**3. Effects of opioid maintenance treatment on sexual dysfunctions**

Consideration of side effects of opioid pharmacotherapies like cognitive impairment or sexual dysfunction is important. Especially sexual dysfunction, besides creating difficulty in intimate relationships, has the potential to lead to decreased compliance with therapy and to interfere with the known benefits of opioid maintenance treatment.

While the impact of sexual dysfunction upon treatment compliance has scarcely been studied in opioid maintenance treatment-receiving samples, sexual dysfunction has been shown to interfere with therapeutic compliance among subjects with depression, HIV, and hypertension (Brown & Zueldorff, 2007; Giacomuzzi 2008).

#### **3.1 Sexual dysfunction among men and woman**

Sexual dysfunction among men on opioid maintenance treatment appears to be related to lower-than-normal serum levels of testosterone. The association between opioids and low serum testosterone levels may occur through a variety of mechanisms (Brown & Zueldorff, 2007). Opioids may also act directly upon testicular tissue to suppress normal testosterone production.

Research regarding sexual dysfunction among females on opioid maintenance treatment is more scant. Sexual dysfunction among women on opioid maintenance treatment appears to be primarily related to interference with the normal cyclic production, possibly due to elevated production of prolactin mechanisms (Brown & Zueldorff, 2007).

This process interferes both with hormones necessary for the maintenance of a normal menstrual cycle (estrogen, progesterone) and for normal libido (androgens). Interference with these sex hormones is thought to lead to the common signs and symptoms of sexual dysfunction and hormonal dysregulation, and among women on opioid maintenance treatment, depressed libido and oligomenorrhea or amenorrhea mechanisms (Brown & Zueldorff, 2007).

Especially literature regarding sexual dysfunction in female subjects on opioid maintenance treatment is also very scant. Studies have indicated that 50% of women switching from heroin to methadone experienced an improvement in sexual function.

Methadone was shown to depress serum testosterone levels in female subjects in one study. This depression of testosterone in women was also associated with increases in serum prolactin (Brown & Zueldorff, 2007).

Nearly 50% of women experience menstrual irregularity while on methadone maintenance. The effect appears to be dose-related, and appears to decline over time, with the potential for resumption of normal menses without alteration of methadone dosing (Brown & Zueldorff, 2007).

While it is clear that impaired androgen production is closely and directly associated with sexual dysfunction in males, the relationship within females is more complicated and less clear (Brown & Zueldorff, 2007; Giacomuzzi, 2009).

The normal mid-cycle rise in serum androgens in women has not been strongly related to sex drive. Transdermal replacement of lower-than-normal serum androgens in female

age of 18 years, in respiratory depressions and in the presence of acute alcoholism (Giacomuzzi, 2008). Further research is needed to determine whether slow-release oral morphine treatment is more effective than methadone or buprenorphine in particular

Consideration of side effects of opioid pharmacotherapies like cognitive impairment or sexual dysfunction is important. Especially sexual dysfunction, besides creating difficulty in intimate relationships, has the potential to lead to decreased compliance with therapy and to

While the impact of sexual dysfunction upon treatment compliance has scarcely been studied in opioid maintenance treatment-receiving samples, sexual dysfunction has been shown to interfere with therapeutic compliance among subjects with depression, HIV, and

Sexual dysfunction among men on opioid maintenance treatment appears to be related to lower-than-normal serum levels of testosterone. The association between opioids and low serum testosterone levels may occur through a variety of mechanisms (Brown & Zueldorff, 2007). Opioids may also act directly upon testicular tissue to suppress normal testosterone

Research regarding sexual dysfunction among females on opioid maintenance treatment is more scant. Sexual dysfunction among women on opioid maintenance treatment appears to be primarily related to interference with the normal cyclic production, possibly due to

This process interferes both with hormones necessary for the maintenance of a normal menstrual cycle (estrogen, progesterone) and for normal libido (androgens). Interference with these sex hormones is thought to lead to the common signs and symptoms of sexual dysfunction and hormonal dysregulation, and among women on opioid maintenance treatment, depressed libido and oligomenorrhea or amenorrhea mechanisms (Brown &

Especially literature regarding sexual dysfunction in female subjects on opioid maintenance treatment is also very scant. Studies have indicated that 50% of women switching from

Methadone was shown to depress serum testosterone levels in female subjects in one study. This depression of testosterone in women was also associated with increases in serum

Nearly 50% of women experience menstrual irregularity while on methadone maintenance. The effect appears to be dose-related, and appears to decline over time, with the potential for resumption of normal menses without alteration of methadone dosing (Brown &

While it is clear that impaired androgen production is closely and directly associated with sexual dysfunction in males, the relationship within females is more complicated and less

The normal mid-cycle rise in serum androgens in women has not been strongly related to sex drive. Transdermal replacement of lower-than-normal serum androgens in female

**3. Effects of opioid maintenance treatment on sexual dysfunctions** 

interfere with the known benefits of opioid maintenance treatment.

elevated production of prolactin mechanisms (Brown & Zueldorff, 2007).

heroin to methadone experienced an improvement in sexual function.

hypertension (Brown & Zueldorff, 2007; Giacomuzzi 2008).

**3.1 Sexual dysfunction among men and woman** 

production.

Zueldorff, 2007).

Zueldorff, 2007).

prolactin (Brown & Zueldorff, 2007).

clear (Brown & Zueldorff, 2007; Giacomuzzi, 2009).

settings or in particular subgroups of patients.

subjects, however, has been shown to result in improvements in mood and libido. Additionally, when given testosterone supplementation, women with normal levels of serum testosterone have demonstrated an increased sexual response mechanism (Brown & Zueldorff, 2007).

Studies have demonstrated higher rates of sexual dysfunction in methadone-maintained groups than in the general population. Estimates of prevalence, however, vary significantly between 30-100%.

Additionally, the prevalence of specific types of sexual dysfunction (libido, erectile, and orgasm dysfunction) has poorly been examined in detail (Brown & Zueldorff, 2007; Giacomuzzi, 2009).

In one of the first studies to examine particular types of sexual dysfunction in a methadone maintained sample, Teusch et al. (1995) found men maintained on methadone to report reduced libido and orgasm dysfunction more frequently than controls.

Similar to earlier studies, however, the severity of dysfunction and methadone dose were unrelated.

Mendelson et al conducted a prospective study of the effect of acetylmethadol administration on serum testosterone levels in 13 men with opioid dependence which yielded significant results. A statistically and biologically significant decrease in serum testosterone was found 7-9 hours after acetylmethadol administration. Testosterone levels attained normal levels 48 hours after drug administration.

Mendelson also conducted some of the earliest work demonstrating a relationship between methadone dose and serum testosterone concentration. When the sample (n =38) was dichotomized into groups receiving lower dose (10-60 mg) and higher dose (80-150 mg) methadone, the men receiving higher daily doses of methadone were found to be more likely to have abnormally low serum testosterone.

As further evidence of an inverse relationship between methadone dose and serum testosterone levels in this study, reductions in methadone dose were associated with recovery of testosterone levels.

