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CORK Bibliography: Steroids

78 citations. January 2003 to present

Prepared: September 2008

Abrams RI. Professional sports and collective bargaining: Alcohol, drugs and the national pastime. University of Pennsylvania Journal of Labor and Employment Law 8(Summer): 861-881, 2006. (17 refs.)

Summary: The author recounts the history of performance-enhancing drug use among professional athletes. In the mid-1800s pro swimmers in Amsterdam's canal races and cyclists later in the century were accused of using drugs to enhance their performance. French cyclists in 1879 were found to have used a simple caffeine stimulant, and a Belgian team used ether-laced sugar cubes. Sprint cyclists tried nitroglycerine. A British cyclist died in 1886 after using ephedrine. Athletes in various sports used concoctions to dull pain. For example, boxers used a potent combination of alcohol and strychnine to reduce pain during midday matches that would last for hours. The Boston Globe asked the most famous athlete of the day, heavyweight champion John L. Sullivan, about the Brown-Sequard elixir. This was the first known manufactured steroid, created by Dr. Brown-Sequard, derived from the testicles of guinea pigs and a dogs. Other recreational drugs, like cocaine and marijuana, have been the bane of numerous baseball superstars. The problems of alcohol and drugs among major sports figures are discussed as well as their impact on the sport.

Agullo-Calatayud V; Gonzalez-Alcaide G; Valderrama-Zurian JC; Aleixandre-Benavent R. Consumption of anabolic steroids in sport, physical activity and as a drug of abuse: An analysis of the scientific literature and areas of research. British Journal of Sports Medicine 42(2): 103-109, 2008. (24 refs.)

Objective: The consumption of anabolic steroids (AS) has been growing continuously in recent years. It has gone beyond the sports world; anabolic steroids are now widely used as drugs of abuse in connection with bodybuilding. This study sets out to assess the state of scientific research in the area. Design: Bibliometrics were employed to evaluate the literature retrieved from the principal relevant bibliographic databases: MEDLINE, SportDiscus, the Science Citation Index Expanded and the Social Sciences Citation Index. The core journals were identified along with the leading authors and research groups and their institutional affiliations. Techniques based on social network analysis were applied in order to build up a concept map of research. Results: 1325 documents were retrieved. They were produced by 3131 different researchers giving a Collaboration Index of 3.32. The institutions with the most productive authors were Ball State University (Muncie, IN, USA), the Ecole Nationale Veterinaire de Nantes (ENVN), the Institut Municipal dInvestigacio Medica (IMIM) (Barcelona, Spain), the Institute of Biochemistry of the German Sport University Cologne (DSHS), Iowa State University, Maastricht University and the University of Iowa. Conclusions: It was concluded that there has been an upward trend in the number of research projects. The sources used complemented one another, as 78.04% of the documents retrieved were unique to one source. The productivity ranking was headed by sports medicine journals, followed by journals of chemistry, physiology, endocrinology and substance abuse. Besides sporting activities, the most important research clusters were those connected with bodybuilding and with youth groups.

Anielski P. Hair analysis of anabolic steroids in connection with doping control - results from horse samples. Journal of Mass Spectrometry 43(7): 1001-1008, 2008. (33 refs.)

Doping control of anabolic substances is normally carried out with urine samples taken from athletes and horses. Investigation of alternative specimens, e.g. hair samples, is restricted to special cases, but can also be worthwhile, in addition to urine analysis. Moreover, hair material is preferred in cases of limited availability or complicated collection of urine samples, e.g. from horses. In this work, possible ways of interpretation of analytical results in hair samples are discussed and illustrated by practical experiences. The results demonstrate the applicability of hair analysis to detect anabolic steroids and also to obtain further information about previous abuse. Moreover, the process of incorporation of steroids into hairs is described and the consequences on interpretation are discussed, e.g. on the retrospective estimation of the application date. The chosen examples deal with the detection of the anabolic agent testosterone propionate. Hair samples of an application study, as well as a control sample taken from a racing horse, were referred to. Hair material was investigated by a screening procedure including testosterone, nandrolone and several esters (testosterone propionate, phenylpropionate, decanoate, undecanoate, cypionate; nandrolone decanoate, dodecanoate and phenylpropionate; limits of detection (LODs) between 0.1 and 5.0 pg/mg). Confirmation of testosterone propionate (LOD 0.1 pg/mg) was carried out by an optimised sample preparation. Trimethylsilyl (TMS) and tert-butyl dimethylsilyl derivatives were detected by gas chromatography-high-resolution mass spectrometry (GC-HRMS) and gas chromatography-tandem mass spectrometry (GC-MS/MS).

Baker JS; Graham MR; Davies B. Steroid and prescription medicine abuse in the health and fitness community: A regional study. European Journal of Internal Medicine 17(7): 479-484, 2006. (44 refs.)

Background: The purpose of this study was to identify the prevalence of abuse of certain prescription medicines (POM) amongst health club attendees. The non-therapeutic use of such medicines has previously been considered to be restricted to the professional athlete. Methods: In the summer of 2005, health club users in the South Wales area were given questionnaires and asked to return them in a stamped, addressed envelope. Anonymity of the respondents was assured. Results: From the distribution of 2 10 questionnaires, the response rate was 69.5% (146 questionnaires). The mean age of the sample was 33.6 +/- 6.7 years (range 15-72 years). Anabolic-androgenic steroid (AAS) use is prominent amongst recreational gym users in this regional sample, with 70% (102 individuals) reporting AAS use, 65.8% (96 individuals) of whom were currently still using. Some 7% of respondents (10 individuals) were female and they also reported taking medication. This research demonstrated an enormous increase in the use of growth hormone (24%), insulin (14%), and tamoxifen (22%), with smaller increases in other drugs. Conclusion: Drug users were from all levels of society and reported various physiological and psychological side effects from their use. The present study indicated that the most used medicine/drug from less than reputable sources was still AAS but that, as a consequence of the internet revolution, they were being caught up by the more expensive designer drugs, particularly growth hormone. Physicians and medical personnel must become aware that the use of AAS and other prescription medicines is on the increase and appears to be predominantly used for cosmetic reasons.

Baume N; Mahler N; Kamber M; Mangin P; Saugy M. Research of stimulants and anabolic steroids in dietary supplements. Scandinavian Journal of Medicine & Science in Sports 16(1): 41-48, 2006. (38 refs.)

The purpose of this study was to analyze the composition of 103 dietary supplements bought on the internet. The supplements were dispatched in four different categories according to their announced contents [creatine, prohormones, "mental enhancers" and branched chain amino acids (BCAA)]. All the supplements were screened for the presence of stimulants and main anabolic steroids parent compounds. At the same time, the research was focused on the precursors and metabolites of testosterone and nandrolone. The study pointed out three products containing an anabolic steroid, metandienone, in a very high amount. The ingestion of such products induced a high quantity of metandienone metabolites in urines that would be considered as a positive antidoping test. The results have also shown that one creatine product and three "mental enhancers" contained traces of hormones or prohormones not claimed on the labels and 14 prohormone products contained substances other than those indicated by the manufacturer. The oral intake of the creatine product revealed the presence of the two main nandrolone metabolites (19-norandrosterone and 19-noretiocholanolone) in urine.

Calfee R; Fadale P. Popular ergogenic drugs and supplements in young athletes. (review). Pediatrics 117(3): E577-E589, 2006. (102 refs.)

Ergogenic drugs are substances that are used to enhance athletic performance. These drugs include illicit substances as well as compounds that are marketed as nutritional supplements. Many such drugs have been used widely by professional and elite athletes for several decades. However, in recent years, research indicates that younger athletes are increasingly experimenting with these drugs to improve both appearance and athletic abilities. Ergogenic drugs that are commonly used by youths today include anabolic-androgenic steroids, steroid precursors (androstenedione and dehydroepiandrosterone), growth hormone, creatine, and ephedra alkaloids. Reviewing the literature to date, it is clear that children are exposed to these substances at younger ages than in years past, with use starting as early as middle school. Anabolic steroids and creatine do offer potential gains in body mass and strength but risk adverse effects to multiple organ systems. Steroid precursors, growth hormone, and ephedra alkaloids have not been proven to enhance any athletic measures, whereas they do impart many risks to their users. To combat this drug abuse, there have been recent changes in the legal status of several substances, changes in the rules of youth athletics including drug testing of high school students, and educational initiatives designed for the young athlete. This article summarizes the current literature regarding these ergogenic substances and details their use, effects, risks, and legal standing.

Casavant MJ. Consequences of use of anabolic androgenic steroids. (review). Pediatric Clinics of North America 54(4): 677-690, 2007. (92 refs.)

Whether providing anticipatory guidance to the young adolescent patient, conducting a preparticipation examination on a young athlete, or treating a sick user of anabolic androgenic steroids (AASs), the primary care physician must be familiar with the adverse consequences of the use of these compounds. This article reviews the endocrine, cardiovascular, neuropsychiatric, musculoskeletal, hematologic, hepatic, and miscellaneous effects of AASs, highlighting effects reported in children and adolescents, and relying on consequences in adults when pediatric data is unavailable.

Collins T. Symposium: From grand slams to grand juries. Performance-enhanicng drug use in sport. Changing the Game: The Congressional response to sports doping via the anabolic steroid control Act. New England Law Review 40: 753-763, 2006. (41 legal refs.)

This article focuses on the use of anabolic steroids and steroid precursors by sports competitors and how federal legislators have responded by subjecting possessors of steroid precursor products - which were openly sold in health food stores until January 2005 - to arrest and prosecution. In the mid 1980s, reports of increasing use of anabolic steroids in organized sports came to the attention of Congress. Between 1988 and 1990, congressional hearings were held to determine whether the Controlled Substances Act should be amended to include anabolic steroids. (Significantly, medical professionals and representatives of regulatory agencies (including the Food and Drug Administration, the Drug Enforcement Administration, and the National Institute on Drug Abuse) testified against the proposed amendment to the law. The majority of witnesses at the hearings, consistent with Congress's apparent main concern, focused on the purported need for legislative action to solve an athletic "cheating" problem. Congress consequently passed the Anabolic Steroid Control Act of 1990, criminalizing the possession of anabolic steroids without a valid prescription. The law placed steroids in the same legal class as barbiturates, ketamine, LSD precursors, and narcotic painkillers such as Vicodin, the only hormones in the schedules. The 1990 law only listed twenty-seven compounds, along with their muscle-promoting salts, esters, and isomers. However, there are in theory hundreds or even thousands of anabolic steroidal compounds - many of which might enhance athletic performance - which could be created in laboratories and offered for human use. By the early part of the current decade, some of these substances were being openly marketed as performance-enhancing dietary supplements. Called "pro-hormones" or in some cases "pro-steroids," these products were frequently metabolic precursors to testosterone or other listed anabolic steroids. The Anabolic Steroid Control Act of 2004 was passed to deal with this. The new law also changes the general requisite elements of an anabolic steroid. Ironically, there is no longer any requirement for evidence that an anabolic steroid is "anabolic," i.e., that it promotes muscle growth. The ramifications for the criminal justice system are outlined. The approach to combat steroid and steroid precursor use in competitive athletics has been two-fold: the imposition of administrative penalties by the sports agencies for those who test positive for the drugs, and the imposition of sanctions to criminalize those who possess them unlawfully, regardless of sports involvement. The focus in both instances is on the drugs or substances themselves. Neither approach is free of problems. Drug testing continues to be a game of cat-and-mouse as new performance-enhancing compounds and masking techniques emerge; catching up to the cheaters can take decades. Criminal laws and sanctions may be largely irrelevant to athletic steroid use, at least at commercialized levels, based upon the lack of enforcement efforts targeting competetive athletes to date. Steroid use in sports is not so much a drug crisis as an ethics crisis. If that is the true heart of the problem, we need to look beyond drug testing and new criminal laws. We need to ask the tough questions about what drives the "winning at all costs" attitude.

