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NATIONAL INSTITUTE ON ABUSE Research Report SERIES Persistent reports of anabolic abuse by professional , many of whom are regarded as role models by young people, highlight the fact that we are now facing a very damaging message in our society— that bigger is better, and being the best is more important than how you get there. Abuse of anabolic differs from the abuse of other illicit sub- stances because the initial abuse of anabolic steroids is not driven by the immediate that accompanies most of abuse, such as , , and marijuana, but by the What are Anabolic steroids were devel- desire of abusers to change their oped in the late 1930s primarily appearance and performance, characteristics of great importance anabolic steroids? to treat , a condi- to adolescents. The effects of steroids nabolic steroids” is the tion in which the testes do not can boost confidence and strength, “ familiar name for synthetic produce sufficient leading abusers to overlook the poten- tial serious and long-term damage Asubstances related to the for normal growth, development, that these substances can cause. male sex (e.g., testos- and sexual functioning. The r While anabolic steroids can terone). They promote the growth primary medical uses of these enhance certain types of performance of (anabolic compounds are to treat delayed o or appearance, they are dangerous drugs, and when used inappropriately effects) and the development , some types of impo- t they can cause a host of severe, of male sexual characteristics tence, and wasting of the body long-lasting, and in some cases, c irreversible negative health conse- (androgenic effects) in both males caused by HIV infection or other quences. Anabolic steroids can lead and females. The term “anabolic diseases. to early attacks, , e steroids” will be used through- During the 1930s, scientists tumors, , and serious out this report because of its discovered that anabolic steroids r psychiatric problems. In addition, familiarity, although the proper could facilitate the growth of i because steroids are often injected, users who share needles or use non- term for these compounds is skeletal muscle in laboratory sterile techniques when they inject “anabolic-androgenic steroids.” animals, which led to abuse of d steroids are at risk for contracting dangerous infections, such as HIV/AIDS and B and C. I hope that students, parents, 12th-Graders’ Perceived Harmfulness of Steroid Use e teachers, coaches, and others will take advantage of the information 80% about anabolic steroids found on h the NIDA Web site (www.steroid- 68.1%

t 60 abuse.gov) and join us in our 62.1% prevention and education efforts. 57.9% 58.9% 57.1% 55.0% 55.7% 56.8% Participating in offers many 40 benefits, but young people and adults should not take unnecessary health

m risks in an effort to win. 20

Nora D.Volkow,M.D.

o 0 Director 1998 1999 2000 2001 2002 2003 2004 2005

r National Institute on Drug Abuse Source: 2005 Monitoring the Future Survey. f

U.S. Department of Health and Human Services • National Institutes of Health 2NIDA RESEARCH REPORT SERIES