Mendelson et al found similar results in a sample of 10 men administered heroin in a controlled setting for 7 days and then detoxified using methadone at a starting dose of 35 mg. Again, abnormally low serum testosterone levels found during and after the period of heroin administration were found to recover to baseline after methadone detoxification.

#### **3.2 Erectile dysfunctions**

Erectile dysfunction (ED) more commonly has an organic or iatrogenic etiology. A variety of systemic illnesses are associated with ED. These include chronic liver disease, renal failure, arteriosclerotic cardiovascular disease, diabetes mellitus, chronic obstructive pulmonary disease, and malignancy. Spinal trauma and genitourinary surgery are of potential etiologic importance in ED, as well.

Though rarer, congenital and other anatomic genitourinary anomalies (e.g. Peyronie's Disease, phimosis, post-traumatic aneurysm) should also be considered (Brown & Zueldorff, 2007).

Medications commonly associated with ED include antihypertensives, psychotropic agents, and medications with anticholinergic effects.

Smoking, for example, is strongly associated with ED. The relative risk for ED increases by 1.31 for every 10 pack-years of smoking.

Maintenance Therapy and Sexual Behavior 29

The percentage of patients reporting ED is moderately higher than the percentages reporting ED in previous studies of methadone patients (Brown et al., 2004; Hanbury et al.,

The majority of previous studies of ED among drug users have used nonvalidated questionnaires, so caution should be exercised when comparing these earlier study findings

Nevertheless, all the surveys by Quaglio et al. (2008) indicate high rates of ED among methadone/buprenorphine patients. However, the age of the subjects in this study ranged from 18 to 47, with a mean age of 31 where 42% reported ED, while in a general population

In a study by Quaglio et al. (2008), the univariate analysis showed a significant association between treatment and ED, with buprenorphine patients reporting less ED than methadone

Quaglio et al. (2008) did not find any significant association between either methadone dose or buprenorphine dose and ED, or with reported duration of either methadone or

Thus, these data by Quaglio et al. (2008) do not suggest that changing from one medication to the other, or modest changes in the dosage level of either medication, would be effective

The association between depression and ED is well established in literature and the causal relationship is probably bidirectional, i.e. ED may be a consequence of depression and depression may follow ED. About 1/3 of depressed untreated patients report reduced

Comorbidity of mood disorders and opioid dependence has also been frequently observed. Seventeen per cent of our patients suffered from depression, while only 6% were on antidepression treatment, and there was no association between receiving or not receiving treatment and ED. The routine assessment of patients in opioid agonist treatment should include a careful evaluation of depression and, when clinically indicated, vigorous treatment. Three aspects of social/sexual relationships were associated with ED in the study of Quaglio

Living with a sexual partner (compared to living with parents) was associated with a lower likelihood of ED. Having ED may reduce one's ability to develop and maintain a sufficiently strong sexual relationship to lead to the partners living together. Lack of a steady partner

Quaglio et al. (2008) also found that living with a sexual partner who has a history of heroin

The association in the study of Quaglio et al. (2008) was very strong, with an adjusted odds ratio of 5.84, which reflects the relevant decrement of the median ED score from 27 in the patients with a non-heroin user partner to 21 in those with a heroin-user partner. Another study observed that when both members of a couple are strongly addicted to heroin, they

All the patients in this study, however, had entered drug abuse treatment in order to reduce their heroin use, and it was assumed that interest in sex would return during treatment.

Difficulties in the relationship between two people with histories of heroin abuse may lead to ED, and/or males with a pre-disposition to ED may selectively seek out females who use

There are (at least) two interesting mechanisms in this strong association.

study of more than 2000 Italian males, only 2% in the age group 18–39 reported ED.

patients, but this was not confirmed by the multivariate analysis.

1977; Teusch et al., 1995; Cushman, 1972).

buprenorphine treatment and ED.

libido, delayed ejaculation, anorgasm or ED.

use was associated with current ED in these patients.

to the present results.

in reducing ED.

et al. (2008).

may also contribute to ED.

almost always lose interest in sex.

heroin as sexual partners.

Though organic factors commonly cause ED, mental and emotional health issues may be significant contributors, as well. Depressive symptoms have been most strongly associated with ED, with 90% of men with severe depression reporting ED in one study. Association with anxiety disorders has also been reported (Brown & Zueldorff, 2007).

Several previous studies have demonstrated that erectile dysfunction (ED) is common among heroin users and people undergoing treatment for heroin addiction. Estimates of the prevalence of ED in methadone-maintained patients vary widely: 16% (8 cases/50 subjects), 23%.

Many patients with ED fail to mention ED to clinicians and counsellors and many clinicians and counsellors feel uncomfortable and embarrassed about dealing with sexual problems.

Nevertheless, the assessment of ED in these patients may be quite important. Identification and management of ED problems can improve adherence to treatment, the effectiveness of which, as is well-known, is associated with high doses and long treatment duration.

It is hard to establish the relative importance of possible causes of ED among opioid users.

Many drugs commonly prescribed for co-morbid conditions among drug users (antidepressants, antipsychotics, sedatives, anxiolytics, anticholinergics, etc.) can negatively affect sexual performance (Brown & Zueldorff, 2007).

Low testosterone levels may be a relevant cause of ED among opioid users, although no conclusive results have been reached. Two physiological mechanisms are thought to be responsible for the reported ED associated with opioid use.

The first is the inhibition of the production of gonadotropin-releasing hormone, decreasing the release of the luteinizing hormone (LH) and therefore reducing the production of testosterone.

Opioids can also cause hyperprolactinemia, which produces negative feedback on the release of LH and consequently on the secretion of testosterone.

However, existing studies involve few patients, and no correlation between duration of methadone treatment and testosterone blood levels has been found. Moreover, in the general population, endocrinal causes are responsible only in a small number of cases of ED (Brown & Zueldorff, 2007).

A study by Quaglio et al. (2008) included 201 males; subjects were 18–47 years old (mean = 31, S.D. = 6.0). Eighty-five patients (42%) were on methadone maintenance with a median dose of 40 mg/day (min 10, max 180 mg, 5% above 100 mg/day).

One hundred sixteen patients (58%) were on buprenorphine maintenance with a median dose of 6 mg/day (min 1, max 24, slightly more than 10% had dosages over 12 mg/day). As reported, subjects in methadone and buprenorphine treatment had similar sociodemographic characteristics (the hypothesis of distribution homogeneity was not rejected for almost all study variables).

Fifty-nine percent reported no depression, 24% reported mild depression, 12% moderate and 4% serious depression.

In all, 67 patients declared they did not have a steady sexual partner: consequently, the characteristics of steady sexual partners are based on data from 134 subjects. These partners were, on average, 3.4 years (S.D. = 6.3) younger than the index subjects, 68% of the partners were employed, 40% had no more than 8 years of education, and 14% of the partners had used heroin.

In the study of Quaglio et al. (2008), very substantial rates of ED were found: 19%of the patients reported severe ED and another 23%reported mild to moderate ED.

