T Nation

TRT and Opiate Pain Medicine

Hey guys,

Newbie here to the forums although I have been on trt for several years. I am a 54 yo male with a long history of physical ailments including major back surgery, shoulder surgery, and surgery on both knees along with some other less serious problems. I am currently taking an average of 10 to 20 mg of oxycodone per day and injecting 150 ml of testosterone cypionate every week. Have been in the gym regularly 5 days per week plus for the last 8 years.

When I get my blood tested at the end of my weekly cycle my free t levels would always drop below the recommended amount of 7.2 pg/ml - 24.0 pg/ml. Although my total t might be within the range but a little low say 350 to 500 ng/dl.

So recently met with my primary doc who prescribes the trt and he thought it’s possible the oxycodone is having an effect on the free t levels. Anyway, 3 months ago he upped the cypionate to 150 ml per week and I had my first test recently at the end of my weekly cycle. My total t was up to 605 ng/dl and my free t was up to 8.5 pg/ml which was just barely in the range of 7.2 to 24.0.

So my question is about the ratio of free t to total t. It seems like I have a big difference between them. Is it likely that the pain medicine is causing this? I don’t have a lot of confidence in this doctor managing this for me, it’s just not his specialty as a primary care doctor. I tried to transfer into an endocrinologist but he pretty much wouldn’t do anything until I completely quit the pain meds. I’m assuming it affects my t-levels too much for him to accurately prescribe trt.

Any info and tips would be great appreciated. Thanks

Post all of your labs. Many of the super high SHBG guys have high Total T with low Free T and require higher doses. I can’t imagine the opiates are having that kind of direct suppressing effect on your levels when using exogenous Testosterone (natural levels yes). If you haven’t had your SHBG tested then you should. It’s likely way up there. Search “high SHBG” here and you’ll find folks that are in a similar circumstance.

By chance have you ever used Finasteride?

I’m afraid this isn’t the case, you just need to inject twice weekly because you are metabolizing T faster. You probably have high SHBG and need more testosterone to get Free T to increase and twice weekly to keep it elevated throughout the entire week.

Your doctor shouldn’t be concerned about a high Total T value because it’s inactive, the Free T is what needs to be consistently elevated if you are going to benefit 24/7. I doubt you have ever been optimized on TRT and had Free T close to the top of the ranges.

If you want optimal levels of testosterone, you may have to seek care privately because I find a lot of doctors unwilling to allow for high Total T values outside the reference ranges which is what’s needed with men who have high SHBG that require a high Total T value to have optimal levels of Free T.

I would want my Free T levels at the top of reference ranges or higher.

These pain meds you’re are known to decrease natural testosterone, he probably thought by stopping these pain meds that your natural T would increase and therefore you wouldn’t need TRT. The notion that pain meds can affect exogenous testosterone is a stretch of the imagination because you’re injecting the same amount.

There’s plenty of evidence that shows opiates, especially long-acting ones, have a big impact on test levels. Some rehabs are including hormone testing as part of their therapy programs now too. Starting TRT has helped me taper my opiate dose down dramatically, and I hope to be off by the summer

Free T is going to be about 2-3% of totally T ideally , that’s why there’s such a big difference in their levels. 10-20mg daily probably isn’t having a huge impact on your test levels, but chronic use can cause problems long term. Either way it looks like you’ve got some room to play with your dose to get TT and FT up.

Does it effect exogenous testosterone levels? I’ve read about it’s impact on natural levels. I used opiates for a very long time and before TRT was on Suboxone (not an opiate as I’m sure you know) and my levels weren’t horrible at 575. Not sure about free T though.

More T!

Exogenous I don’t think so. I’m on Suboxone now, and it is def an opiate, with limited activation but very strong binding to the receptors. I started TRT before I started the Subs, but I’m getting all the benefits of TRT while I’m still on 2.5mg Sub and going down every couple weeks.

Before TRT I used about opiates regularity for 10 years, TT 305ng but no idea what free was either. Wish I knew to check hormones back before I started

Here’s one quick recent study. I can’t tell if they continued to use opiates during therapy, but adding in TRT def helped regardless of the painkillers

Thanks for mentioning the SHBG. I looked this up a while back and mentioned it to my doc. He doesn’t test for it usually as most insurance companies won’t pay for it. I actully have really good insurance and found out they would pay for it as long as the doctor provides reason to have it tested. I completely forgot to remind him to put this in the last test. He agreed though that this may be the problem. So, just a hypothetical here…if that number is way off, what is the solution? Just raise your dose higher? I have not been on any other medication for the trt including finasteride. I will get my labs posted up to help on what they have tested for.

It’s only a partial agonist of the main opioid receptor (the “mu” receptor) so it’s not quite the same thing as true opiates such as heroin that are full agonist opioids. I’m sure that’s what you were saying but just in case.

Yep we’re on the same page

Here’s another one:

https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=167&ContentID=shbg_blood

This says that opioids can affect the SHBG blood test. Maybe they do raise it somehow? Could be part of their impact

Yes you could require a higher dosages to get the same free T levels of someone with a lower SHBG on a lower dose. That’s if your SHBG is really high though. There’s drugs like Danazol that some use to lower SHBG but I haven’t seen many people use it here successfully and probably comes with it’s own issues. Folks like @ncsugrad2002 came here with high SHBG of I remember correctly.

That would be interesting. My SHBG on TRT is around 40.

Interesting, do you think just splitting my current dose would be enough or do you think the total dose needs raised as well? It’s funny, when I first started this trt I was getting a once a month 400ml injection and just hitting a wall for the last 2 weeks every month. Not knowing any better I just thought it was part of the deal. After reading a lot of things online since then I got him to go every 2 weeks and then about a year ago I got him to agree to 100ml once per week, then 125, and now 150ml. But no, I agree my free t has never been optimum, not even close. Would be nice to feel what that might be like.

It will help but not likely enough to be optimal without upping the dose some. Many here use more frequent injections than just once a week.

The only opiate demonstrated to have minimal impact on T is tapentadol and perhaps buprenorphine

https://www.ncbi.nlm.nih.gov/m/pubmed/25985806/

A drop in testosterone of 1.5nnol is fairly minimal

https://www.ncbi.nlm.nih.gov/m/pubmed/15483091/

Oxycodone, morphine, methadone etc crush T… shut down/ decrease GnRH secretion… on synthetic T however (exogenously administered) it won’t make the slightest difference

The real question is… the guy says he’s taking oxycodone 10-20mg daily

Is this once per day? Oxycodone once daily isn’t going to provide significant therapeutic relief

Or is it targin (oxycodone CR)… also has naloxone in an attempt to be an effective abuse deterrent

I think I’m in like the top 3 highest my doc had ever seen. 150 something pre TRT. Down to 70’s now

Opiates sent going to effect injected T. They lower natural T. I’m on methadone. 145mg daily split. I inject 23mg cyp daily and my t levels are 1400 and 500 free

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The opiates are not effecting your trt. The Endo wants you off them so your natural T goes up when he makes you take a break then he can discontinue trt once your in range naturally