Anabolic Steroid Abuse

Definition/Description

Anabolic-androgenic steroids, commonly called “anabolic steroids”, are synthetic substances that resemble male sex hormones (e.g., testosterone). Anabolic steroids promote the growth of skeletal muscle and cause increased production of red blood cells (anabolic effects), and the development of male characteristics (androgenic effects) in both males and females.[1][2]   Anabolic steroids are also responsible for muscle and bone cell proliferation, while androgenic is responsible for both primary and secondary sex characteristics.  Further benefits of anabolic steroids is the anti-catobolic properties, preventing tissue breakdown commonly assosciated with greater and greater intensity activities (i.e. greater distances, weights, times, etc.).[3]

Common medical uses of anabolic steroids include replacement therapy to treat delayed puberty in adolescent boys, hypogonadism and impotence in men, breast cancer in women, anemia, osteoporosis, weight loss and other conditions with hormonal imbalance.[2]

Anabolic steroids can be injected, taken orally, or applied externally as a gel or cream. Due to the possibility of serious adverse effects and a high potential for abuse, they are classified as Schedule III Controlled Substances in the U.S.[4] Doses taken by abusers can be 10 to 100 times higher than doses used for medical conditions.[1]

Some commonly abused anabolic steroids are listed in the table below.[1]

Image from anabolic steroid abuse research report.png

Prevalence

Prevalence of anabolic steroid use is poorly researched, particularly in longevity.  Individuals using AAS range from adolescent weight trainers to high level professional athletes and olympians. Most research data collected is acquired through direct survey methods.  Due to the nature of self reporting surveys, AAS is likely to be underreported.  As social attitude towards the acceptance of anabolic androgenic steroid use changes, better profiling of this patient population may be seen.  Current research suggest prevelence among adolescence at 1-5%.[5][6]

The 2005 Monitoring the Future study, a NIDA-funded survey of drug use among adolescents in middle and high schools across the United States, reported that past year use of steroids decreased among 8th- and 10th-graders since peak use in 2000. Among 12th-graders, there was a different trend—from 2000 to 2004, past year steroid use increased, but in 2005 there was a significant decrease, from 2.5 percent to 1.5 percent.[1]

Some research has indicated prevalence rates for males being 6.4% (95% CI, 5.3–7.7, I2 = 99.2, P < .001), which is significantly higher than the rate for females, at 1.6% (95% CI, 1.3–1.9, I2 = 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.[7]

Characteristics/Clinical Presentation

Clinical signs and symptoms of anabolic steroid use include:

• Chest pain[8]
• Elevated blood pressure[8][9]
• Ventricular tachycardia [8]
• Altered ejection fraction (lower end of normal: under 55%)[9]
• Rapid weight gain (10-15 pounds in 2-3 weeks)[8][9]

• Peripheral edema[8][9]
• Acne on face, upper back, chest[8][9]
• Altered body composition with marked development of the upper torso[8]
• Muscular hypertrophy[9]
• Stretch marks around the back, upper arms, and chest[8][9]
• Needle marks in large muscle groups (e.g., buttocks, thighs, deltoids)[8][9]
• Development of male pattern baldness[8]
• Gynecomastia (breast tissue development in males); breast tissue atrophy in females[8]
• Frequent hematoma or bruising[8]
• Personality changes called “steroid psychosis” (rapid mood swings, sudden increased aggressive or even violent tendencies)[8][9]
• Females: Secondary male characteristics (deeper voice, breast atrophy, abnormal facial and body hair); menstrual irregularities[8]
• Abdominal pain, diarrhea[9]
• Bladder irritation, urinary frequency, urinary tract infections[9]
• Sleep apnea, insomnia[9]
• Jaundice (chronic use)[8]

Severe depression leading to suicide can occur with anabolic steroid withdrawal.[8] 

In the pediatric population, there is a risk of decreased of delayed bone growth. Tendon or muscle strains are common and take longer than normal to heal.[8]

Associated Co-morbidities

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Medications

Please reference medical management for pharmacological intervention of those recovering from long term side effects of anabolic-androgenic steroid use.

Diagnostic Tests/Lab Tests/Lab Values

A urinalysis is the most common screening method with the use of GC-MS, known as gas chromatography and mass spectrometry, which identifies a specific substance in a certain provided sample. Traditionally, gas chromatography (GC) coupled with mass spectrometry (MS) has been used for confirmation of anabolic steroids and their metabolites in human urine.[10][11]

Etiology/Causes

One of the main reasons people give for abusing steroids is to improve their athletic performance. Another is to increase their muscle size or to reduce their body fat. This group includes people suffering from the behavioral syndrome called muscle dysmorphia. In one series of interviews with male weightlifters, 25 percent who abused steroids reported memories of childhood physical or sexual abuse. Similarly, female weightlifters who had been raped were found to be twice as likely to report use of anabolic steroids or another purported muscle building drug, compared with those who had not been raped. Also, some adolescents abuse steroids as part of a pattern of high-risk behaviors.[1]

Systemic Involvement

Systemic involvement resulting from anabolic-androgenic steroid abuse varies amongst individuals related to length of use and dosage. Sytems involved include, but are not limited to: endocrine, urogenital, integumentary, cardiovascular, hepatic, skeletal muscle, psychological, pulmonary, integumentary. 