Though organic factors commonly cause ED, mental and emotional health issues may be significant contributors, as well. Depressive symptoms have been most strongly associated with ED, with 90% of men with severe depression reporting ED in one study. Association

Several previous studies have demonstrated that erectile dysfunction (ED) is common among heroin users and people undergoing treatment for heroin addiction. Estimates of the prevalence of ED in methadone-maintained patients vary widely: 16% (8 cases/50 subjects),

Many patients with ED fail to mention ED to clinicians and counsellors and many clinicians and counsellors feel uncomfortable and embarrassed about dealing with sexual problems. Nevertheless, the assessment of ED in these patients may be quite important. Identification and management of ED problems can improve adherence to treatment, the effectiveness of

Low testosterone levels may be a relevant cause of ED among opioid users, although no conclusive results have been reached. Two physiological mechanisms are thought to be

The first is the inhibition of the production of gonadotropin-releasing hormone, decreasing the release of the luteinizing hormone (LH) and therefore reducing the production of

Opioids can also cause hyperprolactinemia, which produces negative feedback on the

However, existing studies involve few patients, and no correlation between duration of methadone treatment and testosterone blood levels has been found. Moreover, in the general population, endocrinal causes are responsible only in a small number of cases of ED

A study by Quaglio et al. (2008) included 201 males; subjects were 18–47 years old (mean = 31, S.D. = 6.0). Eighty-five patients (42%) were on methadone maintenance with a median

One hundred sixteen patients (58%) were on buprenorphine maintenance with a median dose of 6 mg/day (min 1, max 24, slightly more than 10% had dosages over 12 mg/day). As reported, subjects in methadone and buprenorphine treatment had similar sociodemographic characteristics (the hypothesis of distribution homogeneity was not rejected

Fifty-nine percent reported no depression, 24% reported mild depression, 12% moderate

In all, 67 patients declared they did not have a steady sexual partner: consequently, the characteristics of steady sexual partners are based on data from 134 subjects. These partners were, on average, 3.4 years (S.D. = 6.3) younger than the index subjects, 68% of the partners were employed, 40% had no more than 8 years of education, and 14% of the partners had

In the study of Quaglio et al. (2008), very substantial rates of ED were found: 19%of the

patients reported severe ED and another 23%reported mild to moderate ED.

which, as is well-known, is associated with high doses and long treatment duration. It is hard to establish the relative importance of possible causes of ED among opioid users. Many drugs commonly prescribed for co-morbid conditions among drug users (antidepressants, antipsychotics, sedatives, anxiolytics, anticholinergics, etc.) can negatively

with anxiety disorders has also been reported (Brown & Zueldorff, 2007).

affect sexual performance (Brown & Zueldorff, 2007).

responsible for the reported ED associated with opioid use.

release of LH and consequently on the secretion of testosterone.

dose of 40 mg/day (min 10, max 180 mg, 5% above 100 mg/day).

23%.

testosterone.

(Brown & Zueldorff, 2007).

for almost all study variables).

and 4% serious depression.

used heroin.

The percentage of patients reporting ED is moderately higher than the percentages reporting ED in previous studies of methadone patients (Brown et al., 2004; Hanbury et al., 1977; Teusch et al., 1995; Cushman, 1972).

The majority of previous studies of ED among drug users have used nonvalidated questionnaires, so caution should be exercised when comparing these earlier study findings to the present results.

Nevertheless, all the surveys by Quaglio et al. (2008) indicate high rates of ED among methadone/buprenorphine patients. However, the age of the subjects in this study ranged from 18 to 47, with a mean age of 31 where 42% reported ED, while in a general population study of more than 2000 Italian males, only 2% in the age group 18–39 reported ED.

In a study by Quaglio et al. (2008), the univariate analysis showed a significant association between treatment and ED, with buprenorphine patients reporting less ED than methadone patients, but this was not confirmed by the multivariate analysis.

Quaglio et al. (2008) did not find any significant association between either methadone dose or buprenorphine dose and ED, or with reported duration of either methadone or buprenorphine treatment and ED.

Thus, these data by Quaglio et al. (2008) do not suggest that changing from one medication to the other, or modest changes in the dosage level of either medication, would be effective in reducing ED.

The association between depression and ED is well established in literature and the causal relationship is probably bidirectional, i.e. ED may be a consequence of depression and depression may follow ED. About 1/3 of depressed untreated patients report reduced libido, delayed ejaculation, anorgasm or ED.

Comorbidity of mood disorders and opioid dependence has also been frequently observed. Seventeen per cent of our patients suffered from depression, while only 6% were on antidepression treatment, and there was no association between receiving or not receiving treatment and ED. The routine assessment of patients in opioid agonist treatment should include a careful evaluation of depression and, when clinically indicated, vigorous treatment.

Three aspects of social/sexual relationships were associated with ED in the study of Quaglio et al. (2008).

Living with a sexual partner (compared to living with parents) was associated with a lower likelihood of ED. Having ED may reduce one's ability to develop and maintain a sufficiently strong sexual relationship to lead to the partners living together. Lack of a steady partner may also contribute to ED.

Quaglio et al. (2008) also found that living with a sexual partner who has a history of heroin use was associated with current ED in these patients.

The association in the study of Quaglio et al. (2008) was very strong, with an adjusted odds ratio of 5.84, which reflects the relevant decrement of the median ED score from 27 in the patients with a non-heroin user partner to 21 in those with a heroin-user partner. Another study observed that when both members of a couple are strongly addicted to heroin, they almost always lose interest in sex.

All the patients in this study, however, had entered drug abuse treatment in order to reduce their heroin use, and it was assumed that interest in sex would return during treatment. There are (at least) two interesting mechanisms in this strong association.

Difficulties in the relationship between two people with histories of heroin abuse may lead to ED, and/or males with a pre-disposition to ED may selectively seek out females who use heroin as sexual partners.

Maintenance Therapy and Sexual Behavior 31

that in fact mean total testosterone levels of those patients being treated with buprenorphine did not significantly differ from levels in the healthy control group sample (4.9 ± 1.3

Mean levels of prolactin were significantly higher in the methadone group (8.7 ± 8.3 ng/mL) than in the buprenorphine group (5.0 ± 2.0 ng/mL), though all groups were in the normal

In an examination of BDI scores collected in the same study, mean scores of the opioid

This lack of difference, as well as a lack of significant difference in age, medical status, length of addiction, concurrent medications, or frequency of illicit opioid use led the authors to conclude that it was most likely the treatment drug rather than other variables that contributed to the differences between therapy groups in hormone levels and reports of

The aim of our own examination was to determine which substitution agent seemed most suitable as a substitution drug for narcotic-addicted men and women in relation to both sexuality and relationship quality. In particular, the examination of female sexuality amongst women administered substitutes presented a considerable challenge, both in

As part of sex research by Büsing, Hoppe und Liedtke in 2000, an examination of 'Sexual satisfaction amongst women – survey development and results' was carried out. The subject of this study focussed on the conception, creation and execution of a survey to determine the sexual satisfaction of women. As basic data, the survey considered the frequency and duration of sexual activity, satisfaction with the frequency and duration of the activity and desired sexual behavior. In the first study, 112 heterosexual women between the ages of 20- 48 were interviewed. On the one hand, the results reveal the importance of the orgasm experience, which is emphasised through the high rate of desire concerning coital orgasm. On the other hand, half of the women who participated in the study did not state orgasm as their favourite part of sex. 37% of the women state that the emotional and physical closeness to their partner is more important than climaxing. In between-group comparison, sexual satisfaction above all correlates with the degree of autonomy within the relationship, satisfaction of communicative desires within the relationship and the need for affection.

