Anabolic androgenic steroids in the general population: user characteristics and associations with substance use

A review of recent evidence on androgen abuse from interviews with users

PURPOSE OF REVIEW

Androgens (also known as anabolic-androgenic steroids; AAS) are increasingly being abused worldwide to enhance body physique or athletic performance. Qualitative studies including interviews provide a wider understanding of androgen abuse and focus specific support needs to this group. This narrative review summarizes recent studies (2021-2023) using interviews with individuals abusing androgens.

RECENT FINDINGS

Motivations for androgen abuse in men include desires to achieve certain physicality, enhance self-confidence and improve libido. The risks of androgen abuse are justified to achieve these outcomes and men may use other illicit substances as postcycle-therapy to lessen the risks. Some adverse effects may be more pronounced with certain substances. The therapeutic relationship with healthcare professionals is often described negatively by androgen abusers due to stigma and a perceived lack of knowledge. Both healthcare professionals and androgen abusers agree that development of guidelines are needed. Androgen abuse in women is rare however body dissatisfaction and desires for improve appearance and strength are motivators.

SUMMARY

Recent qualitative studies have helped further our understanding of men and women who abuse androgens, however the small number of recently published studies confirms there is still a paucity of evidence in the literature. Further research is needed to develop specific harm minimization strategies in those abusing androgens.

Anabolic androgenic steroids used as performance and image enhancing drugs in professional and amateur athletes: Toxicological and psychopathological findings

OBJECTIVE

The use of anabolic androgenic steroids (AASs) as performance and image enhancing drugs (PIEDs), once restricted to professional athletes, now includes amateurs and regular gym visitors. AAS use is associated with psychopathology, yet this relationship is complex and not fully understood. We aimed to assess the presence of AASs and other misused substances in athletes' biological samples and link toxicological to psychopathological findings.

METHODS

A multicentre, cross-sectional study in fitness centres in Italy recruited 122 professional and amateur athletes training in several sports (84 men; age range = 18-45 years). Athletes completed questionnaires, interviews, and toxicology testing for AASs, other PIEDs, illicit drugs, and non-prescribed psychotropics. Toxicology was conducted in blood, urine, and hair.

RESULTS

Self-reported and toxicologically detected use rates of AASs and other misused substances showed slight-to-fair agreement (Fleiss' κ = 0.104-0.375). There was slight-to-moderate agreement among the three biological samples used for AAS testing (κ = 0.112-0.436). Thirty-one athletes (25.4%) tested positive for AASs. More sport hours/week, narcissistic or antisocial personality disorders, and higher nonplanning impulsiveness scores predicted AAS use (pseudo-R²  = 0.665). AAS users did not differ significantly from non-users in major psychopathology, but their Hypomania Checklist-32 score, which also predicted AAS use, was significantly higher (p < 0.001), suggesting increased odds for cyclothymic disorder or subthreshold hypomania.

CONCLUSIONS

Our results have implications for studying AAS users, as they identify a cluster of variables that may be relevant in future understanding of AAS use risks (e.g., personality disorders). Possible disagreements between AAS assessment methods should be considered when implementing harm reduction interventions, such as needle and syringe distribution, health education, and counselling, as well as surveillance programmes.

Androgen Misuse and Abuse

Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.

Review Article: Anabolic-Androgenic Steroids, Violence, and Crime: Two Cases and Literature Review

BACKGROUND AND OBJECTIVES

Anabolic-androgenic steroid (AAS) use has become a major worldwide substance use disorder, affecting tens of millions of individuals. Importantly, it is now increasingly recognized that some individuals develop uncharacteristically violent or criminal behaviors when using AAS. We sought to summarize available information on this topic.

METHODS

We reviewed the published literature on AAS-induced behavioral effects and augmented this information with extensive observations from our clinical and forensic experience.

RESULTS

It is now generally accepted that some AAS users develop uncharacteristically violent or criminal behaviors while taking these drugs. Although these behaviors may partially reflect premorbid psychopathology, sociocultural factors, or expectational effects, accumulating evidence suggests that they are also attributable to biological effects of AAS themselves. The mechanism of these effects remains speculative, but preliminary data suggest a possible role for brain regions involved in emotional reactivity, such as the amygdala and regions involved in cognitive control, including the frontal cortex. For unknown reasons, these effects appear idiosyncratic; most AAS users display few behavioral effects, but a minority develops severe effects.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Professionals encountering AAS users in clinical or forensic settings should be alert to the possibility of AAS-induced violence or criminality and should employ strategies to assess whether AAS is indeed a contributory factor in a given case. Further research is needed to elucidate the mechanism of AAS-induced violence and to explain why only a subset of AAS users appears vulnerable to these effects. (Am J Addict 2021;00:00-00).

Random forest model to identify factors associated with anabolic-androgenic steroid use

Background

One of the types of doping that is commonly used by bodybuilders, is androgenic-anabolic steroids (AAS). The use of AAS besides violating sporting ethics would have serious consequences on physical and mental health statuses. This study aimed to determine the most important factors of using AAS among bodybuilders by prototype willingness model (PWM).

Methods

In this analytical cross-sectional study, 280 male bodybuilders were selected from the bodybuilding clubs in Hamadan city using multistage sampling in 2016. A self-administered questionnaire consisting of demographic information and constructs of the PWM was then used to collect data and random forest model was also applied to analyze the collected data.

