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The International Journal of the Addictions, 27(1 I), 1325-1334, 1992
Sexual Dysfunction and Psychological Distress in Methadone Maintenance William D. Spring Jr., M.D.,192y'Mark L. Willenbring, M.D.,'12 and Thomas L. Maddux, C.C.D.C.R.'
' Department of Psychiatry, Department of VeteransAffairs Medical Center, Minneapolis, Minnesota 554 1 7 *Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota 55455
ABSTRACT We adminstered the Derogatis Sexual Functioning Inventory to 25 methadone maintenance patients who had been on a stable dose of methadone for at least 2 months, and obtained ratings of depression and anxiety, levels of sex hormones, and liver function tests. Five subjects with significantly lower Global Sexual Satisfaction Index scores (p < .OO01) had more psychological symptoms, higher methadone doses, poorer body image, and less sexual drive and satisfaction, but normal fund of sexual information and lifetime experience. Sexual dysfunction among methadone maintenance patients may be due to coexisting psychiatric problems rather than caused by opiates. Methadone patients presenting with sexual dysfunction should receive psychiatric evaluation. Key words. Methadone maintenance; Sexual dysfunction; Depression; Anxiety *TO whom correspondence should be addressed at Psychiatry Service (ll6-A), DVA Medical Center, 1 Veterans Drive, Minneapolis, Minnesota 55417. Telephone: (612) 725-2000, ext. 3978. I325 Copyright 01992 by Marcel Dekker, Inc.
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INTRODUCTION Sexual dysfunction has long been associated with opiate use (Abel, 1984; Smith et al., 1980; Cushman, 1972; Bloom and Butcher, 1970). However, most surveys to date have been reports of symptoms among patients and have generally not compared opiate users to control groups. As part of a larger study of prolactin in opiate use, we administered a standardized sexual behavior inventory to a group of methadone maintenance patients.
SUBJECTS AND METHODS In 1987, 25 methadone maintenance patients out of 40 eligible volunteered to be in the study. Subjects were deemed eligible if they had been on a constant dose of methadone for at least 2 months and had adequate venous access. They were told that preliminary research had revealed that methadone maintenance patients sometimes had high levels of the hormone prolactin and that because elevated prolactin levels were known to cause psychological symptoms and sexual dysfunction in other populations, we wanted to find out if these problems were related. They were given the Derogatis Sexual Function Inventory (DSFI) (Derogatis and Melisaratos, 1979). The reliability and validity of the DSFI have been thoroughly established in normal and sexually dysfunctional populations of both sexes (Derogatis and Melisaratos, 1979). The test is a selfreport measure that requires about an hour to complete. There were occasional subjects who asked the monitoring nurse how to interpret certain questions. The DSFI has 10 subscales, each of which focuses on one aspect of psychosexual functioning. Subscale descriptions derived from the scoring manual (Derogatis, 1975) and Derogatis (1983) are as follows: 1. Information: Twenty-six true-false items measuring the person’s general fund of information about sexual functioning. 2. Experience: The number of various sexual experiences reported within the past 60 days and over the individual’s lifetime. 3 . Drive: Five items reflecting actual frequencies of four categories of sexual behavior and the preferred frequency of intercourse. 4. Attitude: Thirty items representing degrees of sexual liberalism or conservatism, liberalism being scored in the positive direction. 5. Symptoms: A psychological symptom inventory (the Brief Symptom Inventory). 6 . Afects: A scale comprised of affect-descriptive adjectives (the Affects Balance Scale), scored by subtracting the total negative affects score from the total positive affects score.