This study shows that assessing sexual satisfaction amongst heterosexual women without addiction represents a significant hurdle within research. There are several reasons for this: women have different sexual requirements, and their sexual behavior cannot be compared to that of men. Given that this subject area deals largely with 'virgin territory', the focus now turns to general studies of sexual behavior in order to better address the questions

Our own study aimed therefore to evaluate patterns of sexual behavior and dysfunction prevalence within buprenorphine and methadone maintenance treatment (Giacomuzzi, 2009). Two questionnaires, in addition to socio-demographic data sets, adapted Relationship Quality Test System (Qualität der Partnerschaftsbeziehung) and EQ-5D (EuroQol), were randomly administered in person by a researcher. A response rate of 100% was obtained. 60 patients (30 buprenorphine; 30 methadone), mean age 30.2 years (IQR 22.5–43.3), were

range. There were no other significant differences found in the hormonal analysis.

therapy groups were not found to differ significantly from one another.

ng/mL).

sexual dysfunction.

(Büsing et al. 2000)

posed by this thesis.

enrolled in the study (Giacomuzzi, 2009).

psychological and medical terms.

In this study, Quaglio et al. (2008) found a high rate of ED among Italian methadone and buprenorphine patients—18% had severe ED and 24% had mild to moderate ED. Both psychological factors (depression) and social factors (living situation, lack of steady partner, whether partner had a history of heroin use) were associated with ED.

The cross-sectional design of the study precludes determining whether these associations represented mere correlations without causal relationships, whether the factors were causes of ED, or whether ED was the cause of the factors, or some combination of all of these possibilities.

It is also important to note that no data was available on ED among these patients prior to their entry into methadone or buprenorphine treatment, either during periods of intense heroin use or during periods of abstinence from heroin.

There was also no data on the current use of other drugs which might influence the sexual functioning of the patients.

The strengths of the study of Quaglio et al. (2008) include a large sample of patients, its multicentral nature and the identification of predictors for diagnosis.

In addition, their paper presents ED for a large cohort of patients in buprenorphine treatment.

Quaglio et al. (2008) conclude that ED is likely to be an important problem for many males in methadone and buprenorphine treatment, and good addiction treatment will need to address this issue. Androgen replacement and pharmacological treatment may be effective approaches for these patients.

Counselling of couples may also be useful. In our view, taking patients off methadone or buprenorphine, with the high risk of relapse to intensive heroin use, would not be suitable.

#### **Specific study findings on buprenorphine**

Studies comparing buprenorphine to the more commonly used methadone have found that rates of success in treatment are similar and that buprenorphine may result in fewer adverse effects. However, only a few studies to date have examined the prevalence of sexual dysfunction in particular among patients treated with buprenorphine and it is important that the influence of buprenorphine on ED be investigated further in the near future (Brown & Zueldorff, 2007; Giacomuzzi 2008; 2009).

One previous study found that buprenorphine has fewer negative effects on male sexual performance than methadone (Bliesener et al., 2005). This study, however, included only a small number of subjects, 17 patients in buprenorphine and 37 in methadone treatment.

In 2005, Bliesener and colleagues examined 17 male patients maintained on buprenorphine and 37 male patients maintained on methadone. Patients self-reported effects on libido and potency, and total and free testosterone, estradiol, and prolactin were assayed. Blood samples from 51 male volunteers were used as a control group for the hormone analyses. Twenty-three percent of patients in the buprenorphine group reported a decrease in libido, compared to 83% in the methadone group. Twelve percent reported reduced potency, compared to 72% in the methadone group.

Other forms of sexual dysfunction, such as orgasm dysfunction, were not examined in this study.

The Bliesener study also found that patients treated with buprenorphine had significantly higher mean levels of total (5.1 ± 1.2 ng/mL) and free (17.1 ± 4.8 pg/mL) testosterone than patients treated with methadone (2.8 ± 1.2 ng/mL and 7.8 ± 2.9 pg/mL, respectively), and

In this study, Quaglio et al. (2008) found a high rate of ED among Italian methadone and buprenorphine patients—18% had severe ED and 24% had mild to moderate ED. Both psychological factors (depression) and social factors (living situation, lack of steady partner,

The cross-sectional design of the study precludes determining whether these associations represented mere correlations without causal relationships, whether the factors were causes of ED, or whether ED was the cause of the factors, or some combination of all of these

It is also important to note that no data was available on ED among these patients prior to their entry into methadone or buprenorphine treatment, either during periods of intense

There was also no data on the current use of other drugs which might influence the sexual

The strengths of the study of Quaglio et al. (2008) include a large sample of patients, its

In addition, their paper presents ED for a large cohort of patients in buprenorphine

Quaglio et al. (2008) conclude that ED is likely to be an important problem for many males in methadone and buprenorphine treatment, and good addiction treatment will need to address this issue. Androgen replacement and pharmacological treatment may be effective

Counselling of couples may also be useful. In our view, taking patients off methadone or buprenorphine, with the high risk of relapse to intensive heroin use, would not be suitable.

Studies comparing buprenorphine to the more commonly used methadone have found that rates of success in treatment are similar and that buprenorphine may result in fewer adverse effects. However, only a few studies to date have examined the prevalence of sexual dysfunction in particular among patients treated with buprenorphine and it is important that the influence of buprenorphine on ED be investigated further in the near future (Brown

One previous study found that buprenorphine has fewer negative effects on male sexual performance than methadone (Bliesener et al., 2005). This study, however, included only a small number of subjects, 17 patients in buprenorphine and 37 in methadone treatment. In 2005, Bliesener and colleagues examined 17 male patients maintained on buprenorphine and 37 male patients maintained on methadone. Patients self-reported effects on libido and potency, and total and free testosterone, estradiol, and prolactin were assayed. Blood samples from 51 male volunteers were used as a control group for the hormone analyses. Twenty-three percent of patients in the buprenorphine group reported a decrease in libido, compared to 83% in the methadone group. Twelve percent reported reduced potency,

Other forms of sexual dysfunction, such as orgasm dysfunction, were not examined in this

The Bliesener study also found that patients treated with buprenorphine had significantly higher mean levels of total (5.1 ± 1.2 ng/mL) and free (17.1 ± 4.8 pg/mL) testosterone than patients treated with methadone (2.8 ± 1.2 ng/mL and 7.8 ± 2.9 pg/mL, respectively), and

whether partner had a history of heroin use) were associated with ED.

multicentral nature and the identification of predictors for diagnosis.

heroin use or during periods of abstinence from heroin.

possibilities.

treatment.

study.

functioning of the patients.

approaches for these patients.