Results

Behavioral willingness, attitude, and previous AAS use were found as the most important factors in determining the behavioral intention. Moreover, subjective norms, attitude, BMI, and prototypes were the factors with the greatest effect on predicting behavioral willingness of AAS use. As well, behavioral intention was observed to be more important than behavioral willingness for predicting of AAS use.

Discussion

The obtained results show that the reasoned action path has a greater impact to predict AAS use among bodybuilders compared to social reaction path.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00257-5.

Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review

Anabolic-androgenic steroids (AASs) are a large group of molecules including endogenously produced androgens, such as testosterone, as well as synthetically manufactured derivatives. AAS use is widespread due to their ability to improve muscle growth for aesthetic purposes and athletes’ performance, minimizing androgenic effects. AAS use is very popular and 1–3% of US inhabitants have been estimated to be AAS users. However, AASs have side effects, involving all organs, tissues and body functions, especially long-term toxicity involving the cardiovascular system and the reproductive system, thereby, their abuse is considered a public health issue. The aim of the proposed review is to highlight the most recent evidence regarding the mechanisms of action of AASs and their unwanted effects on organs and lifestyle, as well as suggesting that AAS misuse and abuse lead to adverse effects in all body tissues and organs. Oxidative stress, apoptosis, and protein synthesis alteration are common mechanisms involved in AAS-related damage in the whole body. The cardiovascular system and the reproductive system are the most frequently involved apparatuses. Epidemiology as well as the molecular and pathological mechanisms involved in the neuropsychiatric side-effects of AAS abuse are still unclear, further research is needed in this field. In addition, diagnostically reliable tests for AAS abuse should be standardized. In this regard, to prevent the use of AASs, public health measures in all settings are crucial. These measures consist of improved knowledge among healthcare workers, proper doping screening tests, educational interventions, and updated legislation.

Use of anabolic-androgenic steroids and other substances prior to and during imprisonment - Results from the Norwegian Offender Mental Health and Addiction (NorMA) study

BACKGROUND

Anabolic-androgenic steroid (AAS) use is associated with health problems and substance use. Substance use is common among inmates. This study aims to estimate lifetime and prison use of AAS and other substances, compare characteristics of groups of inmates, and describe factors associated with AAS use in a national prison population.

METHODS

Data from the Norwegian Offender Mental Health and Addiction (NorMA) Study, a cross-sectional survey of people in prisons, included sociodemographic variables and lifetime and prison use of AAS and other substances. Altogether 1,499 inmates, including 96 (6.4%) women, were divided into three mutually exclusive groups according to lifetime AAS use, non-AAS substance use and no substance use.

RESULTS

Lifetime AAS use was reported by 427 (28.5%) inmates; 6 women and 421 men. Non-AAS substance use was reported by 593 (39.6%) and 479 (31.9%) had never used AAS or non-AAS substances. Compared to the non-AAS substance group, the AAS group reported younger debut ages for nearly all non-AAS substances, higher mean number of non-AAS substances used in their lifetime (8.9, 6.6, p < 0.001), during the six months prior to incarceration (5.2, 3.1, p < 0.001), and during (2.3, 1.3, p < 0.001) imprisonment. Although 120 (8.0%) inmates used AAS during the six months prior to incarceration, only ten continued during imprisonment.

CONCLUSIONS

Lifetime AAS use is common among inmates and may be an indicator of more severe substance use problems. Screening for previous and present AAS use at incarceration and increased staff awareness are needed to tailor treatment approaches appropriately.

Pharmaceutical Care in Sports

Pharmaceutical care in sports is a new field of work to clinical pharmacists, focused on promoting pharmacotherapeutic follow up and clinical services to athletes, physical activity practitioners and enthusiasts of any sports modality. A broad range of pharmaceuticals, dietary supplements and herbal drugs have been used historically as performance promoters, doping or ergogenic aids. In this context, the role of pharmacists in prevent adverse events, drug interactions or any drug related problems, as doping issues, was described. Its actions can be important to contribute with a multi professional clinical health team, leading athletes to use these resources in a rational way, promoting and optimizing the therapeutic when its necessary.

Anabolic androgenic steroid abuse in the United Kingdom: An update

Anabolic androgenic steroids (AASs) are prescribed for medical conditions related to low testosterone. Abuse of AASs has surged as they become recognised as potent image enhancement drugs. The primary goal of most abusers is to obtain a more attractive outward appearance. Abuse is complex. There are a vast range of AAS substances illegally available, the nature of their true composition is difficult to evaluate. Users follow dosing patterns which incorporate a number of different AASs, in addition to other pharmaceutical substances believed to complement the desired physical effects or manage unwanted effects. Animal work and medical case reports suggest potential to cause serious hepatotoxicity, plus possible neurotoxicity, nephrotoxicity and damage to the cardiovascular and reproductive systems. As the long-term AASs users reach maturity, further controlled experimentation, with larger sample sizes, is required. Data gathering should be directed towards the most vulnerable group of AAS users, females and adolescent boys.

