Exam Room 3: "He Can't get it up on Suboxone..."

[drusso]

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43 year old male with FBSS, moderate OUD, ORT =7, DIRE = 14, PHQ-9 = 9, previously tolerant to oxycodone 30 mg Q4 by written another RX-er, with history of early outs and discordant UDS's ("I had taken some old Vikes I found in my friend's pickup and my PCP fired me") presents with wife status post elective & consented rotation to abuse-deterrent buprenorphine 2 weeks ago. Patient is stable on 12 mg SL daily. Wife says, "He's f*cking useless on this ****." Per wife, the couple engaged in intercourse 2-3 times per day and "twice as often on the weekends." Serum AM testosterone is 320 ng/mL. Patient rates his pain as a 2/10 on the med (its the best I've had), but admits to not feeling "in the mood."

What's your next move?

 

[TheLoneWolf]

43 year old male with FBSS, moderate OUD, ORT =7, DIRE = 14, PHQ-9 = 9, previously tolerant to oxycodone 30 mg Q4 by written another RX-er, with history of early outs and discordant UDS's ("I had taken some old Vikes I found in my friend's pickup and my PCP fired me") presents with wife status post elective & consented rotation to abuse-deterrent buprenorphine 2 weeks ago. Patient is stable on 12 mg SL daily. Wife says, "He's f*cking useless on this ****." Per wife, the couple engaged in intercourse 2-3 times per day and "twice as often on the weekends." Serum AM testosterone is 320 ng/mL. Patient rates is pain as a 2/10 on the med (its the best I've had), but admits to not feeling "in the mood."

What's your next move?

Oh, I have seen this before. Syndrome commonly underdiagnosed in married men. New wife/ tinder dates/ girlfriend usually clears this right up.

Every man, myself included, at some point thinks they want a nymphomaniac who can go several times each day. Problem is actually keeping up with their sex drives is a full time job. Exhausting and can't get any work done.

In this guys case, your responsibility is strictly to him and his pain control. Let him balance good pain control on the new medication and the needs of his spouse. OUD and his old regimen not acceptable alternative.

 

[Orin]

Trial of Wellbutrin to give him the dopamine he needs while weaning the Suboxone due to side effects?

 

[bedrock]

43 year old male with FBSS, moderate OUD, ORT =7, DIRE = 14, PHQ-9 = 9, previously tolerant to oxycodone 30 mg Q4 by written another RX-er, with history of early outs and discordant UDS's ("I had taken some old Vikes I found in my friend's pickup and my PCP fired me") presents with wife status post elective & consented rotation to abuse-deterrent buprenorphine 2 weeks ago. Patient is stable on 12 mg SL daily. Wife says, "He's f*cking useless on this ****." Per wife, the couple engaged in intercourse 2-3 times per day and "twice as often on the weekends." Serum AM testosterone is 320 ng/mL. Patient rates his pain as a 2/10 on the med (its the best I've had), but admits to not feeling "in the mood."

What's your next move?

Don’t budge on using bup instead of traditional opioid. I’ve seen this issue before and it’s often dose dependent.

His pain is doing great, and he could certainly tolerate a lower bup dose. I’d wean as much as possible, things start to “pickup” below 6mg daily.

I’d tell patient this is your overall plan, however if he wants you could first prescribe him viagra/cialis, but if he fails those meds, the next step is a partial wean.

 

[lobelsteve]

Wife doesnt want the meat, just the oxys. She was using too.

 

[Ducttape]

simple answer: the guy woke up from the opioid haze from the oxys and realized how unappealing his wife really is...

 

[Orin]

That's a well described side effect of bupe, naltrexone, and methadone.

The dude's wife might not be hot, or maybe he's not into women anymore, but simple things being simple, it's probably the drug. That could be a great motivator to help wean off or go to the lowest tolerable dose.

 

[Blitz2006]

That's a well described side effect of bupe, naltrexone, and methadone.

The dude's wife might not be hot, or maybe he's not into women anymore, but simple things being simple, it's probably the drug. That could be a great motivator to help wean off or go to the lowest tolerable dose.

Good to know. Found a nice paper on this topic:

Sexual dysfunction among male patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. - PubMed - NCBI

"About 83% of the men on buprenorphine and 90% on naltrexone reported at least one of the sexual dysfunction symptoms."

 

[jettavr6]

Trial of Wellbutrin to give him the dopamine he needs while weaning the Suboxone due to side effects?

No - subtract, don't add.

 

[bedrock]

Good to know. Found a nice paper on this topic:

Sexual dysfunction among male patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. - PubMed - NCBI

"About 83% of the men on buprenorphine and 90% on naltrexone reported at least one of the sexual dysfunction symptoms."

Interesting that it went both ways equally. Half the time they had premature ejaculation , and half the time they had impotence.