|Year : 2017 | Volume
| Issue : 3 | Page : 256-261
Psychosexual disorders: A cross-sectional study among opioid-dependent individuals
MI Singh Sethi1, Himanshu Sareen2, Bhuwan Sharma3, Pradeep Atter1
1 Intern at PIMS Medical College Jalandar, Jalandhar, India
2 Department of Psychiatry at PIMS Medical College Jalandhar, Jalandhar, India
3 Department of Social and Preventive Medicine, PIMS Medical College, Jalandhar, India
|Date of Web Publication||14-Sep-2017|
M I Singh Sethi
MBBS Intern PIMS Medical College Garha Road Jalandhar, Punjab
Source of Support: None, Conflict of Interest: None
Context: Punjab is in hold of a drug abuse-related epidemic, and the prevalence of opioid misuse is increased in the last few decades. A large-scale epidemiological data on sexual disorders among opioid users are lacking in literature. Aim: The aim of this articles was to study the prevalence of sexual disorders in patients with opioid dependence. Settings and Design: A cross-sectional study was conducted at a de-addiction clinic of a tertiary care centre from Punjab, India. Methods and Materials: A total of 109 consecutive patients attending the de-addiction clinic and fulfilling the eligibility criteria were assessed for sexual dysfunction by a predesigned, pretested, semistructured questionnaire. International Index of Erectile Function (IIEF-15) was administered to all patients to explore various aspects of sexual dysfunction. Statistical Analysis: Collected data were analyzed by SPSS version 20 using appropriate statistical test. Results: Mean age of participants was 29.9 years, 67% were married and heroin was the opioid of choice for 81.7%. Impaired sexual desire (59.6%) was the commonest psychosexual problem, followed by decreased orgasmic function (57.8%), erectile dysfunction (56.4%), decreased overall satisfaction (52.2%), and decreased intercourse satisfaction (46.7%). Conclusions: The prevalence of all types of sexual dysfunction was found to be statistically significant with more than 1 year of opioid use. These findings can be used to motivate the patients to enter a rehabilitation program at an earlier stage of opioid dependence. Opioid-dependent individuals should be thoroughly investigated for sexual dysfunction and its treatment should be made an integral part of de-addiction and rehabilitation program.
Keywords: Erectile dysfunction, opioid dependence, orgasmic dysfunction, psychosexual disorders, sexual dysfunction
|How to cite this article:|
Singh Sethi M I, Sareen H, Sharma B, Atter P. Psychosexual disorders: A cross-sectional study among opioid-dependent individuals. Indian J Soc Psychiatry 2017;33:256-61
|How to cite this URL:|
Singh Sethi M I, Sareen H, Sharma B, Atter P. Psychosexual disorders: A cross-sectional study among opioid-dependent individuals. Indian J Soc Psychiatry [serial online] 2017 [cited 2020 Oct 30];33:256-61. Available from: https://www.indjsp.org/text.asp?2017/33/3/256/214602
| Introduction|| |
Punjab is in hold of a drug abuse-related epidemic. Consumption of opioids in Punjab is three times the national average. According to a study of rural Punjab, the prevalence was found to be 30.83%, which largely comprises youth.
Sexual dysfunctions, though being very common among people, in a large number of cases remain unreported. This is due to the conservative Indian society. Vulnerable people try to gain knowledge regarding sexual functioning from inappropriate and unreliable sources, which are easily misinterpreted, thereby exacerbating preexisting anxiety related to sexual functioning and performance.
There is a lot of literature on prevalence of opioid dependence and prevalence of sexual dysfunction individually, but we came across a very few studies on prevalence of sexual dysfunction in opioid-dependent individuals.,, Because literature lacks epidemiological data on sexual disorders among opium-dependent individuals, smaller studies should be integrated to obtain population estimates regarding the prevalence of sexual disorders in this group.