Danaher S. Drug abuse in major league baseball: A look at drug testing in the past, in the present, and steps for the future. Journal of Sports and Entertainment Law 14: 305-334, 2004. (192 legal refs.)

Over the past few years in Major League Baseball ("MLB"), there erupted a growing concern amongst the league, owners, and lawmakers that players were using steroids and other muscle enhancing supplements to boost production. Whether or not there actually is a correlation between drug or supplement use and the increase in hitter statistics has yet to be determined, regardless, steroids are still illegal and harmful to the body of adults, and children more so. Finally, thirty-four years after the inaugural collective bargaining agreement in MLB and professional sports , the owners and players agreed to implement a policy for testing steroid use as a part of the 2002 collective bargaining agreement. This comment will focus on: (I) why the issue of drug testing (including illegal drugs and all supplements) is an important topic; (II) pre-2002 collective bargaining agreements and attempts at drug testing; (III) an explanation of the 2002 collective bargaining agreement and its criticisms; (IV) an overview of drug testing in other major sports; and (V) steps for future collective bargaining agreements in major league baseball. In 1986, Ueberroth again tried to institute a drug-testing program for all major league players by inserting clauses into player contracts that required mandatory drug testing. However, drug testing is a mandatory subject of collective bargaining, therefore, any program that is instituted must be agreed to by both MLB and the MLBPA.

D'Andrea A; Caso P; Salerno G; Scarafile R; De Corato G; Mita C et al. Left ventricular early myocardial dysfunction after chronic misuse of anabolic androgenic steroids: A Doppler myocardial and strain imaging analysis. British Journal of Sports Medicine 41(3): 149-155, 2007. (38 refs.)

Background: Anabolic androgenic steroids (AAS) are sometimes used by power athletes to improve performance by increasing muscle mass and strength. Recent bioptical data have shown that in athletes under the pharmacological effects of AAS, a focal increase in myocardial collagen content might occur as a repair mechanism against myocardial damage. Objective: To investigate the potential underlying left ventricular myocardial dysfunction after chronic misuse of AAS in athletes by use of Doppler myocardial imaging (DMI) and strain rate imaging (SRI). Methods: Standard Doppler echocardiography, DMI, SRI and ECG treadmill test were undertaken by 45 bodybuilders, including 20 athletes misusing AAS for at least 5 years ( users), by 25 anabolic-free bodybuilders (non-users) and by 25 age-matched healthy sedentary controls, all men. The mean (SD) number of weeks of AAS use per year was 31.3 (6.4) in users, compared with 8.9 (3.8) years in non-users, and the mean weekly dosage of AAS was 525.4 (90.7) mg. Results: The groups were matched for age. Systolic blood pressure was higher in athletes ( 145 ( 9) vs 130 ( 5) mm Hg) than in controls. Left ventricular mass index did not significantly differ between the two groups of athletes. In particular, both users and non-users showed increased wall thickness and relative wall thickness compared with controls, whereas left ventricular ejection fraction, left ventricular end-diastolic diameter and transmitral Doppler indexes were comparable for the three groups. Colour DMI analysis showed significantly lower myocardial early: myocardial atrial diastolic wave ratios in users at the level of the basal interventricular septum (IVS) and left ventricular lateral wall ( p< 0.01), in comparison with both non-users and controls. In addition, in users, peak systolic left ventricular strain rate and strain were both reduced in the middle IVS ( both p< 0.001) and in the left ventricular lateral free wall ( both p< 0.01). By stepwise forward multivariate analyses, the sum of the left ventricular wall thickness (beta coefficient = 20.32, p<0.01), the number of weeks of AAS use per year (beta = -0.42, p< 0.001) and the weekly dosage of AAS (beta = -0.48, p, 0.001) were the only independent determinants of middle IVS strain rate. In addition, impaired left ventricular strain in users was associated with a reduced performance during physical effort ( p, 0.001). Conclusions: Several years after chronic misuse of AAS, power athletes show a subclinical impairment of both systolic and diastolic myocardial function, strongly associated with mean dosage and duration of AAS use. The combined use of DMI and SRI may therefore be useful for the early identification of patients with more diffused cardiac involvement, and eventually for investigation of the reversibility of such myocardial effects after discontinuation of the drug.

Denham BE. Effects of mass communication on attitudes toward anabolic steroids: An analysis of high school seniors. Journal of Drug Issues 36(4): 809-829, 2006. (28 refs.)

Drawing on a national probability sample of high school seniors (n = 2,560), this research explores relationships between exposure to four types of mass communication-magazines, movies, newspapers, and television-and attitudes toward anabolic steroids, operationalized along three dependent measures. Logistic regression analyses revealed statistically significant relationships among (a) magazine exposure and estimates of drug use in professional sports, (b) newspaper and television exposure and disapproval of steroid use, (c) newspaper exposure and estimates of self-inflicted harm caused by steroid use, and (d) exposure to anti-drug spots and each of the three dependent variables. Theoretical and methodological Implications and suggestions for future research are discussed.

Dhar R; Stout CW; Link MS; Homoud MK; Weinstock J; Estes NAM. Cardiovascular toxicities of performance-enhancing substances in sports. (review). Mayo Clinic Proceedings 80(10): 1307-1315, 2005. (91 refs.)

Athletes commonly use drugs and dietary supplements to improve athletic performance or to assist with weight loss. Some of these substances are obtainable by prescription or by illegal means; others are marketed as supplements, vitamins, or minerals. Nutritional supplements are protected from Food and Drug Administration regulation by the 1994 US Dietary Supplement Health and Education Act, and manufacturers are not required to demonstrate proof of efficacy or safety. Furthermore, the Food and Drug Administration lacks a regulatory body to evaluate such products for purity. Existing scientific data, which consist of case reports and clinical observations, describe serious cardiovascular adverse effects from use of performance-enhancing substances, including sudden death. Although mounting evidence led to the recent ban of ephedra (ma huang), other performance-enhancing substances continue to be used frequently at all levels, from elementary school children to professional athletes. Thus, although the potential for cardiovascular injury is great, few appropriately designed studies have been conducted to assess the benefits and risks of using performance-enhancing substances. We performed an exhaustive OVID MEDLINE search to identify all existing scientific data, review articles, case reports, and clinical observations that address this subject. In this review, we examine the current evidence regarding cardiovascular risk for persons using anabolic-androgenic steroids including 2 synthetic substances, tetrahydrogestrinone and androstenedione (andro), stimulants such as ephedra, and nonsteroidal agents such as recombinant human erythropoietin, human growth hormone, creatine, and beta-hydroxy-beta-methylbutyrate.

Dotson JL. The history of the development of anabolic-androgenic steroids. Pediatric Clinics of North America 54(4): 761-769, 2007

The history of anabolic-androgenic steroids (AASs) is an interesting tale that has its roots in ancient "endocrinology." More than 6000 years ago, farmers noted enhanced domestication of animals after castration. The development of AASs, and, later, their artificial synthesis, have remained a hot topic in scientific research and pharmaceuticals. Over the years, AASs have been used as a proposed treatment for a wide variety of ailments, despite deleterious side effects. Unfortunately, they have been, and still are, abused by body builders, athletes, and teens.

editors. SPORT: NFL General Counsel Adolpho Birch Speaks on the NFL's Drug Policy. Vanderbilt Journal of Entertainment Law and Practice 5(Winter): 6+, 2003. (0 refs.)

This article is an interview between the journal and Adolpho Birch, the General Counsel of the National Football League. It focuses upon the League's drug policy, what is incorporated in the policy and how it is applied, the role of drug testing, and the diverse goals of insuring the competitive integrity of the game, the relationship of discipline and treatment, the goals of protecting health, and obligations to provide healthy role models.

Elliot DL; Cheong J; Moe EL; Goldberg L. Cross-sectional study of female students reporting anabolic steroid use. Archives of Pediatrics & Adolescent Medicine 161(6): 572-577, 2007. (52 refs.)

Objective: To determine the characteristics of female US high school students reporting anabolic steroid use. Design: Cross-sectional assessment using the 2003 Centers for Disease Control and Prevention national school-based Youth Risk Behavior Survey database. Setting: Nationally representative sample of US high schools. Participants: Female students in grades 9 through 12 (n = 7544). Main Outcome Measures: Participants' self-reported anabolic steroid use was compared with other health-related behaviors and with sports participation. Results: Prior or ongoing anabolic steroid use was reported by 5.3% of female high school students. Those adolescent girls had a marked increase in other health-compromising behaviors, including past 30-day use of alcohol (odds ratio [OR], 8.83; 95% confidence interval [CI], 5.49-14.20]), cigarettes (OR, 5.14; 95% CI, 3.14-8.42), marijuana (OR, 7.91; 95% CI, 5.20-12.04), cocaine (OR, 10.78; 95% CI, 6.18-18.81), and diet pills (OR, 4.86; 95% CI, 2.98-7.93). They were more likely to carry a weapon (OR, 7.54; 95% CI, 4.83-11.76), have had sexual intercourse before age 13 years (OR, 2.90; 95% CI, 1.58-5.33), and have had feelings of sadness or hopelessness almost every day for at least 2 consecutive weeks (OR, 4.13; 95% CI, 2.57-7.22). They were less likely to play school-sponsored team sports (OR, 0.52; 95% CI 034-0.80). Steroid users participating in sports shared the same problem behaviors as steroid users not participating in team athletics. Conclusion: Self-reported anabolic steroid use is not confined to adolescent girls in competitive athletics and is an indicator of adolescent girls with a marked increase in a cluster of other health-harming behaviors.

Elliot DL; Moe EL; Goldberg L; DeFrancesco CA; Durham MB; Hix-Small H. Definition and outcome of a curriculum to prevent disordered eating and body-shaping drug use. Journal of School Health 76(2): 67-73, 2006. (37 refs.)

Almost one half of male and female students participate in high school-sponsored athletics, and high school also is a time when classroom health promotion curricula are less effective. The Athletes Training and Learning to Avoid Steroids is a sport team-centered drug-use prevention program for male high school athletes, which has been shown to reduce alcohol and illicit drug use. Just as anabolic steroid use is associated with male athletes, female sport participants may be at a greater risk for disordered eating and body-shaping drug use. Extending sport team-centered programs to young women athletes required defining and ranking factors related to developing those harmful behaviors. Survey results from a cross-sectional cohort of female middle and high school student athletes were used to identify and prioritize potential curriculum components, including mood and self-esteem, norms of behavior, perceptions of healthy body weight, effects of media depictions of women, and societal pressures to be thin. The derived sport team-centered program was prospectively assessed among a second group of female student athletes from 18 high schools, randomized to receive the intervention or the usual care control condition. The Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) intervention is a scripted, coach-facilitated, peer-led 8-session program, which was incorporated into a teams usual training activities. The ATHENA program significantly altered the targeted risk factors and reduced ongoing and new use of diet pills and body-shaping substances (amphetamines, anabolic steroids, and sport supplements). These findings illustrate the utility of a structured process to define curriculum content, and the program's positive results also confirm the sport team's potential as a vehicle to effectively deter health-harming behaviors.

Fisher GL; Harrison TC. Substance Abuse: information for School Counselors, Social Workers, Therapists, and Counselors, 3rd edition. Boston: Pearson/Allyn and Bacon, 2005. (650 book refs.)

