When you’re on long-term opioids for chronic pain, you might blame fatigue, low sex drive, or mood swings on stress, aging, or the pain itself. But there’s a hidden side effect many doctors still miss: opioid-induced low testosterone. It’s not rare. In fact, up to 90% of men using opioids for more than three months develop it. And it’s not just about libido-it affects your energy, muscles, bones, heart, and even how long you live.
How Opioids Kill Your Testosterone
Opioids don’t just block pain signals. They also mess with your brain’s hormonal control center-the hypothalamus and pituitary gland. These areas normally send signals to your testicles to make testosterone. But when opioids bind to receptors in the brain, they shut down the release of gonadotropin-releasing hormone (GnRH). No GnRH means no luteinizing hormone (LH). No LH means your testicles stop making testosterone.
This isn’t a side effect you feel right away. It creeps in over weeks or months. By the time you notice low energy or trouble getting an erection, your testosterone might already be 50% below normal. Long-acting opioids like methadone and buprenorphine are especially bad at this. One study found men on methadone had testosterone levels averaging 245 ng/dL-well below the normal range of 300-1000 ng/dL. Those on buprenorphine did better, but still averaged only 387 ng/dL.
What Low Testosterone Feels Like on Opioids
If you’re on opioids and feel like you’re running on empty, here’s what might be going on:
- Low sex drive-reported in 68-85% of men on long-term opioids
- Erectile dysfunction-affects 60-75% of cases
- Chronic fatigue-fatigue scores are 2.5 times higher than normal
- Mood changes-depression symptoms increase by 40%, irritability spikes
- Muscle loss and fat gain-lean mass drops, belly fat increases
- Bone weakness-spinal bone density can drop 15-20%
- Anemia-hemoglobin levels average 12.3 g/dL (normal is 14-18)
- Brain fog-trouble concentrating, memory lapses
These symptoms often get mislabeled as "just part of chronic pain" or "depression from illness." But they’re not. They’re direct results of low testosterone. And they’re reversible-if you catch them early.
Testing for Opioid-Induced Low Testosterone
There’s no mystery here. If you’ve been on opioids for more than 90 days and have any of the symptoms above, get tested. But don’t just ask for a simple blood test. You need two things:
- Total testosterone-measured in the morning, between 7 and 10 AM, when levels are highest
- Free testosterone-this shows how much active hormone is actually available to your body
One low reading isn’t enough. The Endocrine Society says you need two low results on separate days to confirm hypogonadism. Many doctors skip this step. Don’t let them. Bring up the Androgen Deficiency in Aging Males (ADAM) questionnaire. It’s a quick 10-question screen. If you answer "yes" to three or more-like "Do you have a decreased libido?" or "Do you feel less energetic?"-you need lab work.
Treatment: Testosterone Replacement Therapy (TRT)
TRT works. Not just to boost your sex drive-but to lower your risk of heart attacks, fractures, anemia, and even death. A 2019 JAMA study followed over 1,500 men on long-term opioids. Those who got testosterone had:
- 49% lower risk of dying from any cause
- 42% lower risk of heart attacks or strokes
- 35% fewer hip or femur fractures
- 26% lower chance of developing anemia
And it’s not just numbers. Men on TRT reported better sleep, more energy, improved mood, and stronger muscles. One study showed a 3.2 kg increase in lean mass and a 2.1 kg drop in fat over six months.
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 because they’re easier to manage. Your doctor will aim to keep your testosterone between 350-750 ng/dL. Too high can cause problems. Too low won’t help.
What You Need to Know About TRT Risks
TRT isn’t risk-free. The FDA requires black box warnings for testosterone because of potential dangers:
- Polycythemia-blood thickens. Happens in 15-20% of users. Requires regular blood draws.
- Lower HDL (good cholesterol)-drops by 10-15 mg/dL. Increases heart disease risk if not managed.
- Acne-affects 25% of gel users.
- Increased risk of blood clots and stroke-relative risk up by 1.4-2.0x.
- Prostate and breast cancer-TRT is absolutely not safe if you have or are at risk for these cancers.
That’s why monitoring matters. If you start TRT, you’ll need:
- PSA and digital rectal exam every 6 months (especially if over 50)
- Testosterone and hematocrit levels checked at 3-6 months, then yearly
- Regular check-ins with an endocrinologist or pain specialist familiar with OPIAD
Some clinics refuse to prescribe TRT because of these risks. But the bigger risk? Leaving it untreated.
Can You Fix It Without Pills?
