**Substance Abuse Treatment**

**Advisory**

***News for the Treatment Field***

**June 2006, Volume 5, Issue 3**

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

**Anabolic SteroidS**

Recent events, especially in professional sports, have triggered
increased media coverage and congressional hearings on anabolic steroid
use. Awareness is growing that steroid use can cause significant
physical and mental harm and may be life threatening. Some studies have
identified steroids as gateway drugs to other substance use, including
opioids.^1^ People who inject steroids risk diseases passed by needle
sharing. Substance abuse treatment programs are logical resources for
steroids education and treatment, but most are not well informed.
Providers may believe that steroids are not addictive or the effects
self-correct after stopping. Programs may lack guidelines for screening,
assessment, and treatment.

**What are anabolic steroids?**

Anabolic steroids---more specifically anabolic-androgenic steroids
(AAS)---are synthetic compounds that have muscle-building (anabolic) and
masculinization (androgenic) effects. Medical uses include prevention of
tissue wasting in some diseases. People also use AAS to boost athletic
performance or look more muscular. The Drug Enforcement Administration
(DEA) categorizes AAS as schedule III controlled substances (substances
with accepted medical uses, which may cause moderate or low physical
dependence or high psychological dependence). The Anabolic Steroid
Control Act of 2004 lists 59 AAS. Although controlled, AAS are
relatively easy to obtain.^2^ The number of people abusing AAS
nationwide is unknown.^3^ The last comprehensive survey of AAS use in
the United States was in 1994. The 2004 Monitoring the Future report
noted declining adolescent AAS use in grades 8 and 10 but not among 12th
graders.^4^

**Can AAS use cause dependence?**

Evidence is growing that some people lose control of AAS use. One review
documented at least 165 cases that met dependence criteria.^5^ Many
people cycle on and off AAS and combine them with other AAS or
supplements (known as pyramiding and stacking) to control AAS effects
and avoid tolerance. Those who lose control of AAS cycles may develop
neuroadaptations in brain reward systems, which cause craving or
withdrawal symptoms on discontinuation. These symptoms compel them to
increase dosage or shorten periods of nonuse until they may use daily
for months at a time. Such individuals need specialized treatment to
stop using AAS.^6^

**What are AAS-related behavioral, psychological, and physical
disorders?**

AAS use has been linked to severe mental disorders, including mania,
depression, suicidality, and psychoses. High AAS dosages can cause
uncontrolled anger or combative behavior ("roid rage"). These episodes
may be manifestations of an AAS-induced hypomanic syndrome, which begins
with feelings of invincibility and worsens as dosages increase. Some
people using AAS experience a body dysmorphic disorder (BDD) called
muscle dysmorphia, the obsessive belief that they are not adequately
muscular or "chiseled." Some people start using other drugs to ease mood
swings or conditioning pain. For example, they may add an opioid
analgesic such as nalbuphine to their AAS regimen and progress to pure
opioids.^1^ These individuals often learn about illicit drugs from other
people who use AAS and buy their drugs from the people who sell them
AAS. Psychological barriers to injection have been breached by AAS use,
so injecting other drugs may seem like a small step. Reports exist, for
example, of people who used AAS and then developed opioid addiction. In
one study of 227 men admitted to opioid addiction treatment, 21 (9%)
reported beginning their substance use with AAS.^7^ Significant physical
harm has been linked to long-term use, including damage to liver, heart,
and sexual organ systems.^3^ Adolescent AAS use has been linked to
stunted growth, usually permanent.^3^ Needle injection increases risk of
blood-borne diseases.^3^

[]{.mark}

**How should treatment providers screen and assess AAS use?**

Treatment providers should screen for AAS use in muscular clients.
During screening, providers should look for visual or behavioral "red
flags" of AAS use.

[]{.mark}

If any red flags are present, the provider should ask^6^---

1.  About athletic or fitness activities. Young males who lift weights
    are at greatest risk to use AAS.

2.  About use of mail-order or over-the-counter supplements (e.g.,
    protein shakes, creatine, dehydroepiandrosterone \[commonly called
    DHEA\]). Use of supplements is commonly associated with AAS use.