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SEXUAL DYSFUNCTION A N D PSYCHOLOGICAL DISTRESS
I327
7. Gender Role DeBnition: A scale consisting of adjectives descriptive of traditionally masculine and feminine behavior traits. The individual reports the degree to which each adjective fits him or her. The score reflects the magnitude of the difference between masculinity and femininity scores, i.e. polarization of gender role. 8. Fantasy: Twenty items depicting fantasy themes, scored as the number of themes having been experienced in daydreams or while asleep. 9. Body Image: Fifteen items reflecting satisfaction with the appearance and attractiveness of one’s body. 10. Satisfaction: Ten true-false statements reflecting satisfaction with specific aspects of sexual behavior. 1 1 . Global Sexual Satisfaction Index (GSSI):A nine-point scale rating the individual’s global satisfaction with his or her present sexual relationship. In order to improve accuracy of data, we asked for ratings of recent sexual experience in the last 30, rather than 60, days. We then compared the DSFI standized ( T ) scores of subjects against the norms provided with the instrument. The Hamilton Depression (Ham-D) (Hamilton, 1960) and Anxiety (Ham-A) (Hamilton, 1969) scales were administered to assess levels of psychological distress. Blood was drawn prior to the daily dose of methadone for determination of serum prolactin, testosterone, FSH, and LH. Samples were assayed by commercial radioimmunoassay kits in the hospital clinical laboratory. Student’s t-tests with Bonferroni correction for multiple tests were used on continuous variables to assess the significance of differences between subjects measuring high and low on the GSSI scale. Pearson product-moment correlations were used to assess the relationships among the DSFI subscales, the methadone dose, the hormone levels, and the psychological rating instruments.
RESULTS Of the 25 participants, the mean methadone dose was 58.0 f 9.1 mg, range 40-75 mg. Mean age was 39.0 f 6.9 years, range 30-60 years. Of the nonparticipants, the mean methadone dose was 62.7 f 11.8 mg, range 25-75 mg ( t = 1.56, df = 47, p = .1262); the mean age was 43.6 f 9.7 years, range 31-64 years ( t = 1.93, df = 47, p = .0597). (See Table 1.) Mean subscale scores on the DSFI were within one standard deviation of normal group means on all but three subscales: sexual experience in the past 30 days, T = 31; affects scale, T = 38; and role definition scale, T = 32 (a T score of 50 means that the individual scored at the midpoint of the normative sample. Each standard deviation is 10 points). Mean ( f SD) Ham-D score was
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SPRING, WILLENBRING, AND MADDUX
Table 1. Subject Background Characteristics
Standard deviation
Range
1.38
30-60
1.12
10-15
21.2 17.5
4.3 6.98
15-31 5-40
100 48 32 32 28 3.16
3.48
0-13
33.4 32.9 58.0
9.27 5.03 1.81
22-60 2-84 40-75
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Mean Sex, % male Age, years Ethnicity: % White % Black Urbanization: % urban % rural Education, years Vocational class: % skilled labor % unskilled labor Unemployment (current) Living situation, % living alone Psychiatric diagnoses (current), % Medical problems (current), % Legal problems (history of), % Substance abuse history: Initial age of use, years Duration of use, years Drugs used (history of), %: Opiates Alcohol Marijuana Benzodiazepines Cocaine Treatments for substance abuse, number Methadone maintenance history: Age first enrolled, years Months enrolled in this program Methadone dose, milligrams
100 39.0 88 12 84 16 12.2 28 12 36 24 44 32 80
11.5 f 6.7; Ham-A mean score was 9.3 f 6.0, indicating generally mild depression and anxiety symptoms. Mean hormone levels were all within normal reference limits for our laboratory; however, the testosterone level was negatively correlated with methadone dose ( r2 = - .3723; p < .01). Hamilton Depression ( r 2 = - ,6384; p < .001) and Anxiety ( r = - .5099;p c .00l) scale scores were negatively correlated with the DSFI global satisfaction subscale, as was methadone dose ( r 2 = - .4122; p < .001). The Global Sexual Satisfaction Index (GSSI) does not have any “abnormal” values on the low end; a score of 0 still falls within 2 standard deviations of the mean. However, upon examination of the distribution of scores, a subset of five patients appeared to have distinctly lower GSSI scores, compared with
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SEXUAL DYSFUNCTION AND PSYCHOLOGICAL DISTRESS
I329
the rest of the group (low group = 0.80 f 0.45; high group = 4.4 f 1.3; r = 5.73, df = 23, p < .OOOl). We then compared these two groups on all variables (Tables 2 and 3). The low GSSI group had higher methadone doses and more depression and anxiety. On the DSFI, the low GSSI group reported less sexual drive and satisfaction, and more psychological symptoms, negative affect, and body image, but normal information and lifetime experience. Examination of the clinical records and interviews with the counselor familiar with the subjects revealed that the low GSSI group tended to have diagnoses of coexisting anxiety and/or affective disorders, and were seen by the counselor as compliant but more troubled than the high GSSI group in such areas of their lives as jobs and relationships. They generally made more extensive use of counseling than other patients. Several of the patients had sexual identity and/or relationship issues as well. Records of random drug screens revealed no differences between high and low GSSI subjects in number of positive drug screens or types of drugs observed.