Prevalence and Risk Factors Associated with Anabolic-androgenic Steroid Use: A Cross-sectional Study among Gym Users in Riyadh, Saudi Arabia

Objectives

Anabolic-androgenic steroids (AAS) have been used internationally for enhancing physical appearance and performance despite their significant side effects. We sought to identify the prevalence of AAS use and its different risk factors among gym users in Riyadh, Saudi Arabia.

Methods

A cross-sectional survey was distributed among gym users across 20 gyms in Riyadh. The cluster sampling technique was used to represent the four regions of Riyadh (North, South, East, and West). Univariate and multivariate analyses were performed to identify the factors associated with AAS.

Results

Out of 482 participants, 29.3% reported using AAS. The mean age of the study participants was 27.2±6.9 years, 61.0% were single, 67.1% were educated, 35.5% were government employees, and 31.1% were students. The use of AAS was more prevalent among gym members who practiced weightlifting (45.5%), were employed in the private sector (35.8%), and aged > 25 years old (53.3%). Multiple logistic regression showed that the most significant factors associated with the use of AAS among gym members were: weightlifting, using supplementary vitamins or minerals, following special diets, knowing individuals who used AAS, and being offered AAS.

Conclusions

Our study provides clear evidence that the lifetime prevalence of AAS use is high among male gym members in Riyadh with modifiable risk factors. The results could help public health policymakers to take the necessary measures to alleviate the potential negative implications of AAS use at the community level.

The Anabolic Androgenic Steroid Treatment Gap: A National Study of Substance Use Disorder Treatment

Background:

Anabolic androgenic steroid (AAS) use is associated with serious mental and physical health problems. Evidence indicates that AAS use among people who use psychoactive substances is higher than in the general population. This study aims to estimate lifetime AAS use among patients in substance use disorder (SUD) treatment, compare characteristics of AAS and non-AAS users and identify whether AAS use was addressed during treatment.

Methods:

This cross-sectional survey included 563 (142 women, 24.2%) patients in 38 SUD treatment facilities in Norway. Respondents reported on AAS and substance use, and treatment experiences.

Results:

Lifetime AAS use was reported by 156 (28.3%) SUD patients, thereof 35.6% of the men and 8.0% of the women. Lifetime AAS use was highest among men with stimulants (55.8%) as preferred substance, and lowest among men who preferred alcohol (14.6%). Initiation of AAS use due to getting thinner following substance use was reported by 44.5% of the AAS using men. AAS users reported more severe substance use than non-AAS users. More than half (58%) of all patients had not been asked about AAS use, and 42.4% of those who were asked, experienced that treatment providers lacked expertise about AAS.

Conclusion:

Lifetime AAS use in this sample of SUD patients is common practice and comprise an underrecognized problem in SUD treatment. Given the deleterious implications to the individual and society that concomitant use of AAS may cause, it would be essential to raise the awareness about AAS use among SUD patients, and the level of competence among health professionals.

Anabolic-Androgenic Steroid Use in the Eastern Mediterranean Region: a Scoping Review of Extant Empirical Literature

The use of image- and performance-enhancing drugs particularly anabolic-androgenic steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with mainstream populations using these drugs for aesthetic purposes. Prevalence has been predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature from the Eastern Mediterranean region described and mapped what is known about the extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects. The review highlights a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review underscores the need to carry out further research, particularly qualitative and quantitative studies with both genders, and cognisant of the complexities of culture and religiosity.

Diagnosis and Management of Anabolic Androgenic Steroid Use

CONTEXT

The lifetime prevalence of anabolic androgenic steroid (AAS) use is estimated at 1% to 5% worldwide. AAS use occurs primarily male elite athletes and men who want a muscular appearance. The evidence for effective, safe management of AAS cessation and withdrawal is weak.

DESIGN

Key studies were extracted from PubMed (1990-2018) and Google Scholar with reference searches from relevant retrieved articles.

RESULTS

The proven adverse effects of AASs include suppression of the gonadal axis and infertility, hirsutism and defeminization in women, and erythrocytosis. Alkylated AASs that are taken orally may cause hepatopathy. There is an association between high-dosage AAS use and increased risk of cardiovascular disease. Clues for AAS use include very low serum high-density cholesterol and sex hormone-binding globulin concentrations and unexplained erythrocytosis. For elite athletes, the biological passport (monitoring of blood or urinary androgen and androgen precursor concentrations after determining the athlete's baseline) is useful for detecting AAS use. For nonelite athletes, the best method to confirm AAS use is to inquire in a nonjudgmental manner. Cessation of chronic AAS use is associated with a withdrawal syndrome of anxiety and depression.

CONCLUSIONS

Men who use AASs <1 year typically recover normal hypothalamic-pituitary-testicular axis function within 1 year after cessation. Men who have infertility due to high-dosage AAS use ≥1 year might benefit from short-term treatment with clomiphene or human chorionic gonadotropin.

The Relationship Between the Big Five Personality Traits, Impulsivity, and Anabolic Steroid Use

BACKGROUND

The increase in the prevalence of anabolic-androgenic steroids (AAS) use has been the subject of study in the last decades. Several studies indicated a strong association between the use of AAS and the performance of risky behaviors mediated by factors such as aggression, impulsivity, depression, and anxiety.

