Anabolic Steroid Use, Misuse And Addiction JASSIN M. JOURIA Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT The synthetic versions of the male hormone testosterone, also known as anabolic steroids, can play an important role in the treatment of health conditions when used as prescribed by a medical clinician. However, misuse of anabolic steroids occurs when these substances are used solely to improve physical appearance or performance. Because there are some potentially serious physical effects of anabolic steroid use, it is important that anabolic steroids are only used as prescribed and always under a medical clinician’s guidance. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacy content is 4 hours. Statement of Learning Need Health clinicians need to understand the varied uses of anabolic steroids, including those of body builders attempting to gain strength and muscle mass. As a DEA Schedule III substance, anabolic steroids are known and accepted for medical uses with potential health risks, including addiction. Course Purpose To provide clinicians with knowledge on the medical and sports-related uses of anabolic steroids, including side effects and health risks associated with misuse and addiction. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. The stimulus for the formation of testosterone arises in the a. hypothalamus. b. testes. c. thymus. d. pituitary gland. 2. Gonadotrophin Releasing Hormone (GnRH) is secreted by the hypothalamus and it is sent to the pituitary gland by a. the iliac vein. b. the diploic veins. c. the portal system. d. the splenic vein. 3. True or False: “Anabolic steroids” refers exclusively to the synthetic version of the androgenic hormone known as testosterone. a. True b. False 4. The total testosterone production in an adult male is around a. 7 grams per day. b. 7 milligrams per hour. c. 17 milligrams per week. d. 7 milligrams per day. 5. Corticosteroids (such as prednisolone and cortisone) are prescribed a. for muscle building. b. to promote free testosterone. c. as an anti-inflammatory. d. as a type of anabolic steroid. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction Anabolic steroids have an important role to play in the treatment of medical conditions. There is, however, an illicit use of anabolic steroids. Today, most athletes, involved in sports activities that require greater strength, take anabolic steroids to increase their weight and strength. These sports include competitive sports like weight lifting, wrestling, and other strength based contests. In addition, people who are obsessed about having a “perfect” physical appearance also misuse anabolic steroids. The number of individuals using anabolic steroids for sports or to improve their looks is growing. This increased use of anabolic steroids is driven by the perception that they may give a person an edge when it comes to sports activities. Unfortunately, many individuals use anabolic steroids without regard for the disastrous impacts it can have on their bodies. Anabolic Steroids And Testosterone: An Overview Anabolic steroids are an androgenic hormone, and is also known by its proper name anabolic-androgen steroids (AAS). Testosterone is a natural anabolic steroid and it is the primary sex hormone in males. In order to understand anabolic steroids, it is important to know how testosterone works. Testosterone is vital for the development of reproductive organs like the prostate and testes. It enhances male sexual features such as increased bone mass, muscles and body hair growth.1 Testosterone also promotes health and overall wellbeing. For example, it helps prevent osteoporosis. Many abnormalities in the body, such as bone nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 loss or frailty, are associated with testosterone deficiency.2 Synthetic anabolic steroids are an artificial form of the male hormone testosterone. The two major impacts they have on the body are 1) an anabolic impact (the muscle building effect), and 2) an androgenic impact (the masculinizing effect).3 Anabolic steroids differ from corticosteroids such as prednisolone and cortisone. Corticosteroids do not deliver masculinizing or muscle building results. These corticosteroids are prescribed for asthma patients and people having skin problems. They are often medically prescribed as anti-inflammatories.4 Testosterone Formation and Impact Testosterone is produced by the adrenal glands, testes, placenta and ovaries. It is made from cholesterol through a complicated process that takes place in the steroid-producing glands. The total testosterone production in an adult male is around 7 milligrams per day.5 The stimulus for the formation of testosterone arises in the brain, specifically in the hypothalamus. The hypothalamus is a part of the brain where various hormones are produced. These hormones are linked to the function of other glands. For example, the hypothalamus secretes Gonadotrophin Releasing Hormone (GnRH), which is sent to the pituitary gland by special veins called the portal system. Once transmitted, the pituitary gland forms Luteinizing Hormone (LH). Luteinizing Hormone is then released into the blood.6 This hormone is sent to the testis, which is the gland where Leydig cells produce testosterone from stored cholesterol. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 The feedback mechanism in the pituitary gland controls the rate of hormone production and it is regulated by the blood level of testosterone. With an increase in this level, the secretion of GnRH and LH hormone is reduced or may stop completely. This results in a decline in hormone production. If the opposite happens, i.e., if testosterone blood levels fall, then pituitary secretion is enhanced. In this way, the body maintains an equilibrium in hormone levels. Mode of Mechanism After the formation and secretion of testosterone into the blood stream, a greater percentage of the hormone is tied to protein as it is sent throughout the body. Only the untied or free-state testosterone is biologically active.5 The free-state testosterone in the blood makes up around 1 to 3 percent of the total amount of hormone found in circulation so only 1 to 3 percent of the testosterone level in the blood can interact with tissue receptors. Testosterone’s half-life (the time it takes for half of a substance to degrade or decay) is around 10 minutes. Once testosterone reaches the cell, it is turned into 5 alpha di-hydrotestosterone (DHT). The hormone is then bound to androgen receptors (AR) present in the cells. Finally, it is transported into the nucleus where critical muscle building reactions take place.7 Receptors for injectable or oral steroids works in the same manner. The actual protein production is based on the cell where the reaction takes place. Hence, a muscle cell may only produce muscle protein, irrespective of the kind of anabolic steroid used. After