Anabolic-Androgenic Steroid Abuse

The topic of drug abuse of any kind is very complex and often difficult to assess accurately and objectively. The abuse of anabolic-androgenic steroids (AASs) is no different. The complex myriad of neurologic effects of AASs is still being studied. Relating this biopharmacology to the individual abusing AASs is a particularly difficult task because of several factors. For one, many individuals abusing AASs have done so in relative secrecy, and many have been reluctant to engage in valid medical research. The lack of a standard when performing research—because of the vast numbers of agents that are sold worldwide on the black market and their relative potency, or complete lack thereof—is another problem. Many counterfeit products are sold and used, which complicates the study of abuse.

In more than a few cases, contradictory data exist, especially concerning psychological effects. One must remember that the interaction of forces, which ultimately influences the abuser, is vast and multidimensional, a complex web of presumed gain and reward that exists due to conditioning and related psychosocial issues. The use of performance-enhancing substances is not a novel idea and can be dated back to the Greeks. The use of AASs for performance enhancement began in the 1950s with elite athletes, and the use has slowly trickled down to include the high school and junior high school levels. With a "win at all costs" mentality and the high regard our society has for successful athletes, it is easy to see how this has occurred. AAS use in teenage years can prematurely fuse epiphyseal plates and stunt growth, as well as cause psychological problems.

When testosterone and/or AASs are used in the nonclinical setting, many problems arise. Athletes' self-prescribing habits are usually excessive and are often based more on fiction than on fact. It is very common for the AAS abuser to "stack" drugs, or to use multiple drugs at the same time. Surveys of weightlifters have documented the concurrent use of multiple drugs, employed in a cyclic fashion for a period of 12-16 weeks; the dose used is typically 2-8 times higher than the therapeutic dose range. The use of multiple drugs greatly increases side effects and risks to the user. These factors, coupled with decreased medical surveillance, place the AAS abuser at high risk for serious complications.

AASs have been shown to alter moods by a number of mechanisms.[35, 36, 37] Studies show that testosterone and AASs may act as a central MAO inhibitor. Indeed, AASs are mood elevators and have been studied in depressed individuals. Vogel and colleagues compared the antidepressant effects of amitriptyline (75 mg/d, up to a maximum of 300 mg/d) with those of mesterolone (100 mg/d, up to a maximum of 550 mg/d) in a double-blind design with 34 depressed male outpatients.[38] The investigators found that the 2 drugs were equally effective in reducing depressive symptoms and that mesterolone produced significantly fewer adverse effects than did amitriptyline.

Another study combined methyltestosterone (15 mg/d) with imipramine (25-50 mg/d) and found a prompt paranoid response in 4 of 5 men treated.[39] This was likely due to the central MAO inhibition by methyltestosterone, combined with the known effects of imipramine. The response quickly abated when the methyltestosterone was discontinued.

Other studies have indicated that testosterone, particularly in the prenatal period but also during puberty and adulthood, is important in establishing a biological readiness for normal aggressive behavior and in facilitating the expression of aggression in appropriate social settings. The reports have also indicated that social factors and learning significantly influence the actual expression of aggression in adulthood.[40] In a 1983 study of 32 weightlifters using AASs, 56% reported a temporary increase in self-defined irritability and aggressive behavior. When these psychoactive effects combine with strong positive reinforcement from weight and strength gains, as well as from improved self-image, AASs can prove addictive.[1, 13]

AAS addiction is generally held as a psychic addiction, but the withdrawal effects that occur when AAS use stops clearly indicate an element of physical addiction as well. Multiple studies have shown that the withdrawal symptoms include depression, fatigue, paranoia, and suicidal thoughts and feelings.[35] Furthermore, a strong desire to continue abusing AASs exists even in the face of negative consequences; thus, the drugs are continued in order to provide a continuation of their perceived positive effects and to inhibit withdrawal effects.

A 1989 review suggested that the psychoactive effects, withdrawal symptoms, and underlying biological mechanisms of AASs appear to be similar to the mechanisms and complications that accompany cocaine, alcohol, or opioid abuse. The review also proposed that a portion of AAS abusers may develop a sex-steroid hormone dependence disorder.

The abuse of AASs, especially since the late 20th century, has had a deleterious effect on the clinical use of these compounds. These drugs are now considered controlled substances in the United States (schedule 2 and 3), and this, along with excessive negative media attention, has resulted in a steep decline in their appropriate clinical use.

Indeed, many AASs have been withdrawn from the US market; however, clinical interest in the beneficial effects of these drugs has once again been coming to the forefront. With recent increases in use (estimated at 400%), AASs are once again being prescribed for known applications, and ongoing research will continue to uncover novel uses for these agents and will further define their mechanisms of action. Physicians should be aware of the clinical and underground worlds of AASs and, as with opioids and other potential drugs of abuse, should not allow the abuse of these drugs to limit their appropriate therapeutic use. A particular agent is not inherently good or evil; instead, it is the end use of that compound that can be viewed positively or negatively. Thus, the physician must help to ensure that AASs are used appropriately and are not abused.