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Abstract: Despite their classification as a Schedule III Controlled Substance, anabolic-androgenic steroids continue to be used by adolescents who seek increased muscularity as well as enhanced athletic performance. Although the potential side effects of steroids are relatively well known, problems with counterfeit substances and steroid-spiked dietary supplements have received less attention. Drawing on scholarly literature and reports from government units such as the Drug Enforcement Administration and the Food and Drug Administration, this article addresses those issues and makes recommendations for communicating with adolescents about the use of steroids.
As synthetic derivatives of testosterone, anabolic-androgenic steroids (AAS) have been used in the treatment of hypogonadism and delayed puberty, as well as anemia, osteoporosis, and severe muscle deterioration (Kochakian & Yesalis, 2000). In young men, potential side effects of AAS include cosmetic concerns such as acne and oily skin, as well as more serious problems including testicular atrophy, infertility, gynecomastia, and liver toxicity (Bonetti et al., 2008; Friedl, 2000). Women who use AAS may experience similar skin problems and liver ailments (Neri et al., 2011), in addition to beard growth and deepening of the voice, as well as menstrual irregularities and enlargement of the genitalia (Elliot & Goldberg, 2000). AAS may contribute to heart disease in both men and women (Bonetti et al., 2008; Friedl, 2000), in part because the substances decrease high-density lipoproteins while simultaneously increasing low-density lipoproteins (Brower, 2002). Psychologically, researchers have identified associations between AAS and depression, mania, aggression, and psychotic episodes (Bahrke & Yesalis, 2002; Brower, 2002). These conditions can be exacerbated by nonmedical dosages of AAS that range between 10 and 100 times the amounts normally prescribed by physicians (Brower, 2002). Such dosages can lead to dependence, which one recent article characterized as a "valid diagnostic entity, and probably a growing public health problem" (Kanayama, Brower, Wood, Hudson, & Pope, 2009, p. 1966). The current article summarizes AAS regulatory efforts, reviews problems associated with the acquisition and use of these drugs, and makes recommendations for communicating with adolescents about AAS.
In the United States, the Anabolic Steroid Control Act of 1990 (Pub. L. No 101-647, 104 Stat. 4851) classified AAS as a Schedule III Controlled Substance, a category in the Omnibus Controlled Substances Act reserved for drugs with limited medicinal use. Fourteen years after the initial legislation, the Anabolic Steroid Control Act of 2004 (Pub. L. No. 108-358, 118 Stat. 1661) added steroid precursors such as androstenedione to the Schedule III list. Both policy actions followed moral crises in high-profile sports (Denham, 1997, 2006; Yesalis, 1999), and in both instances, legislators grounded policy appeals in the need to protect impressionable adolescents from physical harm. In the United States, between 2% and 10% of adolescents risk undermining their health with AAS by the time they graduate from high school (Irving, Wall, Neumark-Sztainer, & Story, 2002; Metzl, 2005; Miller et al., 2005; Reents, 2000). Male adolescents generally report higher use rates than female adolescents, but research has shown consistent use of AAS by young women (Elliot, Cheong, Moe, & Goldberg, 2007). Both men and women stand to be adversely affected by substances they purchase in the underground steroid market.
Few health professionals would dispute the need to protect vulnerable populations from potentially dangerous substances; however, excessive moralizing about AAS appears to have resulted in assumptions that actually stand to compromise the health of adolescents. First among these asumptions is that individuals who obtain AAS actually ingest AAS. Like those who deal in narcotics, underground steroid dealers often sell counterfeit or mislabeled substances to unsuspecting youth (George, 2003; Strauss & Yesalis, 1991; Yesalis, 2000). By the late 1980s, in fact, the counterfeit steroid market in the United States had eclipsed $100 million (Masland & Marshall, 1990; Moken, 2003), with many of the drugs manufactured in unsanitary, makeshift laboratories (George, 2003). The title of a 2005 U.S. Government Accountability Office investigation (Pub. No. GAO-06-243R)-"Anabolic steroids are easily purchased without a prescription and present significant challenges to law enforcement officials"-offers a more recent characterization of the underground steroid market. As part of its 2005 investigation, the Government Accountability Office placed 22 orders for steroids through Internet sites, receiving 10 shipments from foreign countries and four from within the United States; eight orders were never received. Of the four orders received from within the United States, none of the substances contained actual anabolic steroids.
Retired boxer Robert Hazelton shed light on counterfeit AAS when he testified at a hearing held in reference to the Anabolic Steroid Control Act of 2004. Hazelton told policymakers that he had once injected Armor All upholstery protectant into his hip, believing it to be an anabolic steroid he had obtained (Denham, 2006). Although Hazelton may have used his own syringes, those who share needles for administering AAS risk not only injecting toxic substances but also possibly contracting HIV, hepatitis B, or hepatitis C (Aitken, Delalande, & Stanton, 2002; Evans, 2004). As with the purchase of narcotics, adolescents who purchase AAS from an Internet source or from someone at a gym basically take their chances with content and administration (Cordaro, Lombardo, & Cosentino, 2011; Graham et al., 2009; U.S. Drug Enforcement Administration, 2009a).
