1 CHANGES IN SEXUAL INTEREST AND PERFORMANCE FOLLOWING OPIATE DETOXIFICATION AND ORAL NTX TREATMENT A PROSPECTIVE STUDY Emmanuel Koukidis, MSc, BTEC in Counselling, Life Care NGO, Piraeus, Greece. Colin Brewer, Research Director, The Stapleford Centre, London UK. Matina Lagoudaki, Psychologist, Life Care NGO, Piraeus, Greece.

Conflict of Interest statement Dr Brewer has nothing to declare. The other authors are employed by Life- care NGO. 2

3 Opioids change physiological functioning. Dependence/abuse changes psycho-social functioning. Opiate withdrawal can cause premature ejaculation. Even therapeutic opiate doses can delay it – and/or reduce potency and libido. With physical dependence, the need for sex may take second place to the need for opioids. Heroin addicts may not seem ideal partners – except to other addicts.

4 What happens in the period after detoxification? Do sexual activity and performance return to pre-detox levels or is there persisting impairment? Does naltrexone have any effect (good or bad) on sexual enjoyment or performance?

5 These questions led to six hypotheses. Hyp. 1 : Becoming addicted to heroin has an adverse effect on sexual performance and satisfaction in most addicts but not all. Hyp. 2 : In both men and women, there is a steady return to normal (or pre-addiction) sexual performance if abstinence from opiates is maintained and if no other major or regular abuse (including alcohol) replaces heroin. Hyp. 3 : Apart from ensuring true detox completion and abstinence, compliance with daily naltrexone might have additional effects on sexual performance or enjoyment,which disappear and return in a consistent manner if naltrexone is not used every day (and if there is no relapse to opiate use during these naltrexone-free days). Hyp. 4 : In women, heroin is associated with less frequent and less satisfying orgasm. Hyp. 5 : Methadone has similar effects to those of heroin. Hyp. 6 : The effects of both heroin addiction and of consistent abstinence post-detox will be more complex and varied in women than in men.

6 Research setting. Context: Life Care NGO Sample: N = 50 detoxified heroin-users enrolled in a 12-month program of psychosocial care with family-supervised oral NTX. Gender: 78% male, 22% female Age range: years; Voluntary participation. Period of research: July 2008-July 2009.

Dropout rate. 1 month – none. 3months – 3 6 months – 12 (total) 5 of these stayed opiate-free but declined further research involvement. 7

8 Research method Structured questionnaire with 5-point scale. Personal interview (MK, ML) at 14 days, 1 month, 3 months and 6 months after completing detox and starting oral NTX.

9..And some results Hyp 1: Confirmation that heroin dependence has an effect on sexual performance and satisfaction for most users - but not all.

10 Changes in sexual activity on opiates

11 Quest. 2 (2 weeks): Thinking about your sexual activity before you began heroin use and now that you have withdrawn, have you returned to your initial state before heroin use ? Hyp 2: After withdrawal both men and women generally return to "normal"(or pre-addiction) sexual behavior.

Of the men not fully recovered.. 46% were improved/improving The rest complained mainly of premature ejeculation. 12

13 Quest. 2 (1 month): Thinking about your sexual activity before you began heroin use and now that you have withdrawn, have you returned to your initial state?

14 Quest. 2 (3 months): Thinking about your sexual activity before you began heroin use and now that you have withdrawn, have you returned to your initial state?

15 Quest. 2 (6 months): Thinking about your sexual activity before you began heroin use and now that you have withdrawn, have you returned to your initial state?

16 Quest. 3: (2 weeks) Have you observed differences in your sexual activity from the time that you began taking naltrexone? Hyp 3: No evidence of significant effect of naltrexone on sexual activity, apart from a relatively small number of responses early in treatment. This probably represents withdrawal effects (incl. precipitated withdrawal) rather than true NTX effects.

17 Quest.3 (2 weeks) changes after NTX

18 Quest. 3: (1 month) Have you observed differences in your sexual activity from the time that you began taking naltrexone?

19 Quest. 3: (3 months) Have you observed differences in your sexual activity from the time that you began taking naltrexone?

20 Quest. 3: (6 months) Have you observed differences in your sexual activity from the time that you began taking naltrexone?

21 Quest 4: (for women) When you were using opiates (heroin/methadone/buprenorphine) did it adversely affect your sexual appetite (less orgasm/less satisfaction)? Hyp 4: There is an adverse effect of heroin on female orgasm/enjoyment but it is fairly small.

22 Qu. 4: (men) While you were using opiates, did it adversely affect your sexual appetite?

23 Hyp 5: Too few patients with primary methadone dependence for meaningful results. Hyp 6: There was some evidence of a more complex effect of heroin dependence in women but the small numbers do not permit generalizations. The impression of ML is that more female than male heroin addicts have a rather low sexual drive to begin with.

24 These questions led to six hypotheses. Hyp. 1 : Becoming addicted to heroin has an adverse effect on sexual performance and satisfaction in most addicts but not all. Hyp. 2 : In both men and women, there is a steady return to normal (or pre-addiction) sexual performance if abstinence from opiates is maintained and if no other major or regular abuse (including alcohol) replaces heroin. Hyp. 3 : Apart from ensuring true detox completion and abstinence, compliance with daily naltrexone might have additional effects on sexual performance or enjoyment,which disappear and return in a consistent manner if naltrexone is not used every day (and if there is no relapse to opiate use during these naltrexone-free days). Hyp. 4 : In women, heroin is associated with less frequent and less satisfying orgasm. Hyp. 5 : Methadone has similar effects to those of heroin. Hyp. 6 : The effects of both heroin addiction and of consistent abstinence post-detox will be more complex and varied in women than in men.

25 Thank you for your attention.