OBJECTIVE

This study aimed to identify differences in personality trait, impulsivity, and the ability to delay gratification between AAS users and non-users that predispose or serve as a buffering mechanism against its usage and whether it is related to an increased likelihood of engaging in infidelity.

METHODS

Two hundred and twelve male volunteers (88 AAS users), aged between 21 and 36 years (M = 28.22), completed self-report measures of personality, impulsivity, delayed gratification, and attitudes toward infidelity. Multivariate analysis of variance and logistic regression were conducted to establish differences between AAS users and non-users.

RESULTS

The results showed that AAS users displayed an inability to delay gratification, a greater impulsivity, and a more benevolent attitude toward infidelity. AAS users obtained higher scores on openness and neuroticism, which was larger "off-cycle," although they presented lower scores on extraversion compared to the non-users group. Regression analysis revealed that neuroticism, impulsivity, and delaying gratification scores were significant predictors of AAS usage. In addition, impulsivity functioned as a partial mediator in the relationship between neuroticism and AAS use.

CONCLUSION

The results of this research highlight a pivotal implication of impulsivity in AAS use in conjunction with neuroticism, openness, and extraversion traits.

Associations of anabolic-androgenic steroid use with other behavioral disorders: an analysis using directed acyclic graphs

BACKGROUND

Anabolic-androgenic steroid (AAS) use is known to be associated with other psychiatric disorders, such as body image disorders, conduct disorder/sociopathy, and other substance use disorders (SUD) - but the causal pathways among these conditions remain poorly delineated.

METHODS

We created a directed acyclic graph to diagram hypothesized relationships among AAS use and dependence, body image disorder (BID), conduct disorder/sociopathy, and other SUD. Using proportional hazards models, we then assessed potentially causal relationships among these variables, using a dataset of 233 male weightlifters, of whom 102 had used AAS.

RESULTS

BID and conduct disorder/sociopathy both strongly contributed to the development of AAS use, but did not appear to contribute further to the progression from AAS use to AAS dependence. Other SUD beginning prior to first AAS use - whether broadly defined or restricted only to opioids - failed to show an effect on AAS use or progression to AAS dependence. Conversely, AAS use contributed significantly to the subsequent first-time development of opioid use disorders but did not significantly increase the risk for first-time development of non-opioid SUD, taken as a whole.

CONCLUSIONS

Our analysis suggests that AAS use and other SUD are mutually attributable to underlying conduct disorder/sociopathy. SUD do not appear to represent a 'gateway' to subsequent AAS use. AAS use may represent a gateway to subsequent opioid use disorder, but probably not to other SUD.

Identifying a typology of men who use anabolic androgenic steroids (AAS)

BACKGROUND

Despite recognition that the Anabolic Androgenic Steroid (AAS) using population is diverse, empirical studies to develop theories to conceptualise this variance in use have been limited.

METHODS

In this study, using cluster analysis and multinomial logistic regression, we identify typologies of people who use AAS and examine variations in motivations for AAS use across types in a sample of 611 men who use AAS.

RESULTS

The cluster analysis identified four groups in the data with different risk profiles. These groups largely reflect the ideal types of people who use AAS proposed by Christiansen et al. (2016): Cluster 1 (You Only Live Once (YOLO) type, n = 68, 11.1%) were younger and motivated by fat loss; Cluster 2 (Well-being type, n = 236, 38.6%) were concerned with getting fit; Cluster 3 (Athlete type, n = 155, 25.4%) were motivated by muscle and strength gains; Cluster 4 (Expert type, n = 152, 24.9%) were focused on specific goals (i.e. not 'getting fit').

CONCLUSION

The results of this study demonstrate the need to make information about AAS accessible to the general population and to inform health service providers about variations in motivations and associated risk behaviours. Attention should also be given to ensuring existing harm minimisation services are equipped to disseminate information about safe intra-muscular injecting and ensuring needle disposal sites are accessible to the different types.

History and epidemiology of anabolic androgens in athletes and non-athletes

The use of androgens, frequently referred to as anabolic-androgenic steroids (AAS), has grown into a worldwide substance abuse problem over the last several decades. Testosterone was isolated in the 1930s, and numerous synthetic androgens were quickly developed thereafter. Athletes soon discovered the dramatic anabolic effects of these hormones, and AAS spread rapidly through elite athletics and bodybuilding from the 1950s through the 1970s. However it was not until the 1980s that widespread AAS use emerged from the elite athletic world and into the general population. Today, the great majority of AAS users are not competitive athletes, but instead are typically young to middle-aged men who use these drugs primarily for personal appearance. AAS abuse has now become particularly prevalent in regions such as Scandinavia, the United States, Brazil, and British Commonwealth countries, but remains rare in countries such as China, Korea, and Japan - a pattern that reflects cultural differences in attitudes towards male muscularity.