**Specific study findings on buprenorphine** 

& Zueldorff, 2007; Giacomuzzi 2008; 2009).

compared to 72% in the methadone group.

that in fact mean total testosterone levels of those patients being treated with buprenorphine did not significantly differ from levels in the healthy control group sample (4.9 ± 1.3 ng/mL).

Mean levels of prolactin were significantly higher in the methadone group (8.7 ± 8.3 ng/mL) than in the buprenorphine group (5.0 ± 2.0 ng/mL), though all groups were in the normal range. There were no other significant differences found in the hormonal analysis.

In an examination of BDI scores collected in the same study, mean scores of the opioid therapy groups were not found to differ significantly from one another.

This lack of difference, as well as a lack of significant difference in age, medical status, length of addiction, concurrent medications, or frequency of illicit opioid use led the authors to conclude that it was most likely the treatment drug rather than other variables that contributed to the differences between therapy groups in hormone levels and reports of sexual dysfunction.

The aim of our own examination was to determine which substitution agent seemed most suitable as a substitution drug for narcotic-addicted men and women in relation to both sexuality and relationship quality. In particular, the examination of female sexuality amongst women administered substitutes presented a considerable challenge, both in psychological and medical terms.

As part of sex research by Büsing, Hoppe und Liedtke in 2000, an examination of 'Sexual satisfaction amongst women – survey development and results' was carried out. The subject of this study focussed on the conception, creation and execution of a survey to determine the sexual satisfaction of women. As basic data, the survey considered the frequency and duration of sexual activity, satisfaction with the frequency and duration of the activity and desired sexual behavior. In the first study, 112 heterosexual women between the ages of 20- 48 were interviewed. On the one hand, the results reveal the importance of the orgasm experience, which is emphasised through the high rate of desire concerning coital orgasm. On the other hand, half of the women who participated in the study did not state orgasm as their favourite part of sex. 37% of the women state that the emotional and physical closeness to their partner is more important than climaxing. In between-group comparison, sexual satisfaction above all correlates with the degree of autonomy within the relationship, satisfaction of communicative desires within the relationship and the need for affection. (Büsing et al. 2000)

This study shows that assessing sexual satisfaction amongst heterosexual women without addiction represents a significant hurdle within research. There are several reasons for this: women have different sexual requirements, and their sexual behavior cannot be compared to that of men. Given that this subject area deals largely with 'virgin territory', the focus now turns to general studies of sexual behavior in order to better address the questions posed by this thesis.

Our own study aimed therefore to evaluate patterns of sexual behavior and dysfunction prevalence within buprenorphine and methadone maintenance treatment (Giacomuzzi, 2009). Two questionnaires, in addition to socio-demographic data sets, adapted Relationship Quality Test System (Qualität der Partnerschaftsbeziehung) and EQ-5D (EuroQol), were randomly administered in person by a researcher. A response rate of 100% was obtained. 60 patients (30 buprenorphine; 30 methadone), mean age 30.2 years (IQR 22.5–43.3), were enrolled in the study (Giacomuzzi, 2009).

Maintenance Therapy and Sexual Behavior 33

A significant correlation between treatment mode and ejaculation praecox, erectile

Sexual life satisfaction was scored significantly higher by the buprenorphine-maintained

The question as to whether climax is experienced during sex was answered with 'mostly' by the median of participants in both substitution groups. The question of how often participants had sex with their partner was answered by participants from the methadone group with a median of 'once a week', and by participants in the buprenorphine group with a median of 'two to three times a week'. However, on average, both groups would like to have sex with their partner 'two to three times a week'. No significant group differences

In relation to questions concerning the degree of satisfaction with how participants or their partners reacted sexually, consistently high levels of satisfaction (80 to 90%) were recorded.

Furthermore, sexual partnership was scored significantly higher by women within the

Further significant differences between the substitution groups were noticed amongst women concerning the question of affection, which was dealt with in the 'Relationship Quality' survey. It was interesting to note that women using methadone as a substitute

N [%] N [%] p-valuea

your partner? yes 19 63.3 27 90.0 0.030\*

reactions? yes 24 80.0 26 86.7 0.731

reactions. yes 25 83.3 27 90.0 0.706

Methadone Buprenorphine

group (90%) compared with the methadone-maintained (63.3%) group (p = 0.030).

were identified in relation to these three questions concerning sexual behaviour.

Significant group differences were not identified in relation to these two questions.

rated affection higher than women administered the substitute substance Subutex.

Medication

Is your actual sexual life satisfaying with no 11 36.7 3 10.0

Do you feel comfortable with your sexual no 6 20.0 4 13.3

I feel comfortable with my partners sexual no 5 16.7 3 10.0

buprenorphine-maintained group (p = 0.020).

a

\* p < 0.050; \*\* p < 0.001

Table 2. Sexual satisfaction

dysfunction, vaginal cramps and sexual aversion could not be observed.

The study assumed that, in comparison to methadone, the effect of buprenorphine would reduce the additional use of substances. However, this hypothesis could not be established. Neither the substances specified by the various groups in relation to additional use, nor the frequency of consumption were statistically significant.

As a result of this, the study results of Fischer et al. (1999) concerning additional consumption were confirmed. Another assumption of our study was that individuals who take buprenorphine enjoy certain advantages concerning sexual behavior in comparison to those who are administered methadone.

Significant differences were noted between the substitution groups in relation to the question of whether their current sexual life was satisfying. In specific, it is significant that more participants from the buprenorphine group (90%) were satisfied with their current sexual life than participants in the methadone group (63.3%). AT p = 0.030, this difference was of considerable statistic significance.

Men on methadone maintenance treatment, but not buprenorphine maintenance treatment, had a high prevalence of sexual excitation disturbances and ability to orgasm in this study.

Significant differences between both groups could be observed regarding sexual excitation disturbances and ability to orgasm. 33.3% of the methadone-maintained group showed significantly higher sexual excitation disturbances (p = 0.006) and problems reaching orgasm (40%) (p = 0.015) compared with 3.3% respectively 10% within the buprenorphinemaintained group. These results were not affected by sex, since both groups exhibited the same sex distribution (30 men; 30 women).

