Well, I took an unexpected few days off.  Took off for my secret volcano lair for a weird bit of Zen.  This is an odd time of year as a couple of significant anniversaries fall this time of year, and I am easily triggered, so I spend a great deal of time doing reflective things (besides I needed a break from all the poker).

Don’t ever let anyone tell you that you should not take mental health days or vacations.  The time spent is well worth it, especially if you change your focus, do something different, don’t answer your phone or emails, and if possible tune out the outside world.  Pick a project, any project and then painstakingly work on it to the living end so to speak.  I built a very sturdy table with scrap lumber. I took time to sand it until it was smooth with no imperfections (this takes a long time done correctly), stained it and then have begun applying polyurethane.  It looks great.  The whole time I did this, I listened to books on tape and found an odd inner calm.  I needed it.  You need it too and should make time for this when the need arises.

I had a patient, younger man who was injured and has all kinds of a messed-up spine.  This is well known, and the patient is seen by pain service for opiate therapy. Thankfully I do not write the numerous controlled substances for him.  He is recently remarried, and his current wife would like to have kids and yet try as he may (he recounts his sex in great gory detail, not sure why) she cannot seem to get pregnant.  He finally decides to swing by primary care to talk about this problem that has caused marital discord (meaning his current wife wants kids and he seems to be at fault).

While I am pretty sure of the cause, we go through a full workup. His health history is relatively unremarkable except for his back injury. His sexual history is unremarkable.  He has an appropriate level of libido as indicated above.  Testosterone is a little suppressed but not significantly.  His labs are very normal except the tox screen which shows opiates (we knew this already, or hoped).  We finally hit the semen analysis and low and behold we found a low viable sperm count.  He has fathered a child so what has changed?

I told you kind folks in the beginning that I would throw out some unusual cases.  This one was straightforward, but it brings out a pretty good point.  Cleveland Clinic has a pretty good explanation Opiates include both prescription medications (for treating pain and addiction) and illegal street drugs. Long-term use of opiates can disrupt the signals that control testosterone production, which can cause low testosterone and decrease the quantity and quality of the sperm. The extent of the impact depends on the opiates being used, the dose, and how long the man is using the opioids.

While many times we take medication and glance at the side-effects to see what might be a problem. There are many standard side effects with a medication that we breeze through.  Diarrhea, constipation (which is very common with opiates), stomach upset, rashes, etc. Many times, folks don’t even take a look at the side effects and take medicine and just continue upon their day. The problem with this is when a side effect does occur it is often difficult to sort that out of everything else that is going on. Meaning simply, when you notice the side effect you should report it immediately to your provider so that they can discern whether this is a known side effect of the medication or there is something of a completely different concern. Waiting days or weeks with a strange side effect require some sleuth work to determine if it is because of the medication or if it is something you ate or something environmental.

That said opiates and other “narcotics” do have a suppressive effect on testosterone production as well as sperm count. “Narcotics” includes things like marijuana, testosterone injections, anabolic steroids, cocaine, and I’m sure you have a pretty good idea by now. This is a lot of the reason why we ask you about substances that you take as it helps us understand where side effect may be coming from or possible interaction between that medication and the medication we wish to prescribe.

So what can be done about our patient with chronic opioid use? Since we are prescribing this medication, we need to continue as always to look at the alternatives to having a patient on chronic opiates. This may not be possible, and in this patient’s case, he is run the gambit of alternative pain management. One possibility is given his lower testosterone we could provide supplementation; however, most insurance plans will not pay for testosterone unless the level is below the normal range. He did have a significant amount of dead sperm in his semen which drastically reduces the chance of fertilization. Sperm encounter and a lot of obstacles getting to the egg due to the pH of the vagina and other environmental factors. Because the suppression is caused by opiates (at least we assume at this point) (we did do additional testing on the sperm and found the living ones to be otherwise healthy) the only real way to solve the problem is to discontinue the opiates. At this point, it becomes a couple’s decision of whether he does just this and they deal with the level of pain, or they accept the fact that they may be childless while he’s on opiates. However, even if the opioids are discontinued, it may be a considerable amount of time before spermatogenesis is affected.

This is the kind of news that many patients don’t want to hear. After all, you go to your provider to get a solution to your problem when it may not be that simple. In this case for this patient lifestyle modifications are the only thing that we can do for him. I did encourage him to continue to try in the hopes that he might have a “lucky swimmer” but to realize that that makes the chance of pregnancy about the same.

Well, that’s a bummer for a first article back from the volcano. I thought this was a compelling case because a lot of people don’t understand the long-term effects of medication and the choices that have to be made in some situations. I guess the upside is at least it didn’t affect his libido negatively. Which ironically is the most common reason that a man will finally see his provider.

Be good to each other and be careful out there.