This volume is directed not to those who work in the substance abuse field, but to the range of mental health professionals who while not exclusively involved with substance abuse can anticipate a significant proportion of their clients to have substance abuse problems. The first chapter provides an overview of the book, and considers the need for generalist training. Chapter 2 deals with the major drug classes, the acute and chronic effects, with sections on central nervous system depressants, central nervous system stimulants, opioids, hallucinogens, cannabis, inhalants, steroids, and club drugs. Chapter 3 focuses upon different models of addiction: the moral model, sociocultural and psychological models, the disease concept, and the biopsychosocial model. Chapter 4 considers the major cultural and ethnic groups in the US -- Native Americans and Alaska natives, Asian Americans, African Americans, Latino and Hispanics -- and general principles in working with culturally and ethnically diverse populations. Chapter 5 addresses assessment and diagnosis; Chapter 6, engaging the client and brief interventions; and Chapter 7 treatment approaches and settings, principles of effective treatment, and client-treatment matching. Chapter 8 focuses upon relapse prevention and the process of recovery. Chapter 9 deals with Twelve-Step programs as well as other types of support groups. Chapters 10 and 11 consider the family and children in the family, and adult children. Chapter 12 focuses upon HIV/AIDS. Chapter 13 provides an overview of a variety of other addictions including gambling. The final chapters deal with prevention and confidentiality and ethical concerns.

Fortenberry PA; Hoffman BE. Illegal muscle: A comparative analysis of proposed steroid legislation and the policies in professional sports' CBAs that led to the steroid controversy. Virginia Sports and Entertainment Law Journal 5(121-147), 2006. (161 refs.)

The purpose of this paper is to compare, contrast, and evaluate the steroid clauses within the collective bargaining agreements (CBA) of the four major sports, to look at the steroid policies in the various CBAs prior to the recent steroids controversy, to examine the current steroids policy of the four major sports due to changes made as a result of public pressure and congressional scrutiny, and to discuss the possible future steroid policy that would be mandated by proposed legislation. The respective CBA language concerning steroids and other league steroid policies will be reviewed, specifically looking at (1) their prohibitions, (2) their testing procedures and (3) their disciplinary remedies for steroid violations. A review of the changes voluntarily agreed to by the subject professional sports organizations and the respective unions will be conducted and an analysis of proposed legislation in the Senate and House will also be undertaken.

Fritz MS; MacKinnon DP; Williams J; Goldberg L; Moe EL; Elliot DL. Analysis of baseline by treatment interactions in a drug prevention and health promotion program for high school male athletes (rapid communication). Addictive Behaviors 30(5): 1001-1005, 2005. (6 refs.)

This paper investigates baseline by treatment interactions (BTI) of a randomized anabolic steroid prevention program delivered to high school football players. Baseline by treatment interactions occur when a participant's score on an outcome variable is associated with both their pretreatment standing on the outcome variable and the treatment itself. The program was delivered to 31 high school football teams (Control=16, Treatment=15) in Oregon and Washington over the course of 3 years (Total N=3207). Although most interactions were nonsignificant, consistent baseline by treatment interactions were obtained for knowledge of the effects of steroid use and intentions to use steroids. Both of these interactions were beneficial in that they increased the effectiveness of the program for participants lower in knowledge and higher in intentions at baseline.

Furlanello F; Serdoz LV; Cappato R; De Ambroggi L. Illicit drugs and cardiac arrhythmias in athletes. (review). European Journal of Cardiovascular Prevention & Rehabilitation 14(4): 487-494, 2007. (99 refs.)

The current management of athletes with cardiac arrhythmias has become complicated by the widespread use of illicit drugs, which can be arrhythmogenic. The World Anti-Doping Agency annually updates a list of prohibited substances and methods banned by the International Olympic Committee that includes different classes of substances namely, anabolic androgenic steroids, hormones and related substances, beta 2-agonists, diuretics, stimulants, narcotics, cannabinoids, glucocorticosteroids, alcohol, beta-blockers and others. Almost all illicit drugs may cause, through a direct or indirect arrhythmogenic effect, a wide range of cardiac arrhythmias (focal or reentry type, supraventricular and/or ventricular) that can even be lethal and which are frequently sport activity related. A large use of illicit drugs has been documented in competitive athletes, but the arrhythmogenic effect of specific substances is not precisely known. Precipitation of cardiac arrhythmias, particularly in the presence of a latent electrophysiologic substrate including some inherited cardiomyopathies, at risk of sudden death or due to long-term consumption of the substances, should raise the suspicion that illicit drugs may be a possible cause and lead cardiologists to investigate carefully this relationship and appropriately prevent the clinical consequences.

Garibaldi DA. Symposium: From grand slams to grand juries. Performance-enhanicng drug use in sport. The challenge and the tragedy. New England Law Review 40: 717-727, 2006. (35 legal refs.)

This article provides a personal perspective on the dangers of the use of performance-enhancing drugs among student athletes. It is authored by a mother whose son committed suicide after a several year period of steroid use, sparked by his desire to become a professional athlete. The complicacy of trainers are coaches are described, as well as the sources of the drugs, and the physical and behavioral changes which occurred with long term use.

George AJ. Androgenic anabolic steroids. IN: Mottram DR, ed. Drugs in Sport, 3rd edition. New York: Routledge, 2003. pp. 138-188. (115 refs.)

The conclusions reached in surveying anabolic steroid use in male and female athletes are that anabolic steroids do increase muscle bulk and body weight in all anabolic steroid takers but that increases in strength are certain to occur at low doses only in those undertaking regular training exercise. The long-term side-effects of anabolic steroids may be severe and will depend on dosage and duration. In particular, early death from cardiovascular disease, sterility in men and, in women, masculinization and possible fetal effects constitute the most serious hazards. More recently, studies have suggested that psychological and behavioural changes and addiction may result from chronic anabolic steroid abuse, but methodological inconsistencies still make evaluation of these side-effects very difficult. There is evidence of increased abuse of steroids for cosmetic reasons, and among college and school students and that intensive eduction programs have had little effect. The chapter considers the testosterone family of drugs, the structural analogues of testosterone (the anabolic steroids), compounds that are the precursors -- nandrolone and metabolites -- and side-effects with particular reference to athletes.

Green GA. Doping control for the team physician: A review of drug testing procedures in sport. American Journal of Sports Medicine 34(10): 1690-1698, 2006. (28 refs.)

Drug testing is now ubiquitous in sport, and it often falls to the team physician to perform a variety of roles including interpreting test results, designing drug-testing programs, acting as medical review officer, and providing therapeutic use exemptions, education, and counseling. Proper understanding of current testing methods for drugs such as anabolic-androgenic steroids, erythropoietin, and growth hormone is essential if the team physician is going to assume these positions. This article outlines the basics of athletic drug testing from the collection process through the interpretation of results to assist the team physician in this field.

Greydanus DE; Patel DR. The adolescent and substance abuse: Current concepts. Disease-a-Month 51(7): 392-431, 2005. (93 refs.)

This review addresses alcohol and other drug use among adolescents. The article addresses its etiology, adolescent development and how this is affected by and influences substance use. It also addresses factors which may be risk factors including the presence of psychiatric illness, environmental stresses and the widespread availability and access to drugs. The symptoms and stages of drug use and abuse are described. Specific attention is directed to alcohol, marijuana, nicotine, cocaine, opiates, amphetamines, methamphetamines, ecstasy, ketamine, the inhalants, gamma-hydroxybutyrate, barbiturates, PCP, as well as agents used to enhance athletic performance, including the anabolic steroids. There is also discussion of management and approaches to treatment. There are twenty-nine accompanying tables.

Hall RCW; Hall RCW. Abuse of supraphysiologic doses of anabolic steroids. (review). Southern Medical Journal 98(5): 550-555, 2005. (65 refs.)

The following article is a literature review of supraphysiologic doses of anabolic-androgenic steroids (AAS). This article contains a brief review of the history of AAS, the chemistry of the varying forms of AAS, and proposed mechanisms of action. The article then focuses on how AAS are used in an illicit manner by the general population. Terms such as "stacking" and "pyramiding" are discussed. The article concludes by looking at the major detrimental side effects, such as liver damage and cardiovascular changes, which physicians may encounter when treating AAS abusers.

Hayward E; Healy D; Wimbush S. Awareness, dreaming or steroid-induced psychosis? (letter). Anaesthesia 61(11): 1127-1128, 2006. (3 refs.)

This is a case report the a middle-aged man undergoing craniotomy and excision of a solitary parietal metastasis from a lung adenocarcinoma, which had been resected the previous year. To reduce the cerebral oedema associated with the tumour he had been commenced on dexamethasone 12 mg daily, 3 weeks prior to surgery. He developed side-effects from the steroids including sleep disturbance and lability of mood, which led to a pre-operative diagnosis of steroid-induced psychosis. Following surgery he reported events he believed to be intraoperative awareness. This was with evidence of neither recollection of events, nor dreaming, but in keeping withthe pre-operative diagnsosis of steroid-induced psychosis.

Hoaken PNS; Stewart SH. Drugs of abuse and the elicitation of human aggressive behavior. (review). Addictive Behaviors 28(9): 1533-1554, 2003. (158 refs.)

The drug-violence relationship exists for several reasons, some direct (drugs pharmacologically inducing violence) and some indirect (violence occurring in order to attain drugs). Moreover, the nature of that relationship is often complex, with intoxication, neurotoxic, and withdrawal effects often being confused and/or confounded. This paper reviews the existing literature regarding the extent to which various drugs of abuse may be directly associated with heightened interpersonal violence. Alcohol is clearly the drug with the most evidence to support a direct intoxication-violence relationship. The literatures concerning benzodiazepines, opiates, psychostimulants, and phencyclidine (PCP) are idiosyncratic but suggest that personality factors may be as (or more) important than pharmacological ones. Cannabis reduces likelihood of violence during intoxication, but mounting evidence associates withdrawal with aggressivity. The literature on the relationship between steroids and aggression is largely confounded, and between 3,4-methylenedioxymethamphetamine (MDMA) and aggression insufficient to draw any reasonable conclusions. Conclusions and policy implications are briefly discussed.

Johnston LD; O'Malley PM; Bachman JG; Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2003. Bethesda MD: National Institute on Drug Abuse, 2004. (0 refs.)

This report presents the key findings for the 2003 Monitoring the Future Survey, which ascertains adolescents' use of alcohol, nicotine and other drugs, the attitudes toward use, perception of risks associated with use, and perception of availability. Information is presented by drug class, and specific substances. Trend data is also provided.

Johnston LD; O'Malley PM; Bachman JG; Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2004. Bethesda MD: National Institute on Drug Abuse, 2005. (0 refs.)

This is a summary of the key finding from the Monitoring the Future's 2004 survey of 8th, 10th, and 12th graders in respect to alcohol and other drug use, levels of perceived risk, and approval/disapproval of different substance use, as well as trend in drug use, with data from 1991-2004 provided. For this survey there are declines in several classes of drug use (marijuana, amphetamines, methamphetamines, anabolic steroids). Among those whose use has held steady are the hallucinogens, heroin and other narcotics (except for OxyContin and Vicodin) cocaine, tranquilizers, and two of the "club drugs", Rohypnol and GHB. Drugs with increased use include the inhalants and OxyContin. In terms of licit drugs more than half of teens have tried cigarettes by 12th grade, a quarter by 8th grade and 11% are current smokers, this represents a slight improvement over recent years. Drinking too remains widespread, with three-quarters being drinkers by senior year, although the figures are slightly improved for the two younger age grouups. The findings are summarized in 13 tables and 64 figures.

Kanayama G; Boynes M; Hudson JI; Field AE; Pope HG. Anabolic steroid abuse among teenage girls: An illusory problem? Drug and Alcohol Dependence 88(2/3): 156-162, 2007. (38 refs.)