the compounds first by body- builders and weightlifters and What is the scope Why do people then by athletes in other sports. of steroid use in abuse abuse has become so widespread in athletics that it the United States? steroids? can affect the outcome of sports he 2005 Monitoring the ne of the main reasons contests. Future study, a NIDA-funded people give for abusing Illicit steroids are often sold at Tsurvey of drug use among steroids is to improve their adolescents in middle and high O gyms, competitions, and through athletic performance. Among mail order operations after being schools across the United States, athletes, steroid abuse has been smuggled into this country. Most reported that past year use of estimated to be less that 6 per- illegal steroids in the United States steroids decreased significantly cent according to surveys, but are smuggled from countries that among 8th- and 10th-graders anecdotal information suggests do not require a prescription for since peak use in 2000. Among more widespread abuse. the purchase of steroids. Steroids 12th-graders, there was a differ- Although testing procedures are are also illegally diverted from ent trend—from 2000 to 2004, now in place to deter steroid U.S. pharmacies or synthesized in past year steroid use increased, abuse among professional and but in 2005 there was a signifi- clandestine laboratories. Olympic athletes, new designer cant decrease, from 2.5 percent drugs constantly become avail- to 1.5 percent. Steroid abuse affects individu- able that can escape detection What are steroidal als of various ages. However, it and put athletes willing to cheat supplements? is difficult to estimate the true one step ahead of testing efforts. This dynamic, however, may n the United States, supple- prevalence of steroid abuse in be about to shift if the saving ments such as tetrahydro- the United States because many of and blood samples (THG) and data sources that measure drug I abuse do not include steroids. for retesting at a future date (street name becomes the standard. The high “Andro”) previously could be Scientific evidence indicates that anabolic steroid abuse among probability of eventual detection purchased legally without a athletes may range between one of the newer designer steroids, prescription through many and six percent. once the technology becomes commercial sources, including health food stores. Steroidal supplements can be converted Commonly Abused Steroids into testosterone or a similar compound in the body. Less is known about the side effects of Oral Steroids Injectable Steroids steroidal supplements, but if I Anadrol I Deca-Durabolin large quantities of these com- () ( decanoate) pounds substantially increase I I Durabolin testosterone levels in the body, Oxandrin (nandrolone phenpropionate) then they also are likely to pro- () I duce the same side effects as I Dianabol Depo-Testosterone anabolic steroids themselves. The (methandrostenolone) () purchase of these supplements, I Equipoise with the notable exception of I Winstrol ( undecylenate) (DHEA), () became illegal after the passage I (THG) in 2004 of amendments to the Controlled Substances Act. NIDA RESEARCH REPORT SERIES 3

Annual Prevalence of Steroid Use Among Males , stacking, and pyramiding Grades 8, 10, 12 Steroids are often abused in 3.5% patterns called “cycling,” which 3.0 involve taking multiple doses of 2.5 steroids over a specific period of time, stopping for a period, 2.0 and starting again. Users also fre- 1.5 quently combine several different 1.0 types of steroids in a process 0.5 known as “stacking.” Steroid 0.0 abusers typically “stack” the 8th Grade 10th Grade 12th Grade drugs, meaning that they take Source: 2005 Monitoring the Future Survey. two or more different anabolic steroids, mixing oral and/or available, plus the fear of who had been raped reported injectable types, and sometimes retroactive sanctions, should give that they markedly increased even including compounds that athletes pause. their activities are designed for veterinary use. Another reason people give after the attack. They believed Abusers think that the different for taking steroids is to increase that being bigger and stronger steroids interact to produce an their muscle size or to reduce would discourage further attacks effect on muscle size that is their body fat. This group because men would find them greater than the effects of each either intimidating or unattractive. includes people suffering from drug individually, a theory that Finally, some adolescents the behavioral syndrome called has not been tested scientifically. abuse steroids as part of a pattern muscle dysmorphia, which causes Another mode of steroid abuse them to have a distorted image of high-risk behaviors. These is referred to as “pyramiding.” of their bodies. Men with muscle adolescents also take risks such This is a process in which users dysmorphia think that they look as drinking and driving, carrying slowly escalate steroid abuse small and weak, even if they are a gun, driving a motorcycle with- (increasing the number of ste- large and muscular. Similarly, out a helmet, and abusing other roids or the dose and frequency women with this condition think illicit drugs. Conditions such as that they look fat and flabby, muscle dysmorphia, a history of of one or more steroids used at even though they are actually physical or sexual abuse, or a one time), reaching a peak and muscular. history of engaging in high-risk amount at mid-cycle and gradu- Some people who abuse behaviors have all been associat- ally tapering the dose toward the steroids to boost muscle size ed with an increased risk of initi- end of the cycle. Often, steroid have experienced physical or ating or continuing steroid abuse. abusers pyramid their doses in sexual abuse. In one series of cycles of 6 to 12 weeks. At the interviews with male weight- beginning of a cycle, the person lifters, 25 percent who abused How are anabolic starts with low doses of the steroids reported memories of steroids abused? drugs being stacked and then childhood physical or sexual ome anabolic steroids are slowly increases the doses. In abuse. Similarly, female weight- taken orally, others are the second half of the cycle, the lifters who had been raped were injected intramuscularly, doses are slowly decreased to S zero. This is sometimes followed found to be twice as likely to and still others are provided in report use of anabolic steroids gels or creams that are applied to by a second cycle in which the or another purported muscle- the . Doses taken by abusers person continues to train but building drug, compared with can be 10 to 100 times higher without drugs. Abusers believe those who had not been raped. than the doses used for medical that pyramiding allows the body Moreover, almost all of those conditions. time to adjust to the high doses, 4NIDA RESEARCH REPORT SERIES

