Anabolic-Androgenic Steroids

The anabolic-androgenic steroids (AAS) are a family of drugs that includes the natural male hormone, testosterone, along with dozens of other chemical compounds that are synthetic derivatives or variations on the testosterone molecule. These drugs have two properties: the “anabolic” effects refer to the muscle-building effects; it is because of the anabolic effects of testosterone that men have more muscle (especially in the upper body) and less body fat than women. The “androgenic” effects refer to the masculinizing effects of these drugs, such as beard growth, deepening of the voice, and male sexual characteristics.

AAS should not be confused with corticosteroids, which represent a completely different class of drugs. Corticosteroids, like cortisone and prednisone, are widely prescribed by doctors to treat inflammatory conditions, such as poison ivy, asthma, and many other disorders. Corticosteroids have no value for muscle growth or athletic performance, and therefore they have virtually no potential for abuse. If you hear that a doctor has prescribed “steroids” to a patient, this almost undoubtedly refers to corticosteroids and not AAS, because doctors rarely use AAS for legitimate medical purposes. Indeed, the only common medical use of AAS is by endocrinologists who treat so-called “hypogonadal” men – men who for some reason do not create enough testosterone in their own testes, and who therefore need supplemental testosterone to maintain normal function.

When testosterone or other AAS are taken illicitly in doses far above the normal amount present in the body, they can allow an individual to gain huge amounts of muscle mass. It is not uncommon to hear of men who have gained 40 or 50 pounds of extra muscle by taking repeated courses of AAS and lifting weights. These muscle gains far exceed the gains that can be achieved by even the most dedicated weightlifter without drugs – and it is for this reason that AAS abuse is appealing to many young men, especially those between 18 and about 35 years of age.

AAS use by women, on the other hand, is extremely rare. Women rarely want to have huge muscles, and they are also deterred from AAS use by the masculinizing effects, such as beard growth and loss of their female sexual characteristics, which occur with even modest doses of AAS. Thus, although some surveys and press reports have implied that large numbers of girls and women use AAS, this is completely erroneous.

Among men, AAS often don’t produce any immediate medical problems – and so young men tend to assume that AAS are safe and therefore ignore warnings about AAS use. However, AAS can produce psychiatric effects such as exaggerated self-confidence, reckless behavior, irritability, aggressiveness, and sometimes violence. These effects occur in only a minority of users, but it is not possible to tell in advance who will develop these effects and who will not. Indeed, there are several reports in the scientific literature of men with no prior history of psychiatric disorders, no history of violence, and no prior criminal record, who took AAS and became uncharacteristically violent; some men even committed murders or attempted murder, and were subsequently convicted and incarcerated.

Another psychiatric risk of AAS is AAS-withdrawal depression, which may eventually contribute to the development of an AAS dependence syndrome. Specifically, AAS suppress the body’s tendency to manufacture its own testosterone, because the brain sees large amounts of AAS coming in from the outside, and therefore signals the testes that they can stop making testosterone. Gradually the testes shrink, and their daily output of testosterone falls almost to zero. Then, when the individual stops using AAS, it may take weeks or even months for the testes to resume testosterone production. This causes the AAS user to experience a hypogonadal state, which may be accompanied by severe depression (loss of energy, appetite, and sex drive; feelings of depression and hopelessness; increased anxiety; and sometimes suicidality). Often, AAS users who experience these reactions will be tempted to resume using AAS as soon as possible, because resuming AAS will counteract the hypogonadism and the depressive symptoms. Thus, AAS users may gradually spiral into a syndrome of AAS dependence, where they take more and more courses of AAS over the years, with fewer spaces off AAS in between, and often with worsening depression every time that they stop the drugs.

To break this cycle of AAS dependence, it is often necessary to use antidepressant treatment, and sometime to seek intervention from an endocrinologist, in addition to standard substance-abuse interventions.

It must also be remembered that AAS dependence is different from most other forms of substance dependence, in that AAS do not deliver a “reward” to the brain in the form of an immediate “high” in the manner of most other drugs of abuse. Instead, the “reward” is the increased muscularity and lower body fat that occurs after weeks of use. However, in men who have body-image concerns, the reward of big muscles can be just as addictive as the bottle for an alcoholic, the racetrack for a pathological gambler, or Internet pornography for individuals with so-called sexual addictions. AAS users may become fixated on their muscularity, and terrified of losing an ounce of muscle or gaining an ounce of fat if they stop their AAS use. Thus, they may be very reluctant to seek treatment, and may justify their AAS use as part of a “healthy” bodybuilding lifestyle. Treatment of AAS dependence is likely to fail unless body-image concerns are understood and addressed.

Another problem among long-term AAS users is progression to opiate dependence. Many AAS users get introduced to opiates at the gym, where they may buy drugs such as Nubain, Vicodin, or Percocet from their local AAS dealer in order to treat sore shoulders, knees, or other training injuries. Soon, however, they may progress to Oxycontin or to injectable opiates, such as morphine or heroin. Since most AAS users have already learned to use a needle to inject AAS, it isn’t a big step for them to graduate to using a needle to inject opiates as well. In cases like this, treatment of the opiate dependence becomes the most pressing problem, but the issue of AAS use, both in the past and potentially in the future, should not be ignored.

Science still does not fully understand the long-term dangers of AAS, because AAS use did not become widespread until the 1980's, and therefore most former AAS users are still too young to have entered the age of risk for chronic diseases associated with advancing age. It is already clear, however, that long-term AAS use adversely affects cholesterol levels, thus accelerating atherosclerosis (“hardening of the arteries”), and making users more likely to get heart attacks and strokes at a premature age. AAS can also cause cardiomyopathy – damage to the muscle tissue of the heart. These cardiovascular effects have already been blamed for a number of deaths in AAS users as young as their 20s and 30s; scientists believe that we will see many more such deaths as former AAS users in the population grow older.

Harrison G. Pope, Jr., M.D.
Professor of Psychiatry
Harvard Medical School

Director, Biological Psychiatry Laboratory
McLean Hospital
Belmont, Massachusetts

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