This learning module reviews relevant terminology and explores the types of anabolic steroids, their therapeutic and illegal use, signs of abuse, and complications.
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the Controlled Substance Act (CSA), which defined AAS as "any drug or hormonal substance chemically and pharmacologically related to testosterone (other than estrogens, progestins, and corticosteroids) that promote muscle growth" (DEA, 2004, para. 9). This Act also defined the newly created drug class of AAS in a way that allows the government to control the production of newly synthesized AAS. As technology developed and the production and distribution of AAS evolved, Congress enacted the Anabolic Steroid Control Act of 2004. This Act banned all over-the-counter (OTC) steroid precursors from being sold and increased the penalties for making, selling, or possessing these steroid precursors. This Act also provided funding for the development of preventative education programs (DEA, 2004; NIDA, 2018b).
AAS production, sale, or possession (without a valid prescription) is illegal in the US. There are several penalties for federal offenses. Possession of AAS for personal use carries a maximum sentence of 1 year in prison and a minimum fine of $1,000 for a first-time drug offender. If a person is caught distributing or trafficking AAS, there is a maximum penalty of 5 years in prison and a fine of $250,000 for a first-time felony drug charge. For a repeat felony offender, the maximum prison sentence and fines are doubled. Additionally, each state has penalties for producing, distributing, and possessing AAS (DEA, 2004).
Many professional athletic organizations, including the International Olympic Committee (IOC), National Collegiate Athletic Association (NCAA), and professional sports leagues (e.g., Major League Baseball [MLB], National Football League [NFL], National Hockey League [NHL], National Basketball Association [NBA]), have banned the use of AAS. They regularly test their athletes for the presence of AAS in their system. The IOC, NCAA, and NFL have even banned the use of AAS precursors by their athletes. AAS abuse is typically discovered based on a urine or blood sample. One commonly used laboratory advertises a urine test that can detect 40 different anabolic compounds. Professional sports organizations perform rigorous tests via blood and urine to identify athletes abusing AAS and other performance-enhancing drugs. For eight years, the US Anti-Doping Agency (USADA) budgeted $2 million per year to research the areas of AAS and other doping agents (see the section on performance enhancers below). Despite this research in detecting AAS and other performance-enhancing substances, new compounds are continually being developed that are undetectable by current tests (Bhasin et al., 2021; DEA, 2004; NIDA, 2018b).
Anabolic Androgenic Steroids
There are two types of AAS: 17 alpha alkyl derivatives include oxandrolone (Oxandrin), oxymetholone (Anadrol), fluoxymesterone (Halotestin), methandriol (Anabol), ethylestrenol (Duraboral, Maxibolin), methyltestosterone (Android, Testred), stanozolol (Winstrol), methandrostenolone (Dianabol) and 17 beta-ester derivatives including testosterone cypionate (Depo-Testosterone), testosterone enanthate (Delatestryl, Xyosted), testosterone propionate (Testoviron), nandrolone decanoate (Deca-Durabolin), nandrolone phenpropionate (Durabolin), and dromostanolone propionate (Drolban, Masteril, Masteron; DEA, 2004; NIDA, 2018b). Steroids that are commercially available in the US include:
oral steroids: oxymetholone (Anadrol), oxandrolone (Oxandrin), stanozolol (Winstrol), methyltestosterone (Android, Testred), fluoxymesterone (Halotestin)
injectable steroids: nandrolone decanoate (Deca-Durabolin), nandrolone phenpropionate (Durabolin), testosterone cypionate (Depo-Testosterone), testosterone enanthate (Delatestryl, Xyosted), testosterone propionate (Testoviron)
veterinary steroids: boldenone (Equipoise), mibolerone (Matenon), and trenbolone (Revalor; DEA, 2004; NIDA, 2018b)
Other steroids illicitly marketed that are not approved for use in the US are ethylestrenol (Duraboral, Maxibolin), methandriol (Anabol), methenolone (Primobolan), and methandrostenolone (Dianabol). Some of the most abused steroids include nandrolone decanoate (Deca-Durabolin), nandrolone phenpropionate (Durabolin), boldenone (Equipoise), and stanozolol (Winstrol; DEA 2004; NIDA, 2018b).
