Due to the quickly developing and changing pattern of substance usage in Egypt, addiction is a big issue [28]. Tramadol is a commonly abused narcotic, particularly among the young and middle aged [47].
The current study is a case-control study involving 67 tramadol male abusers hospitalized to Assiut University Hospital between January 1 and June 30, 2017, and 67 healthy male non-abusers. The abusers’ average age was30.46 ± 6.14 years, and more than half of them (56.7%) were between the ages of 25 and 35. This finding was similar to another study done by Maruf et al. [36] in Dhaka, Bangladesh, which found that about half of the abusers (50.5%) were between the ages of 21 and 30, while about a quarter were between the ages of 31 and 40. This could be explained by the fact that persons over the age of 40 are not frequently exposed to new medications in the same way that young people are [53]. Furthermore, young individuals are more prone to be active substance abusers and to be affected by substance abuse issues [54].
In the current study, the majority of abusers (58.2%) were unemployed. These findings were supported by Colpaert et al. [14], who stated that the high prevalence of substance abuse among free workers (e.g., mechanics and technicians) can be attributed to their lower education and socioeconomic status, as well as the relatively high income that is directed to substance use rather than other productive activities.
The majority of abusers (64.2%) in the current study came from rural areas, while the rest came from metropolitan areas (35.8%). This may be due to the fact that rural populations make up 72.8% of the Assiut Governorate’s population [21]. This was in contrast to Hamdi’s [28] findings, which revealed that those from rural backgrounds were the least likely to use substances in Egypt, including Upper Egypt.
In terms of educational attainment, nearly half of the abusers (46.3%) were secondary-technical school graduates, with university graduates accounting for 31.3%. This conclusion matched a cross-sectional research of students from secondary or technical schools in Assiut province, which found that 11.6% of pupils tested positive for bango misuse [55]. In contrast to the current findings, a study conducted in Zagazig found no statistically significant link between substance abusers and their degree of education [39]. Another study in Damghan, Iran’s Semnan region, found no link between tramadol addiction and academic performance [43].
In terms of marital status, married people made up 59.7% of the sample, while singles, divorced people, and separated people made up 32.8, 6, and 1.5%, respectively. The off-label usage of tramadol to improve premature ejaculation and increase sexual satisfaction could explain these findings [47]. Those findings are similar to those published by Dawood [17], who found that 49.2% of relapsed drug dependents in Baghdad were married, with the author attributing this to an inability to confront marital problems.
In terms of conventional family structure, the biggest percentage of abusers (46.3%) lived with non-extended family, followed by 44.8% who lived with extended family and 8.9% who lived alone in the current study. This finding corroborated Dew et al. [18] findings, which suggested that changes in conventional family structures and the weakening of parental connections may contribute to substance dependence. Furthermore, in most Arabic countries, most young adults live with their parents until they marry, and familial relationships are highly prized [25].
In this study, the youngest siblings accounted for nearly half of the abusers (43.3%), whereas the middle siblings and eldest siblings accounted for 35.8% and 20.9%, respectively. Last-born children had the highest risk of becoming drug dependents and are overrepresented in psychiatric populations, according to Eckstein and Kaufman [19]. This risk is explained by the fact that younger siblings are frequently reared as pampered children, robbing the youngster of his or her independence. Psychological dependence can lead to substance abuse, and older siblings may expose a later-born child to abused substances at a younger age [9].
The current study found that in 71.64% of cases, the number of family members were between 5 and 10. Due to the parents’ inability to control their children, the size of the family plays an essential role as a risk factor for substance misuse [22]. Inept parenting exposes children to a variety of threats, including substance misuse and other crimes [3].
According to the findings, 52.2% of the participants had a positive family history of substance misuse. This could be due to adolescent maltreatment, which is prevalent solely because of family history [2].
Early initiation of substance misuse raises the chance of psychosocial issues in a variety of areas of life, including behavior, psychiatric disorders, family, peer relationships, and work adjustment [42]. The current investigation discovered a strong relationship between the average age of first substance abuse and the substance utilized. Single substance abusers (tramadol only) had a greater age (23.65 ± 5.46 years) than multiple substance abusers (19.80 ± 5.75 years). Early-onset substance abuse has been linked to a high rate of polysubstance misuse [52]. Injection was employed as a technique of abuse by 20.9% of abusers, according to our findings. By using needles and equipment previously used by others, injection is linked to greater rates of sickness and mortality, primarily due to bacterial, fungal, or viral infection [34].