3.  Whether the client knows anyone who has tried AAS.

4.  Whether the client has tried or thought about trying AAS.

If the client admits AAS use, the provider should note it. Then ask the
following:

-   What are the client's perceptions of AAS benefits and consequences?

-   What are the dates of first and last use, AAS names and dosages,
    sources (e.g., prescription diversion, veterinary sources,
    Internet), routes of administration, and use patterns?

-   What measures are taken to avoid detection?

-   Is there depression during withdrawal periods? How severe? How does
    the client cope?

-   Has the client used other drugs to augment AAS effects, reduce side
    effects, or mask use?

During physical assessment, physicians should look for needle marks in
large muscles (gluteals, thighs, deltoids). Men may present with
enlarged breasts and/or testicular atrophy. Male pattern baldness,
excessive hair, hypertension, enlarged liver or prostate, right
upper-quadrant abdominal pain, and jaundice are possible. Although women
are much less likely to use AAS, some women who use AAS develop
excessive hair and a deepened voice. Urinalysis must be at a laboratory
that can test for AAS. Standard urine tests do not screen AAS,
particularly variants produced to elude drug tests. However, standard
tests should be ordered as well, given the association of AAS with other
substance use. Blood testosterone levels may be grossly depressed
because AAS inhibit endogenous testosterone production.

**"Red Flags" for AAS Use**

-   Very low body fat, extreme muscularity, disproportionately large
    upper torso

-   Acne on face, shoulders, back

-   Pigmented striae on skin

-   Excessive facial or body hair

-   Superficial confidence; feelings of invincibility or grandiosity

-   Restlessness, anxiety, guardedness

-   Frustration or excessive argumentativeness to the point of rage

-   Obsession with weight training, conditioning, body image, appearance

-   Dissatisfaction with appearance despite what others perceive

-   Extremely baggy or loose clothing

**How are AAS use and its effects treated?**

-   The treatment plan needs to address all substances being used.^8^

-   Counselors should acknowledge the muscle development ability of AAS,
    while emphasizing AAS risks. To achieve credibility, counselors need
    to understand the body-building lifestyle, how AAS are used, and AAS
    slang. Clients are likely to be very educated about using AAS to
    achieve specific body building or muscle strengthening goals. They
    are unlikely to perceive AAS use as addictive.^6^

-   Stopping AAS use reverses most physical and psychological
    changes---but not all. Voice deepening and other signs of
    masculinization in females may be irreversible. Stunted growth in
    adolescents is often permanent. Organ system damage may be
    irreversible. Prolonged sexual side effects may require hormonal
    therapy by an endocrinologist. The client should be advised about
    and tested for blood-borne diseases.^3,6^

-   Depression is common during AAS withdrawal, typically easing without
    medication after several weeks. Severe depression may lead to
    suicidal ideation.^3^ Clients with severe depression should be
    treated by mental health professionals. Severe or persistent
    symptoms respond to selective serotonin reuptake inhibitors such as
    fluoxetine, which is also effective for BDDs.^6^

-   Manic symptoms usually remit when AAS use is stopped. Temporary
    treatment can include neuroleptics or other antimanic drugs. If a
    client has a history of mood disorders or manic/psychotic symptoms
    persist over 2 weeks, an underlying disorder should be investigated.
    Standard approaches such as cognitive--behavioral therapy are
    appropriate for AAS disorders.^6^

-   The client may need to change lifestyles to maintain abstinence.
    This could entail switching gyms, workout friends, competitive
    events, and/or sports. Discussions of body image issues may be
    necessary. Counselors may need to refer clients to specialists who
    can help them develop healthy fitness regimens. Programs are advised
    to form strong relationships with experts in sports medicine for
    advice and referral.^9^

**Resources for Additional Information**

*Substance Abuse and Mental Health Services Administration (SAMHSA)*

1 Choke Cherry Road

Room 8-1054

Rockville, MD 20857

Phone: 240-276-2130 (Office of Communications)