Just as adolescents who purchase AAS from an Internet source or from a local dealer may or may not receive actual steroids, individuals who purchase legal body-building supplements from a nutrition retailer may or may not receive products free of AAS. As an example, in September 2009, federal agents raided the headquarters and storage facilities of Bodybuilding.com near Boise, Idaho, seizing more than 60 "supplements" that contained at least one steroid (U.S. Food and Drug Administration [FDA], 2009). In 2008, the U.S. FDA seized approximately $1.3 million in steroid-spiked supplements. With the Dietary Supplement Health and Education Act of 1994 (Pub. L. No. 103-417, 108 Stat. 4325) categorizing dietary supplements as a subcategory of food, manufacturers need not obtain premarket product approval from the FDA. Consequently, disreputable manufacturers may be willing to spike supplements with actual steroids to enhance the effects of their products (Petroczi, Taylor, & Naughton, 2011), increasing sales in what is now a $2.7 billion sports nutrition segment of a $26 billion market for dietary supplements (Singer & Schmidt, 2009).
Apart from spiking supplements with controlled substances, unscrupulous firms sometimes market products that contain few, if any, active ingredients while making bold health claims. Policy actions surrounding the supplement dehydroepiandrosterone (DHEA) are instructive in this regard. DHEA, an endogenous steroid hormone, received an exemption from the Anabolic Steroid Control Act of 2004 when U.S. Senator and Dietary Supplement Health and Education Act sponsor Orrin Hatch threatened to scuttle the entire bill if it did not exempt the substance as an "antiaging" product (Kornblut & Wilson, 2005). Despite potential health risks (U.S. General Accounting Office, 2001), DHEA, which generated sales exceeding $47 million in 2003 (Kornblut & Wilson, 2005), received the exemption as a substance that occurred naturally in the human body. Because the steroid precursor androstenedione did not receive a similar exemption and was classified as a Schedule III Controlled Substance in 2004, adolescents looked to DHEA as an over-the-counter muscle builder. On the basis of the results of one study (Parasrampuria, Schwartz, & Petesch, 1998) that examined DHEA products prior to the 2004 legislation, adolescent purchasers may or may not have received a bonafide product. The study examined 16 DHEA supplements, only seven of which were found to contain between 90% and 110% of the label claim. One product contained 150% of the label amount, one contained no DHEA at all, and two others contained only trace amounts. Other product labels did not specify exact amounts with which to compare laboratory results. That 1998 study notwithstanding, the U.S. Federal Trade Commission, which is charged with protecting U.S. consumers from fraudulent claims, reported in May 2010 that it had initiated more than 100 law enforcment actions against producers of dietary supplements, in general, during the previous decade (U.S. Federal Trade Commission, 2010).
It should be noted that unscrupulous behavior surrounding AAS is not limited to spiked and bogus product manufacturers in the dietary supplement industry, nor is it limited to those who deal in the steroid underground. In fact, health practitioners should recognize that individuals within the medical field have chosen to obtain and sell AAS, human growth hormone, and other substances such as narcotic pain relievers. In September 2011, for example, the U.S. Department of Justice announced indictments against 13 individuals, including five doctors and a pharmacist, for the illegal distribution of pain killers, AAS, and human growth hormone (U.S. Department of Justice, 2011). The defendants had allegedly been associated with "pill mills" operating in the South Florida counties of Broward, Palm Beach, and Martin. Earlier, in June 2010, a pharmacist in Colorado Springs received a 40-month sentence in federal prison for importing and distributing AAS and human growth hormone (U.S. Department of Justice, 2010), and in January 2009, a federal grand jury indicted three owners of a Mobile, Alabama pharmacy, in addition to four pharmacists and five others, for their roles in a steroid operation that spanned 10 states (U.S. Drug Enforcement Administration, 2009b). Notably, these indictments followed what the U.S. Drug Enforcement Administration called the "largest steroid enforcement action in U.S. history" (U.S. Drug Enforcement Administration, 2007), with agents in 2007 arresting 124 individuals, seizing 56 laboratories, and confiscating 11.4 million AAS dosage units as well as 242 kg of raw steroid powder.