We aimed to add to the existing data, the prevalence of sexual problems in patients coming to de-addiction clinic in our tertiary care center. The paucity of research on sexual dysfunction among patients with opioid dependence in India and in other countries is a crucial concern. Assessment of sexual dysfunction in these patients is important because identification and management of sexual dysfunction can increase compliance to the treatment procedure. The present study is designed to examine the prevalence of sexual dysfunction and to investigate its correlation with drug use.
| Materials and Methods|| |
Setting and design
This was a cross-sectional, observational type of study done in the outpatient department (OPD) of the department of psychiatry of a tertiary care hospital in Jalandhar and conducted for the Indian Council of Medical Research (ICMR) Short Term Research Studentship (STS-2014) Program. Permission from ethics committee was obtained. The study duration was 2 months (June-August 2014).
Patients and procedure
All male patients diagnosed as having opioid dependence syndrome as per International Classification of Disease-10 diagnosis criteria, attending de-addiction OPD on specific days ( first time/follow-up), who were dependent on heroin, and/or were being prescribed buprenorphine, were considered for the study.
- Age between 18 and 55 years
- A stable sexual partner (ie, in an active sexual relationship with the same person for >1 year)
- Giving informed consent
- Chronic physical disorders
- Urologic disorders
- History of pelvic trauma or spinal injury
A total of 129 patients were eligible for the study as per inclusion/exclusion criteria; 20 of them left the questionnaire midway due to embarrassing nature of the questions. So, final analysis was done on 109 patients.
The interviews were conducted in quiet, comfortable settings, and each interview lasted about an hour. All participants were provided with written consent forms. Most of the patients were accompanied by their relatives who were supporting or sponsoring their de-addiction effort. To make the patient talk comfortably about his sexual life, these accompanying guests had to be asked to move out of the OPD chamber to facilitate proper diagnosis and treatment.
A structured interview was administered, which included questions on sociodemographics, drug use details, and comorbid substance use. In addition, the International Index of Erectile Function (IIEF-15) was administered. Since most of the patients were illiterate the questions were translated for them in their vernacular language. Standard English version of IIEF was compared with Hindi version in a pilot study on 30 patients. The results were found to be similar (P > 0.05), that is, there was no difference in the results of Hindi and English questionnaires.
The IIEF-15 is a reliable multidimensional scale test that explores various aspects of sexual dysfunction. The test is self-administered and has 15 questions that examine five aspects of sexual dysfunction, that is, erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Maximum mean scores for the IIEF-15 are as follows: erectile function (30), orgasmic function (10), sexual desire (10), intercourse satisfaction (15), and overall satisfaction (10). Higher scores indicate less dysfunction. A cutoff score of <25 was kept for assessing erectile function, <8 for orgasmic function, <7 for sexual desire, <10 for intercourse satisfaction, and <8 for overall satisfaction.
The collected data were entered in Microsoft Excel Sheet and were analyzed using IBM Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) software. Descriptive statistics were calculated for the study sample for the demographic and clinical variables. The differences in these characteristics were tested by the chi-square test. Two-tailed tests were used and a P value of 0.05 or less was regarded as significant.
| Observations and Results|| |
The 109 participants averaged 29.9 years of age; 67% (n = 73) participants were married, 53.2% (n = 58) were unskilled farmers, and 87.15% (n = 95) were current smokers. Heroin was the primary opioid of choice for 81.7% (n = 89). Mean duration of opioid use was 2.5 years. Alcohol was consumed at least once in the past 30 days by 45.8% of the participants. In addition, mean dose of heroin was 1.38 g/day. The most followed route of administration was inhaling fumes 58.7% (n = 64) as seen in [Figure 1]. Comorbid substance use was seen in 88.1% (n = 96). Demographic and social characteristics of the sample are presented in [Table 1].
|Figure 1: Pie chart depicting route of administration of drugs among participants.|
Click here to view
|Table 1: Demographic and Social Characteristics of Participants With Comorbid Substance Use Details|
Click here to view
Mean IIEF scoring among the participants are given in [Table 2], according to which a loss in sexual desire present in 59.63% (n = 65) was the most common sexual dysfunction.