DISCUSSION Our findings suggest that sexual dysfunction among methadone maintenance patients may be present in a subgroup of psychiatrically symptomatic patients rather than more continuously distributed among the population. These Table 2. Descriptive Information in Two Groups of Methadone Maintenance Patients. Patients Were Grouped by Inspection of the Distribution of DSFI Global Sexual Satisfaction Index (GSSI) Score; the Bottom Five Stood Out Clearly from the Rest. All Laboratory Values Refer to Serum Samples. Values Are Means with Standard Deviations in Parenthesesa
Variables Age (years) Dose (mg)* Months in program Positive weekly urine drug screens (%) Prolactin (ng/mL) Testosterone (ng/dL) Aspartate aminotransferase (IUIL) Gamma glutamate aminotransferase (IU/L) Luteinizing hormone (bIU/ml) Follicle stimulating hormone (pIU/ml) Hamilton Depression Scale** Hamilton Anxiety Scale**
Low GSSI score (n = 5)
High GSSI score ( n = 20)
39.5 (5.4) 66.0 (7.4) 40.8 (30.5) 20 7.8 (3.5) 558 (320) 26.0 (11.4) 60.4 (55.1) 17.7 (9.9) 11.3 (5.5) 19.4 (5.4) 15.6 (6.5)
38.8 (7.3) 56.0 (8.5) 30.9 (47.3) 25 7.5 (5.7) 570 (238) 40.5 (55.3) 43.8 (55.7) 24.1 (12.9) 14.7 (15.3) 9.6 (5.5) 7.8 (4.8)
aSignificance level by t-test with Bonferroni correction for multiple tests: *p < 0.05; **p < 0.01.
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Table 3.
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DSFI Scale Scores in Methadone Maintenance Patients Grouped by the Global Sexual Satisfaction Index (GSSI) Score. Values Are Means with Standard Deviations in Parenthesesa
DSFI Scale scores Information Experience: Lifetime Past 30 days Drive** Attitude Symptoms* Affects** Role Definition Fantasy Body Image** Satisfaction* GSSI***
Low GSSI score (n = 5)
High GSSI score ( n = 20)
21.6(1.5) 19.6 (8.2) 2.8 (3.6) 8.8 (3.7) 21.8 (7.3) 1.07 (0.7) -0.15 (1.0) 10.0 (2.2) 5.8 (3.4) 23.2 (4.3) 5.6 (2.6) 0.8(0.45)
19.8 (2.3) 19.3 (2.9) 8.8 (7.5) 16.8 (4.4) 16.6 (11.7) 0.44 (0.39) 0.79 (0.57) 5.7 (5.1) 5.2 (2.5) 16.9 (4.2) 7.8 ( I .6) 4.4(1.3)
aSignificance by f-test with Bonferroni correction for multiple tests: *p .05; **p < .01; ***p < ,001.
