Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’

by Natan Schleider, M.D.

August 19th, 2018

While the USA suffers through another opiod use epidemic (yes, we’ve had them before but I’ll give you the history lesson another time), the focus of press and medical/government powers that be are appropriately focused on preventing overdose and death. Far less attention is paid to adverse effects of chronic opiate use.

Whether used for pain management or for Medication Assisted Therapy (MAT) [IE using buprenorphine or methadone to manage Opiod Use Disorder formerly called opiod dependence] here is an important medical fact: if you are taking any opiate, you are at risk for testosterone deficiency. While not life threatening directly, common signs and symptoms of testosterone deficiency are decreased libido, depressed mood, lack of energy, diminished muscle mass/trouble gaining muscle size and strength at the gym, increased body fat, erectile dysfunction, and infertility.

Opiates reduce leuteinizing protein (LH) and follice-stimulating protein (FSH) production at the brain’s pituitary gland. LH and FSH tell the testicles to make testosterone.

In my practice, 50% to 75% of my male patient’s on opiods have low testosterone and half of them have some of the symptoms listed above.

I would argue that suffering the above symptoms poses risk of relapse to illicit opiod use and should be investigated and treated when indicated.

The good news about testosterone supplementation: it can help many of the symptoms above. The bad news: testosterone supplementation increases risk of prostate disease, prostate cancer, blood clots, and possibly heart disease (depending on the study).

Testosterone is broken down/destroyed by the stomach if swallowed so it has to be supplemented via transdermal gel (that goes on the skin daily) or by injection into the muscle (usually the gluteus) weekly to monthly. A few formulations I am not that experienced with as I can rarely get them covered are available: buccal (melts in the mouth) Striant, intransal gel (Natesto) [has to be given 3 times daily–annoying].

Most of my patients prefer the injectable formulations being least expensive and allowing for the patient and I to optimize how frequently to give the shot. I find weekly injections the best as if given less often, testosterone levels tend to peak for several days after the injection and wear off faster than the manufacturer suggests.

I would love to hear your experience or horror stories or opinion about testosterone therapy in opiate users via Twitter.com @DrSchleider or Facebook or Instagram.

Thanks for reading and stay tuned for part II, testosterone supplementation in women and transgender patients.

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I: Poikiloderma of Civatte

A Family Doctor’s Visit to See a Cosmetic Dermatologist for Sun Damaged Skin Part I : Poikiloderma of Civatte

By Natan Schleider, M.D.

Dr. Natan Schleider’s Forehead. Note what appears different color tones which was diagnosed a poikiliderma.

I don’t wear skinny jeans. I wear flip flops whenever I can which apparently are out of style. And while starting to go bald–which I’ve decided to ‘own’ rather than pursue hair plugs or the ever popular toupee, the sun-damaged skin on my forehead has been bothering me (only when I look in the mirror).

Having spoken to my regular dermatologist, Dr. Roy Seidenberg (great, brilliant physician), he suggested a cosmetic dermatology consult for possible laser treatment.

Now I’ve had laser treatment before in my early 30s: laser hair removal on my back and chest. After 18 months of treatment every 6-8 weeks for a total package deal of about $3500, my back and chest were about 60% improved but I learned one valuable lesson: as I aged new hairs began to sprout on my back and chest (not to mention my ears, yikes!). So what I presumed–and is often advertised as a ‘permanent’ fix–not the case with me.

Friends have raved about various laser treatment for skin as the definitive cure while many patients of mine love Retin-A, a prescription cream or gel FDA approved for anti-aging (improving fine lines and sun spots). I tried Retin-A for a few weeks but realized I was soon forgetting to apply it at night (when I was negotiating with my 5 year old daughter Elie on the benefits of tooth brushing, a nightly debate).

Treatment for this would not be ‘one and done’ but would require a ‘series’ of treatments–the doctor would not commit on even a ballpark number but I would surmise 5-10 treatments. lasting ‘minutes’ after a numbing cream was applied. The stronger the laser each session, the better/faster the final results (meaning the more sun-damaged blood vessels are destroyed). If the laser is put on mild, minimal downtime, skin feels slightly sunburned, you can work same day. If laser is put on high power, skin is very red and inflamed and downtime expected to be 1 week. The cosmetic dermatologist suggested an in between setting.oping for a ‘one and done’ laser treatment to leave my forehead smooth and uniform in color, I saw a cosmetic dermatologist yesterday.

I tried to get a price idea on these laser treatments before the consult but found no great source?

Anywho, while I do have a few sun spots medically called solar lentigos, my primary problem in poikiliderma, a benign discoloration of blood vessels brought on by sun exposure underlying the skin leaving colors darker and lighter.

Treatments would occur about once a month and I ultimately got a price of $450 per treatment (which I think is low in the NYC area as it is a small region of skin being zapped as opposed to chest or neck where poikiloderma occurs more commonly.

The staff seemed surprised when I declined treatment at this time. Given this would be a long expensive process with best outcomes (based on my research) about 75% improvement, I paid my $200 consult fee and told them ‘I’d think about it’ which I will do.

The treatment would involve some type of laser which would take ‘a few

Any comments or experiences with cosmetic dermatologic treatments appreciated via Twitter.com or Facebook.com or Instagram.com.

Thanks for reading and I’ll keep you posted if I go back for laser treatment.

 

 

 

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

Medicine Changes It’s Mind Every 10 Years, Case in Point, Vitamin D Supplements No Longer Advised

By Natan Schleider, M.D.

August 13th, 2018

Having been in practice 13 years now, I’ll let you in on a secret: fifty percent of everything you learn or read about in the news regarding health and medicine will be obsolete or wrong, sometimes even harmful, within 10 years or so. Does that mean I should ask for 50% of my money back from my medical school, hmmmm?

Case in point: In the 2000s, a lot of interest in Vitamin D testing and supplementation ensued with the consensus being, take Vitamin D if you don’t get enough sun, have low levels (my lab says low levels are less than about 30 ng per ml), are elderly and at fall risk, have mood disorder such as depression, are at risk for heart attack…the list went on.

Less than a decade later, recommendations have shifted 180 degrees, that is, studies in recent years show no benefit to taking Vitamin D for all the disorder above unless your levels are below 12-20 ng per ml making you Vitamin D deficient. If you are deficient in Vitamin D or your diet lacks the needed 600-800 IUs recommended daily, take Vitamin D (FYI most multivitamins have about 200-400 IUs of Vitamin D).

I’ve stopped supplementing with Vitamin D and plan on checking my levels in a month or two.

If you have been prescribed Vitamin D but are not in fact deficient and have questions or comments, speak to your doctor or contact me on Twitter. Facebook, Instagram, etc.

SOURCE: AMERICAN FAMILY PHYSICIAN V.97 NO.4 FEB 15th, 2018