The study by Bliesener et al. (2004) was confirmed by these results. It should, however, be added that only male participants were represented in the study carried out in 2004. Nevertheless, Bliesener et al. did identify significant results between the methadone and buprenorphine group in relation to libido and virility. In the study presented here, one might assume that these results are influenced by the confounding variable of 'sex', although in light of the identical sex distribution, this was not possible.


a \* p < 0.050; \*\* p < 0.001 (2 sided)

b range from -0.3841 to 0.9599 regarding german norm values (the higher the score, the better QOL)

c range from 1–3 (1 = better, 2 = equal, 3 = worse)

d range from 0–100 (0 = low QOL vs. 100 = high QOL)

Table 1. Quality of Life EQ-5D

The study assumed that, in comparison to methadone, the effect of buprenorphine would reduce the additional use of substances. However, this hypothesis could not be established. Neither the substances specified by the various groups in relation to additional use, nor the

As a result of this, the study results of Fischer et al. (1999) concerning additional consumption were confirmed. Another assumption of our study was that individuals who take buprenorphine enjoy certain advantages concerning sexual behavior in comparison to

Significant differences were noted between the substitution groups in relation to the question of whether their current sexual life was satisfying. In specific, it is significant that more participants from the buprenorphine group (90%) were satisfied with their current sexual life than participants in the methadone group (63.3%). AT p = 0.030, this difference

Men on methadone maintenance treatment, but not buprenorphine maintenance treatment, had a high prevalence of sexual excitation disturbances and ability to orgasm in this study. Significant differences between both groups could be observed regarding sexual excitation disturbances and ability to orgasm. 33.3% of the methadone-maintained group showed significantly higher sexual excitation disturbances (p = 0.006) and problems reaching orgasm (40%) (p = 0.015) compared with 3.3% respectively 10% within the buprenorphinemaintained group. These results were not affected by sex, since both groups exhibited the

The study by Bliesener et al. (2004) was confirmed by these results. It should, however, be added that only male participants were represented in the study carried out in 2004. Nevertheless, Bliesener et al. did identify significant results between the methadone and buprenorphine group in relation to libido and virility. In the study presented here, one might assume that these results are influenced by the confounding variable of 'sex',

 N Md IQR N Md IQR p-valuea EQ5D-Indexb 30 0.752 0.5–0.9 30 0.843 0.7–0.9 0.112

months agoc 30 2.0 1.0–2.0 30 2.0 1.0–2.0 0.725

Self rating regarding acutal health status<sup>d</sup> 30 62.5 43.8–75.0 30 72.5 60.0–80.0 0.032\*

range from -0.3841 to 0.9599 regarding german norm values (the higher the score, the better QOL)

although in light of the identical sex distribution, this was not possible.

Medication

Methadone Buprenorphine

frequency of consumption were statistically significant.

those who are administered methadone.

was of considerable statistic significance.

same sex distribution (30 men; 30 women).

Actual health status in comparison with 12

range from 1–3 (1 = better, 2 = equal, 3 = worse)

range from 0–100 (0 = low QOL vs. 100 = high QOL)

\* p < 0.050; \*\* p < 0.001 (2 sided)

Table 1. Quality of Life EQ-5D

a

b

c

d

A significant correlation between treatment mode and ejaculation praecox, erectile dysfunction, vaginal cramps and sexual aversion could not be observed.

Sexual life satisfaction was scored significantly higher by the buprenorphine-maintained group (90%) compared with the methadone-maintained (63.3%) group (p = 0.030).

The question as to whether climax is experienced during sex was answered with 'mostly' by the median of participants in both substitution groups. The question of how often participants had sex with their partner was answered by participants from the methadone group with a median of 'once a week', and by participants in the buprenorphine group with a median of 'two to three times a week'. However, on average, both groups would like to have sex with their partner 'two to three times a week'. No significant group differences were identified in relation to these three questions concerning sexual behaviour.

In relation to questions concerning the degree of satisfaction with how participants or their partners reacted sexually, consistently high levels of satisfaction (80 to 90%) were recorded. Significant group differences were not identified in relation to these two questions.

Furthermore, sexual partnership was scored significantly higher by women within the buprenorphine-maintained group (p = 0.020).

Further significant differences between the substitution groups were noticed amongst women concerning the question of affection, which was dealt with in the 'Relationship Quality' survey. It was interesting to note that women using methadone as a substitute rated affection higher than women administered the substitute substance Subutex.


a \* p < 0.050; \*\* p < 0.001

Table 2. Sexual satisfaction

Maintenance Therapy and Sexual Behavior 35

Methadone Buprenorphine

Do you masturbate regularly? No 76.7 60.0

Do you have arousal disorders? No 66.7 96.7

Do you have difficulty reaching orgasm? No 60.0 90.0

Do you suffer from premature ejaculation? No 86.7 100.0

Do you suffer from erectile dysfunction? No 93.3 100.0

Do you have vaginal cramps during sex? No 93.3 100.0

Do you have cramp-like pain during sex? No 93.3 100.0

Do you have sexual aversion? No 73.3 93.3

Table 4. Frequency comparison concerning questions on sexuality according to substitution

Substitution therapy has become the main form of post-acute treatment of opiate addicts. Despite this, the most suitable substitution substance remains a topic of controversial debate today. Alongside methadone, which is by far the most researched substance, buprenorphine

On the one hand, methadone substitution has become established as suitable treatment worldwide, given that it not only has a stabilising and health-maintaining effect, but also leads to an improvement in social rehabilitation (Giacomuzzi, 2009). A central argument put forward by those in favour of methadone against buprenorphine is the danger of intravenous consumption of this substance, through which the 'rush' is achieved, which is missing with oral administration. In contrast, methadone opposers contend that precisely the low euphoric effect of methadone causes problems with the acceptance of the substitute

On the other hand, in light of the diverse side effects of methadone, new substances like buprenorphine are becoming increasingly popular. Proponents affirm that when compared

Do you climax (orgasm) when

masturbating?

\* p < 0.050; \*\* p < 0.001

**4. Conclusions** 

is now increasingly used.

and leads to increased parallel consumption behavior.

substance

[%] [%] p-

Substitution substance

No 30.0 16.7

Yes 23.3 40.0 0.267

Yes 70.0 83.3 0.360

Yes 33.3 3.3 0.006\*

Yes 40.0 10.0 0.015\*

Yes 13.3 0.0 0.483

Yes 6.7 0.0 1.000

Yes 6.7 0.0 1.000

Yes 6.7 0.0 1.000

Yes 26.7 6.7 0.330

value

Significante differences between the groups were also identified in the area of quality of life. Patients receiving Subutex as a substitute agent gave considerably higher values concerning their self-rated physical health condition than methadone patients.

The self-rated physical health score was significantly higher in the buprenorphinemaintained group compared with the methadone group (p = 0.032). A significant correlation could be found between physical health and substitution mode (p =0.039).


\* p < 0.050; \*\* p < 0.001

Table 3. Frequency comparison of sexual satisfaction according to substitution substance

Concerning the self-rated physical health condition on a scale of 0 to 100, participants from the Subutex group achieved a median of 72.5, which was significantly higher than the median value of 62.5 recorded in the methadone group.

In relation to the EQ-5D index, both groups achieved a relatively high index value. The figure for the methadone group was 0.752, whilst the Subutex group even achieved 0.843. Nevertheless, this difference did not reveal any statistical significance. If we consider the answers to 'Current physical health compared with the last 12 months', the median of both groups stated 'Approximately the same'.

In a further step, the connection between the life quality index and the four scales of the relationship survey was calculated. Here, the highest scores on the affection scale amongst men, and the raw scores amongst the female participants, revealed significant results.

In order to verify the results obtained, a covariance test was carried out to explain whether the significant results could be irrefutably attributed to the substitution substance or the intervening covariates. The conclusion of this analysis was that the differences identified were indeed attributable to the different substances.