Therapeutic Use
There are FDA-approved indications for prescribing AAS and off-label uses of these medications. FDA-approved indications for AAS use consist of primary hypogonadism, delayed puberty in boys, hypogonadotropic hypogonadism, pituitary-hypothalamic axis dysfunction, and primary testicular failure in patients diagnosed with cryptorchidism, orchitis, testicular torsion, vanishing testis syndrome, Klinefelter syndrome, or damage from heavy metals. Off-label or non-FDA-approved uses of AAS include bone marrow stimulation in patients diagnosed with leukemia, aplastic anemia, growth failure, and stimulation of muscle mass in patients with cachexia from malignancy or acquired immunodeficiency syndrome (AIDS). These medications are available as pills, topical creams or gels, and transdermal patches (Ganesan et al., 2021).
Recently, testosterone supplementation has become more popular among men to combat the natural decrease of testosterone associated with aging to improve sexual performance and boost muscle mass. AAS have even been prescribed, controversially, for this purpose to younger men. Consequently, the FDA released a safety announcement that testosterone is only approved for men with low testosterone due to a medical condition such as disorders of the testicles, pituitary gland, or brain causing hypogonadism. This safety announcement was released due to the increasing number of men being prescribed testosterone for no other reason than low testosterone due to aging. The FDA also cited an increased risk of heart attack, stroke, and death in aging men using testosterone. As a result, the FDA required all manufacturers of testosterone to change their labels to reflect this increased risk (FDA, 2018; Ganesan et al., 2021; NIDA, 2018b).
Before treatment with AAS is initiated, the patient must have a documented diagnosis of hypogonadism. This diagnosis must be supported by low early morning testosterone levels on two separate days, as measured via serum blood draw. While actively being treated with AAS, patients should have their lipid profile, hepatic function, hemoglobin, and hematocrit monitored at 3 to 6 months and then every year. For patients with male reproductive organs over 40, a prostate-specific antigen (PSA) test and prostate exam must be completed before treatment. Since the prostate is a testosterone-dependent gland with an androgen receptor (AR), AAS bind to this receptor and promote cell growth. This cell growth can increase PSA, benign prostatic hypertrophy (BPH), and prostatitis. Therefore, if the patient has an initial PSA above 0.6 ng/mL, they should have their PSA monitored and undergo a prostate exam 3 to 6 months after initiating treatment. The use of AAS can also lead to the proliferation of androgen-based malignant cells. Due to this, AAS use is contraindicated in patients with a PSA greater than 4 ng/mL or a palpable prostate nodule and those with a high risk of developing prostate cancer with a PSA greater than 3 ng/mL (Cannarella et al., 2021; Ganesan et al., 2021; Snyder, 2022).
Illegal Use
In general, AAS tend to be abused by athletes, particularly bodybuilders, due to their ability to increase lean muscle mass. Steroid usage is less common among females, as the masculinizing results are less desirable. Historically, most people who abused AAS were professional male weightlifters in their 20s or 30s or competitive athletes; however, a recent survey revealed that 75% of AAS users are noncompetitive bodybuilders and athletes who utilize AAS for cosmetic effects instead of performance enhancement. Common "street" names for anabolic steroids include Arnolds, gym candy, pumpers, roids, stackers, weight trainers, and juice. Abusers of AAS may administer the drugs using different routes, including orally, intramuscularly (IM), or topically. When AAS are misused, the dosage is often 10-100 times higher than the therapeutic dose. The oral route generally clears from the body quicker than other routes, which users may prefer if drug testing is expected. AAS may be used in specific patterns to produce an even more significant effect on muscle mass, including mixing different types (DEA, 2004; McBride et al., 2018; NIDA, 2018a).
Various patterns for misusing steroids have been documented (DEA, 2004; NIDA, 2018a):
Cycling involves taking AAS for a period, discontinuing use for a time, and then resuming AAS use. Cycling periods usually last 6-16 weeks. Perceived benefits of cycling include reducing tolerance and adverse effects, preventing detection, and ensuring peak performance.
Stacking occurs when an individual combines different AAS or uses multiple administration routes (e.g., IM and oral).
Pyramiding involves a slow increase in AAS dosage or frequency of use until a peak amount is reached and then tapering off the dosage or frequency until discontinuation. This regimen is thought to give optimal effects while decreasing the likelihood of detection.
Plateauing describes the process of alternating, overlapping, or changing the AAS used to prevent developing a tolerance.
Individuals can obtain illegal AAS through various avenues. AAS are commonly smuggled into the US through Mexico or European countries. The drugs are easier to obtain in these countries since a prescription is not required for purchase. Sometimes, AAS are stolen from legitimate sources (e.g., pharmacies or veterinary offices) or obtained through inappropriate prescribing by healthcare professionals (HCPs; DEA, 2004; NIDA, 2018b).
