause is psychological, said Wartenberg.
Sadly, there is little literature or guidance for clinicians on how to help methadone or buprenorphine patients with sexual dysfunction.
Normally, a woman would tell her gynecologist, a man would go to a urologist, the end consultant might be endocrinology, and there would be work-ups and even sex therapy. Most people with opioid use disorders receive none of this.
Neither the American Urological Association nor the American College of Obstetricians and Gynecologists responded to Filter’s requests for comment about sexual dysfunction and opioids.
“The American attitude is that addicts are sick, they need help, but they’re also sinners so we shouldn’t help them too much.”
“There are people who are very good in endocrinology but don’t know much about addiction,” said Ling. “And people who are interested in addiction aren’t particularly good at addressing those problems.”
As Ling puts it, “the American attitude about addicts is that addicts are sick, they need help, but they’re also sinners so we shouldn’t help them too much.” But it’s important to have clinicians who help give patients “meaning and purpose” to their lives, beyond just being in recovery, he said. “We have to do something to help them achieve that.”
Patients need to have something to look forward to—everyone does—and one of those things is having children, said Ling. Many women were not able to get pregnant when they were actively using illicit opioids, but did after after entering treatment with methadone, he said.
Wartenberg agreed, noting that sexual function isn’t just a matter of pleasure—it’s procreation. As people leave active addiction and enter recovery, they may want to have a family, he said. This is another reason for a good workup if there is impotence or sexual dysfunction.
If it doesn’t bother you, it’s normal.
It is always to be recommended that MAT patients try standard solutions to sexual dysfunction issues before seeking complex testing and medications—and definitely before dropping out of treatment. There are recommendations for decreased libido in women, for example, which should apply whether they are in methadone/buprenorphine treatment or not, and issues like anorgasmia may be more easily resolved than people imagine.
There is also a pervasive sense in the medical world that if it doesn’t bother you, it’s normal. Wartenberg stressed that how people feel about their sex lives is important. “People may be married for 30 years and perfectly happy having sex two or three times a month,” he said. For others, this may be completely inadequate.
* for one example of Mendelson’s work, see Plasma testosterone levels in heroin addiction and during methadone maintenance. Mendelson JH, Mendelson JE, Patch VD. J Pharmacol Exp Ther. 1975 Jan;192(1):211-17.)
Photo modified from S A R A H ✗ S H A R P on Unsplash