Tweet
An estimated 3 million individuals have abused performance-enhancing drugs (PEDs) during their lifetime, and of these, nearly a third will develop a long-term dependence on PED agents, according to a just-released scientific statement by the Endocrine Society published online December 17 in Endocrine Reviews.
Adverse events associated with long-term PED use include an increased risk for cardiovascular disease; liver toxicity; the development of mood and psychiatric disorders; and an increased risk for early death due to suicide, homicide, and fatal accidents.
Although such adverse events have been reported in the past, what is most striking about the society's statement is the emphasis on just who is abusing PEDs.
"There's a widespread perception that the abuse of performance-enhancing drugs is limited to elite athletes, that the adverse effects of performance-enhancing drugs are few, and that they can be managed," said Shalender Bhasin, MD, an expert on androgen biology at Harvard Medical School, Boston, Massachusetts, and one of the coauthors of the report, discussing his findings at a press conference. "The reality is that professional athletes constitute only a very small fraction of PED users in our society. The vast majority are not athletes at all, but recreational weight lifters."
In contrast to professional athletes, who may abuse steroids only for the few years they are in professional competition — and then only in the off season, to avoid detection —recreational PED users indulge long-term to improve their personal appearance and to look leaner and more muscular. "These people mostly use anabolic steroids, and they use supraphysiologic doses over many years," Dr. Bhasin said, "and this population is largely subterranean."
In recognition of this fact and the increasing number of reports associating steroid abuse with adverse events, Dr. Bhasin and colleagues formed an expert panel to assess the scope of the problem and make recommendations as to how it may be ameliorated.
The Emerging Epidemic and Recommendations
The scientific statement first makes the case for ringing the alarm bells. "This cultural tsunami of PED use at the corner gym started in the early1980s," explained Dr. Bhasin. "Therefore, the people who started using PEDs at that time are now entering their fifth and sixth decade of life. We should anticipate that over the next decade we will see increasing numbers of PED users coming to doctors' offices with various complications that reflect the combined effects of aging and long-term PED use."
Unfortunately, because the nonprofessional steroid user has never really been on the clinical radar, there are few data to be cited to gain a clearer picture of the just how these complications will manifest and what patient-management strategies may be.
"Although randomized controlled trials have shown inconsistent effects of these compounds on mood and behavior, there are lots of data to show that abuse is associated with mania, depression, and 'roid rage' behavior," said Dr. Bhasin, adding, "One side effect that is nearly universal in the users of anabolic steroids is a suppression of testicular function."
Even after the exogenous hormones are withdrawn, testosterone levels are slow to recover. Rather than endure a period of fatigue, depression, and sexual dysfunction associated with "low T," individuals will often resume steroid abuse as a form of dependence.
Further assertions regarding PED use will, however, require more data. Therefore, the scientific statement calls for:
• Observational studies, implemented by establishing a registry to monitor long-term health consequences of PEDs.
• Randomized controlled trials to facilitate recovery of testosterone levels in men with low testosterone due to PED use.
• Mechanistic studies to elucidate just how PEDs induce adverse events.
• The use of innovative approaches to enhance public awareness of the seriousness of PED use.
This last point is perhaps the most difficult to envision, because PED abuse lacks a prominent poster child. "People see Lance Armstrong today and feel that he's perfectly fit, and [Alex Rodriguez] A-Rod as well, but there are consequences of using PEDs you can't see," said Teresa Woodruff, PhD, director of the Oncofertility Consortium and Thomas J. Watkins Professor of Obstetrics and Gynecology at the Feinberg School of Medicine at Northwestern University, Evanston, Illinois, and president of Endocrine Society, commenting to Medscape Medical News. "But the cardiovascular impacts on these elite athletes are really going to come out in the next few decades.
"What the endocrine society is doing now is to place a flashlight on the issue because, yes, the public sees elite players in their prime. The Endocrine Society now takes the position that there are deeper consequences that you may not see in these individuals.
"What we are also saying with our recommendations is that the statement reveals the boundary condition of our knowledge." Clearly, there are many issues to be further explored.
Target Audience
Coauthor, H.G. Pope, MD, from Harvard Medical School, would like the message of the scientific statement to reach 3 distinct stakeholders.
- Clinicians: "There are many clinicians who encounter anabolic-steroid users but who have very little information to go on. Medical schools provide little if any training regarding PED use. We need more clinicians to be aware."
- Researchers: "Research on PEDs remains quite limited, and part of the reason for that is because the advent of steroids is so recent, unlike, say, opiates, which have been in use since ancient Greece. Right now we're just in the beginning stages of acquiring information about these drugs and their long-term consequences."
- Policy makers: Research and public-awareness initiatives cost money. "The policy makers need to know what we're up against."
In the meantime, while the information and recommendations of the Endocrine Society's scientific statement takes hold, Dr. Pope has this advice for the clinician who is likely to see a PED patient.
"If you see an unusually muscular young men in your practice, be sure to take a proper history." If the patient does not readily disclose steroid use (as is common) yet suspicions remain, physicians need to engage in what Dr. Pope refers to as part of the art of medicine. "If you have suspicions, you need to communicate to the patient you're uncomfortable with the patient's given history, and then you need to encourage the patient to be more candid."
Comment