The International Journal of the Addictions, 27(1 I), 1325-1334, 1992
Sexual Dysfunction and Psychological Distress in Methadone Maintenance William D. Spring Jr., M.D.,192y'Mark L. Willenbring, M.D.,'12 and Thomas L. Maddux, C.C.D.C.R.'
' Department of Psychiatry, Department of VeteransAffairs Medical Center, Minneapolis, Minnesota 554 1 7 *Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota 55455
ABSTRACT We adminstered the Derogatis Sexual Functioning Inventory to 25 methadone maintenance patients who had been on a stable dose of methadone for at least 2 months, and obtained ratings of depression and anxiety, levels of sex hormones, and liver function tests. Five subjects with significantly lower Global Sexual Satisfaction Index scores (p < .OO01) had more psychological symptoms, higher methadone doses, poorer body image, and less sexual drive and satisfaction, but normal fund of sexual information and lifetime experience. Sexual dysfunction among methadone maintenance patients may be due to coexisting psychiatric problems rather than caused by opiates. Methadone patients presenting with sexual dysfunction should receive psychiatric evaluation. Key words. Methadone maintenance; Sexual dysfunction; Depression; Anxiety *TO whom correspondence should be addressed at Psychiatry Service (ll6-A), DVA Medical Center, 1 Veterans Drive, Minneapolis, Minnesota 55417. Telephone: (612) 725-2000, ext. 3978. I325 Copyright 01992 by Marcel Dekker, Inc.
1326
SPRING, WILLENBRING, AND MADDUX
Subst Use Misuse Downloaded from informahealthcare.com by Chulalongkorn University on 01/09/15 For personal use only.
INTRODUCTION Sexual dysfunction has long been associated with opiate use (Abel, 1984; Smith et al., 1980; Cushman, 1972; Bloom and Butcher, 1970). However, most surveys to date have been reports of symptoms among patients and have generally not compared opiate users to control groups. As part of a larger study of prolactin in opiate use, we administered a standardized sexual behavior inventory to a group of methadone maintenance patients.
SUBJECTS AND METHODS In 1987, 25 methadone maintenance patients out of 40 eligible volunteered to be in the study. Subjects were deemed eligible if they had been on a constant dose of methadone for at least 2 months and had adequate venous access. They were told that preliminary research had revealed that methadone maintenance patients sometimes had high levels of the hormone prolactin and that because elevated prolactin levels were known to cause psychological symptoms and sexual dysfunction in other populations, we wanted to find out if these problems were related. They were given the Derogatis Sexual Function Inventory (DSFI) (Derogatis and Melisaratos, 1979). The reliability and validity of the DSFI have been thoroughly established in normal and sexually dysfunctional populations of both sexes (Derogatis and Melisaratos, 1979). The test is a selfreport measure that requires about an hour to complete. There were occasional subjects who asked the monitoring nurse how to interpret certain questions. The DSFI has 10 subscales, each of which focuses on one aspect of psychosexual functioning. Subscale descriptions derived from the scoring manual (Derogatis, 1975) and Derogatis (1983) are as follows: 1. Information: Twenty-six true-false items measuring the person’s general fund of information about sexual functioning. 2. Experience: The number of various sexual experiences reported within the past 60 days and over the individual’s lifetime. 3 . Drive: Five items reflecting actual frequencies of four categories of sexual behavior and the preferred frequency of intercourse. 4. Attitude: Thirty items representing degrees of sexual liberalism or conservatism, liberalism being scored in the positive direction. 5. Symptoms: A psychological symptom inventory (the Brief Symptom Inventory). 6 . Afects: A scale comprised of affect-descriptive adjectives (the Affects Balance Scale), scored by subtracting the total negative affects score from the total positive affects score.
