What is steroid abuse?
Anabolic steroids are prescription medications that are used to treat hormonal or muscular problems in patients with delayed-onset puberty, cancers, or acquired immune deficiency syndrome (AIDS), among other conditions. Unlike most other abused drugs, steroids do not cause euphoria or other immediate pleasurable reactions. Rather, the steroid abuser is seeking a change in body configuration—a build-up in muscle mass—and to improve athletic performance. Abusers do not become physically addicted to steroids, but they can develop a compulsive reliance on them.
The frequency and amount of dosing increase through continued use. Abusers may start taking several different formulations simultaneously; such formulations may include pills, intramuscular injections, and topical creams, gels, or transdermal patches. Down time or withdrawal from the drugs becomes increasingly uncomfortable.
Adolescents and adults under the age of thirty, especially those involved in such competitive sports as weightlifting, rugby, football, track and field, and wrestling, and professional athletes are the most likely to use anabolic-adrenergic steroids. Most do so to boost athletic performance and increase muscle mass. Poor body image and psychiatric conditions such as depression also increase the odds that an individual will begin abusing steroids. A wide range of steroids are readily available at gyms and through websites.
Steroid abusers may develop severe acne on the face, shoulders, and back; excessive facial or body hair; pigmented lines (striae) on the skin; baldness; and voice changes. In men, the testicles may shrink and the breasts may show evidence of development. In women, the clitoris may become enlarged, breast development may be delayed, and menstruation may be affected. Behavioral consequences of steroid abuse may include “roid rage,” which consists of mood swings, anxiety, irritability, and aggressiveness. Jealousy, delusions, and feelings of invincibility can also arise.
Withdrawal from steroids can cause depression, headaches, fatigue, loss of appetite, and insomnia. Depression can lead to suicidal thoughts and actions. Other controlled substances may be used to ease the adverse effects of steroid abuse. The suppliers of steroids often deal in other illegal drugs.
Treatment providers should screen for steroid abuse in young patients with low body fat, extreme muscularity, and a disproportionately large upper torso. In addition to the symptoms outlined above, needle marks may be detected in large muscles (gluteals, thighs, deltoids). The history of athletic or fitness activity may reveal an obsession with weight training and body conditioning, often coupled with dissatisfaction with appearance, despite what others perceive. This is defined as body dysmorphic disorder.
Standard urine tests do not screen for steroids. Urinalysis must be done at a specialized laboratory equipped to test for steroids. Even then, abusers may be taking newer formulations not as yet included in the screening choices. Abusers may also employ “stacking,” in which they combine relatively small quantities of several steroids administered by different routes, in part to keep individual steroid types below detection levels. Some also will temporally suspend usage if they suspect or know that testing will occur.
If a person admits to steroid abuse, the physician or drug counselor needs to query that person regarding his or her perception of the benefits and understanding of the consequences of using steroids. The health professional needs to establish when steroids were first and most recently used and to determine the pattern of use (for example, on-and-off periods or high- and low-dose cycles); what steroids were used, how they were administered, and at what dosage; how the steroids were obtained; and whether the patient is using other drugs to augment or complement the steroids' effects, to reduce side effects, or to cope with depression or other adverse effects during off periods. In all this, the health provider should convey a supportive rather than judgmental attitude.
All substances being used need to be addressed; individuals abusing steroids are at risk of also abusing analgesics, antiestrogens, cardiovascular medications, stimulants, depressants, acne medication, diuretics, weight-loss drugs, growth hormones, sexual enhancement drugs, and recreational drugs. The patient should be told about the risks involved in abusing steroids. Patients who injected steroids should be tested for blood-borne diseases, including human immunodeficiency virus infection and hepatitis B and C virus infection.
Not all changes caused by the abuse of steroids can be reversed. Adverse sexual side effects may require hormonal therapy under the direction of an endocrinologist. Depression related to withdrawal of steroids may need to be addressed by a mental health professional. Severe or persistent depression may respond to selective serotonin reuptake inhibitors, such as fluoxetine (Prozac). Headaches and muscle and joint pain related to withdrawal are responsive to analgesics. Lifestyle changes may be required to maintain abstinence. The patient may need to switch gyms, workout friends, competitive events, and sport types to avoid the risk of relapse.
Most prevention efforts focus on athletes involved in professional and Olympic sports. The primary approach to prevention is to expose steroid abuse through testing and banning of abusers from competition and to strip athletes of records and rewards that were attained while using banned steroids. It is hoped that the consequences of these actions will deter current and potential users.
Most first-time users of banned steroids are high school students. However, few schools at this level have offered steroid abuse programs. Even if drug-testing were more widely utilized at this level, it is not clear how great an effect it would have on preventing use. Providers of steroids offer new formulations that they claim cannot be detected by current tests, and abusers stack several different steroids or temporally stop using them.
Simply warning students about the adverse effects of steroid abuse does not convince them that they will be adversely affected. They often believe that they can beat the odds. It may even pique their interest in the drugs, pushing them to try them. Steroid drug testing among adolescents has not gained wide acceptance. Legal and cost concerns are raised by parents and school districts.
What appears necessary is an approach that, in addition to explaining the risks involved in using steroids, offers effective and healthy alternatives. Such an approach would allow students to make decisions based on informed knowledge and experience. To this end, for example, the Oregon Health and Science University, with sponsorship from the US government, developed the Athletes Training and Learning to Avoid Steroids (ATLAS) program. ATLAS was initially developed for use with high school football players. It is now more widely applied. Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA), a similar program, was developed for high school girls on sports teams.
With these programs, coaches and team leaders are trained to present information to small groups of students engaged in a shared experience as an integral part of athletic training. Students learn through an interactive approach that they can build strong bodies and improve athletic ability without the use of steroids. Strength-training and nutritional habits that promote healthy muscular conditioning without the use of drugs are put into practice as part of the programs.
A research study on ATLAS has shown that one year after completing the program, study participants versus a control group of similar student athletes who did not participate had one-half the incidence of new steroid abuse and less intention to abuse in the future. Experimental group participants also showed less abuse of other athletic-enhancing supplements and of alcohol, marijuana, amphetamines, and narcotics.
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