Relationship between duration of use in years and sexual dysfunction is depicted in [Table 3]. It is seen that the prevalence of sexual dysfunction increases two-fold with increase in the duration of use. The association of duration of opioid use with all types of sexual dysfunction was found to be statistically significant.
|Table 3: Results of International Index of Erectile Function (IIEF) of Participants|
Click here to view
It was seen that orgasmic dysfunction among participants who relapsed from treatment was significantly more as compared to drug naïve patients [Table 4].
|Table 4: Relationship Between Sexual Dysfunction and Relapse From Treatment|
Click here to view
No significant difference was observed in sexual dysfunction between married and unmarried individuals [Table 5]. Similarly, no association was observed for duration of use in relapsed versus drug-naïve patients [Table 6]. However, significant corelation was observed between duration of opioid use and erectile function sexual desire and overall satisfaction [Table 7].
|Table 6: Association of Sexual Dysfunction with Duration of Use and Relapse|
Click here to view
| Discussion|| |
The present study was one of the few Indian studies on sexual dysfunction among opioid-dependent males. Prevalence of sexual dysfunction was observed as a common problem among opioid-dependent patients.
Various hypotheses have been postulated to explain the sexual dysfunctions in opioid–dependent males. Plasma testosterone levels have been shown to be consistently lower in opioid dependent individuals as compared with controls. Apart from the effect of heroin on reducing testosterone levels in males, other explanations offered to explain opioid-induced sexual dysfunctions, which include alfa-adrenergic blocking activity of opioids, which may directly influence the functioning of accessory sex organs, psychological factors such as sedation, euphoria, and a chaotic life style in opioid dependent individuals impairing sexual desire and performance, and these patients preferring drug-procuring behaviors to sexual encounter opportunities.
The mean age of presentation was 29.9 years, which represents typical age of opioid-dependent patients in treatment programs as shown by other studies.,
The urge to quit was observed more in married or soon to be married men. We had 67% participants who were married, and all other soon to be married participants maintained that their major motivating factor to quit use of opioids was to improve their matrimonial harmony and marriage prospects.
An important finding in the study is that prolonged use of opioids lead to increased prevalence of sexual dysfunction in the people with opioid dependence. It was observed that the prevalence of all parameters of sexual dysfunction doubled with more than 1 year of opioid use, which was found to be statistically significant and is a rather lesser known fact hitherto not reported in any other study that we come across on this subject. Sexual desire, erectile function, and overall sexual satisfaction were found to be the most disturbed aspects with increased duration of opioid use. It may be because of endocrine deficiency due to prolonged opioid use.
It was observed that 72.5% participants were already on buprenorphine maintenance treatment (buprenorphine maintenance therapy for de-addiction could have caused their sexual ailments, but according to the literature, it is least likely of all drugs used for de-addiction to cause sexual ailments) and only 5% among them had previously consulted the doctor about their associated sexual ailments. This is due to the stigma attached with sexual dysfunction and lack of confidence in the doctor patient confidentiality.
In the present study, the most commonly used comorbid substance was nicotine (87.5%) followed by alcohol (45.87%). These are in line with the studies of Singh et al. which found that opium and alcohol were the most commonly used comorbid substances (66.75% and 48.68%) respectively. Saluja et al. in their study found that 76.2% participants were opioid dependent and 54.2% were also nicotine dependent.,
The results of this study supported the findings of other studies that repeatedly emphasized the prevalence of sexual dysfunction in patients who were referred for treatment.,,
It was found that orgasmic dysfunction was the most pressing complaint among participants, that is, 57.8% (n = 63). This finding was consistent with the research of Palha and Esteves who studied sexual dysfunction among 101 heroin dependents in Portugal and found that 60% of men in their study had problems in achieving orgasms.
Of the few studies conducted on sexual dysfunction, Tatar et al in their study on 157 drug dependent subjects in Kermanshah, Iran have found the prevalence rates of Erectile to be 60.5% which is similar to our findings.