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SEXUAL DYSFUNCTION A N D PSYCHOLOGICAL DISTRESS
I327
7. Gender Role DeBnition: A scale consisting of adjectives descriptive of traditionally masculine and feminine behavior traits. The individual reports the degree to which each adjective fits him or her. The score reflects the magnitude of the difference between masculinity and femininity scores, i.e. polarization of gender role. 8. Fantasy: Twenty items depicting fantasy themes, scored as the number of themes having been experienced in daydreams or while asleep. 9. Body Image: Fifteen items reflecting satisfaction with the appearance and attractiveness of one’s body. 10. Satisfaction: Ten true-false statements reflecting satisfaction with specific aspects of sexual behavior. 1 1 . Global Sexual Satisfaction Index (GSSI):A nine-point scale rating the individual’s global satisfaction with his or her present sexual relationship. In order to improve accuracy of data, we asked for ratings of recent sexual experience in the last 30, rather than 60, days. We then compared the DSFI standized ( T ) scores of subjects against the norms provided with the instrument. The Hamilton Depression (Ham-D) (Hamilton, 1960) and Anxiety (Ham-A) (Hamilton, 1969) scales were administered to assess levels of psychological distress. Blood was drawn prior to the daily dose of methadone for determination of serum prolactin, testosterone, FSH, and LH. Samples were assayed by commercial radioimmunoassay kits in the hospital clinical laboratory. Student’s t-tests with Bonferroni correction for multiple tests were used on continuous variables to assess the significance of differences between subjects measuring high and low on the GSSI scale. Pearson product-moment correlations were used to assess the relationships among the DSFI subscales, the methadone dose, the hormone levels, and the psychological rating instruments.
RESULTS Of the 25 participants, the mean methadone dose was 58.0 f 9.1 mg, range 40-75 mg. Mean age was 39.0 f 6.9 years, range 30-60 years. Of the nonparticipants, the mean methadone dose was 62.7 f 11.8 mg, range 25-75 mg ( t = 1.56, df = 47, p = .1262); the mean age was 43.6 f 9.7 years, range 31-64 years ( t = 1.93, df = 47, p = .0597). (See Table 1.) Mean subscale scores on the DSFI were within one standard deviation of normal group means on all but three subscales: sexual experience in the past 30 days, T = 31; affects scale, T = 38; and role definition scale, T = 32 (a T score of 50 means that the individual scored at the midpoint of the normative sample. Each standard deviation is 10 points). Mean ( f SD) Ham-D score was
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SPRING, WILLENBRING, AND MADDUX
Table 1. Subject Background Characteristics
Standard deviation
Range
1.38
30-60
1.12
10-15
21.2 17.5
4.3 6.98
15-31 5-40
100 48 32 32 28 3.16
3.48
0-13
33.4 32.9 58.0
9.27 5.03 1.81
22-60 2-84 40-75
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Mean Sex, % male Age, years Ethnicity: % White % Black Urbanization: % urban % rural Education, years Vocational class: % skilled labor % unskilled labor Unemployment (current) Living situation, % living alone Psychiatric diagnoses (current), % Medical problems (current), % Legal problems (history of), % Substance abuse history: Initial age of use, years Duration of use, years Drugs used (history of), %: Opiates Alcohol Marijuana Benzodiazepines Cocaine Treatments for substance abuse, number Methadone maintenance history: Age first enrolled, years Months enrolled in this program Methadone dose, milligrams
100 39.0 88 12 84 16 12.2 28 12 36 24 44 32 80
11.5 f 6.7; Ham-A mean score was 9.3 f 6.0, indicating generally mild depression and anxiety symptoms. Mean hormone levels were all within normal reference limits for our laboratory; however, the testosterone level was negatively correlated with methadone dose ( r2 = - .3723; p < .01). Hamilton Depression ( r 2 = - ,6384; p < .001) and Anxiety ( r = - .5099;p c .00l) scale scores were negatively correlated with the DSFI global satisfaction subscale, as was methadone dose ( r 2 = - .4122; p < .001). The Global Sexual Satisfaction Index (GSSI) does not have any “abnormal” values on the low end; a score of 0 still falls within 2 standard deviations of the mean. However, upon examination of the distribution of scores, a subset of five patients appeared to have distinctly lower GSSI scores, compared with
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SEXUAL DYSFUNCTION AND PSYCHOLOGICAL DISTRESS
I329
the rest of the group (low group = 0.80 f 0.45; high group = 4.4 f 1.3; r = 5.73, df = 23, p < .OOOl). We then compared these two groups on all variables (Tables 2 and 3). The low GSSI group had higher methadone doses and more depression and anxiety. On the DSFI, the low GSSI group reported less sexual drive and satisfaction, and more psychological symptoms, negative affect, and body image, but normal information and lifetime experience. Examination of the clinical records and interviews with the counselor familiar with the subjects revealed that the low GSSI group tended to have diagnoses of coexisting anxiety and/or affective disorders, and were seen by the counselor as compliant but more troubled than the high GSSI group in such areas of their lives as jobs and relationships. They generally made more extensive use of counseling than other patients. Several of the patients had sexual identity and/or relationship issues as well. Records of random drug screens revealed no differences between high and low GSSI subjects in number of positive drug screens or types of drugs observed.