Interaction of Anabolic Androgenic Steroids and Induced Tooth Movement in Rats

This study evaluated the interaction between tooth movement and two anabolic androgenic steroids (AAS), Deposteron® and Nebido®. One hundred Wistar rats were divided into 3 groups: control (C) n=30, Nebido experimental (N) n=35 and Deposteron experimental (D) n=35. The control group was subdivided into 6 subgroups: 1, 2, 3, 5, 7 and 14. The experimental groups were subdivided into 7 subgroups: 0, 1, 2, 3, 5, 7 and 14, which corresponded to the day of animal's euthanasia after applying orthodontic force. Orthodontic devices were used to induce tooth movement using 50 cN of reciprocal force between the maxillary right first molar and the maxillary incisors. After euthanasia, the tissues were processed and stained with hematoxylin and eosin (HE) and tartrate-resistant acid phosphatase (TRAP). Osteoclasts, Howship's lacunae and blood vessels were quantified. Groups N and D showed acceleration in the reorganization of the periodontal ligament compared to group C. The peak of the histological events occurred in group C on day 5 and in groups N and D on day 3 after installation of the orthodontic device. There was a statistically significant difference in the number of osteoclasts (p<0.05) between groups N3 and C3, and between groups N3 and D3. Supra-physiological doses of the AAS Nebido® and Deposteron® altered the number of osteoclasts, Howship's lacunae and blood vessels, accelerating the reorganization of the periodontal ligament, resulting in accelerated biological effects from the induced tooth movement in rats.

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review

Injecting use of image and performance-enhancing drugs (IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme (CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention.

Use of doping agents and symptoms of eating disorders among male and female patients in drug addiction treatment

Aims

This study investigates the prevalence of use of doping agents and symptoms of eating disorders among patients in drug addiction treatment. The aim is also to look for characteristics of the groups reporting the use of doping agents or symptoms of eating disorders.

Design

A survey including questions on exercise, the use of doping agents and Eating Disorder Inventory-2 was administered in a Norwegian drug addiction facility. The study included 109 patients in residential drug treatment, 30 females and 79 males (ranging from 17 to 50 years old).

Results

–Symptoms of eating disorders were reported by 33 percent of the females and 7.6 percent of the males. Previous use of doping agents (anabolic-androgenic steroids in particular) was reported by 40.5 percent of the men and 20 percent of the women. The results are discussed in light of the theory on emotion regulation, gender and cultural expectations, drug treatment as a liminal phase and similarities to drug addiction.

Conclusions

The symptoms of eating disorders and the use of doping agents are prevalent in this sample of male and female drug addicts in treatment. Drug treatment facilities should be aware of this and take the appropriate actions regarding attention, screening and treatment.

Anabolic-Androgenic Steroid use in the Nordic Countries: A Meta-Analysis and Meta-Regression Analysis

Aims

To investigate the lifetime prevalence and moderators of non-medical AAS use in the five Nordic countries.

Methods

We conducted a meta-analysis and meta-regression using studies gathered from searches in PsycINFO, PubMed, ISI Web of Science, Google Scholar, and reference checks. Included were 32 studies that provided original data on 48 lifetime prevalence rates based on a total of 233,475 inhabitants of the Nordic countries.

Results

– The overall lifetime prevalence obtained was 2.1% [95% confidence interval (CI): 1.3-3.4, I2 = 99.5, P < 0.001]. The prevalence for males, 2.9% (95% CI: 1.7-4.8, I2 = 99.2, P < 0.001), was significantly higher (Qbet = 40.5, P < 0.001) than the rate for females, 0.2% (95% CI: 0.1-0.4, I2 = 90.5, P < 0.001). Sweden has the highest prevalence of AAS use: 4.4%, followed by Norway: 2.4%, Finland: 0.8%, Iceland: 0.7%, and Denmark: 0.5%. Country, sample type, and male sample percentage significantly predicted AAS use prevalence in a meta-regression analysis. No indication of publication bias was found.

Conclusion

– Though subject to some limitations, our findings suggest that non-medical AAS use should be regarded as a serious public health problem in the Nordic countries.

The risk environment of anabolic-androgenic steroid users in the UK: Examining motivations, practices and accounts of use

BACKGROUND

The numbers using illicit anabolic-androgenic steroids are a cause of concern for those seeking to reduce health harms. Using the 'risk environment' as a conceptual framework to better comprehend how steroid users' practices and perspectives impact on health risks, this paper examines steroid user motivations, patterns of use, and the ways in which these practices are accounted for.

METHODS

As part of a wider mixed-method study into performance and image enhancing drug (PIED) use and supply in one mid-sized city in South West England, qualitative interviews were undertaken with 22 steroid users. Participants were recruited from a local safer injecting service, rather than bodybuilding gyms, in order to access a wider cross-section of steroid users. A limitation of this approach is potential sample bias towards those showing more health optimising behaviours.

RESULTS

The research findings highlight that patterns of steroid use varied according to motivation for use, experience and knowledge gained. Most reported having had little or no knowledge on steroids prior to use, with first use being based on information gained from fellow users or suppliers-sometimes inaccurate or incomplete. In accounting for their practices, many users differentiated themselves from other groups of steroid users-for example, older users expressed concern over patterns of use of younger and (what they saw as) inexperienced steroid users. Implicit in these accounts were intimations that the 'other' group engaged in riskier behaviour than they did.

CONCLUSION

Examining social contexts of use and user beliefs and motivations is vital to understanding how 'risk' behaviours are experienced so that this, in turn, informs harm reduction strategies. This paper examines the ways in which use of steroids is socially situated and the implications of this for policy and practice.