but lose hair. With contin- Annual Prevalence of Use of Steroids ued administration of steroids, 8th-Graders, 10th-Graders, and 12th-Graders some of these effects become irreversible. 2.5% 8th 10th Musculoskeletal system 2.0 Rising levels of testosterone and 12th 1.5 other sex hormones normally trigger the growth spurt that 1.0 occurs during puberty and ado- 0.5 lescence and provide the signals to stop growth as well. When a 0.0 2000 2001 2002 2003 2004 2005 child or adolescent takes anabolic Source: 2005 Monitoring the Future Survey. steroids, the resulting artificially high sex levels can and the drug-free cycle allows may be underrecognized or prematurely signal the to the body’s hormonal system time underreported, especially since stop growing. to recuperate. As with stacking, they may occur many years later. the perceived benefits of pyra- Data from animal studies seem Cardiovascular system Steroid abuse has been associated miding and cycling have not to support this possibility. One with cardiovascular diseases been substantiated scientifically. study found that exposing male (CVD), including heart attacks mice for one-fifth of their life- and strokes, even in athletes span to steroid doses comparable What are to those taken by human athletes younger than 30. Steroids con- the health caused a high frequency of early tribute to the development of deaths. CVD, partly by changing the consequences of levels of lipoproteins that carry steroid abuse? Hormonal system in the blood. Steroids, particularly oral steroids, increase nabolic steroid abuse has Steroid abuse disrupts the normal been associated with a production of hormones in the the level of low-density lipo- wide range of adverse side body, causing both reversible and (LDL) and decrease the A irreversible changes. Changes that level of high-density lipoprotein effects ranging from some that are physically unattractive, such can be reversed include reduced (HDL). High LDL and low HDL as and breast development production and shrinking levels increase the risk of athero- in men, to others that are life of the (testicular atrophy). sclerosis, a condition in which threatening, such as heart attacks Irreversible changes include fatty substances are deposited and liver . Most are rever- male-pattern baldness and breast inside arteries and disrupt blood sible if the abuser stops taking development () flow. If blood is prevented from the drugs, but some are perma- in men. In one study of male reaching the heart, the result nent, such as voice deepening in bodybuilders, more than half can be a heart attack. If blood females. had testicular atrophy and/or is prevented from reaching the Most data on the long-term gynecomastia. brain, the result can be a . effects of anabolic steroids in In the female body, anabolic Steroids also increase the risk humans come from case reports steroids cause masculinization. that blood clots will form in rather than formal epidemiologi- Breast size and body fat decrease, blood vessels, potentially disrupt- cal studies. From the case the skin becomes coarse, the ing blood flow and damaging the reports, the incidence of life- enlarges, and the voice heart muscle so that it does not threatening effects appears to be deepens. Women may experience pump blood effectively. low, but serious adverse effects excessive growth of NIDA RESEARCH REPORT SERIES 5