As technology improves and individuals buy more goods online, AAS are not exempt from this practice. The drugs are often produced in laboratories and sold on the internet. Researchers of one study googled "buy steroids" and evaluated the ease of purchasing AAS through the top eight resulting websites. Of the eight websites, seven (87%) offered injectable testosterone, including enanthate (Delatestryl, Xyosted), cypionate (Depo-Testosterone), and propionate (Testoviron). None of the sites required a prescription for purchase; however, they did include a disclaimer that the consumer was required to follow local laws. Furthermore, 75% of these sites accepted common forms of payment (i.e., credit cards), and products could be shipped to the buyer's home address. The websites even offered resources on how to take the medications, including information on stacking and pyramiding. Additionally, none of the medications offered on the reviewed websites were oral meds; only injectable options were offered. The injectable form raises the risk of the individual contracting a blood-borne pathogen, such as hepatitis B, hepatitis C, or human immunodeficiency virus (HIV; DEA, 2004; McBride et al., 2018; NIDA, 2018b).
Use in Adolescents
AAS use is not just a problem among adults. Teenagers have also reported using AAS, which can be even more detrimental to their still-developing bodies. It is difficult to determine the prevalence of AAS abuse among adolescents since their use is not typically included in questionnaires. In the US, the use of AAS is more prevalent among boys compared to girls. The NIDA-funded study Monitoring the Future reported a prevalence of 0.5% in 8th-grade boys, 0.3% in 10th-grade boys, and 1.0% in 12th-grade boys this is compared to 0.4% in 8th-grade girls, 0.2% in 10th-grade girls, and 0.1% in 12th-grade girls. These numbers are a decrease from the 2019 survey. It is thought that this decrease in adolescent AAS use is due to the decrease in sporting events and the closure of gyms during the COVID-19 pandemic (Nagata et al., 2020; NIDA, 2018b)
Types of Performance Enhancers
Although this module focuses on AAS, other drugs are used for performance enhancement that is not addressed in detail in this module. These are referred to as image-, appearance-, or performance-enhancing drugs (IPEDs, APEDs, PEDs), and they are frequently used concurrently with AAS. Examples of IPEDs, APEDs, and PEDs include non-steroidal anabolics, ergo/thermogenics, and steroid precursors (NIDA, 2018b).
Non-Steroidal Anabolics
The class of non-steroidal anabolics includes human growth hormone (HGH), insulin-like growth factor (IGF), and insulin. These drugs have legitimate medical uses; however, they are attractive to potential PED users due to their mechanism of action that promotes increased lean muscle mass and a decreased ability to be detected on routine drug screenings. Utilizing insulin as a PED could signal a potentially deadly trend due to the known risks of insulin overdose, particularly severe hypoglycemia, coma, and death (NIDA, 2018b; Snyder, 2022).
The use of growth hormones has been linked to many professional athletes in various sports. In addition, approximately 5% of high-school students report using HGH. The risks and side effects of using HGH include insulin resistance, hyperglycemia, sodium retention, hypertension, and myopathy. It is also reported that weightlifters who use HGH have a higher rate of illicit drug use, including cocaine and opioids (NIDA, 2018b; Snyder, 2022).
Ergo/Thermogenics
Ergo/Thermogenics are drugs used to decrease body fat or promote leanness. This category of PEDs includes xanthines, sympathomimetics, and thyroid hormones. Xanthines are compounds that increase wakefulness and suppress appetite and include caffeine, theobromine (found in chocolate, tea, and coffee), and the respiratory medication theophylline (Theo-24, Uniphyl). Theophylline (Theo-24, Uniphyl) can cause many adverse effects when used as prescribed, including insomnia, anxiety, nausea, vomiting, tachycardia, seizures, flushing, headaches, and diarrhea. Those who abuse this medication will not self-report use and are at high risk of toxicity and associated detrimental effects (NIDA, 2018b; Skidmore, 2023).
Sympathomimetics are drugs similar in chemical structure and action to natural epinephrine and norepinephrine produced in the body. These chemicals increase heart rate, constrict blood vessels, and increase blood pressure. Examples of sympathomimetics are ephedrine (Corphedra, Akovaz) and the herbal supplement ephedra. On February 9, 2004, the FDA "issued a final rule prohibiting the sale of dietary supplements containing ephedrine alkaloids (ephedra) because such supplements present an unreasonable risk of illness or injury" (National Institutes of Health [NIH], 2004, para. 1). This announcement resulted from many studies indicating that these supplements cause an increased risk of many adverse symptoms, including seizures, psychiatric events, palpitations, and cerebrovascular events, among others. With the expanding use of the internet to obtain supplements with questionable ingredients, providers should be aware of the potential effects of sympathomimetic drugs, particularly with ingredients such as ephedra found in herbal supplements. Clenbuterol (Dilaterol; street name Clen) is a highly potent and long-lasting bronchodilator approved for human use in other countries, but in the US, it is only approved for use in horses. Bodybuilders and athletes abuse this drug due to its ability to increase lean muscle mass and reduce body fat. Clenbuterol (Dilaterol) is popular among female athletes due to its ability to repartition body fat with fewer masculinizing side effects (DEA, 2019; NIDA, 2018b; NIH, 2004).