Significante differences between the groups were also identified in the area of quality of life. Patients receiving Subutex as a substitute agent gave considerably higher values concerning

The self-rated physical health score was significantly higher in the buprenorphinemaintained group compared with the methadone group (p = 0.032). A significant correlation

Substitution substance

No 36.7 10.0

No 20.0 13.3

No 16.7 10.0

Yes 63.3 90.0 0.030\*

Yes 80.0 86.7 0.731

Yes 83.3 90.0 0.706

their self-rated physical health condition than methadone patients.

Is your current sex life with your

I am satisfied with the way in which I

I am satisfied with the way in which

median value of 62.5 recorded in the methadone group.

were indeed attributable to the different substances.

groups stated 'Approximately the same'.

my partner reacts sexually.

partner satisfying?

\* p < 0.050; \*\* p < 0.001

react sexually.

could be found between physical health and substitution mode (p =0.039).

Methadone Buprenorphine

[%] [%] p-value

Table 3. Frequency comparison of sexual satisfaction according to substitution substance

Concerning the self-rated physical health condition on a scale of 0 to 100, participants from the Subutex group achieved a median of 72.5, which was significantly higher than the

In relation to the EQ-5D index, both groups achieved a relatively high index value. The figure for the methadone group was 0.752, whilst the Subutex group even achieved 0.843. Nevertheless, this difference did not reveal any statistical significance. If we consider the answers to 'Current physical health compared with the last 12 months', the median of both

In a further step, the connection between the life quality index and the four scales of the relationship survey was calculated. Here, the highest scores on the affection scale amongst men, and the raw scores amongst the female participants, revealed significant results. In order to verify the results obtained, a covariance test was carried out to explain whether the significant results could be irrefutably attributed to the substitution substance or the intervening covariates. The conclusion of this analysis was that the differences identified


\* p < 0.050; \*\* p < 0.001

Table 4. Frequency comparison concerning questions on sexuality according to substitution substance

#### **4. Conclusions**

Substitution therapy has become the main form of post-acute treatment of opiate addicts. Despite this, the most suitable substitution substance remains a topic of controversial debate today. Alongside methadone, which is by far the most researched substance, buprenorphine is now increasingly used.

On the one hand, methadone substitution has become established as suitable treatment worldwide, given that it not only has a stabilising and health-maintaining effect, but also leads to an improvement in social rehabilitation (Giacomuzzi, 2009). A central argument put forward by those in favour of methadone against buprenorphine is the danger of intravenous consumption of this substance, through which the 'rush' is achieved, which is missing with oral administration. In contrast, methadone opposers contend that precisely the low euphoric effect of methadone causes problems with the acceptance of the substitute and leads to increased parallel consumption behavior.

On the other hand, in light of the diverse side effects of methadone, new substances like buprenorphine are becoming increasingly popular. Proponents affirm that when compared

Maintenance Therapy and Sexual Behavior 37

Bliesener, N., Albrecht, S., Schwager, A., Weckbecker, K., Lichtermann, D. and Klingmuller,

Büsing, S., Hoppe, C. & Liedtke, R. (2001). Sexuelle Zufriedenheit von Frauen – Entwicklung

Fischer, G., Gombas, W., Eder, H., Jagsch, R., Peternell, A., Stühlinger, G., Pezawas, L.,

for the treatment of opioid dependence. *Addiction*, Vol. 94(9), pp. 1337–1347. Giacomuzzi S.M., Garber, K. & Riemer, Y. (2011). Patient-specific perceptions and effects on

Giacomuzzi, S.M., Khreis, A, Riemer, A., Garber, K. & Ertl, M. (2009). Buprenorphine and

Giacomuzzi, S. (2008). A Contribution to the Understanding of the Addiction Phenomenon, IUP, Innsbruck University Press, ISBN 13: 978-3-902571-28-1, Innsbruck, Austria Giacomuzzi, S.M., Ertl, M., Riemer, Y., Kemmler, G., Rössler, H., Hinterhuber, H. & Kurz,

Giacomuzzi, S.M.; Riemer, Y.; Ertl, M.; Kemmler, G.; Rössler, H.; Hinterhuber, H. & Kurz,

Haebere, E.J. (1981, 1983). The Sex Atlas. New popular Reference Edition Revised and

Mattick R.P., Kimber, J., Breen, C. & Davoli, M. (2004). Buprenorphine maintenance versus

Mendelson, J. H., Inturrisi, C. E., Renault, P. & Senay, E. C. (1976): Effects of acetylmethadol

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Buprenorphine: Sexual Dysfunction as a Side Effect of Therapy. Heroin Addiction

und Ergebnisse eines Fragebogens. PPmP Psychother Psychosom med Psychol

Aschauer, H.N. & Kasper, S. (1999). Buprenorphin versus methadone maintenance

Sublingual Suboxone® maintenance treatment and their impact regarding the acceptance as treatment choice – a semi-qualitative analysis. *Gobal Addiction* 

Methadone Maintenance Treatment – Sexual Behaviour and Dysfunction

M. (2005). Sublingual buprenorphine and methadone maintenance treatment - a 3 year follow up of quality of life assessment. *The Scientific World Journal*, Vol.5, pp.

M. (2003). Buprenorphine versus methadone maintenance treatment in an ambulant setting - a health-related quality of life assessment. *Addiction*, Vol.98, pp.

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and protracted astinence. A study of Hong Kong addicts. *Clin. Pharmacol. Ther*. 17,

heroin and methadone on plasma cortisol and testosterone. *J. Pharmacol. Exp. Ther*.

**5. References** 

directly with methadone, buprenorphine presents more advantages. A wide range of studies have shown that even in high doses, buprenorphine causes fewer side effects than methadone, presents a lower dependence potential, increases drive and has anti-depressive properties.

The standard substitution therapy continues to be methadone. All new drugs or substances used must be able to compete with the success or failure experiences of traditional methadone substitution (Giacomuzzi, 2009).

The clarification of the individual needs of different groups of drug addicts seems particularly important for the future (Giacomuzzi, 2009). Therapy studies have proven that psychosocial measures, coupled with substitution, achieve significantly better effects than psychopharmacotherapy alone. The current offer of drug clinics, private associations, etc. is not sufficient to meet patients' needs.

Opioid maintenance treatment, primarily methadone, appears to be associated with alteration of serum levels of hormones related to normal sexual function.

In males, opioids may act via: (1) interference with the normal production of hypothalamic and pituitary regulatory hormones, (2) elevation of serum prolactin, (3) direct action on the testes to suppress testosterone production (Brown & Zueldorff, 2007).

While elimination of other common medical and psychiatric etiologies for sexual dysfunction is warranted, replacement of abnormally low serum testosterone may effectively treat libido or erectile dysfunction, and potentially delayed orgasm or anorgasmia. Replacement of abnormally low androgens in women on opioid maintenance treatment may also improve libido as well as mood.