Background: Recent media reports have portrayed an alarming increase in apparent anabolic-androgenic steroid (AAS) use among American teenage girls; Congress even held hearings on the subject in June 2005. We questioned whether AAS use among teenage girls was as widespread as claimed. Methods: We reviewed four large national surveys and many smaller surveys examining the prevalence of AAS use among teenage girls. Virtually all of these surveys used anonymous questionnaires. We asked particularly whether the language of survey questions might generate false-positive responses among girls who misinterpreted the term "steroid." We also reviewed data from other countries, together with results from the only recent study (to our knowledge) in which investigators personally interviewed female AAS users. Results: The surveys produced remarkably disparate findings, with the lifetime prevalence of AAS use estimated as high as 7.3% among ninth-grade girls in one study, but only 0.1% among teenage girls in several others. Upon examining the surveys reporting an elevated prevalence, it appeared that most used questions that failed to distinguish between anabolic steroids, corticosteroids, and over-the-counter supplements that respondents might confuse with "steroids." Other features in the phrasing of certain questions also seemed likely to further bias results in favor of false-positive responses. Conclusions: Many anonymous surveys, using imprecise questions, appear to have greatly overestimated the lifetime prevalence of AAS use among teenage girls; the true lifetime prevalence may well be as low as 0.1%. Future studies can test this impression by using a carefully phrased question regarding AAS use.

Kanayama G; Cohane GH; Weiss RD; Pope HG. Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: An under-recognized problem? Journal of Clinical Psychiatry 64(2): 156-160, 2003. (64 refs.)

Background: Recent reports suggest that anabolic-androgenic steroids (AAS) may cause mood disorders or dependence syndromes and may help to introduce some individuals to opioid abuse. At present, however, little is known about prior AAS use among men entering inpatient substance abuse treatment. Method: We assessed lifetime AAS use in 223 male substance abusers admitted to a substance abuse treatment unit primarily for treatment of alcohol, cocaine, and opioid dependence. Subjects reporting definite or possible AAS use were then asked to participate in a detailed semi-structured interview that covered demographics, drug use history, and symptoms experienced during AAS use and withdrawal, and whether AAS use had helped introduce the subject to other classes of drugs. Results: Twenty-nine men (13%) reported prior AAS use, but this history was documented on physicians' admission evaluations in only 4 cases. Among 88 men listing opioids as their drug of choice, 22 (25%) acknowledged AAS use, versus only 7 (5%) of the other 135 men (p < .001). Twenty-four (83%) of the 29 AAS users were interviewed in detail. Seven (29%) of the men interviewed, all with opioid dependence, reported that they first learned about opioids from friends at the gym and subsequently first obtained opioids from the same person who had sold them AAS. Eighteen (75%) of the men interviewed 7 reported that AAS were the first drugs that they had ever self-administered by injection, 4 (17%) reported severe aggressiveness or violence during AAS use, 1 (4%) attempted suicide during AAS withdrawal, and 5 (21%) described a history of AAS dependence. Conclusion: Prior AAS use appears to be common but underrecognized among men entering inpatient substance abuse treatment, especially those with opioid dependence. AAS use may serve as a "gateway" to opioid abuse in some cases and may also cause morbidity in its own right.

Kanayama G; Pope HG; Cohane G; Hudson JI. Risk factors for anabolic-androgenic steroid use among weightlifters: a case-control study. Drug and Alcohol Dependence 71(1): 77-86, 2003. (58 refs.)

Anabolic-androgenic steroid (AAS) use represents a major public health problem in the United States, but the risk factors for this form of drug use are little studied. We evaluated 48 men who had used AAS for at least 2 months and 45 men who had never used AAS, using a verbal interview and a battery of questionnaires covering hypothesized demographic, familial, and psychosocial risk factors for AAS use. All subjects in both groups were experienced weightlifters; thus, differences between groups were likely to be associated specifically with AAS use, rather than with weightlifting in general. The AAS users and non-users generally described similar childhood and family experiences, but users reported significantly poorer relationships with their fathers and greater childhood conduct disorder than non-users. At the time that they first started lifting weights, AAS users and non-users were similar in their perceived physical, social, and sexual status, but users were significantly less confident about their body appearance. AAS users displayed much higher rates of other illicit substance use, abuse, or dependence than non-users, with use of other illicit substances almost always preceding first use of AAS. These findings suggest that AAS use may be most likely to occur in men with high levels of antisocial traits and low levels of body esteem.

Karila T; Hovatta O; Seppala T. Concomitant abuse of anabolic androgenic steroids and human chorionic gonadotrophin impairs spermatogenesis in power athletes. International Journal of Sports Medicine 25(4): 257-263, 2004. (24 refs.)

Abuse of anabolic androgenic steroids (AASs) may be an aetiological factor in male infertility among recreational power athletes. They try to avoid AAS-induced deterioration in spermatogenesis by combining doses of human chorionic gonadotrophin (HCG) and/or antiestrogens with their AAS abuse. Eighteen healthy male power athletes using massive doses of AASs were recruited for the study. Semen samples were collected during AAS abuse and 1.5 and 6 months after cessation of the abuse. They were also asked about their reproductive activity six years after the study. At the end of the AAS cycle, the sperm count was 33 49 x 10(6)/ml (mean +/- SD), and only one subject had azoospermia. At 1.5 months after cessation of the AAS cycles, the mean sperm concentration was 30 42 x 10(6)/ml, and after six months 77 +/- 70 x 10(6)/ml. There were significant differences between the sample drawn six months after cessation of AAS abuse and both samples drawn during and 1.5 months after the abuse (p less than or equal to 0.05, repeated measures of ANOVA). There was a significant positive correlation between HCG dose during the cycle and the relative amount of morphologically abnormal spermatozoa (r = 0.60, p < 0.01). The concomitant abuse of HCG and supra-physiological AAS dose cause transient impairment on semen quality in males, although spermatogenesis is maintained with this regimen despite prolonged abuse of massive doses of AAS.

Kerr JM; Congeni JA. Anabolic-androgenic steroids: Use and abuse in pediatric patients. Pediatric Clinics of North America 54(4): 771-785, 2007. (94 refs.)

The "win at all costs" mentality fuels athletes to seek performance-enhancing substances, such as anabolic-androgenic steroids (AASs), to gain an advantage over their opponents. Non-athletes espouse this same attitude to "win" the battle of attractiveness. They view AASs as the means to achieving what they believe is a more desirable muscular physique. These beliefs have filtered from professional, Olympic, and collegiate levels into high schools, middle schools, and grade schools. This review covers the history of steroid use, physiology, clinical uses, non-medical use and the related legal issues, sources of steroids by athletes, prevalence of adolescent use, risk factors including demographic and behavioral factors, the dosage and patterns of use by athletes, and adverse effects, presented by body system.

Klotz F; Petersson A; Isacson D; Thiblin I. Violent crime and substance abuse: A medico-legal comparison between deceased users of anabolic androgenic steroids and abusers of illicit drugs. Forensic Science International 173(1): 57-63, 2007. (39 refs.)

Several case reports and survey studies have indicated that abuse of anabolic androgenic steroids (AAS) often leads to increased aggressiveness and feelings of hostility that may occasionally trigger violent behaviour. Other observations indicate that many users of AAS also abuse alcohol and/or various illegal substances. Since substance abuse is a well-known risk factor for violent behaviour, it could be that violence committed by AAS users might, at least in many cases, actually be caused by abuse of other drugs. In order to examine this possibility further here, the criminal histories (in terms of incidences of convictions) of deceased users of AAS with (AASpos-subst.pos) and without (AASpos-subst.neg) signs of abuse of other illegal substances were compared to the corresponding histories of deceased users of illicit substances testing negatively for AAS (subst.pos-AASneg) at the time of autopsy. The risk of being convicted for a crime against property was significantly higher in the subst.pos-AASneg group than in either the AASpos-subst.neg or AASpos-subst.pos groups (RR = 0.048 versus 0.408). At the same time, the risk of being convicted for a crime of violence was at least as high for the two AAS-positive groups as for the AAS-negative group. Furthermore, when compared with the first 3 years after the first criminal conviction, a pronounced increase in the proportion of incidence of violent crimes and a marked reduction in the proportion of incidence of crime against property was observed during the 3-year period immediately preceding death only among the AASpos-subst.neg subjects. In conclusion, the incidence of violent crime among users of AAS without signs of other drug abuse was comparable to the corresponding incidences for drug addicts without AAS use. This observation suggests that the violent criminality observed among AAS users is not confounded in any systematic fashion by abuse of other drugs. The findings also indicate that use of AAS in certain predisposed individuals might cause a high rate of violent crimes, especially if the use of AAS is combined with the use of other illegal substances.

Laure P; Binsinger C; Lecerf T. General practitioners and doping in sport: Attitudes and experience. British Journal of Sports Medicine 37(4): 335-338, 2003. (14 refs.)

Objectives: To examine the attitudes to, and knowledge of, doping in sport of French general practitioners (GPs), and their contact with drug taking athletes on an everyday basis.Methods: A total of 402 GPs were randomly selected from all over France and interviewed by telephone, using a prepared script. Results: The response rate was 50.5% (153 men and 49 women; mean (SD) age 45.6 (5.6) years). Of the respondents, 73% confirmed that they had the list of banned products, and only 34.5% stated that they were aware of the latest French law, brought into effect in March 1999, concerning the fight against doping. Some 11% had directly encountered a request for prescription of doping agents over the preceding 12 months (the requested substances were mainly anabolic steroids, stimulants, and corticosteroids), and 10% had been consulted by an athlete who was using doping drugs and was frightened of the health risks (the substances used were mainly anabolic steroids). Over half (52%) of the GPs favoured the prescription of drug substitutions to athletes who used doping agents. According to 87.5% of respondents, doping is a public health problem, and 80% stated that doping is a form of drug addiction. Most (89%) said that a GP has a role to play in doping prevention, but 77% considered themselves poorly prepared to participate in its prevention. Conclusion: The results suggest that (a) GPs have limited knowledge of doping and (b) are confronted with doping in their daily practice, at least occasionally.

Lenehan P. Anabolic Steroids and Other Performance Enhancing Drugs. London: Taylor & Francis, 2003. (380 book refs.)

This volume deals with the use of anabolic steroids as well as some other drugs used in conjunction with them for performance enhancement. The book provides an overview of the social history of anabolic steroids, including their development, prevalence of use, and social implications. There is also an extended discussion of physical and psychological effects, with medical sequelae addressed in a systems-oriented fashion. One of the major sections deals with the use of anabolic steroids in sports, including Olympic performance and the Eastern European "doping regimes", the Tour de France of 1998, other uses outside of the Olympics, and the list of banned/prohibited substances. The final section deals with regimens for taking performance enhancing drugs, the costs, sources of drugs, counterfeits and fakes, and a summary of different substances, with generic and trade names, route of administration, and purported benefits and dangers.

Luna N. Facts about drugs. IN: Hogan J; Gabrielsen K; Luna N; Grothaus, eds. Substance Abuse Prevention: The Intersection of Science and Practice. New York: Allyn & Bacon, 2003. pp. 68-102. (28 refs.)

This chapter offers a discussion of different models of addiction and then reviews the major drug classes: depressants; opiates; stimulants; hallucinogens; cannabinols; steroids; and inhalants. For each of these the is a review of the drug effects, symptoms of overdose, posible withdrawal syndrome; and both acute and chronic effects. The chapter concludes with consideration of "gateway" drugs, and data on trends of drug use.

Luncheon C; Bae S; Gonzalez A; Lurie S; Singh KP. Hispanic female adolescents' use of illicit drugs and the risk of suicidal thoughts. American Journal of Health Behavior 32(1): 52-59, 2008. (28 refs.)