Mad men, women and steroid cocktails: a review of the impact of sex and other factors on anabolic androgenic steroids effects on affective behaviors

RATIONALE

For several decades, elite athletes and a growing number of recreational consumers have used anabolic androgenic steroids (AAS) as performance enhancing drugs. Despite mounting evidence that illicit use of these synthetic steroids has detrimental effects on affective states, information available on sex-specific actions of these drugs is lacking.

OBJECTIVES

The focus of this review is to assess information to date on the importance of sex and its interaction with other environmental factors on affective behaviors, with an emphasis on data derived from non-human studies.

METHODS

The PubMed database was searched for relevant studies in both sexes.

RESULTS

Studies examining AAS use in females are limited, reflecting the lower prevalence of use in this sex. Data, however, indicate significant sex-specific differences in AAS effects on anxiety-like and aggressive behaviors, interactions with other drugs of abuse, and the interplay of AAS with other environmental factors such as diet and exercise.

CONCLUSIONS

Current methods for assessing AAS use have limitations that suggest biases of both under- and over-reporting, which may be amplified for females who are poorly represented in self-report studies of human subjects and are rarely used in animal studies. Data from animal literature suggest that there are significant sex-specific differences in the impact of AAS on aggression, anxiety, and concomitant use of other abused substances. These results have relevance for human females who take these drugs as performance-enhancing substances and for transgender XX individuals who may illicitly self-administer AAS as they transition to a male gender identity.

Severe rhinovirus pneumonia in a young woman taking performance-enhancing drugs

A 22-year-old woman presented to the emergency room of a local hospital with pleuritic chest pain. She regularly worked out and admitted to taking performance-enhancing drugs (PEDs). Clinical findings and further diagnostic work up revealed a diagnosis of perimyocarditis, and adequate therapy was initiated. During the course of the first day, the patient had to be intubated and mechanically ventilated. A diagnosis of bilateral pneumonia and acute respiratory distress syndrome (ARDS) due to an infection by rhinovirus spp was made. A smoking habit, the intense physical training and the use of PED's may have exacerbated the course of the viral pneumonia. After 12 days the patient could be extubated. The length of stay in the intensive care unit was 16 days. After hospital discharge, the patient went to a pulmonary rehabilitation facility for 2 weeks. The outcome was favourable and the patient resumed her strength and endurance training.

Non-medical prescription drug use (NMPDU) and poor quality of life in the Swedish general population

BACKGROUND AND OBJECTIVES

Quality of life has become an increasingly important measurement in the substance use field. The main aim of the present study was to examine the relationships between non-medical use of prescription analgesics and sedatives and poor quality of life in the general population.

METHODS

Data were drawn from a Swedish national household survey conducted in 2008-2009. A stratified sample of 58,000 individuals aged 15-64 was randomly selected, with a response rate of 38.3% (n = 22,095). We examined the relationships between non-medical prescription drug use and quality of life in a logistic regression analysis, controlling for other substance use and sociodemographic variables.

RESULTS

In the final logistic regression model, both non-medical use of prescription analgesics and sedatives were independently associated with poor quality of life. Non-medical use of prescription sedatives was the strongest correlate of poor quality of life among the substance use variables.

DISCUSSION AND CONCLUSIONS

The associations between non-medical prescription drug use and poor quality of life might imply a need to better identify and provide treatment for this group, especially individuals with non-medical prescription sedative use, which seems to be a particularly strong correlate of poor quality of life.

SCIENTIFIC SIGNIFICANCE

Using a large, general population sample, the present paper is one of few to examine the relationships between non-medical prescription drug use and quality of life.

Anabolic androgenic steroids and violent offending: confounding by polysubstance abuse among 10,365 general population men

BACKGROUND AND AIMS

Anabolic androgenic steroid (AAS) use is associated with aggressive and violent behaviour, but it remains uncertain if this relationship is causal in humans. We examined the link between AAS use and violent crime while controlling for polysubstance abuse and additional suggested risk factors for violence.

DESIGN

Cross-sectional study of a population-based sample.

SETTING

In 2005, all Swedish-born male twins aged 20-47 years were invited to participate in the Swedish Twin Adults: Genes and Environment (STAGE) survey of the Swedish Twin Register (response rate = 60%).

PARTICIPANTS

A total of 10,365 male survey participants with information on AAS use.

MEASUREMENT

Data on self-reported use of AAS, alcohol and other substances, attention deficit hyperactivity disorder (ADHD) and personality disorder symptoms were linked to nation-wide, longitudinal register information on criminal convictions, IQ, psychological functioning and childhood socio-economic status (SES) covariates.

FINDINGS

Any life-time use of AAS was associated strongly with conviction for a violent crime [2.7 versus 0.6% in convicted and non-convicted men, respectively; odds ratio (OR) = 5.0, 95% confidence interval (CI) = 2.7-9.3]. However, this link was substantially reduced and no longer significant when controlling for other substance abuse (OR = 1.6, 95% CI = 0.8-3.3). Controlling for IQ, psychological functioning, ADHD, personality disorder symptoms and childhood SES did not reduce the risk further.

CONCLUSION

In the general population, co-occurring polysubstance abuse, but not IQ, other neuropsychological risks or socio-economic status, explains most of the relatively strong association between any anabolic androgenic steroid use and conviction for a violent crime.