For purposes of the current article, the September 2011 indictments in South Florida are important not only as law enforcement actions but also as indicators of how AAS markets tend to operate and how AAS users tend to experiment with multiple substances at any one time. Like steroid dealers "on the street," some of those indicted in 2011 opted to sell AAS as well as narcotic pain relievers and other substances. Studies have found consistent polydrug use among AAS users (Denham, 2009; Durant, Ashworth, Newman, & Rickert, 1994; DuRant, Escobedo, & Heath, 1995; McCabe, Brower, West, Nelson, & Wechsler, 2007; Parkinson & Evans, 2006), and it is likely that both risk-taking tendencies and communication with drug dealers contribute to that behavior. One of the unique issues surrounding AAS is the tendency of users to discount the advice of physicians while favoring instructions from steroid dealers (Monaghan, 1999; Pope, Kanayama, Ionescu-Pioggia, & Hudson, 2004) who often teach individuals how to inject the substances, how to "stack" AAS, and what to do if problems arise. On the basis of interviews with both users and dealers in Australia, the authors of one study noted that, "The anabolic steroid distributor/dealer consistently not only supplied the drugs but also acted as a mentor. The dealer or distributor often played the prophet role, foretelling how things were likely to be and the problems that could be faced in the future" (Maycock & Howat, 2007, p. 859).
Indeed, adolescents sometimes follow the lead of older athletes and body builders, some of whom came of age trusting "gurus" more than medical professionals for advice about AAS (Monaghan, 1999). One can appreciate how naive adolescents who seek to become more muscular might count on dealers to advise them on AAS use as well as "accessory medications" (Kerr & Congeni, 2007) to help combat any side effects that might occur. It would not be unusual for a steroid dealer to sell AAS users (or recommend a source for obtaining) human chorionic gonadotrophin to prevent testicular atrophy or tamoxifen and testolactone to prevent gynecomastia (Brower, 2002). Consequently, those who treat adolescents who have experimented with and experienced side effects from anabolic steroids should appreciate that, in some situations, adolescents may have attempted to treat themselves. In a worst-case scenario, an adolescent who used a toxic, counterfeit steroid may have sought to prevent side effects with a toxic, counterfeit accessory substance.
Given the safety issues surrounding the manufacturing, acquisition, and use of AAS, health professionals who communicate with adolescents about steroids might focus more on practical risks (e.g., counterfeit substances and spiked dietary supplements) than on the moral aspects or the potential side effects of legitimate AAS. Adolescents may be quick to dismiss moral arguments based on assumptions that many of their peers are using steroids, and thus, they are not behaving any differently from those with whom they socialize. When it comes to drug use, adolescents tend to be most concerned with the perceptions and behaviors of their closest friends, and if their peers have rationalized using AAS, then individuals may be inclined to reject what they hear from a medical practitioner. Relatedly, as behavioral deterrents, fear appeals can be difficult to gauge and their effects tend to vary across individuals; mild appeals often have little effect, and strong appeals may lead individuals to focus more on controlling their fear than on the actual message (Atkin, 2002). Listing the potential side effects of AAS, then, may not resonate with those who have been told by steroid dealers and their closest friends to dismiss the "scare tactics" of medical professionals.
Investigators have found some success with peer education techniques (Elliot et al., 2004; Goldberg et al., 1996), with individuals who share similar goals and interests educating one another about AAS. Although the long-term effects of peer education may not be as great as short-term results (U.S. Government Accountability Office, 2007), the strategies are neverthless grounded in education instead of moral appeals or the threat of health problems. In terms of communication, health professionals might consider advice offered in a recent article on dietary supplements (Ashar & Rowland-Seymour, 2008), whose authors stressed that, "It is important for physicians to avoid a policy of displaying universal disdain for the use of supplements, as this can be detrimental to the physician-patient relationship and preclude patients from fully disclosing their use of [supplements]" (p. 92). Similarly, a practitioner who grounds steroid advice in moral absolutism or the threat of imminent maladies may be unsuccessful in communicating with adolescents.
Alternatively, practitioners might influence steroid-related behavior by encouraging adolescents to educate themselves about the substances they have considered using, sharing some of the information covered in the current article. Adolescents may have seen public service announcements that list the side effects of legitimate AAS, but they may be surprised to learn of counterfeiting and product tampering. Encouraging adolescents to educate themselves about legal and illegal substances appeals to their sense of self-efficacy, empowering them to learn more before ingesting potentially dangerous substances. Instead of being placed on the defensive, they might be inclined to spend a few minutes on offense, thinking about dimensions of steroid use they had not considered.
Ultimately, male and female adolescents will likely continue to use AAS for both performance enhancement in athletics as well as muscular enhancement in everyday life. Side effects of these drugs are complicated by counterfeit drugs and the conditions under which adolescents swallow or inject the substances. Moreover, adolescents who seek to enhance their muscularity through legal means (i.e., over-the-counter supplements) run the risk of purchasing products that have been spiked with AAS, in addition to products that contain few, if any, active ingredients. Medical professionals should be aware of these issues, as most will encounter at least one adolescent who has opted to experiment with muscle-building drugs and body-building dietary supplements.
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