Objectives: To examine the association between female adolescents in high school who use illicit drugs and seriously consider attempting suicide. Methods: Data were analyzed from the 2003 Youth Risk Behavioral Surveillance System. Variables for suicidal thought, illicit drugs, and covariables were chosen to explore the association. Results: Seriously considering attempting suicide was associated with Hispanics, suburban youth, use of marijuana, inhalants, methamphetamines, and steroids without MD's prescription. Conclusions: Greater effort may be necessary to raise awareness about the physical and mental health status of Hispanic adolescents and to ensure good mental health programs are available.

Marx CE; Trost WT; Shampine L; Behm FM; Giordano LA; Massing MW; Rose JE. Neuroactive steroids, negative affect, and nicotine dependence severity in male smokers. Psychopharmacology 186(3): 462-472, 2006. (87 refs.)

Nicotine administration alters neuroactive steroids in rodent models, and serum levels of the neuroactive steroid DHEAS (dehydroepiandrosterone sulfate) appear to be higher in smokers. These molecules may be relevant to tobacco addiction and affective symptoms. This study aims to investigate DHEAS, allopregnanolone, pregnenolone, and other steroids in male smokers to determine potential associations with nicotine dependence severity and negative affect. Allopregnanolone and pregnenolone serum levels were determined by gas chromatography/mass spectrometry, while DHEAS and other steroid levels were determined by radioimmunoassay in 28 male smokers. Correlational analyses were performed to determine potential associations with rating measures, including the Fagerstrom Test for Nicotine Dependence (FTND), the addiction subscale of the Ikard Smoking Motivation Questionnaire (ISMQ), the craving item on the Reasons to Smoke (RTS) Questionnaire, and the negative affect and craving subscales of the Shiffman-Jarvik Withdrawal Questionnaire. DHEAS levels were inversely correlated with the negative affect subscale of the Shiffman-Jarvik Withdrawal Questionnaire (r=-0.60, p=0.002) and the RTS craving item (r=-0.43, p=0.03), and tended to be inversely correlated with the FTND scores (r=-0.38, p=0.067) and the ISMQ addiction subscale (r=-0.38, p=0.059), adjusting for age. Allopregnanolone levels were positively correlated with cotinine levels (r=0.57, p=0.006); pregnenolone levels tended to be positively correlated with cotinine levels (r=0.40, p=0.066). DHEAS levels were inversely correlated with negative affect and craving measures, and may predict nicotine dependence severity. Allopregnanolone levels were positively correlated with cotinine levels, suggesting that this neuroactive steroid may be upregulated in smokers. Neuroactive steroids may represent novel smoking cessation agents.

McCabe SE; Brower KJ; West BT; Nelson TF; Wechsler H. Trends in non-medical use of anabolic steroids by US college students: Results from four national surveys. Drug and Alcohol Dependence 90(2/3): 243-251, 2007. (77 refs.)

This study assessed the prevalence, trends, and student- and college-level characteristics associated with the non-medical use of anabolic steroids (NMAS) among U.S. college students. Data were collected through self-administered mail surveys, from 15,282, 14,428, 13,953, and 10,904 randomly selected college students at the same 119 nationally representative colleges in 1993, 1997, 1999 and 200 1, respectively. The prevalence of lifetime, past-year and past-month NMAS was 1% or less and generally did not change significantly between 1993 and 200 1, with one exception: past-year WAS increased significantly among men from 1993 (0.36%) to 2001 (0.90%). Multiple logistic regression analyses revealed that lifetime and past-year NMAS were associated with student-level characteristics such as being male and participation in intercollegiate athletics. Lifetime and past-year NMAS were also positively associated with several risky behaviors, including cigarette smoking, illicit drug use, drinking and driving, and DSM-IV alcohol use disorders. Nearly 7 out of every 10 lifetime non-medical users of anabolic steroids met past-year criteria for a DSM-IV alcohol use disorder. Although the overall prevalence of NMAS remained low between 1993 and 2001, findings suggest that continued monitoring is necessary because male student-athletes are at heightened risk for NMAS and this behavior is associated with a wide range of risky health behaviors. The characteristics associated with NMAS have important implications for future practice and research.

McCloskey J; Bailes J. When Winning Costs Too Much: Steroids, Supplements, and Scandal in Today's Sports. Lanham MD: Taylor Trade, 2005

This book co-authored by a sports writer and physician who has consulted with professional sports teams, covers the problems related to performace-enhancing drugs being used by athletes, among professional athletes, and increasingly among college and high school ages. It covers the use of steroids, designer drugs, and supplements which are largely unregulated and an increasing economic boom. Medical and health roblems related to the use of performance-enhancing drugs is reviewed. Seprate chapters are devoted to heat stroke, brain injury, and unexplained deaths among athletes. A consistent theme throughout the book is the costs to athletes, the undue emphasis on winning, the absence of traditional views of sportsmanship.

McDuff DR; Baron D. Substance use in athletics: A sports psychiatry perspective. (review). Clinics in Sports Medicine 24(4): 885-+, 2005. (55 refs.)

Athletes use substances to produce pleasure, relieve pain and stress, improve socialization, recover from injury, and enhance performance. Therefore, they use some substances in substantially higher rates than nonathletes. Despite these higher rates of use, rates of addiction may in fact be lower in athletes. This article reviews the prevalence and patterns of use, health and performance effects, and preventive and treatment interventions for alcohol, tobacco, stimulants, and steroids. Each substance is considered from the differing perspectives of abuse/addiction and performance enhancement models. Similarities and differences between college an professional athletes are discussed. Finally, suggestions for future research are made.

McGinnis MY. Anabolic androgenic steroids and aggression - Studies using animal models. Annals of the New York Academy of Sciences. Youth Violence: Scientific Approaches to Prevention 1036: 399-415, 2004. (85 refs.)

The use of anabolic androgenic steroids (AASs) has escalated in teenagers and is associated with increased violence. Adolescent exposure to chronic high levels of AASs is of particular concern because puberty is a hormonally sensitive period during which neural circuitry for adult male patterns of behavior develop. Thus, teenage AAS use may have long-term repercussions on the potential for displaying aggression and violence. Animal models have contributed valuable information on the effects of AAS use. For example, studies in rodents confirmed that exposure to the AASs testosterone and nandrolone, but not stanozolol, does indeed increase aggression. A side effect of AAS use reported in humans is "'roid rage," characterized by indiscriminate and unprovoked aggression. Results of animal studies demonstrated that pubertal rats receiving AASs respond appropriately to social cues as they are more aggressive toward intact males than are castrates. Also, testosterone-treated males recognize appropriate environmental cues as they are most aggressive in their home cage. Thus, adolescent AAS exposure increases aggressive behaviors, but does not induce indiscriminate aggression. To assess whether AAS exposure increases aggression after provocation, rats were tested following a mild tail-pinch. In adolescent males, provocation increased aggression after withdrawal from testosterone, nandrolone, and stanozolol, an effect which persisted for many weeks. The data suggest that AASs sensitize animals to their surroundings and lower the threshold to respond to provocation with aggression. Thus, in humans, pubertal AAS exposure may not cause violent behaviors, but may increase the likelihood that aggressive acts will result in violence. This may persist into adulthood.

Miller KE; Hoffman JH; Barnes GM; Sabo D; Melnick MJ; Farrell MP. Adolescent anabolic steroid use, gender, physical activity, and other problem behaviors. Substance Use & Misuse 40(11): 1637-1657, 2005. (70 refs.)

To test the comparative value of strain theory and problem behavior theory as explanations of adolescent anabolic steroid use, this study examined gender-specific relationships among steroid use, physical activity, and other problem behaviors. Based on the United States Centers for Disease Control and Prevention's 1997 Youth Risk Behavior Survey, a nationally representative sample of over 16,000 U.S. public and private high school students, binge drinking, cocaine use, fighting, and sexual risk-taking were associated with higher odds of lifetime steroid use. In gender-specific analyses, steroid use was strongly associated with female fighting and smokeless tobacco use as well as male sexual risk. Neither athletic participation nor strength conditioning predicted odds of steroid use after controlling for problem behaviors, nor did steroid-using athletes report more frequent use than steroid-using nonathletes. The study's limitations and policy implications were noted. These data suggest that other problem behaviors such as substance use, fighting, and sexual risk are better predictors of adolescent steroid use than physical activity. Interventions to prevent steroid use should not be limited to male participants in organized sports programs, but should also target adolescents identified as at risk for other problem behaviors.

Mottram DR, ed. Drugs in Sport, 3rd edition. New York: Routledge, 2003. (Chapter refs.)

This is an edited comprehensive volume on the use of drugs in sports. The material is organized into 10 chapters. The first chapters provide an overview on drug use in sports. A series of chapters deal with different drug classes -- androgenic anabolic steroids, peptide and glycoprotein hormones, anti-anxiety drugs and sport, creatine, and blood boosting. In addition there is consideration of treatment of respiratory tract disorders and treatment of inflammation in sports injuries, in light of drug bans, and also regulation of drug use by the IOC, estimates of the dimensions of drug use to enhance performance. An appendix is included which provides a synopsis of drugs used in sport, organized by drug class following the IOC schema, which identifies the purpose for use in sport, the actions, and related problems. There is a similar listing of over-the-counter and prescription drugs and the limitations tofu their use for medical conditions again following IOC regulation.

Nilsson S; Spak F; Marklund B; Baigi A; Allebeck P. Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden. Substance Use & Misuse 39(8): 1183-1197, 2004. (32 refs.)

This study investigates attitudes toward androgenic anabolic steroids among male adolescents who have used anabolics compared with those who have not. A cross-sectional survey was performed in the year 2000 in all secondary schools in the county of Halland on the west coast of Sweden. An anonymous multiple-choice questionnaire was distributed to all classes with 14-, 16-, and 18-year-old male adolescents. The response rate was 92.7% (n=4049). Those who admitted having used androgenic anabolic steroids differed in several ways from those who had not. Fewer believed androgenic anabolic steroids to be harmful (OR=0.15, 95% CI 0.08-0.30) and more believed that girls preferred boys with large muscles (OR=?6.1, 95% CI 3.4-11.0). They trained more often at gyms (OR=5.6, 95% CI 3.0-10.6), drank more alcohol (OR=4.2, 95% CI 2.0-9.1), and had used narcotic drugs more often (OR=15.3, 95% CI 8.5-27.5) than the other male adolescents. More immigrants than native-born adolescents had used anabolics (OR=4.2, 95% CI 2.2-7.9). Attitudes toward anabolics differ between users and nonusers. These aspects may be beneficial to focus on as one part of a more complex intervention program in order to change these attitudes and decrease the misuse of androgenic anabolic steroids.

Nilsson S; Spak F; Marklund B; Baigi A; Allebeck P. Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden. Substance Use & Misuse 40(1): 1-12, 2005. (32 refs.)

Aims. The aim of this study was to investigate attitudes towards androgenic anabolic steroids among male adolescents who have used anabolics compared to those who have not. Design and Setting. A cross-sectional survey was performed in the year 2000 in all secondary schools in the county of Halland on the west coast of Sweden. Participants and Measurements. An anonymous multiple-choice questionnaire was distributed to all classes with 14-, 16-, and 18-year-old male, adolescents. The response rate was 92.7% (n = 4049). Findings. Those who admitted having used androgenic anabolic steroids differed in several ways from those who had not. Fewer believed androgenic anabolic steroids to be harmful [odds ratio (OR) = 0.15, 95% CI 0.08-0.30] and more believed that girls preferred boys with large muscles (OR = 6.1, 95% CI 3.4-11.0). They trained more often at gyms (OR = 5.6, 95% CI 3.0-10.6), drank more alcohol (OR = 4.2, 95% CI 2.0-9.1), and had used narcotic drugs more often (OR = 15.3, 95% CI 8.5-27.5) than the other male adolescents. More immigrants than native-born adolescents had used anabolics (OR=4.2, 95% CI 2.2-7.9). Conclusion. Attitudes towards anabolics differ between users and nonusers. These aspects may be beneficial to focus on as one part of a more complex intervention program in order to change these attitudes and decrease the misuse of androgenic anabolic steroids.