Recreational Anabolic-Androgenic Steroid Use Associated With Liver Injuries Among Brazilian Young Men

BACKGROUND

The recreational use of anabolic-androgenic steroids (AAS) has reached alarming levels among healthy people. However, several complications have been related to consumption of these drugs, including liver disorders.

OBJECTIVE

To evaluate the prevalence of liver injuries in young Brazilian recreational AAS users.

METHODS

Between February/2007 and May/2012 asymptomatic bodybuilders who were ≥18 years old and reported AAS use for ≥6 months were enrolled. All had clinical evaluations, abdominal ultrasound (AUS), and blood tests.

RESULTS

182 individuals were included in the study. The median age (interquartile range) was 26.0 years (22.0-30.0) and all were male. Elevated liver enzyme levels were observed in 38.5% (n = 70) of AAS users, and creatine phosphokinase was normal in 27.1% (n = 19) of them. Hepatic steatosis was observed by AUS in 12.1% of the sample. One individual had focal nodular hyperplasia and another had hepatocellular adenoma. One case each of hepatitis B and C virus infection was found. A diagnosis of toxic liver injury was suggested in 23 (12.6%) AAS users without a history of alcohol or other medications/drugs consumption, or evidence of other liver diseases.

CONCLUSIONS/IMPORTANCE

Young Brazilian recreational AAS users presented a wide spectrum of liver injuries that included hepatotoxicity, fatty liver, and liver neoplasm. They also presented risk factors for liver diseases such as alcohol consumption and hepatitis B and C virus infection. The results suggest that the risk of AAS use for the liver may be greater than the esthetic benefits, and demonstrate the importance of screening AAS users for liver injuries.

Frequency of use, awareness, and attitudes toward side effects of anabolic-androgenic steroids consumption among male medical students in Iran

This study was conducted to determine the frequency of anabolic-androgenic steroids consumption in male students studying at the university and their awareness, attitude, and role of sports activities; the present descriptive study was conducted on 271 volunteers in 2008. The data collected by self-report questionnaires was analyzed by descriptive inferential statistics. The prevalence of consumption was 3.3%, and it was significantly higher in those with a history of bodybuilding or athletic performance. The overall awareness rate was low, and the attitude was too optimistic. It seems that unawareness, incorrect attitude, and history of athletic performance increases the risk of consumption.

Steroids, psychosis and poly-substance abuse

OBJECTIVE

To review consequences of the changing demographic profile of anabolic-androgenic steroid (AAS) use.

METHOD

Case report and review of key papers.

RESULTS

We report here a case of a 19-year-old Irish male presenting with both medical and psychiatric side effects of methandrostenolone use. The man had a long-standing history of harmful cannabis use, but had not experienced previous psychotic symptoms. Following use of methandrostenolone, he developed rhabdomyolysis and a psychotic episode with homicidal ideation. Discussion Non-medical AAS use is a growing problem associated with medical, psychiatric and forensic risks. The population using these drugs has changed with the result of more frequent poly-substance misuse, potentially exacerbating these risks.

CONCLUSION

A higher index of suspicion is needed for AAS use. Medical personnel need to be aware of the potential side effects of their use, including the risk of violence. Research is needed to establish the magnitude of the problem in Ireland.

Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement

Despite the high prevalence of performance-enhancing drug (PED) use, media attention has focused almost entirely on PED use by elite athletes to illicitly gain a competitive advantage in sports, and not on the health risks of PEDs. There is a widespread misperception that PED use is safe or that adverse effects are manageable. In reality, the vast majority of PED users are not athletes but rather nonathlete weightlifters, and the adverse health effects of PED use are greatly underappreciated. This scientific statement synthesizes available information on the medical consequences of PED use, identifies gaps in knowledge, and aims to focus the attention of the medical community and policymakers on PED use as an important public health problem. PED users frequently consume highly supraphysiologic doses of PEDs, combine them with other PEDs and/or other classical drugs of abuse, and display additional associated risk factors. PED use has been linked to an increased risk of death and a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Because randomized trials cannot ethically duplicate the large doses of PEDs and the many factors associated with PED use, we need observational studies to collect valid outcome data on the health risks associated with PEDs. In addition, we need studies regarding the prevalence of PED use, the mechanisms by which PEDs exert their adverse health effects, and the interactive effects of PEDs with sports injuries and other high-risk behaviors. We also need randomized trials to assess therapeutic interventions for treating the adverse effects of PEDs, such as the anabolic-androgen steroid withdrawal syndrome. Finally, we need to raise public awareness of the serious health consequences of PEDs.

