Sexual Dysfunction in Male Patients with Opioid Use Disorder

The use of substances such as tobacco, alcohol, cannabis, and opioids is widely prevalent across all strata and countries. Young individuals often use various opioids to enhance the sexual experience in terms of sexual desire, erection, time to ejaculate, and orgasm. However, regular long-term opioid use adversely affects all the phases of the sexual cycle, often leading to decreased libido, delayed ejaculation, and anorgasmia.[1] Earlier studies in patients with opioid use disorder (OUD) by Venkatesh et al.[2] and Aggarwal et al.[3] reported the prevalence of sexual dysfunction as 92% and 81.7%, respectively, as assessed by the International Index of Erectile function (IIEF).[4] A similar high prevalence of sexual dysfunction such as intercourse dissatisfaction in 95%, hypoactive sexual desire in 92.5%, and erectile dysfunction in 77.5% was reported in patients receiving buprenorphine-naloxone maintenance therapy.[5] A systematic review and meta-analysis by Zhao et al.[6] found a significant association of opioid use with erectile dysfunction (relative risk = 1.96). A recent systematic review of Indian studies in patients with OUDs reported sexual dysfunction ranging from 40% to 90%; the most common being lack of desire, followed by premature ejaculation and erectile dysfunction.[7] Although these figures suggest a high prevalence of sexual dysfunction in patients with OUD, many times patients do not share their sexual concerns voluntarily.[1] This might be due to lack of awareness, different priorities of clinicians at the time of consultation, general issues with sociocultural milieu, treatment setting, privacy, time-related issues, etc., Thus, sexual dysfunction with OUD emerges as an unrecognized, underacknowledged, and unaddressed area with a huge gap in assessment and management. With this background, after obtaining written informed consent, we assessed sexual function in males using IIEF in 50 OUD cases from our routine outpatient service (none of the patients was on opioid substitution therapy). Their mean age was 34 years with 10 years of education and a mean monthly income of 11,000 INR. Majority of them were married and employed, and nearly half of them were from extended family, urban locality, and with comorbid tobacco dependence (58%). The mean duration of regular opioid use was 7 years. The following substances were used by index subjects: opium/opium husk-15, dextropropoxyphene-16, heroine-6, injection pentazocine-4, injection buprenorphine-4, diphenoxylate-2, codeine containing cough syrup-2, and mixed preparations-1 subject. Three patients had comorbid chronic medical disorder – HIV in one patient and hepatitis C virus in two patients. In our sample, the most common sexual dysfunction was reduced libido (reported in 88% of patients), followed by intercourse dissatisfaction (64%), orgasmic dysfunction (42%), and erectile dysfunction (38%). Patients with comorbid tobacco dependence reported greater orgasmic dysfunction (55% vs. 23%, χ2 = 4.91, P = 0.027) and intercourse dissatisfaction (75% vs. 47%, χ2 = 4.21, P = 0.04). Rates of sexual dysfunction in our sample were high and similar to earlier reports.[1,4] Index preliminary data have limitations such as small sample, recruited from single hospital site, with lack of assessment of other social or relationship factors associated with sexual dysfunction. The abovementioned high figures of sexual dysfunction in patients with OUD raise several concerns for all of us as patients with substance use disorders have a greater treatment gap, i.e., the majority of them are not receiving appropriate medical care as shown in the National Mental Health Survey of India conducted in 2015–2016.[8] Majority of patients drop out in the early phase of treatment and do not follow the clinical advice. Lack of comprehensive assessment including sexual function is also contributing to poor treatment adherence and help-seeking behavior of patients with substance use disorders. Therefore, a detailed assessment of patients with OUD needs to include a thorough evaluation of sexual functions and concerns with making a patient comfortable and to see the potential reversibility, and other possible underlying physical and psychosocial factors. To improve their quality of life and treatment adherence, educating them about the ill effects of substances including sexual dysfunction, and addressing sexual concerns need to be an integral part of the comprehensive management and relapse prevention. We the clinicians need to be aware about that long-term use of opioids is associated with sexual dysfunction in different domains. There is a vital need to increase awareness about this concern, along with potential impact on treatment adherence, help-seeking behavior, and subsequent course. Since the majority of the patients do not report their sexual concern spontaneously, hence clinicians should routinely explore patients’ sexual functions and difficulties at all treatment encounters. This should guide for appropriate liaison and comprehensive management including pharmacological options and psychosocial therapies for addressing the huge treatment gap for substance use disorders and associated sexual dysfunction. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.