Web: www.samhsa.gov

*SAMHSA's National Clearinghouse for Alcohol and Drug Information
(NCADI)*

Phone: 800-729-6686

Español: 877-767-8432

TDD: 800-487-4889

Web: www.ncadi.samhsa.gov

*National Institute on Drug Abuse (NIDA)*

6001 Executive Boulevard

Bethesda, MD 20892-9561

Phone: 301-443-1124

Web: www.drugabuse.gov/drugpages/steroids.html *and*
www.steroidabuse.gov

*U.S. Food and Drug Administration (FDA)*

5600 Fishers Lane

Rockville, MD 20857-0001

Phone: 888-INFO-FDA (888-463-6332)

Web: www.fda.gov

***Substance Abuse Treatment Advisory***

*Substance Abuse Treatment Advisory* was written and produced under
contract number 270-04-7049 by the Knowledge Application Program (KAP),
a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for
the Center for Substance Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration (SAMHSA), U.S. Department of
Health and Human Services (HHS). The content of this publication does
not necessarily reflect the views or policies of SAMHSA or HHS.

**Public Domain Notice:** All material appearing in this report is in
the public domain and may be reproduced or copied without permission;
citation of the source is appreciated. However, this publication may not
be reproduced or distributed for a fee without the specific, written
authorization of the Office of Communications, SAMHSA, HHS.

**Electronic Access and Copies of Publication:** This publication can be
accessed electronically at www.kap.samhsa.gov. Additional free print
copies can be ordered from SAMHSA's NCADI at 800-729-6686.

**Recommended Citation:** Center for Substance Abuse Treatment. Anabolic
steroids. *Substance Abuse Treatment Advisory*. Volume 5, Issue 3, June
2006.

DHHS Publication No. (SMA) 06-4169

Printed 2006

^1^Kanayama, G., Cohane, B.A., Weiss, R.D., and Pope, H.G., Jr. Past
anabolic-androgenic steroid use among men admitted for substance abuse
treatment: An underrecognized problem? *Journal of Clinical Psychiatry*
64(2):156--160, 2003.

^2^Grassley, C. The Abuse of Anabolic Steroids and Their Precursors by
Adolescent and Amateur Athletes. Opening remarks to a hearing before the
Senate Caucus on International Narcotics Control, July 13, 2004.
drugcaucus.senate.gov/steroids04grassley.html \[accessed April 27,
2006\].

^3^Volkow, N.D. Consequences of the Abuse of Anabolic Steroids---Before
the Committee on Government Reform---United States House of
Representatives: Statement for the Record, May 17, 2005. Bethesda, MD:
National Institute on Drug Abuse.
www.drugabuse.gov/testimony/3-17-05testimony.html \[accessed March 30,
2006\].

^4^Johnston, L.D., O'Malley, P.M., Bachman, J.G., and Schulenberg, J.E.
*Monitoring the Future: National Results on Adolescent Drug
Use---Overview of Key Findings, 2004.* NIH Publication No. 05-5726.
Bethesda, MD: National Institute on Drug Abuse, 2005, p. 4.

^5^Brower, K.J. Anabolic steroid abuse and dependence. *Current
Psychiatry Report* 4(5):377--387, 2002.

^6^Pope, H.G., Jr., and Brower, K.J. Anabolic-androgenic steroids. In:
Galanter, M., and Kleber, H.D., eds. *The American Psychiatric
Publishing Textbook of Substance Abuse Treatment,* 3d ed. Arlington, VA:
American Psychiatric Publishing, Inc., 2004, pp. 301--309.

^7^Pope, H.G., Jr., and Kanayama, G. Can you tell if your patient is
using steroids? *Current Psychiatry in Primary Care* 1(2):28--34, 2005.

^8^Arvary, D., and Pope, H.G. Anabolic-androgenic steroids as a gateway
to opioid dependence (letter). *New England Journal of Medicine*
342:1532, 2000.

^9^National Institute on Drug Abuse. *Anabolic Steroids.* NIDA Community
Drug Alert Bulletin, April 2000 (last updated December 2004).
www.nida.nih.gov/SteroidsAlert/SteroidAlert.html \[accessed April 10,
2006\].