U.S DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

Substance Abuse Treatment

ADVISORY

News for the Treatment Field

June 2006 

Volume 5 

Issue 3

continued on reverse...

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 selfcorrect after stopping. Programs may lack guidelines for 

screening, assessment, and treatment.

What are anabolic steroids?

Anabolic steroids—more specifically anabolicandrogenic 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
ADVISORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

June 2006, Volume 5, Issue 3

Substance Abuse Treatment

2

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.

If any red flags are present, the provider should ask6—

ut athletic or fitness activities. Young males who lift 

ghts are at greatest risk to use AAS.

ut use of mail-order or over-the-counter supplements 

., protein shakes, creatine, dehydroepiandrosterone 

mmonly called DHEA]). Use of supplements is 

monly associated with AAS use.

ether the client knows anyone who has tried AAS.

ether the client has tried or thought about trying AAS.

lient admits AAS use, the provider should note it. Then 

ollowing:

at are the client’s perceptions of AAS benefits and 

sequences?

at are the dates of first and last use, AAS names and 

ages, sources (e.g., prescription diversion, veterinary 

ces, Internet), routes of administration, and use patterns?

at measures are taken to avoid detection?

ere depression during withdrawal periods? How severe? 

w does the client cope?

 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. 

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ing used.8

unselors should acknowledge the muscle development 

ility of AAS, while emphasizing AAS risks. To achieve 

edibility, counselors need to understand the body-building 

estyle, how AAS are used, and AAS slang. Clients are 

ely to be very educated about using AAS to achieve 

ecific body building or muscle strengthening goals. They 

e unlikely to perceive AAS use as addictive.6

opping AAS use reverses most physical and psychogical changes—but not all. Voice deepening and other 

gns of masculinization in females may be irreversible. 

unted growth in adolescents is often permanent. 

gan system damage may be irreversible. Prolonged 

xual side effects may require hormonal therapy by an 

docrinologist. The client should be advised about and 

ted for blood-borne diseases.3,6

pression 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

“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

•

•

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•

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•
ADVISORY

Anabolic Steroids

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Substance Abuse Treatment

3

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

Notes

1Kanayama, 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.

2Grassley, 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].

3Volkow, 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].

4Johnston, 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.

5Brower, K.J. Anabolic steroid abuse and dependence. Current 

Psychiatry Report 4(5):377–387, 2002.

6Pope, 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.

•

•

7Pope, 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.

8Arvary, D., and Pope, H.G. Anabolic-androgenic steroids as a 

gateway to opioid dependence (letter). New England Journal of 

Medicine 342:1532, 2000. 

9National 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].

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
ADVISORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

June 2006, Volume 5, Issue 3

Substance Abuse Treatment

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.

National Clearinghouse for Alcohol and Drug Information

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

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Substance Abuse Treatment Advisory 

Anabolic Steroids

DHHS Publication No. (SMA) 06-4169 

Printed 2006