The influence of age of onset and acute anabolic steroid exposure on cognitive performance, impulsivity, and aggression in men

The name of author Heather Berlin omitted a middle initial in the byline and author note and should appear as Heather A. Berlin.] A growing translational literature suggests that adolescent exposure to anabolic-androgenic steroids (AASs) leads to increased aggression and impulsivity. However, little is known about the cognitive effects of AASs among AAS users or the differences between adolescent- and adult-onset users. This study provides a test of the effects of acute naturalistic AAS use and age of onset (adolescent vs. adult) on measures of inhibitory control, planning and attention, and decision making. Seventy-one active adult male AAS users completed self-report measures of impulsivity and aggression, and a subsample (11 adolescent onset vs. 11 adult onset) matched on current age were administered 4 computerized tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB) (Cambridge Cognition, 2002) and the Iowa Gambling Task (Stanton, Liening, & Schultheiss, 2011). Multiple regression analyses and a series of 2 (adolescent vs. adult) × 2 (on-cycle vs. off-cycle) analyses of variance (ANOVAs) were used to examine the differential effects of age of onset and acute drug use on cognition and behavior. Regression analyses revealed larger on-cycle effects for adolescent users than adult users. Subsample analyses indicated that on-cycle users performed less well on cognitive measures of inhibitory control and attention, but not on tests of planning or decision making. Adolescent onset was associated with greater impulsivity and more acute sensitivity to AAS effects on attention. These preliminary findings suggest the possibility that acute AAS use is associated with some differences in inhibitory control and impulsivity and to a lesser degree, aggression. These effects may be more potent for those initiating AAS use in adolescence.

Characteristics and Behaviors of Older Male Anabolic Steroid Users

OBJECTIVE

To compare and contrast the characteristics of 2 groups of men ≥40 years old: reported anabolic-androgenic steroid (AAS) users and nonusers.

DESIGN

Cross-sectional survey.

SETTING

Thirty-eight online fitness, weight lifting, bodybuilding, and steroid Web sites.

PARTICIPANTS

A total of 67 male AAS users and 76 male nonusers ≥40 years old.

MAIN OUTCOMES MEASURED

Demographics, utilization of AAS and other performance-enhancing agents (PEAs), exercise patterns, history of illicit drugs and alcohol use, and psychiatric traits/diagnoses.

RESULTS

The majority of AAS users ≥40 years old were caucasian (92.5%), heterosexual (97.0%), and classified themselves as recreational exercisers (79.1%). AAS users took more PEAs (11.5 ± 5.6 vs 4.6 ± 2.7; P < .001), were more likely to binge drink (47.8% vs 29.0%; P = .025), report heavy alcohol use (21.0% vs 7.9%; P = .031), meet criteria for substance dependence disorder (27.4% vs 4.0%; P < .001), and report an anxiety disorder diagnosis (12.0% vs 2.6%; P = .046) than nonusers.

CONCLUSIONS

AAS misuse is prevalent among older men and is associated with polypharmacy, more aggressive alcohol use, and a higher incidence of substance dependence and anxiety disorders compared to nonusers. This information may help clinicians and researchers identify and develop appropriate intervention strategies for AAS abuse among older men.

The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis

PURPOSE

To estimate the global lifetime prevalence rate of anabolic-androgenic steroid (AAS) use and investigate moderators of the prevalence rate.

METHODS

A meta-analysis and meta-regression analysis was performed using studies gathered from searches in PsycINFO, PubMed, ISI Web of Science, and Google Scholar among others. Included were 187 studies that provided original data on 271 lifetime prevalence rates. Studies were coded for publication year, region, sample type, age range, sample size, assessment method, and sampling method. Heterogeneity was assessed by the I(2) index and the Q-statistic. Random effect-size modeling was used. Subgroup comparisons were conducted using Bonferroni correction.

RESULTS

The global lifetime prevalence rate obtained was 3.3% (95% confidence interval [CI], 2.8-3.8; I(2) = 99.7, P < .001). The prevalence rate for males, 6.4% (95% CI, 5.3-7.7, I(2) = 99.2, P < .001), was significantly higher (Qbet = 100.1, P < .001) than the rate for females, 1.6% (95% CI, 1.3-1.9, I(2) = 96.8, P < .001). Sample type (athletes), assessment method (interviews only and interviews and questionnaires), sampling method, and male sample percentage were significant predictors of AAS use prevalence. There was no indication of publication bias.

CONCLUSION

Nonmedical AAS use is a serious widespread public health problem.

Eating disorders and anabolic androgenic steroids in males--similarities and differences in self-image and psychiatric symptoms

Background

Body dissatisfaction is common among both females and males. Dissatisfaction with the body is a risk factor both for onset of eating disorders and for abuse of anabolic androgenic steroids (AAS). Few studies have however investigated if there are other similarities in respect to self-image or psychiatric symptoms between clinical samples of eating disordered males and males in treatment for negative effects of AAS use.

Aim

The aim of this study was to compare two clinical samples, one of males with ED and one of males who used AAS, regarding self-image and psychiatric symptoms.

Methods

This study compared males with eating disorders (n = 13) and males who recently stopped AAS use (n = 29) on self-image and psychiatric symptoms, using The Structural Analysis of Social Behavior self-questionnaire and a shortened version of The Symptom Check List.

Results

The eating disorder group reported significantly lower scores for Self-emancipation and Active self-love and higher scores for Self-blame and Self-hate. Both groups reported serious psychiatric symptoms. The common denominator between groups was serious psychiatric symptomatology rather than negative self-image.

Conclusions

The negative self-image profile, especially self-hate, found among males with Eating Disorders may indicate that the studied groups differ in aetiology of the underlying problems. The serious psychiatric symptoms in both groups call staff to pay attention to any thoughts of suicide due to severe depressive symptoms where by specialized psychiatric treatment may be needed.