Yes-but only partially. Lifestyle changes won’t fully restore testosterone if opioids are still suppressing your brain. But they help. A lot.
- Weight loss-BMI under 25 can boost testosterone by 20-30%
- Resistance training-3 strength sessions a week can raise testosterone 15-25%
- Sleep-7-9 hours nightly = 20% higher levels
- Quit smoking-smokers have 15-20% lower testosterone
- Limit alcohol-more than 14 drinks a week cuts levels by 25%
- Avoid diabetes-diabetics have 25-35% lower testosterone
These aren’t magic fixes. But they make TRT safer, more effective, and reduce side effects. If you’re trying to cut opioids down or get off them, these steps are essential.
Why So Many Doctors Miss This
The VA Whole Health Library warns that "low testosterone is being promoted by testosterone makers." That’s true-some companies push it too hard. But that doesn’t mean it’s not real. The problem? Most pain doctors aren’t trained in endocrinology. They see you for back pain, not low libido. They don’t test. They don’t ask.
That’s changing. The Pain Physician journal has been saying since 2012: "Screening for hypogonadism should be considered whenever long-term opioid prescribing is undertaken." But it’s still not standard. You have to ask.
And if your doctor says "it’s just aging" or "take a pill for ED"-push back. Say: "I’ve been on opioids for over a year. I’d like to check my testosterone levels. Is that something we can do?"
What Happens If You Don’t Treat It?
Untreated opioid-induced low testosterone doesn’t just make you feel crummy. It makes you more vulnerable.
You’re more likely to:
- Break a bone from minor falls
- Develop heart disease
- Get anemia
- Need hospitalization
- Die earlier
And the longer you stay on opioids without fixing your hormones, the harder it becomes to recover-even after you stop the drugs. Your body forgets how to make testosterone on its own.
This isn’t about being weak. It’s about biology. Opioids are powerful. And they don’t just numb pain-they numb your body’s natural systems. The good news? You can turn it back on.
Final Thoughts: Take Control
If you’re on long-term opioids and feel off-not just in pain, but in your whole body-you’re not imagining it. Low testosterone is real, common, and treatable. It’s not a luxury. It’s a medical necessity.
Don’t wait for your doctor to bring it up. Ask for a blood test. Ask about TRT. Ask about lifestyle changes. And if you’re told it’s "just part of aging" or "not a big deal"-get a second opinion.
Your energy, your sex life, your bones, your heart-they all depend on testosterone. And opioids are stealing it. You don’t have to accept that.
Can opioids cause low testosterone even if I’m not addicted?
Yes. Opioid-induced low testosterone happens whether you’re using opioids for chronic pain, after surgery, or for cancer. It’s a biological side effect of the drug, not a sign of addiction. Anyone taking opioids daily for more than 90 days is at risk.
How long does it take for testosterone to recover after stopping opioids?
It varies. Some men see improvement within 3-6 months after stopping opioids. Others take a year or more. If testosterone levels stay low after quitting, you likely have permanent damage to the HPG axis and may need long-term testosterone replacement. Testing after discontinuation is essential.
Is testosterone therapy safe for older men on opioids?
For men over 50, TRT can be safe if properly monitored. The key is regular PSA checks, blood tests for hematocrit, and avoiding TRT if you have prostate cancer or a strong family history. Studies show older men on TRT have fewer fractures and heart events. The risks are real, but so are the benefits-especially when baseline testosterone is very low.
Can women on opioids also have low testosterone?
Yes. While women produce less testosterone than men, opioids still suppress it. Symptoms include low libido, fatigue, and muscle loss. Some doctors use DHEA supplementation in women, but evidence is limited. Testing total and free testosterone is still recommended for women on long-term opioids with symptoms.
Do I need to stop opioids to fix my testosterone?
Not necessarily. Many men stay on opioids for pain control and still get TRT. The goal is to treat both conditions at once. Stopping opioids can help testosterone recover, but if pain returns, TRT can still improve your quality of life while you’re on them. Work with a specialist to balance both.
What’s the best way to find a doctor who understands this?
Look for endocrinologists, pain specialists with endocrine training, or clinics focused on hormone health. Ask if they’ve treated opioid-induced hypogonadism before. If they haven’t heard of OPIAD, they may not be the right fit. Bring the 2012 Pain Physician review or the 2021 Journal of the Endocrine Society study to your appointment-it helps.
Next steps: If you’re on opioids and feel off, start by asking your doctor for a morning testosterone blood test. Don’t wait for symptoms to get worse. Your body is trying to tell you something. Listen.