Liver acts or property crimes generally Steroid abuse has been associated report that they engage in these Possible Health with liver tumors and a rare behaviors more often when they Consequences of condition called , take steroids than when they Anabolic Steroid Abuse in which blood-filled cysts form are drug free. A recent study in the liver. Both the tumors and suggests that the mood and the cysts can rupture, causing behavioral effects seen during Hormonal system I internal bleeding. anabolic-androgenic steroid men abuse may result from secondary • Skin hormonal changes. • breast development Steroid abuse can cause acne, Scientists have attempted to • shrinking of the testicles • male-pattern baldness cysts, and oily hair and skin. test the association between I women anabolic steroids and • enlargement of Infections by administering high steroid the clitoris Many abusers who inject ana- doses or placebo for days or bolic steroids may use nonsterile • excessive growth weeks to human volunteers and of body hair techniques or share then asking the people to report contaminated needles with other • male-pattern baldness on their behavioral symptoms. abusers. In addition, some To date, four such studies have Musculoskeletal system steroid preparations are manufac- I been conducted. In three, high (if taken tured illegally under nonsterile steroid doses did produce greater by adolescents) conditions. These factors put I tendon rupture feelings of and aggres- abusers at risk for acquiring life- sion than did placebo, although threatening viral infections, such Cardiovascular system I increases in LDL; as HIV and hepatitis B and C. the effects appear to be highly decreases in HDL Abusers also can develop endo- variable across individuals. In I high carditis, a bacterial infection that one study, the drugs did not I heart attacks causes a potentially fatal inflam- have that effect. One possible explanation, according to the I enlargement of the heart’s mation of the inner lining of left the heart. Bacterial infections researchers, is that some but also can cause pain and abscess not all anabolic steroids increase Liver formation at injection sites. irritability and aggression. I cancer Recent animal studies show I peliosis hepatis an increase in aggression after I tumors steroid administration. What effects do Skin anabolic steroids In a few controlled studies, I severe acne and cysts have on behavior? aggression or adverse, overt I oily scalp behaviors resulting from the I ase reports and small studies administration of anabolic steroid I fluid retention indicate that anabolic use have been reported by a steroids, when used in high minority of volunteers. Infection C I HIV/AIDS doses, increase irritability and In summary, the extent to I aggression. Some steroid abusers which steroid abuse contributes hepatitis report that they have committed to and behavioral disor- Psychiatric effects aggressive acts, such as physical ders is unknown. As with the I rage, aggression fighting or armed robbery, theft, health complications of steroid I vandalism, or burglary. Abusers abuse, the prevalence of extreme I who have committed aggressive cases of violence and behavioral 6NIDA RESEARCH REPORT SERIES

disorders seems to be low, but anabolic steroid withdrawal have it may be underreported or been known to persist for a year NIDA-funded underrecognized. or more after the abuser stops prevention research Research also indicates that taking the drugs. some users might turn to other helps reduce drugs to alleviate some of the What can be done steroid abuse. negative effects of anabolic more sophisticated steroids. For example, a study to prevent steroid approach has shown of 227 men admitted in 1999 to promise for preventing a private treatment center for abuse? A steroid abuse among players addiction to heroin or other ost prevention efforts on high school sports teams. found that 9.3 percent in the United States The Adolescents Training and had abused anabolic steroids Mtoday focus on athletes Learning to Avoid Steroids before trying any other illicit involved with the Olympics and (ATLAS) program is showing drug. Of these 9.3 percent, 86 professional sports; few school high school players that percent first used opioids to districts test for abuse of illicit they do not need steroids to counteract insomnia and irrita- drugs. It has been estimated that build powerful muscles and bility resulting from anabolic close to 9 percent of secondary improve athletic performance. steroids. schools conduct some sort of By educating student athletes drug testing program, presum- about the harmful effects of Are anabolic ably focused on athletes, and anabolic steroids and providing that less than 4 percent of the nutrition and weight-training steroids addictive? Nation’s high schools test their alternatives to steroid use, the n undetermined percent- athletes for steroids. Studies are ATLAS program has increased age of steroid abusers may currently under way to determine football players’ healthy behaviors become addicted to the whether such testing reduces and reduced their intentions to A abuse steroids. In the program, drugs, as evidenced by their drug abuse. continued abuse despite physical Research on steroid educa- coaches and team leaders teach problems and negative effects tional programs has shown that the harmful effects of anabolic on social relations. Also, steroid simply teaching students about steroids and other illicit drugs on abusers typically spend large steroids’ adverse effects does not immediate sports performance, amounts of time and money convince adolescents that they and discuss how to refuse offers obtaining the drugs, which is can be adversely affected. Nor of drugs. another indication that they may does such instruction discourage Studies show that 1 year after be addicted. Individuals who young people from taking completion of the program, compared with a control group, abuse steroids can experience steroids in the future. Presenting ATLAS-trained students in 15 withdrawal symptoms when both the risks and benefits of high schools had: they stop taking steroids, such anabolic steroid use is more as mood swings, fatigue, restless- effective in convincing adoles- I Half the incidence of new abuse of anabolic steroids ness, loss of , insomnia, cents about steroids’ negative and less intention to abuse reduced sex drive, and steroid effects, apparently because them in the future; cravings. The most dangerous the students find a balanced I Less abuse of , of the withdrawal symptoms is approach more credible, accord- marijuana, , , because it sometimes ing to the researchers. leads to attempts. If left and ; untreated, some depressive I Less abuse of “athletic symptoms associated with enhancing” supplements; NIDA RESEARCH REPORT SERIES 7