It was also founds that low sexual desire 59.6% (n = 65), decreased intercourse satisfaction 46.7% (n = 51), and decreased overall satisfaction 52.2% (n = 57) were moderately prevalent among participants. These findings were supported by various international studies, which reported a similar trend.,
Despite the opioid-related sexual difficulties and reduction in intercourse frequency found in this and other studies, patients maintained an active sexual life, which is similar to the observations by Palha et al. ED was seen in 54.1% (n = 59) participants, again these numbers are close to those found in other studies.,
An observation made in the study was that orgasmic dysfunction was the most common presenting complaint among the relapsed patients as compared to their dug-naïve counterparts, thus hampering their sexual life and lead to seeking treatment for de-addiction.
In the present study, majority of participants earlier stated that their sexuality had improved during the first 6 months of opioid use. This may support the continuance of drug use during the early months of dependence. Although sexual problems experienced by patients in association with heroin use were not sufficient to bring most of these patients into treatment but, it influenced the decision of 39% of the participants to stop using opioids. This and the fact pointed out by Venkat Chekuri in his study that some of the patients may be using heroin to alleviate sexual complaints. Making it particularly important for health professionals working with drug dependents to enhance their own sexual counseling expertise to increase their familiarity with sexuality and drug use issues and to improve their ability to discuss specific issues.
This study too had some limitations. Since our study was conducted as a part of ICMR Short-Term Studentship Program 2014, the study had to be completed within 2 months, so the sample size was kept moderate. The inability to compare the Hindi and English version of IIEF score at a larger scale to ensure its validity is also one of the limitations of our study. Also, we used historic controls from a research on a different population; therefore, some comparisons (such as mean scores and the frequency of sexual dysfunction) were not possible.
Having not estimated the plasma levels of pituitary or gonadal hormones in our patient sample, it is difficult to comment on the possible etiological mechanisms for sexual dysfunctions in these patients. However, we did exclude the most common etiological factors, that is, chronic physical disease and urological disorders.
Additional studies with a larger sample size are necessary. The conservative mindset of patient population limited the study sample size as is evident from the fact that many patients refused to participate and some of them left the performa incomplete. Many patients refused participation in the study because of traditional negative views on reporting sexual dysfunction or because of apparent discomfort in discussing about sex-related topics.
| Conclusions|| |
The sexual behaviors of opioid-dependent individuals in this sample show significant disturbances, a conclusion that conforms with previous studies. All components of patients sexual response show some impairment, and their overall sexual satisfaction was affected. In spite of the sexual deficits that we found in them, most of the patients maintained an active sexual life or wanted to have one.
In a breakthrough, we observed that matrimony was one of the most important factor motivating dependents to come for de-addiction since it hampered their prospects to get married or was leading to marital discords and divorce.
A cardinal finding in the study is that the prevalence of all types of sexual dysfunction doubled with more than 1 year of opioid use and certain important aspects of sexual life such as sexual desire, overall satisfaction, erectile function deteriorated significantly. This finding can be used to exhort the patients to enter a rehabilitation program at an earlier stage of opioid dependence. Some participants were initiated on low-dose opium to enhance sexual performance, which ultimately lead on to dependence. Disturbing sexual effects of long-term use of opioids may constitute another motivating factor in the process of cessation of drug use for some users.
The health professionals working in this field need to be aware of these problems so that they can consider sexual problems as a part of the whole healing and treatment process of dependence so as to prevent relapse. Psychosexual counseling is an important aspect of de-addiction and rehabilitation program. Any patient coming for opioid de-addiction should be thoroughly investigated for sexual dysfunction and treatment for same should be made an integral part of de-addiction and rehabilitation program.
| Acknowledgments|| |
Dr. Yatin Ghosh, Associate Professor Surgery, PIMS Medical College, Jalandhar, Punjab, for his guidance and support all through the project.
Financial support and sponsorship
The study was approved and sponsored by STS (Short-Term Studentship) ICMR-2014.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dube S, Chaudhary A, Mahajan R, Purohit R, Singh G, Soni R. et al.
