Libido, Drug Abuse, and Me

September 8, 2010
Alan Berkenwald, MD

Being opioid-dependent means dealing with attractions and cravings that never go away--and seeking help for things that have gone away.

I have a small addiction medicine practice where I deal with opioid dependent people who, having hit rock bottom, enter the medical world as a last resort, seeking salvation through pharmacology.

I have a buprenorphine (it is a unique opioid agonist/antagonist, trade name Suboxone) license and I see about 85 poor souls each month at a tiny, part-time office I keep. They are a remnant of the time I was a primary care practitioner. I call them my “COPs”—Children of the Poppies.

Of the 1,500 active patients I had until the insurance industry drove me crazy and out of business, I was able to find replacement physicians for all of them. Except those on "bup." Nobody wanted them. I didn't want to unleash a crime wave on my community were the meds to stop and the withdrawals begin, so I kept them.

These people remain the most interesting of all my clinical patients. The stories they tell me—no, not stories, but their day-to-day adventures—fascinate and frighten me. It's a form of clinical rubber necking. Their lives are best described as one big accident unfolding in slow motion.

Buprenorphine is a wonderful gift for these people—if they remain on it. But, years of exposure and receptor up-regulation have burned permanent cravings in all of them. Even when sober, they are always at risk, should they bump into any of their old drugs of choice. And the narcotics are everywhere—weddings, funerals, bars, parties, even the break rooms at work. I try to explain this risk by using analogies such as the opening greetings at AA meetings: "I'm John. I'm an alcoholic, sober for 20 years." No one ever gets up and says, "I'm John. I'm an ex-alcoholic."

The attraction and the cravings are always there, hidden just below the surface. No one takes John to a bar to celebrate 20 years of sobriety and expects him to stick with soda. Too dangerous. My patients can't watch "Intervention" on TV because they get drug dreams and morning cravings. They can't look away from narcotics once they stumble into them. I've written about this before, what I call the "Bikini Model of Addiction." If the office door opened and a stunning blond in a Bikini walked in, no one is capable of looking away. The men are hard wired to look at the girl, and the women are hard wired to look at the shoes.

But, as wonderful a medication that it is, buprenorphine has its price. For these addicted souls, I don’t just mean physical dependency or monthly visits to the office. No, like all opioid products, it can depress libido and sexual performance.

* * *

Bill S. is on buprenorphine, seeing me now for about 4 months. He lost his job, his savings, and his truck, but he's been able to move back in with his girlfriend. Wiry and high strung, he tends to twitch and jerk, moving all around the chair during his visits. He makes me nervous with his peripatetic perambulations around the office. (If I kept silverware there, I would count it once he left.)

"So, how's it going, Bill?" I listen to the usual issues, make the usual comforting sounds, and give the usual good advice. Stratagems for addiction. Stay away from dark corners and sharp edges, know which friends you can hang with, have a buddy system in place at the bar. But something was revving Bill up more than usual.

"Doc," (twitch, jerk) "I'm back with my girl, but, you know, like, uhh, she uhh..." Cross legs, uncross legs, look over right shoulder, avoid my eyes, twitch jerk. I know what he wants bring up (so to speak).

"Libido issues?" I ask.

"What's that? No, I mean, you know, I'm having trouble with, uhh..." (twitch, jerk, shrug, cross legs, look right, twitch, look left) "Uhh, you know..."

"Sex?"

Shoulders drop, eyes look down. "Yeah. I think it's all the drug stuff. I've lived a hard life. She wants... she wants..."

So, I launch my usual ‘Buck up Your Libido’ talk. It's a side effect of the medicine, it's very common, lots of guys have this issue, once you're off the medication it'll resolve itself. But, in the meantime, we have "Vitamin V."

He stops twirling in his seat to say, "You mean...."

"Yes. Let me write you a prescription."

At this point he's a sprinter, crouched on the blocks, waiting for the starting gun. Visibly shaking with anticipation. I hold the script just out of his reach.

"A few things you need to know. You take it about an hour before you want results. It's not a magic pill. You just don't take it and say, "Stand back! I'm having an erection! You need romance, cuddling, foreplay..." I pause. Is that drool I see?

He grabs the script and is half way out the door, his motor redlining.

"Hey Bill," I say, "One more thing."

"What’s that, Doc?"

“Don't poke yourself in the eye."

-alan berkenwald, md