Possible health consequences of anabolic steroid abuse:[1]

Hormonal system
• Men
-   Infertility
-   Breast development
-   Shrinking of the testicles
-   Male-pattern baldness
• Women
-   Enlargement of the clitoris
-   Excessive growth of body hair
-   Male-pattern baldness


Musculoskeletal system
• Short stature (if taken by adolescents)
• Tendon rupture


Cardiovascular system
• Increases in LDL; decreases in HDL
• High blood pressure
• Heart attacks
• Enlargement of the heart’s left ventricle


Liver
• Cancer
• Peliosis hepatitis
• Tumors


Skin
• Severe acne and cysts
• Oily scalp
• Jaundice
• Fluid retention


Infection
• HIV/AIDS
• Hepatitis


Psychiatric effects
• Rage, aggression
• Mania
• Delusions

Medical Management (current best evidence)

Pharmacological management of androgenic anaboloic steroid abuse is not always indicated, with supportive behavioral psychotherapy and patient education of withdrawal signs and symptoms being sufficient plan of care. Psychopharmacological intervention may include prescription anti anxiety or anti depressants in combination with cognitive behavioral therapy. Pharmacological management of AAS abuse addresses hormonal imbalances as a result of chronic use or addressees specific signs and symptoms of withdrawal including; weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea, abdominal pain[12]

Physical Therapy Management (current best evidence)

Very little information is available providing suggested physical therapy management of patient population abusing AAS. Professional healthcare providers are faced with ethical considerations when treating those using or recovering from anabolic-androgenic steroid use and associated conditions.  The American Medical Assosciation called for a formal ban on over the counter anabolic steroids and associated hormonal derivatives.[13] Physical Therapists may be treating associated symptoms related to systemic involvement of prolonged AAS abuse.

Psychological Management (current best evidence)

There is limited literature available for forms of cognitive psycho therapy aimed at treating clinical depression and associated detrimental behavioral patterns.

Differential Diagnosis

Any young adult with chest pain of unknown cause, possibly accompanied by dyspnea and elevated blood pressure and without clinical evidence of neuromusculoskeletal involvement, may have a history of anabolic steroid use. Consider anabolic steroid use as a possibility in men and women presenting with chest pain in their early 20s who have used this type of steroid since age 11 or 12.[8]

Case Reports/ Case Studies

Rhabdomyolysis of the Deltoid Muscle in a Bodybuilder Using Anabolic-Androgenic Steroids: A Case Report. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629047/

Delayed diagnosis of a cerebrovascular accident associated with anabolic steroid use. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128333/

Multi-organ damage induced by anabolic steroid supplements: a case report and literature review. http://www.jmedicalcasereports.com/content/2/1/340

Anabolic androgenic steroid-induced cardiomyopathy, stroke and peripheral vascular disease. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132623/

Resources

• Are Steroids Worth The Risk? http://kidshealth.org/teen/food_fitness/sports/steroids.html
• Mind Over Matter: Anabolic Steroids. http://teens.drugabuse.gov/educators/curricula-and-lesson-plans/mind-over-matter/anabolic-steroids
• National Institute on Drug Abuse: The Science of Drug Abuse & Addiction. http://www.drugabuse.gov/drugs-abuse/steroids-anabolic
• Performance-enhancing drugs: Know the risks. http://www.mayoclinic.org/performance-enhancing-drugs/ART-20046134?p=1
• Gay Teen Boys More Likely to Use Muscle-Building Steroids: Survey: MedlinePlus. http://www.nlm.nih.gov/medlineplus/news/fullstory_144381.html

References

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  1. 1.0 1.1 1.2 1.3 1.4 1.5 National Institute on Drug Abuse. Anabolic Steroid Abuse. http://www.drugabuse.gov/publications/research-reports/anabolic-steroid-abuse (accessed 11 Mar 2014).
  2. 2.0 2.1 Drugs.com. Androgens and anabolic steroids. http://www.drugs.com/drug-class/androgens-and-anabolic-steroids.html (accessed 22 Mar 2014).
  3. Fahey TD. Anabolic-androgenic steroids: mechanism of action and effects on performance. Encyclopedia of Sports Medicine and Science 1998. http://www.sportsci.org/encyc/anabster/anabster.html (accessed 23 Mar 2014).
  4. Drugs.com. Anabolic Steroids- Abuse, Side Effects and Safety. http://www.drugs.com/article/anabolic-steroids.html (accessed 22 Mar 2014).
  5. Thiblin I,Petersson A. Pharmacoepidemiology of anabolic androgenic steroids: a review. Fundamental & Clinical Pharmacology 2004;19:27–44
  6. President's Council on Physical Fitness. Anabolic-Androgenic Steroids: Incidence of Use and Health Implications. Research Digest 2005; Series 5, No.5:1-8
  7. Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Annals of Epidemiology 2014. http://www.sciencedirect.com/science/article/pii/S1047279714000398 (accessed 23 Mar 2014).
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 Goodman CC, Snyder TE. Screening the Chest, Breasts, and Ribs. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. Philadelphia: Saunders, 2013. p673-712.
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Goodman CC, Snyder TE. Interviewing as a Screening Tool. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. Philadelphia: Saunders, 2013. p31-95.
  10. Jeon B, Yoo H, Jeong E, Kim H, Jin C, Kim D, Lee J. LC-ESI/MS/MS method for rapid screening and confirmation of 44 exogenous anabolic steroids in human urine. Springer-Verlag, Anal Bioanal Chem 2011;401:1353–1363.
  11. Pozo O, Eenoo P, Deventer K, Delbeke F. Development and validation of a qualitative screening method for the detection of exogenous anabolic steroids in urine by liquid chromatography-tandem mass spectrometry. Springer-Verlag, Anal Bioanal Chem 2007;389:1209–1224.
  12. MedicineNet.com. Steroid Drug Withdrawal. http://www.medicinenet.com/steroid_withdrawal/article.htm (accessed 23 Mar 2014).
  13. About.com: Alcoholism. AMA Supports Anabolic Steroids Restrictions: Use of Steriods Increasing in High School Students. http://alcoholism.about.com/cs/steroids/a/blama030624.htm (accessed 23 Mar 2014).