Prevalence of opiate abuse in a rural area of Punjab. Internet J Health 2014;14:1.
Mittal AK, Gupta V, Kapoor A, Dang P. Sexual dysfunctions in rural population as indicators of psychiatric and addiction problems. Int J Scientific Study 2014;2:86-90.
Schensul SL, Mekki-Berrada A, Nastasi B, Saggurti N, Verma RK. Healing traditions and men's sexual health in Mumbai, India: The realities of practiced medicine in urban poor communities. Soc Sci Med 2006;11:2774-85.
Kazami H, Chorbani M, Bahreini-Borujeni M, Sepehri-Borujeni K. Comparison of psychosexual problems between substance dependence patients. J Shahrekord Univ Med Sci 2014;16:1-10.
Grover S, Mattoo SK, Pendharkar S, Kandappan V. Sexual dysfunction in patients with alcohol and opioid dependence. Indian J Psychol Med 2014;36:350-5.
Rosen R, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The International Index of Erectile Function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822-30.
Daniell Harry W. Hypogonadism in men consuming sustained-action oral opioids. The J Pain 2002;3:377-84.
Zhang Y, Wang P, Ma Z, Xu Z, Li Y. Sexual function of 612 male addicts treated by methadone. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2011;36:739-43.
Bliesener N, Albrecht S, Schwager A, Weckbecker K, Lichtermann D, Klingmüller D. Plasma testosterone and sexual function in men receiving buprenorphine maintenance for opioid dependence. J Clin Endocrinol Metab 2005;90:203-6.
Brown RT, Zueldorf M. Opioid substitution with methadone and buprenorphine sexual dysfunction as a side effect of therapy [review]. Heroin Addict Relat Clin Probl 2007;9:35-44.
Al-Gommer O, George S, Haque S, Moselhy H, Saravanappa T. Sexual dysfunctions in male opiate users: A comparative study of heroin, methadone, and buprenorphine. Addict Disord Their Treat 2007;6:137-43.
Singh B, Singh V, Vij A. Sociodemographic profile of substance abusers attending a deaddiction centre in Ghaziabad. Ind Medic 2006;6:1-3.
Saluja BS, Grover S, Tripathi AS, Mattoo SK, Basu D. Drug dependence in adolescents 1978- 2003, a clinical-based observation of North India. Indian J Pediatr 2007;74:33-6.
Vuong C, Van Uum SH, O'Dell LE, Lutfy K, Friedman TC. The effects of opioids and opioid analogs on animal and human endocrine systems. Endocr Rev 2010;31:98-132.
Ramdurg S, Ambekar A, Lal R. Sexual dysfunction among male patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. J Sex Med 2011;10:1743-61.
Palha AP, Esteves M. A study of the sexuality of opiate addicts. J Sex Marital Ther 2002;28:427-37.
Tatari F, Farniya V, Faghiyeh Nasri R, Najafi F. The effects of trazadone on erectile function in patients on methadone maintenance treatment; 2010. Available from: URL: www.kums.ac.ir/article-fa-78.html. [Last accessed on 2015 April 20].
Chekuri V, Gerber D, Brodie A, Krishnadas R. Premature ejaculation and other sexual dysfunctions in opiate dependent men receiving methadone substitution treatment. Addict Behav 2012;37:124-6.
Hallinan R, Byrne A, Agho K, McMahon C, Tynan P, Attia J. Erectile dysfunction in men receiving methadone and buprenorphine maintenance treatment. J Sex Med 2008;5:684-92.
Nik Jaafar NR, Mislan N, Abdul Aziz S, Baharudin A, Ibrahim N, Midin M. Risk factors of erectile dysfunction in patients receiving methadone maintenance therapy. J Sex Med 2013;10:2069-76.
Singer N, Phillips K, White D, Mulleady G. Evaluation of training course on sexual counseling in a drug working setting. AIDS Care 1994;6:221-35.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]