Olrich TW; Vassallo MJ. Symposium: From grand slams to grand juries. Performance-enhanicng drug use in sport. Running Head: Psychological dependency to anabolic-androgenic tteroids: Exploring the role of social mediation. New England Law Review 40: 735-746, 2006. (28 legal refs.)

This article summarizes the findings of two studies to explore the nature of a possible psychological dependence to steroids, based on interviews with males who had used them. They spoke of a dependency not only to the chemicals themselves, but also to the secondary reinforcers found in their environment.

Ozdemir L; Nur N; Bagcivan I; Bulut O; Sumer H; Tezeren G. Doping and performance enhancing drug use in athletes living in Sivas, mid-Anatolia: A brief report. Journal of Sports Science and Medicine 4(3): 248-252, 2005. (15 refs.)

The aim of this study was to determine the rate of doping and performance enhancing drug use in athletes in Sivas, Turkey, and to analyze the main reasons for the use. This was a cross-sectional study based on a self-report questionnaire. The subjects filled the questionnaires under the supervision of the investigators during interviews. This questionnaire included 24 items describing the population in terms of demographics, sport practice, doping in sport and substance use. Moreover, we assessed the frequency of doping drug use. The number of respondents was 883, of which 433 athletes and 450 healthy non-athletes (control group). The mean age of the total volunteers was 21.8 +/- 3.7 yrs. The male and female ratios were 78.2% and 21.8% respectively. Doping and performance enhancing drug usage rate was 8.0% (71 cases in 883 subjects). Doping drug use among the athletes was significantly (p < 0.05) higher (14.5%) compared with the non-athletes (1.8%). The agents used were anabolic steroids in 60.5%, l-carnitene in 12.7%, erythropoietin in 5.4%, Na-bicarbonate in 11.3% and creatinine in 14.1% of 71 cases. The reasons for doping use were to have a better body condition in 34 cases (47.9%) and to solve weight (gaining or loosing) problems in 8 (11.3%) cases. Since the potential side effects of doping drugs are not satisfactorily familiar to the most users, the education of athletes on the matter must be a top priority.

Pagonis TA; Angelopoulos NV; Koukoulis GN; Hadjichristodoulou CS. Psychiatric side effects induced by supraphysiological doses of combinations of anabolic steroids correlate to the severity of abuse. European Psychiatry 21(8): 551-562, 2006. (71 refs.)

Objective. - The objective of our study was to evaluate the psychological consequences of real-world AAS use in athletes abusing such agents, in comparison with a placebo and control group of comparable athletes, while correlating the severity of abuse with the side effects observed. The hypothesis tested by the study was that the use of AAS induces a wide range of psychological side effects whose impact and emergence is dependent upon the severity of the abuse. Design. - The study includes a substantial group of AAS abusing athletes and two more groups demographically similar to the first, one composed of athletes not using any substance and a placebo group. All athletes were stratified according to the severity of AAS abuse. Psychometric instruments were applied to all athletes in specific time intervals, dependent to the AAS abusers' regimens, providing us with a final psychological profile that was to be compared to the pre-study profile. All results were comparable (within and between groups) for statistically significant differences and correlated to the severity of the abuse. Homogeneity of all groups was safeguarded by random doping controls, monitoring of drug levels and analysis of all self obtained drugs by method of liquid chromatography/mass spectrometry. All athletes were provided with a common exercise and dietary regime, so common training and nutritional conditions were achieved. Methods. - We studied a cohort of 320 body-building, amateur and recreational athletes, of whom 160 were active users of AAS (group C), 80 users administering placebo drugs (group B) and 80 not abusing any substance (Group A). Group C athletes were stratified according to AAS abuse parameters, thus providing us with three subgroups of "light, medium and heavy abuse". Athletes of groups A and B were included in a "no abuse" subgroup. The psychometric instruments used were the Symptoms Check List-90 (SCL-90) and the Hostility and Direction of Hostility Questionnaire (HDHQ). The psychometric evaluations took place within a time interval of 13 months. Statistical analysis was performed by using the Mann-Whitney/Wilcoxon two-sample non-parametric test (Kruskal-Wallis test for two groups) for data that were not normally distributed and Linear regression analysis was used to ascertain the correlation between severity of use and escalation of side effects. Results. - The study showed a statistically significant increase in all psychometric subscales recorded in group C, and no statistically significant difference in group C and A. There was a significant increase in the scorings of group C for all subscales of SCL-90 and HDHQ. Correlation of abuse severity and side effects showed that there was a statistical significant increase in Delta values of all SCL-90 and HDHQ subscales that escalated from light abuse to medium and heavy abuse/consumption patterns. Conclusions. - The results of the study suggest that the wide range of psychiatric side effects induced by the use of AAS is correlated to the severity of abuse and the force of these side effects intensifies as the abuse escalates.

Pallesen S; Josendal O; Johnsen BH; Larsen S; Molde H. Anabolic steroid use in high school students. Substance Use & Misuse 41(13): 1705-1717, 2006. (34 refs.)

A total of 1351 high school students (52.3% males, 47.7% females) with mean age 17.5 years (SD = 2.2) from randomized school classes in Hordaland County, Norway, participated in an Internet survey conducted in 2004 about the lifetime use of anabolic steroids and personal acquaintance with at least one user of anabolic steroids. In addition to questions about anabolic steroids the participants completed the Hospitalital Anxiety and Depression Scale and the Alcohol Use Disorders Identification Test. They also answered questions about demography, smoking, and narcotic use. The lifetime prevalence for use of anabolic steroids was 3.6% for males and 0.6% for females. In all, 27.9% of the respondents reported having at least one acquaintance that used or had used anabolic steroids. Use of anabolic steroids and having acquaintances using such drugs were strongly related to use of other drugs such as alcohol, nicotine, and narcotics. Implications for prevention are discussed and the study's limitations are noted.

Pavlovic Z; Jakovljevic B. Frequency and risk factors of the use of psychoactive substances among the young. (Serbian). Vojnosanitetski Pregled 65(6): 441-448, 2008. (17 refs.)

Background/Aim. Socio-economic changes that occured in the wake of dismemberment of former Yugoslavia resulted in the appearance of social pathology, one of which was the increase in the use of psychoactive substances. The overwhole epidemiological research in the use of psychoactive substances has not been conducted so far. The aim of this study was to establish the type and form of the use of psychoactive substances considering sex and age, as well as risk factors for the use of psychoactive substances among the children and adolescents. Methods. The research was carried out among 1011 elementary school children (seventh and eighth grades) and secondary school children (all four grades) in the area of Belgrade from October 2003 to January 2004. Out of the total number 457 (45.2%) were elementary school pupils and 554 (54.8%) secondary school pupils. There were 524 (51.8%) boys and 487 (48.2%) girls, aged from 12 to 18 years (the average age being 15.3 years). The method used was the European School Survey Project on Alcohol and Other Drugs Questionaire. Chisquare test, Mann-Whitney, Student's t test and Logistic Regression test were used in statistical processing of the data. Results. Totally 14.2% examinees tried psychoactive substances. The most frequent drug used at the first contact was marijuana (10.8%) at the age of 15 tried by 12.7% examinees, inhalants (4.4%), amphetamines (4.1%), sedatives (3.7%), alcohol combined with marijuana (3.9%), then cocaine (2.8%), heroin (2.3%), alcohol combined with sedatives (2.2%), and ecstasy (1.6%), followed by anabolic steroids, heroin, diethilamid lisergic acid (LSD) and magic mushrooms. It was determined that going out in the evening, smoking and binge form drinking were directly connected with the use of psychoactive substances. Conclusion. Totally 14.2% of the exameneers used psychoactive substances, mostly marijuana, followed by amphetamines and others. New tendencies of use characterized by the increase in the use are of synthetic substances, simultaneous use of more psychoactive substances and younger age. The risk factors are going out in the evening, smoking, binge drinking and use of synthetic substances among peers. Our research indicates the neccessity of primary prevention.

Perry PJ; Lund BC; Deninger MJ; Kutscher EC; Schneider J. Anabolic steroid use in weightlifters and bodybuilders: An internet survey of drug utilization. Clinical Journal of Sport Medicine 15(5): 326-330, 2005. (10 refs.)

Purpose: Dietary supplements and ergogenic agents, including anabolic steroids, are common components of present-day bodybuilder and weightlifter training regimens. Prior reports of anabolic steroid use suggest polypharmacy and high doses of injectable agents. Hypothesis: To provide an updated description of anabolic steroid regimens employed by weightlifters and bodybuilders and to determine the extent to which anabolic steroid associated behaviors are consistent with substance dependence. Study Design: Web-based survey. Methods: Links to the Web-based survey instrument were established from leading bodybuilding and fitness web pages. The questionnaire included demographic information, anabolic drug use history, adverse effects, information sources, and steroid use behavior consistent with criteria for a substance dependence disorder. Results: A total of 207 subjects provided a detailed anabolic steroid drug history. Steroid regimens included a mean of 11 agents, involved cycles ranging from 5 to 10 weeks, and often included doses 5 to 29 times greater than physiologic replacement doses. Behavior consistent with a substance dependence disorder was endorsed by 33% of respondents. Conclusions: These findings suggest that anabolic steroid use among weightlifters and bodybuilders continues, generally involving multiple steroids and additional dietary supplementary agents. The adverse effects, polypharmacy, large dosages, and risk of substance abuse are all major health care concerns that require further study. Clinical Relevance: The survey findings provide sports medicine practitioners a reasonable estimate of the expected drug history among bodybuilders and weightlifters for the use of performance-enhancing agents.

Petersson A; Garle M; Granath F; Thiblin I. Morbidity and mortality in patients testing positively for the presence of anabolic androgenic steroids in connection with receiving medical care: A controlled retrospective cohort study. Drug and Alcohol Dependence 81(3): 215-220, 2006. (22 refs.)

Observations by health-care professionals suggest that the use of anabolic androgenic steroids (AAS) may be associated with lethal complications, but this has not yet been confirmed by controlled epidemiological Studies. Here, we investigated the diagnoses (in the Swedish patient care records) and mortality rate among patients who tested positively for the presence of AAS (n = 248) in connection with receiving medical care. Patients who had tested negatively (n = 1215) were used for comparison. The proportions of patients who had received institutionalized care for substance abuse, psychiatric disorder or central thoracic pain were significantly higher in the AAS-positive subjects (RR = 2.2, 95% CI = 1.2-4.2: RR = 2.1, 95% CI = IA-3.2 and RR = 3.5, 95% CI = 1.1 - 10.9, respectively). Furthermore, unspecified convulsions were highly over-represented in the AAS-positive group (RR=53.9, 95% CI = 7.0-415.7) and one of these patients died during a seizure. The standardized mortality ratios (SIVIR) in the AAS-positive patients and -negative patients were 20.43 (95% CI = 10.56-35.70) and 6.02 (95% CI = 3.77-9.12), respectively. The relatively higher SMR in the AAS-positive patients was observed irrespective of what type clinic had referred the patients for AAS testing. In conclusion, use of AAS appears to be an indicator of increased risk for premature death in several categories of patients. However, the nature of the association between AAS and premature death remains unclear and additional research on this question is urgently required.