I Less likelihood of engaging Health Services Administration in hazardous have endorsed ATLAS and Where can I get behaviors such as drinking ATHENA as model prevention further scientific and driving; programs. These Oregon Health & Science University programs information about I Increased protection against steroid and other substance have been awarded the 2006 steroid abuse? abuse. Namely, less interest in annual Sports Illustrated maga- o learn more about anabolic trying steroids, less desire to zine’s first-ever “Champion steroids and other drugs of abuse them, better knowledge Award.” Tabuse, contact the National of alternatives to steroid abuse, Clearinghouse for Alcohol and improved body image, and What treatments Drug Information (NCADI) at increased knowledge of diet 800-729-6686. Information supplements. are effective for specialists are available to help you locate information and The Athletes Targeting Healthy anabolic steroid resources. Exercise and Nutrition Alternatives abuse? Fact sheets, including (ATHENA) program was patterned InfoFacts, on the health effects of ew studies of treatments for after the ATLAS program, but anabolic steroids, other drugs of anabolic steroid abuse have designed for adolescent girls on abuse, and other drug topics are been conducted. Current sports teams. Early testing of girls F available on the NIDA Web site knowledge is based largely on (www.drugabuse.gov), and can enrolled in the ATHENA program the experiences of a small showed significant decreases in be ordered free of charge in number of physicians who have English and Spanish from NCADI risky behaviors. While preseason worked with patients undergoing at www.health.org. risk behaviors were similar steroid withdrawal. The physi- among controls and ATHENA cians have found that supportive participants, the control athletes therapy is sufficient in some Access information were three times more likely to cases. Patients are educated on the Internet begin using diet pills and almost about what they may experience • What’s new on the NIDA Web site twice as likely to begin abuse of during withdrawal and are • Information on drugs of abuse other body-shaping substances, evaluated for suicidal thoughts. • Publications and communications including amphetamines, anabolic If symptoms are severe or pro- (including NIDA NOTES) steroids, and muscle-building longed, or hospital- • Calendar of events supplements during the sports ization may be needed. • Links to NIDA organizational units season. The use of diet pills Some medications that have • Funding information (including program announcements and deadlines) increased among control subjects, been used for treating steroid • International activities while use fell to approximately withdrawal restore the hormonal • Links to related Web sites half of the preseason levels system after its disruption by (access to Web sites of many other among ATHENA participants. In steroid abuse. Other medications organizations in the field) addition, ATHENA team members target specific withdrawal symp- were less likely to be sexually toms—for example, antidepres- NIDA Web Sites active, more likely to wear seat- sants to treat depression and www.drugabuse.gov belts, less likely to ride in a car for headaches and www.steroidabuse.gov with a driver who had been muscle and joint pains. www.clubdrugs.gov drinking, and they experienced Some patients require assis- www.hiv.drugabuse.gov fewer during the sports tance beyond pharmacological www..drugabuse.gov season. treatment of withdrawal symp- NCADI Both Congress and the toms and are treated with Web Site: www.health.org Substance Abuse and Mental behavioral therapies. Phone No.: 800-729-6686 8NIDA RESEARCH REPORT SERIES

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