DISCUSSION Our findings suggest that sexual dysfunction among methadone maintenance patients may be present in a subgroup of psychiatrically symptomatic patients rather than more continuously distributed among the population. These Table 2. Descriptive Information in Two Groups of Methadone Maintenance Patients. Patients Were Grouped by Inspection of the Distribution of DSFI Global Sexual Satisfaction Index (GSSI) Score; the Bottom Five Stood Out Clearly from the Rest. All Laboratory Values Refer to Serum Samples. Values Are Means with Standard Deviations in Parenthesesa
Variables Age (years) Dose (mg)* Months in program Positive weekly urine drug screens (%) Prolactin (ng/mL) Testosterone (ng/dL) Aspartate aminotransferase (IUIL) Gamma glutamate aminotransferase (IU/L) Luteinizing hormone (bIU/ml) Follicle stimulating hormone (pIU/ml) Hamilton Depression Scale** Hamilton Anxiety Scale**
Low GSSI score (n = 5)
High GSSI score ( n = 20)
39.5 (5.4) 66.0 (7.4) 40.8 (30.5) 20 7.8 (3.5) 558 (320) 26.0 (11.4) 60.4 (55.1) 17.7 (9.9) 11.3 (5.5) 19.4 (5.4) 15.6 (6.5)
38.8 (7.3) 56.0 (8.5) 30.9 (47.3) 25 7.5 (5.7) 570 (238) 40.5 (55.3) 43.8 (55.7) 24.1 (12.9) 14.7 (15.3) 9.6 (5.5) 7.8 (4.8)
aSignificance level by t-test with Bonferroni correction for multiple tests: *p < 0.05; **p < 0.01.
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Table 3.
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DSFI Scale Scores in Methadone Maintenance Patients Grouped by the Global Sexual Satisfaction Index (GSSI) Score. Values Are Means with Standard Deviations in Parenthesesa
DSFI Scale scores Information Experience: Lifetime Past 30 days Drive** Attitude Symptoms* Affects** Role Definition Fantasy Body Image** Satisfaction* GSSI***
Low GSSI score (n = 5)
High GSSI score ( n = 20)
21.6(1.5) 19.6 (8.2) 2.8 (3.6) 8.8 (3.7) 21.8 (7.3) 1.07 (0.7) -0.15 (1.0) 10.0 (2.2) 5.8 (3.4) 23.2 (4.3) 5.6 (2.6) 0.8(0.45)
19.8 (2.3) 19.3 (2.9) 8.8 (7.5) 16.8 (4.4) 16.6 (11.7) 0.44 (0.39) 0.79 (0.57) 5.7 (5.1) 5.2 (2.5) 16.9 (4.2) 7.8 ( I .6) 4.4(1.3)
aSignificance by f-test with Bonferroni correction for multiple tests: *p .05; **p < .01; ***p < ,001.