Petersson A; Garle M; Holmgren P; Druid H; Krantz P; Thiblin I. Toxicological findings and manner of death in autopsied users of anabolic androgenic steroids. Drug and Alcohol Dependence 81(3): 241-249, 2006. (38 refs.)

With the aim to characterize patterns in toxicological profile and manner of death in deceased users of anabolic androgenic steroids (AAS), a retrospective autopsy protocol study of 52 deceased users of AAS was undertaken. The AAS users were compared to 68 deceased users of amphetamine and/or heroin who were consecutively tested and found to be negative for AAS. Use of AAS was in the majority of cases (79%) associated with concomitant use of psychotropic substances. AAS-related deaths differed in several respects from deaths among users of heroin or amphetamine, most strikingly with regard to: (a) the median age at death, which was significantly lower for AAS users (24.5 years) than for users of heroin and/or amphetamine (34 and 40 years, respectively); (b) the manner of death, with AAS users dying significantly more often from homicide or suicide than users of other drugs; and (c) the body mass index (BMI), with AAS users exhibiting significantly higher BMI than users of other drugs. These results support the earlier reported association between use of AAS and use of other psychoactive substances. In addition, the data suggest that AAS users are more likely to become involved in incidents leading to violent death and have a higher risk of dying at a younger age than users of other drugs.

Pisetsky EM; Chao YM; Dierker LC; May AM; Striegel-Moore RH. Disordered eating and substance use in high-school students: Results from the youth risk behavior surveillance system. International Journal of Eating Disorders 41(5): 464-470, 2008. (31 refs.)

Objective: To examine the association between disordered eating (fasting, diet product use, and vomiting or laxative use) and use of 10 substances (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and hallucinogens) in a nationally representative adolescent sample. Method: Participants were 13,917 U.S. high-school students participating in the 2005 Youth Risk Behavior Surveillance System. Results: Disordered eating was significantly associated with the use of each substance. Using effect size estimates that take base rates into consideration, for female students, associations between substance use and disordered eating were weak for all but three forms of substance use: current smoking, binge drinking, and inhalants. Among male students, strong (marijuana, steroids, and inhalants) or moderate effects (all other substances) were observed. Conclusion: Future research needs to focus on inhalant use and methamphetamine use in males. Increased medical attention should be directed toward adolescents who practice disordered eating behaviors because they are also at elevated risk for using cigarettes, alcohol, inhalants, methamphetamines, and steroids.

Pope HG; Kanayama G; Ionescu-Pioggia M; Hudson JI. Anabolic steroid users' attitudes towards physicians. Addiction 99(9): 1189-1194, 2004. (31 refs.)

Aims:To assess anabolic-androgenic steroid (AAS) users' trust in the knowledge and advice of physicians. Design: Interviews of AAS users and non-users. Setting: Research offices. Participants: Eighty weight-lifters (43 AAS users, 37 non-users) recruited by advertisement in Massachusetts and Florida, USA. Measurements: Personal interviews and questionnaire responses, including subjects' ratings of physicians' knowledge regarding various health- and drug-related topics. AAS users also rated their level of trust in various sources of information about AAS. Findings: Both groups of subjects gave physicians high ratings on knowledge about general health, cigarette smoking, alcohol, and conventional illicit drugs, but gave physicians markedly and significantly lower ratings on knowledge about AAS. When rating sources of information on AAS, users scored physicians as no more reliable than their friends, Internet sites, or the person(s) who sold them the steroids. Forty percent of users trusted information on AAS from their drug dealers at least as much as information from any physician that they had seen, and 56% had never revealed their AAS use to any physician. Conclusion: AAS users show little trust in physicians' knowledge about AAS, and often do not disclose their AAS use to physicians. These attitudes compromise physicians' ability to educate or treat AAS users. Physicians can respond to these problems by learning more about AAS and by maintaining a high index of suspicion when evaluating athletic male patients.

Rapaport MJ; Rapaport VH. Serum nitric oxide levels in "Red" patients: Separating corticosteroid-addicted patients from those with chronic eczema. (letter). Archives of Dermatology 140(8): 1013-1014, 2004. (6 refs.)

Rasmusson AM; Wu R; Paliwal P; Anderson GM; Krishnan-Sarin S. A decrease in the plasma DHEA to cortisol ratio during smoking abstinence may predict relapse: A preliminary study. Psychopharmacology 186(3): 473-480, 2006. (71 refs.)

Increases in depressive symptoms during smoking cessation have been associated with risk for relapse. Several studies have linked plasma levels of cortisol and dehydroepiandrosterone (DHEA) or DHEA-sulfate (DHEAS) to depressive symptoms. To determine whether changes in plasma cortisol, DHEA, or DHEAS levels and emergence of depressive symptoms during smoking cessation are associated with smoking relapse. Subjects were healthy non-medicated men and women, aged 39 +/- 12 years, who smoked, on average, 22 cigarettes per day. Depressive symptoms, smoking withdrawal symptoms, and plasma steroid levels were measured before and after 8 days of verified smoking abstinence. Relapse status at day 15 was then determined. In the full sample (n=63), there was a trend for changes in depressive symptoms to be associated with relapse. In the subset of 25 subjects with plasma neuroactive steroid data, there was a significant interaction between the change in the plasma DHEA/cortisol ratio from day 0 to day 8 and relapse status at day 15. This ratio was similar before abstinence, but lower at day 8 in relapsed, compared to abstinent, subjects. Changes in the DHEA/cortisol ratio tended to predict changes in depressive symptoms in the women only. A decrease in the plasma DHEA/cortisol ratio during 8 days of smoking abstinence was associated with relapse over the following week. Further research is needed to fully characterize sex-specific relationships between abstinence-induced changes in neuroactive steroid levels, depressive or withdrawal symptoms, and relapse. Such research may lead to new interventions for refractory smoking dependence.

Rastegar DA; Fingerhood MI. Addiction Medicine: An Evidence-Based Handbook. Baltimore: Lippincott Williams & Wilkins, 2005. (Chapter refs.)

This handbook, intended for those in clinical medicine, provides practical and evidence-based guidelines for evaluating, treating, and managing patients with substance abuse problems. It is organized into 17 chapters. The initial four chapters provide an overview of basic constructs, responding to addictions in the primary care setting, the medical interview and an overview of treatment. This discussion includes consideration of different models for understanding addiction problems, the natural history of addiction and the recovery process, the basic clinical skills around screening, the use of drug testing, motivational interviewing, and responding to denial, and a introduction to the basic elements of treatment and the settings in which it is provided. The bulk of the book (10 chapters) are directed to the examination of a specific drug, its epidemiology, acute effects, diagnostic considerations, associated medical complications, and drug-specific treatment elements. Individuals chapters are devoted to alcohol, sedative-hypnotics, opioids, tobacco, cocaine and other stimulants, hallucinogens, marijuana, inhalants, and steroids. The final four chapters consider medical care for the addicted patient, including issues such as problems associated with the route of administration, issues around pain management, and "the difficult" patient. Another chapter is devoted to prescription drug abuse -- markers of abuse, strategies to avoid prescription drug abuse, the products most commonly abuse, as well as discussion too of over-the-counter products. The concluding chapters consider special populations -- women, the elderly, adolescents, prisoners -- as well as issues related to co-occurring mental illness.

Sas-Nowosielski K. The abuse of anabolic-androgenic steroids by Polish school-aged adolescents. Biology of Sport 23(3): 225-235, 2006. (33 refs.)

Although anabolic-androgenic steroids (AAS) are perceived primarily as doping agents for athletes, these substances are also used by adolescents for aesthetical purposes. The aim of this study was to determine the knowledge about AAS, the extent, main reasons and consequences of its use among adolescents in Katowice, Poland. An anonymous questionnaire were answered by 1175 students, both sexes, attending three types of schools: grammar, secondary school preparing for university and vocational school. The results suggest that most adolescents, especially from grammar schools, know nothing or hardly anything about AAS and health consequences of using them. Moreover, 9.38% males and 2.08% females were abusing AAS or had abused them at some time of their life. Students from vocational schools had a higher usage rate of AAS than pupils from the other two types of schools. For most of the users the main reasons for using AAS are connected with the will to change their bodies so as to improve appearance by gaining muscle mass, reduce body fat and/or improve muscle cut. Over a half of the users had suffered from some side effects of AAS: acne, hair-loss, sexual disturbances, irritability, voice deepening, depression etc. The results of this study suggest that there is an urgent need to include AAS issues into drug education programs.

Shipp EM; Tortolero SR; Cooper SP; Baumler EG; Weller NF. Substance use and occupational injuries among high school students in South Texas. American Journal of Drug and Alcohol Abuse 31(2): 253-265, 2005. (24 refs.)

This cross-sectional study examined the association between self-reported nonfatal occupational injuries among high school students in South Texas and their self-reported general use of substances. Data were collected using a self-administered, anonymous questionnaire (n=3365). The independent variables included alcohol, marijuana, cocaine, inhalant, and steroid use. The dependent variable was occupational injury. Adjusting for grade, sex, ethnicity, and work intensity, odds ratios were calculated using logistic regression. Supporting an association with each substance, odds ratios consistently strengthened as use increased. Additional research is merited given the scant number of previous studies. The associations for inhalant (OR, 5.61) and steroid (OR, 7.63) use argue for their inclusion in future research.

Simon P; Striegel H; Aust F; Dietz K; Ulrich R. Doping in fitness sports: Estimated number of unreported cases and individual probability of doping. Addiction 101(11): 1640-1644, 2006. (20 refs.)

Aims: Recent studies have suggested that the use of doping substances and particularly of anabolic androgenic steroids (AAS) is often practised by fitness centre visitors. These studies employed direct interview techniques and questionnaires to assess the estimated number of unreported cases of doping. Because people hesitate to provide compromising information about themselves, these techniques are subject to response errors. In this study we applied an alternative interview technique to assess more accurately unreported cases of doping in fitness centres. Design and participants: The present investigation employed the randomized response technique (RRT) to reduce response errors. A cohort of 500 people from 49 fitness centres participated in this study. Finding The RRT revealed a high prevalence of doping (12.5%). In addition, and most importantly, the present RRT study revealed an alarmingly high prevalence of illicit drug use, specifically of cocaine use, that has been severely underestimated by previous studies. Conclusions: The RRT confirmed previously estimated rates of AAS use assessed by direct interview techniques and voluntary questionnaires, but uncovered a much higher usage rate of illicit drugs among fitness centre visitors. This outcome enabled us to construct a 'probability' rating for the use of doping substances in fitness centre visitors. Given its high prevalence and the predominant use of AAS, doping among fitness centre visitors is an issue of extreme relevance for the health care system. Our study may help to characterize further doping substance users and to develop and apply prevention and intervention programmes specifically to individuals at high risk.

Simpson JJ. Review of selected 2005 California Legislation. Addressing the use of steroids ond performance enhancing dietary supplements by high school athletes. University of the Pacific McGeorge Law Review 37: 239-250, 2006. (105 legal refs.)

This article examines the impact of legislation in California on efforts to reduce and prevent the use of steroids and enhancing-performance drugs by student, high school athletes. The author provides a review of perinent federal and California laws. There is consideration of figures with potential to influence student athlete drug use, from coaches to parents. The role of drug testing is also described, including its limitations.

Sirois F. Steroid psychosis: A review. General Hospital Psychiatry 25(2): 27-33, 2003. (55 refs.)

This review is built upon a time-framed perspective to unfold the growth of evidence and the shifting of focus from primary affective short-term reactions to later findings of cognitive deficits and possible permanent impairment linked to steroid treatment. An incidence related to dosage has been documented and delirium and withdrawal symptoms have been reported in later studies. A hypothesis of sensitization process with multiple course of steroids has been proposed with the reporting of recurrent cases. The issue of individual risk appears unsettled while management of psychiatric reactions to steroids has shifted toward prophylactic use of lithium.

