Opioids and Low Testosterone: Symptoms and How to Treat It

When you're on long-term opioids for chronic pain, the last thing you think about is your testosterone levels. But if you're feeling constantly tired, losing interest in sex, or noticing you're gaining weight despite eating the same, there might be a hidden cause: opioid-induced androgen deficiency (OPIAD). This isn't rare. It affects between 50% and 90% of men using opioids for more than three months. And most doctors don't screen for it.

How Opioids Kill Your Testosterone

Opioids don't just block pain signals-they mess with your brain's hormone system. Specifically, they hit the hypothalamic-pituitary-gonadal (HPG) axis, the control center for testosterone production. When you take opioids regularly, they reduce the pulses of gonadotropin-releasing hormone (GnRH) from your hypothalamus. That means your pituitary gland stops sending out enough luteinizing hormone (LH), which tells your testes to make testosterone. Without that signal, testosterone production drops-sometimes by half.

This isn't just a side effect. It's a direct biological response. Long-acting opioids like methadone and buprenorphine are especially bad because they stick around longer, continuously suppressing the system. Studies show men on methadone have testosterone levels averaging 245 ng/dL-well below the normal range of 300-1000 ng/dL. Those on buprenorphine do better, but still average only 387 ng/dL. The longer you're on opioids, the worse it gets. After one year, testosterone can be 50-75% lower than before you started.

What Low Testosterone Feels Like

If you're on opioids and feeling off, it's easy to blame the pain, the meds, or just getting older. But these symptoms are classic signs of low testosterone:

• Low sex drive-reported in 68-85% of affected men
• Erectile dysfunction-affects 60-75% of users
• Chronic fatigue-fatigue scores are 2.5 times higher than normal
• Depressed mood-symptoms are 40% more severe than in men with normal testosterone
• Loss of muscle and increased belly fat
• Brain fog and trouble concentrating
• Bones getting weaker-spine bone density drops 15-20%
• Anemia-hemoglobin levels average 12.3 g/dL, compared to 14-18 g/dL in healthy men

These symptoms don’t show up overnight. They creep in over 3-6 months. Many men assume they’re just "getting older" or "dealing with pain." But when you fix the testosterone, these problems often improve-fast.

How to Know If You Have It

You can’t guess your testosterone level. You have to test it. And timing matters. Testosterone peaks in the morning, so blood work should be done between 7-10 AM. One low reading isn’t enough. The Endocrine Society recommends two low measurements, taken at least a week apart, to confirm hypogonadism.

Doctors should also use the Androgen Deficiency in Aging Males (ADAM) questionnaire. If you answer "yes" to three or more of these questions:

• Do you have less interest in sex?
• Do you feel less energetic?
• Do you feel weaker?
• Have you noticed a decrease in your height?
• Do you feel less happy or more irritable?
• Do you have trouble getting or keeping an erection?
• Have you noticed a decrease in your muscle mass?

-you need lab testing. Many clinics skip this entirely. If your doctor doesn’t bring it up, ask. It’s simple, cheap, and life-changing.

Treatment: Testosterone Replacement Therapy (TRT)

If your levels are low and symptoms match, testosterone replacement therapy (TRT) is the standard treatment. It doesn’t cure the opioid use-it replaces what your body stopped making. And it works.

Studies show TRT improves:

• Sexual function-IIEF scores jump from 12.5 to 19.8 in six months
• Pain sensitivity-reduced by 30% in some patients
• Body composition-lean mass increases by 3.2 kg, fat mass drops by 2.1 kg
• Mortality-men on TRT have 49% lower risk of dying from any cause
• Heart health-38% lower risk of major cardiac events
• Bone strength-fracture risk drops by 35%
• Anemia-risk reduced by 26%

TRT comes in several forms:

• Injections-testosterone cypionate or enanthate, 100-200 mg every 1-2 weeks
• Gels-50-100 mg daily, applied to skin (shoulders, arms, abdomen)
• Patches-5-7.5 mg daily, worn on skin
• Buccal tablets-30 mg twice daily, stuck to the gum

Most men start with gels or injections. Gels are easier to manage daily; injections last longer but cause spikes and dips in levels. Your doctor will pick based on your lifestyle and preferences.

What to Watch Out For

TRT isn’t risk-free. The FDA requires black box warnings because of potential dangers:

• Polycythemia-red blood cell count rises in 15-20% of users, thickening blood and increasing clot risk
• Lower HDL (good cholesterol)-drops 10-15 mg/dL
• Acne-affects about 25% of gel users
• Increased stroke risk-relative risk goes up 1.3-1.8x
• Increased blood clot risk-1.4-2.0x higher chance of venous thromboembolism

TRT is strictly forbidden if you have or have had prostate or breast cancer. It can fuel cancer growth. Your doctor must check your PSA (prostate-specific antigen) every 6 months if you’re over 50 or have risk factors.

Also, once you start TRT, your body stops making its own testosterone. Stopping suddenly can crash your levels. You need to plan long-term with your doctor.

Non-Medical Ways to Help

Even if you’re on TRT, lifestyle changes can make a big difference:

• Keep your weight down-men with BMI under 25 have 20-30% higher testosterone
• Do resistance training-three weekly sessions boost testosterone by 15-25%
• Sleep 7-9 hours-poor sleep cuts levels by 20%
• Avoid smoking-smokers have 15-20% lower testosterone
• Limit alcohol-more than 14 drinks a week drops levels by 25%
• Prevent diabetes-diabetics have 25-35% lower testosterone

These aren’t magic fixes-but they support your treatment and reduce other health risks. And if you’re on opioid agonist therapy (like methadone or buprenorphine for addiction), these habits can be your best defense.

The Big Picture

Over 58 million people used opioids globally in 2022. Even if only half develop OPIAD, that’s tens of millions of men with untreated low testosterone. Most don’t know it’s fixable. They’re told it’s just aging, stress, or pain. But it’s not.

This is a treatable medical condition. And treating it doesn’t mean you’re taking more drugs-it means you’re fixing a side effect that’s stealing your energy, your sex life, your strength, and even your lifespan.

Doctors in the UK and US are starting to wake up. But if you’re on long-term opioids, don’t wait for them to bring it up. Ask for a testosterone test. If your levels are low and symptoms match, ask about TRT. The benefits are real. The risks are manageable-with proper monitoring.

You don’t have to live tired, weak, and sexless just because you’re managing pain. Your body still has the capacity to recover. You just need to ask for the right help.