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RESEARCH to PRACTICE

Anabolic-Androgenic Steroid Abuse

Lymperis (Perry) Koziris, PhD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 12 - DECEMBER 2000


Substance abuse is a major public health concern. Among healthcare professionals involved in sports and exercise, a specific goal is to reduce steroid use among adolescents. According to the Healthy People 2010 report (1), the estimated percentage of US male high school seniors using anabolic-androgenic steroids (AAS) declined from 4.7% in 1989 to 4.1% in 1997. Estimates for 1998 were lower: 2.8% for male and 0.3% for female high school seniors. Some studies have suggested that the actual usage rates are higher than published ones because of underreporting (2). The 2010 target is 0.4% (for combined male and female adolescent rates).

Risks and Warning Signs

AAS treatment does have legitimate uses. In addition to being used in androgen-deficient males, AAS may be a viable therapy for chronic wasting diseases, conditions such as anemia, cachexia, and glucocorticoid-induced wasting (3,4), and musculoskeletal injuries (5).

Negative side effects. Although replacing physiologic levels of circulating testosterone may have no serious risk, long-term treatment with high doses of AAS is linked to many negative side effects in both sexes (table 1) (6,7). Also, when risky injection practices are used—for example, sharing needles—the risk of transmission of human immunodeficiency virus and other infections is elevated.


TABLE 1. Negative Side Effects of Anabolic-Androgenic Steroid Use


General
Severe acne
Edema
Glucose intolerance and insulin resistance
Hair loss
Hepatotoxicity
Increased risk of cardiovascular disease from:
    Elevated hematocrit
    Decreased level of HDL cholesterol
    Hypertension
    Increased level of LDL cholesterol
Increased risk of connective tissue damage
Premature epiphyseal plate closure
Thyroid hormone profile alteration
Suppression of luteinizing hormone and follicle-stimulating hormone

Male-Specific
Gynecomastia
Increased risk of prostate cancer
Testicular atrophy (with accompanying effects on sperm number, form, and function)

Female-Specific
Oligomenorrhea or amenorrhea
Reversible masculinizing effects:
    Breast shrinkage
    Voice deepening and coarsening
Irreversible masculinizing effects:
    Clitoral enlargement
    Hirsutism
    Male-pattern baldness


HDL = high-density lipoprotein; LDL = low-density lipoprotein


An altered psychological profile from steroid abuse has received more notice. It manifests as increased irritability or aggressive behavior in many and as irrational or violent behavior in a few. The latter is commonly referred to as "'roid rage."

Recognizing abuse. Because an adolescent may be more likely to discuss certain issues with a medical professional than with parents, the primary care provider is in an important position to intervene. The first step in diagnosis is to include questions about AAS use in medical history questionnaires. A patient, however, may be reluctant to admit AAS use because in 1990 the drugs were reclassified as a schedule 3 controlled substance and are also banned in sports competition. Therefore, the clinician must recognize the most common physical signs in addition to the rapid, pronounced skeletal muscle hypertrophy.

Most male AAS users exhibit some combination of acne, gynecomastia, and striae. Other obvious symptoms can include edema and evidence of injections in the buttocks or thighs and, for females in particular, virilizing effects. It may also be useful to conduct routine psychological fitness exams. On the one hand, similarities exist in intervention strategies for other substance abuse, and AAS abuse may be a part of a larger problem with illicit drugs. On the other hand, the paradoxical aspect of AAS abuse is that many abusers are otherwise health-conscious persons who use a mix of muscle-building drugs. The most effective form of treatment and prevention may be an educational approach that describes all the potential negative consequences and presents the fact that actual use is lower among their peers than patients perceive it to be. Furthermore, it acknowledges the efficacy of AAS but also emphasizes sports nutrition and training information (8).

Addressing AAS Abuse

For substance abuse other than that of alcohol, only 23% of family physicians regularly screened patients for any type of drug problem in 1992 (9). This total represents less than a third of the Healthy People 2000 target. Of the primary care provider groups surveyed, nurse practitioners had the highest inquiry rate in 1992 (43%) and were the only providers for whom an update (1997) was available. Unfortunately, by 1997 that rate had declined to 36%. Although drug-abuse treatment referral by nurse practitioners increased from 19% to 25% during the same period, the goal had been set at 75%. The fact that this objective has not been included in Healthy People 2010 is ironic because clinician screening, counseling, and referral can be major components of reducing adolescent AAS abuse. In its place is a pair of "developmental" objectives without any accompanying quantitative targets. One of these goals is to increase the number of people being referred for follow-up care after being diagnosed or treated for substance abuse in a hospital emergency department. The other is to increase the number of communities using comprehensive community-level substance abuse prevention programs.

Being mindful of privacy issues, the physician may consider contacting an athlete's coach to obtain additional information on the athlete's behavior. Practitioners should be aware, though, that a growing number of individuals use AAS for enhancing their body image rather than for improving their athletic performance. In extreme cases, this can take the form of compulsive bodybuilding and be described as a "reverse anorexia" or "Adonis complex," in which individuals are never satisfied in their quest for an extremely large and muscularly developed physique.

The Next Steps

Future research should strive to provide a better understanding of the psychological aspects of AAS abuse, including issues such as 'roid rage, reverse anorexia, and psychological and/or physiologic addiction. In the physiologic realm, additional research is needed to collect data from adolescent users rather than extrapolating rates from adult users' data.

References

  1. US Department of Health and Human Services: Healthy People 2010 (conference ed, 2 vol). Dept of Health and Human Services, 2000
  2. Yesalis CE: Incidence of anabolic steroid use: a discussion of methodological issues, in Yesalis CE (ed): Anabolic Steroids in Sport and Exercise. Champaign, IL, Human Kinetics, 1993, pp 49-69
  3. Hickson RC, Ball KL, Falduto MT: Adverse effects of anabolic steroids. Med Toxicol Adverse Drug Exp 1989;4(4):254-271
  4. Creutzberg EC, Schols AM: Anabolic steroids. Curr Opin Clin Nutr Metab Care 1999;2(3):243-253
  5. Di Pasquale MG: Anabolic steroids and injury treatment, in Torg JS, Welsh RP, Shephard RJ (eds): Current Therapy in Sports Medicine, ed 2. Toronto, Decker, 1990, pp 102-105
  6. Narducci WA, Wagner JC, Hendrickson TP, et al: Anabolic steroids: a review of the clinical toxicology and diagnostic screening. Clin Toxicol 1990;28(3):287-310
  7. Sturmi JE, Diorio DJ: Anabolic agents. Clin Sports Med 1998;17(2):261-282
  8. Yesalis CE, Cowart VS: The Steroid Game: An Expert's Inside Look at Anabolic Steroid Use in Sports. Champaign, IL, Human Kinetics, 1998
  9. National Center for Health Statistics: Healthy People 2000 Review, 1998-99. Hyattsville, MD, Public Health Service, 1999

Dr Koziris is an assistant professor in the department of kinesiology, health promotion, and recreation at the University of North Texas in Denton. Address correspondence to Perry Koziris, PhD, Dept of Kinesiology, Health Promotion, and Recreation, University of North Texas, Box 311337, Denton, TX 76203-1337; e-mail to [email protected].


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