One of the major areas of research around the world is the effects of drug dependence on sexual functioning and sex hormones [29]. In humans, opioids have been shown to lower testosterone levels [12]. Not all opioids have the same effect on testosterone levels; tramadol had no effect on plasma testosterone levels in rats [11]. In the current study, measurement of sex hormones in all subjects in the sample found that abusers had considerably lower testosterone and LH levels than non-abusers. There was no statistically significant difference in the mean value of FSH between abusers and non-abusers, on the other hand.
Opioids bind to specific receptors in the hypothalamus and pituitary gland, impair the pulsatile release of corticotrophin-releasing hormone and adrenocorticotropic hormone, and interfere with the generation of cortisol and androgen precursors, according to Auernhammer et al. [5]. Testosterone levels are also lowered as a result of direct testosterone production inhibition in the testes [15]. Chan et al. [13] further suggest that tramadol may cause adrenal insufficiency as a result of continuous use, which would explain the decrease in serum testosterone levels. Chronic tramadol administration causes considerable harm to testicular tissue, according to [4]. Tramadol has been shown to impact male reproductive hormones by lowering serum testosterone and gonadotrophins while raising estradiol and prolactin levels.
A case-control study conducted at Ain Shams University in Cairo, Egypt, to assess the effect of bhang and opium addiction on hypothalamic pituitary gonadal axis hormones found a significant decrease in serum total testosterone, FSH, LH, and prolactin in male addicts when compared to the control group [48]. In addition, a study on adult male Albino rats found that tramadol administration resulted in a considerable fall in testosterone levels, as well as a gradual decline in LH and FSH, as compared to the control group [56].
In tramadol-treated mice, Salah et al. [46] found a drop in blood testosterone, FSH, and LH levels as well as a rise in serum prolactin. Furthermore, long-term tramadol administration has been shown to have negative effects on sperm quality and testicular tissues in mice, with dose-dependent effects [6]. Both endogenous and exogenous opioids are known to cause hypogonadism via binding to opioid receptors in the hypothalamus and pituitary gland. This causes GnRH to be released less frequently, resulting in less LH and FSH being released from the pituitary and, as a result, less testosterone being produced [44].
An experimental investigation on laboratory rabbits, in contrast to the current study, found that tramadol administration resulted in a large drop in FSH while a considerable increase in LH. The effect of opioids on sex hormone release was found to be poorly understood, according to these experts [40].
The results of this investigation showed that there was no link between tramadol dependence and hormone decrease. Tramadol was found to significantly suppress testosterone, LH, and FSH in male rats after 20 and 30 days of therapy, corroborating the current findings [20]. Another study found a decrease in testosterone levels in male Sahel goats in Maiduguri, Nigeria, during the first week of tramadol administration [8]. Caju [10] found that albino rats exposed to acute and chronic morphine dosages have less Sertoli and Leydig cells. In contrast to our findings, a case-control research conducted at Assiut University Hospital in Assiut, Egypt, to investigate the effect of tramadol dependence on sex hormones found a statistically significant link between the severity of male sex hormone reduction and the duration of tramadol misuse [16].
In contrast to our study, another case-control study conducted at Tanta University in Tanta, Egypt, to assess the impact of chronic tramadol administration on sexual functions in tramadol-dependent males found that as tramadol daily dose and duration increased, there was a significant decrease in serum testosterone and an increase in serum prolactin level [32], and other case-control study conducted at Benha University in Benha, Egypt, to determine the possible gonadotoxic effects of tramadol dependence on seminal fluid parameters, prolactin, and testosterone hormone levels revealed a significant increase in erectile dysfunction (ED) and decreased libido in the tramadol-dependent group. In addition, the serum testosterone level in this group was lower, although the serum prolactin level was significantly greater. Except for aberrant forms, which were high in the dependent group, all semen parameters were low in the dependent group. The preceding parameter became more negative when the tramadol dose was raised, whereas ED, libido, semen volume, and concentration remained the same. Increased tramadol treatment time was similarly associated with a worsening of these measures [51].