Abnormalities in the menstrual cycle are thought to be transient and may not require alteration of opioid maintenance treatment dosing. Patients with refractory sexual dysfunction and a stable course in terms of their opioid use disorder may correspond to reduction in the dose of their opioid maintenance treatment agent, with methadone likely being of greater significance here than buprenorphine (Brown & Zueldorff, 2007).

Sexual behavior is not only of basic biological importance, but also of central social importance. Not only does it perpetuate the human species, but it is the central behavior around which families are formed and defined, a vital aspect of the psychological well-being of individuals, and a component of a variety of social problems.

There has been very little research on ED among buprenorphine patients. Men on methadone maintenance treatment, but not buprenorphine maintenance treatment, had a high prevalence of sexual excitation disturbances and ability to orgasm. Orgasm dysfunction seems to be a special case and may respond to methadone dose (Giacomuzzi, 2009).

In light of the paucity of studies in the area of sexual dysfunction as an adverse effect of buprenorphine, more research is needed, utilizing larger patient populations and examining more thoroughly specific types of dysfunction in both male and female populations.

Future studies of sexual dysfunction in opioid-treated persons should examine the potential benefits of dose reduction, androgen replacement, and choice of opioid (Giacomuzzi, 2009).

Practitioners should screen for sexual dysfunction in men receiving opioid replacement treatment. Orgasm dysfunction seems to be a special case and may correspond more to methadone dose. Future studies of sexual dysfunction in opioidtreated persons should examine the potential benefits of dose reduction, androgen replacement, and choice of opioid (Giacomuzzi, 2009).

Therapy and patient care should be structured in a more flexible manner.

#### **5. References**

36 Sexual Dysfunctions – Special Issue

directly with methadone, buprenorphine presents more advantages. A wide range of studies have shown that even in high doses, buprenorphine causes fewer side effects than methadone, presents a lower dependence potential, increases drive and has anti-depressive properties. The standard substitution therapy continues to be methadone. All new drugs or substances used must be able to compete with the success or failure experiences of traditional

The clarification of the individual needs of different groups of drug addicts seems particularly important for the future (Giacomuzzi, 2009). Therapy studies have proven that psychosocial measures, coupled with substitution, achieve significantly better effects than psychopharmacotherapy alone. The current offer of drug clinics, private associations, etc. is

Opioid maintenance treatment, primarily methadone, appears to be associated with

In males, opioids may act via: (1) interference with the normal production of hypothalamic and pituitary regulatory hormones, (2) elevation of serum prolactin, (3) direct action on the

While elimination of other common medical and psychiatric etiologies for sexual dysfunction is warranted, replacement of abnormally low serum testosterone may effectively treat libido or erectile dysfunction, and potentially delayed orgasm or anorgasmia. Replacement of abnormally low androgens in women on opioid maintenance

Abnormalities in the menstrual cycle are thought to be transient and may not require alteration of opioid maintenance treatment dosing. Patients with refractory sexual dysfunction and a stable course in terms of their opioid use disorder may correspond to reduction in the dose of their opioid maintenance treatment agent, with methadone likely

Sexual behavior is not only of basic biological importance, but also of central social importance. Not only does it perpetuate the human species, but it is the central behavior around which families are formed and defined, a vital aspect of the psychological well-being

There has been very little research on ED among buprenorphine patients. Men on methadone maintenance treatment, but not buprenorphine maintenance treatment, had a high prevalence of sexual excitation disturbances and ability to orgasm. Orgasm dysfunction seems to be a

In light of the paucity of studies in the area of sexual dysfunction as an adverse effect of buprenorphine, more research is needed, utilizing larger patient populations and examining

Future studies of sexual dysfunction in opioid-treated persons should examine the potential benefits of dose reduction, androgen replacement, and choice of opioid (Giacomuzzi, 2009). Practitioners should screen for sexual dysfunction in men receiving opioid replacement treatment. Orgasm dysfunction seems to be a special case and may correspond more to methadone dose. Future studies of sexual dysfunction in opioidtreated persons should examine the potential benefits of dose reduction, androgen replacement, and choice of

more thoroughly specific types of dysfunction in both male and female populations.

being of greater significance here than buprenorphine (Brown & Zueldorff, 2007).

of individuals, and a component of a variety of social problems.

special case and may respond to methadone dose (Giacomuzzi, 2009).

Therapy and patient care should be structured in a more flexible manner.

alteration of serum levels of hormones related to normal sexual function.

testes to suppress testosterone production (Brown & Zueldorff, 2007).

treatment may also improve libido as well as mood.

methadone substitution (Giacomuzzi, 2009).

not sufficient to meet patients' needs.

opioid (Giacomuzzi, 2009).


**3** 

Atara Ntekim

*Nigeria* 

 **Sexual Dysfunction** 

**Among Cancer Survivors**

*Department of Radiation Oncology, College of Medicine, University of Ibadan* 

"Sexual and reproductive health and wellbeing are essential if people are to have responsible, safe and satisfying sexual lives. Sexual health requires a positive approach to human sexuality and an understanding of the complex factors that shape human sexual behaviour. These factors affect whether the expression of sexuality leads to sexual health and well- being or to sexual behaviour that put people at risk or make them vulnerable to sexual and reproductive ill- health. Health program managers, policy – makers and care providers need to understand and promote the potentially positive role sexuality can play in peoples' lives and to build health services that can promote sexually health societies." –

There is increasing number of cancer survivors worldwide. A lot of them experience sexual dysfunction for a long time which can last beyond ten years post treatment. Sexual dysfunction can occur as a result of any aspect of cancer and cancer treatment. Sexual functioning and/or satisfaction have been found to be of concern to many cancer survivors. Sexual function can be affected by physical or emotional trauma especially if the genitals are affected and can adversely affect the quality of life of the patients. Sexual dysfunction includes erectile dysfunction in males and disruption in the sexual response cycle (sexual desire, excitement, arousal, orgasm and resolution) and dyspareunia in women. There are differences in the pattern of sexual dysfunction between males and females as females may be able to cope better than males emotionally. Bonini-Colmano et al. (2007) noted that malignant diseases have a strong influence in quality of life, sexuality being one of the most affected variables. In their study to determine the prevalence of sexual dysfunction in a cohort of patients with cancer and its relationship with the following: pain, fatigue, nausea, vomiting, mechanisms of adaptation to stress, anxiety and depression, questionnaires were used which included treatment, adverse events, Zimong and Snaith depression and anxiety scale, sexual dysfunction questionnaire, coping strategies of Tobin David, Hopwood body image scale and the analogical visual test for pain evaluation. Sixty four patients were evaluated. Seventy two percent were women and median age was 50 years. Libido was absent in 50%; this was associated with gender (better in men; p=0,05) and the presence of pain (p=0,05) and fatigue (p=0,05) but not with age. All patients who had intact libido also had arousal and orgasms; this was more prevalent in men than in women and in subjects younger than 60 years. Arousal was absent in 47% of cases. Forty four percent of men had erectile dysfunction; this was present in all patients older than 60 years. Frequency of

**1. Introduction** 

(WHO 2006)