Erythropoietin (EPO)
The hormone EPO regulates red blood cell (RBC) production and is commonly used to treat anemia. EPO stimulates erythropoiesis, increasing RBCs and hemoglobin mass. This increase allows hemoglobin to carry more oxygen. EPO's positive impact on aerobic exercise capacity within athletics is widely known, and it is often abused by athletes who compete in endurance sports (Haider et al., 2020).
Androgen Precursors
Some dietary supplements contain steroid precursors and are taken in conjunction with AAS. Steroid precursors previously sold in the US include androstenedione, dehydroepiandrosterone (DHEA), and tetrahydrogestrinone (THG). Athletes frequently consume steroid precursors to boost testosterone and the effects of AAS. There is limited research on these substances; however, since they increase the testosterone level in the body, they would produce similar side effects to AAS. After the Anabolic Steroid Control Act of 2004 was passed, the OTC sale of tetrahydrogestrinone (THG) and androstenedione was made illegal. DHEA is still available as a nutritional supplement and is widely promoted by bodybuilding and fitness magazines as a substance that can increase muscle strength (NIDA, 2018b; Snyder, 2022).
Complications of Abuse
AAS use affects many body systems. Some side effects are long-lasting, and some are more serious than others. Due to the lack of honest AAS use reporting these signs and symptoms may be the only indication an HCP has that an individual is using AAS. Possible adverse effects of AAS are discussed in Table 1.
Since AAS abusers may engage in risky injection behaviors, HCPs should screen them regularly for blood-borne pathogens such as HIV, hepatitis B, and hepatitis C and treat them accordingly (NIDA, 2020).
AAS Addiction and Treatment
AAS cannot cause users to feel high; however, these substances can be addictive, and users can become dependent on them. Substance use disorder (SUD), potentially progressing to addiction, is demonstrated by an individual continuing to use AAS despite experiencing physical and psychological adverse effects, the high cost of obtaining the drugs, and the detrimental impact on personal relationships. If a person abruptly stops using AAS, they can experience withdrawal effects, including fatigue, restlessness, loss of appetite, sleep problems, decreased sex drive, AAS cravings, mood swings, and depression, which can last for up to a year and lead to suicide in some cases. To help manage withdrawal symptoms, individuals can be prescribed medications to restore hormonal balance, antidepressants to manage depression, and pain medication to relieve headaches and muscle and joint pain (DEA, 2004; NIDA, 2018a, 2018b).
Anti-Doping Campaign
The USADA provides athletes with education and conducts research and testing to promote fair, drug-free athletic competitions. The most effective way to decrease AAS abuse is through education, which is considered the first line of defense to protect clean athletes in sports. The USADA provides education to thousands of athletes per year. Topics of discussion include which substances are prohibited, the sample collection procedure, and awareness of dietary supplement ingredients. Instruction is provided through in-person training, webinars, interactive tutorials, and distribution materials such as brochures, pamphlets, and packets. The USADA is often referred to as the gold standard of the anti-doping movement (USADA, 2019).
Athletes Training and Learning to Avoid Steroids (ATLAS) is an anti-doping campaign created to address adolescent steroid use specifically. The ATLAS program is designed to reduce or eliminate the use of AAS, alcohol, illicit drugs, and supplements while promoting healthy dietary and exercise practices. The ATLAS education program is delivered to high schools or athletic teams in person. The students are separated into small groups of 5-6, with a leader appointed for each group. This approach is designed to promote positive peer pressure and role modeling. Programs consist of educational games, skill-building, role-playing exercises, creating public service announcements, and competition among the groups. The program aims to teach students that they can achieve their performance goals using high-quality nutrition, supplements, and equipment (Youth.gov, n.d.).
Future Research
The literature highlights the need for increased research on AAS abuse and its complications. However, this research must address several challenges, namely reporting biases by the research participants. Few people will admit to illegally using a controlled substance. With so many illicit compounds being sold easily over the internet, research on the effects of particular compounds amplifies these challenges (McBride et al., 2018).
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