Skarberg K; Engstrom I. Troubled social background of male anabolic-androgenic steroid abusers in treatment. Substance Abuse Treatment, Prevention, and Policy 2(e-article 20), 2007. (33 refs.)

Background: The aim of this study was to investigate the social background and current social situation of male abusers of anabolic-androgenic steroids (AAS). Methods: We compared thirty-four AAS-abusing patients from an Addiction Centre (AC) with two groups, 18 users and 259 non-users of AAS from a public gym in Orebro, Sweden. The study is based on semi-structured interviews and questionnaires. Results; Histories of a troubled childhood as well as current social disadvantage were both more frequent among the AAS users. Users also reported poor relationships with their parents and almost half of them had experienced physical or mental abuse. The AC group's experiences from school were mostly negative, and included concentration problems, boredom and learning difficulties. Their current circumstance included abuse of other drugs, battering of spouses and other criminality such as assault, illegal possession of weapons and theft. Conclusion: In conclusion, this study shows that abusers of AAS often have a troubled social background. This underlines the importance of making a thorough social assessment as a part of the treatment programme. The results of the study may help in directing appropriate questions relevant to the abuse of AAS.

Striegel H; Simon P; Frisch S; Roecker K; Dietz K; Dickhuth HH et al. Anabolic ergogenic substance users in fitness-sports: A distinct group supported by the health care system. Drug and Alcohol Dependence 81(1): 11-19, 2006. (28 refs.)

Background: Anabolic ergogenic substance use, in particular the use of anabolic androgenic steroids, is a serious problem in general. Nevertheless, it is subject to debate whether ergogenic substance users exhibit similar features as multiple substance users or whether they constitute a discrete group. Methods; One thousand eight hundred and two standardized, anonymous questionnaires were distributed among visitors of 113 fitness centers. Questions were asked concerning biometric parameters, social indicators, physical fitness, use of natural stimulants, general illicit drugs and ergogenic substances. With logistic regression analysis, multivariate odds ratios were estimated to investigate the association of anabolic ergogenic substance or general illicit drug use with other parameters. Results; 13.5% of all participants confessed to having used anabolic ergogenic substances at some point in time. Anabolic ergogenic substance use was positively related with cocaine use, training years, training frequency, negatively related to the level of education, alcohol intake and less frequently used by Germans than by non-Germans. General illicit drug use. however, was positively related with alcohol intake, smoking and a university degree and negatively with having children. In addition, anabolic ergogenic substance use was significantly related with the use of general illicit drugs based on the strong relation with the use of cocaine, which is an ergogenic substance itself. The health care system supplies 48.1% of the anaolic ergogenic substance users with their substances and 32.1% are even monitored by a physician. Conclusions; The results of this study strengthen the notion that anabolic ergogenic substance users constitute a specific body-oriented substance user group. Uncommon for general illicit drug use, the health care system is a major sponsor of anabolic ergogenic substance users. These findings suggest the need for alternative approaches for successful prevention and intervention programs.

Striegel H; Simon P; Wurster C; Niess AM; Ulrich R. The use of nutritional supplements among master athletes. International Journal of Sports Medicine 27(3): 236-241, 2006. (25 refs.)

We assessed the use of nutritional supplements among master athletes focusing on their source of information and source of supply of nutritional supplements. 1560 standardized, anonymous questionnaires were distributed among participants of the World Masters Athletics Championships Indoors 2004. These questions were related to biometric parameters, social indicators, training parameters, illicit drugs, and nutritional supplements. chi(2)-tests were computed to reveal meaningful associations between basic information (age, gender, family Status, children, education, country of origin, disciplines, training years, smoking, and the use of alcohol, illicit drugs, and doping) and the intake of nutritional supplements. Descriptive information on the history of their use of nutritional supplements was also provided. 60.5% of all participants reported the actual use of nutritional supplements. We found no significant differences between nutritional supplement users and non-users with regard to basic information. The substances predominantly used were vitamins (35.4%) and minerals (29.9%). In contrast to elite athletes who use nutritional supplements to increase their athletic performance, master athletes use these substances predominantly for health reasons and, thus, have a closer contact to the health care system. Physicians are their preferred source of information about nutritional supplements. More than half of the interviewed athletes obtain their nutritional supplements from pharmacies or physicians. The results of this study indicate that nutritional supplement users in master athletics show no specific user profile. Since it is not rare for nutritional supplements to contain trace contaminations of anabolic androgenic steroids or pro-hormones, physicians should also inform master competitive athletes of the clances of testing positive for doping substances due to their intake of nutritional supplements and advise them accordingly.

Talih F; Fattal O; Malone D. Anabolic steroid abuse: Psychiatric and physical costs. (review). Cleveland Clinic Journal of Medicine 74(5): 341-+, 2007. (77 refs.)

The psychiatric effects of anabolic-androgenic steroids (ie, testosterone and its derivatives) have been less well studied than their physical effects but are reported to include depression, mania, psychosis, and aggression. Dependence can also occur, with withdrawal involving psychiatric and physical symptoms. Adverse effects of steroid abuse should be managed by discontinuing the drugs -- by tapering if necessary -- and by treating the symptoms.

Togna GI; Togna AR; Graziani M; Franconi M. Testosterone and cocaine: Vascular toxicity of their concomitant abuse. Thrombosis Research 109(4): 195-201, 2003. (48 refs.)

Over the last few years, several studies have described an increase in the use of anabolic-androgenic steroids (AAS). More important, frequency of AAS use was significantly associated with frequency of psychotropic drug use, such as cocaine. Since information is not available on the effects of their concomitant abuse, and taking into account that cocaine and testosterone, when singly abused, are known to induce severe adverse effects on vascular system, our purpose was to evaluate in vitro the combined effect of these drugs on platelet and endothelial functions. Results show that testosterone, at concentrations not exerting any appreciably acute effects on their own, is capable of potentiating the cocaine effect on endothelial and platelet functions, indicating that concomitant use of testosterone and cocaine could result in enhancement of the thrombotic risk ascribed to these drugs.

Tokish JM; Kocher MS; Hawkins RJ. Ergogenic aids: A review of basic science, performance, side effects, and status in sports. (review). American Journal of Sports Medicine 32(6): 1543-1553, 2004. (102 refs.)

The use of drugs and supplements to enhance performance has become a part of mainstream athletics. Many team physicians and sports medicine practitioners are unfamiliar with the benefits and risks of these products and thus are unable to educate young athletes on this topic. In spite of numerous reports on the health risks of anabolic steroid use, 1 to 3 million Americans have used them. Human growth hormone has been tried by up to 5% of 10th graders, although no scientific study has shown that it is an effective performance-enhancing drug. Amphetamines and similar compounds may be the most widely abused drug in baseball; recently, they have come under increased scrutiny in sport. Erythropoietin is a highly effective aerobic enhancer that has been linked to multiple deaths in cyclists and other endurance athletes. The neutraceutical industry, led by supplements such as creatine, ephedra, and androstenedione, remains unregulated by the Food and Drug Administration and has serious issues with quality and side effects. An understanding of these products is essential for the sports medicine practitioner to provide sound, safe advice to the athlete.

van Breda E; Keizer HA; Kuipers H; Wolffenbuttel BHR. Androgenic anabolic steroid use and severe hypothalamic-pituitary dysfunction: A case study. International Journal of Sports Medicine 24(3): 195-196, 2003. (9 refs.)

The data of the present case demonstrate that the abuse of androgenic anabolic steroids (AAS) may lead to serious health effects. Although most clinical attention is usually directed towards peripheral side effects, the most serious central side effect, hypothalamic-pituitary-dysfunction, is often overlooked in severe cases. Although this latter central side-effect usually recovers spontaneously when AAS intake is discontinued, the present case shows that spontaneous recovery does not always take place. We suggest that hypothalamic-pituitary dysfunction should always be considered in the differential diagnosis in athletes seen with typical presentation of anabolic steroid use. in order to regain normal hypothalamic-pituitary function, supraphysiological doses of 200 mug LH-RH should be considered when the physiological challenge test with LH-RH (50 mug) fails to show an acceptable response.

Van Eenoo P; Delbeke FT. The prevalence of doping in Flanders in comparison to the prevalence of doping in international sports. International Journal of Sports Medicine 24(8): 565-570, 2003. (19 refs.)

For many years, doping has been considered a major problem in Sports. Recent doping cases have shocked the general public and press reports have further generated the idea that a great number of athletes are doped. In this study statistical data provided by the International Olympic Committee (1996-2000) to IOC accredited laboratories and results from the Flemish anti-doping program (1993 - 2000) are discussed. During these periods, the average percentage positive samples in the IOC accredited laboratories and in Flanders were 1.8% and 4.1%, respectively. The percentage of positive samples was significantly higher for in-competition than for out-of-competition samples. During the period 1993 - 2000, doping was detected in all sports in Flanders, for which a representative number of samples (n > 50) was tested except mini-soccer, where no positive doping samples were found. The use of doping among male athletes is significantly higher than for female athletes. Bodybuilding and power lifting had the highest incidence of positive cases in Flanders. The distribution of detected drugs among the different groups of prohibited substances shows a significant increase in the number of samples containing cannabis over the last years. The occurrence of cannabis in all sports and the high frequency of detection in Flanders, indicate that cannabis is predominantly misused as a "social" drug rather than for doping purposes. In Flanders, multiple prohibited substances were detected in 41% of all positive cases. At least 27.6% out of those were due to co-administration of drugs.

Verroken M. Drug use and abuse in sport. IN: Mottram DR, ed. Drugs in Sport, 3rd edition. New York: Routledge, 2003. pp. 29-62. (31 refs.)

Use of drugs to enhance performance dates back to the ancient Greeks, the medieval knights, and even horses in races in the early 1900s. The phenomenon of drug use in sport must be seen in parallel with two other factors. First, the sixties heralded a more liberal approach to experimentation in drug taking, particularly among the followers of pop music. Second and of far greater significance, a 'pharmacological revolution' began in the 1960s. Pharmaceutical research provided an array of powerful agents capable of altering many biochemical, physiological and psychological functions in the body, beyond anything that could be achieved by hard work and rigorous training. Originally athletes used amphetamines and other stimulants, mainly on the day of, or during, performance. There was growing evidence that these drugs might be linked with sudden collapse or death, usually from cardiac or respiratory arrest, particularly during competition, yet the long term side-effects on the body were regarded as minor. By comparison the drugs which emerged in the 1950s among body builders in America and later among athletes and weightlifters, the anabolic steroids, were a different story. These drugs, whilst increasing size and strength in some athletes, also cause significant side-effects. The advantage these drugs offered was their usefulness to an athlete in training, in preparation for a competition. Evidence for the performance-enhancing properties of drugs is sparse. Consequently, much of the rationale behind drug taking in sport is based on hypothetical performance-enhancing properties, speculation, misinformation from 'underground' booklets and sheer ignorance. Data assembled by the IOC's accredited laboratories since 1993 indicates anabolic steroids are the most frequently detected substance, consistently representing a significant percentage of the total findings. In addition to the rationale for use, this chapter considers athletes attitudes toward durg use, ethical issues associated with drug use in sport, and international policies in respect to performance-enhancing drugs.

Walker ET. Missing the target: How performance-enhancing drugs go unnoticed and engender the lives of athletes. Villanova Sports and Entertainment Law Journal 10(1): 181-209, 2003. (180 legal refs.)

This Comment focuses on the anti-doping policies of different athletic organizations and groups within both the amateur and professional ranks. Section II examines the drug testing policies of assorted athletic settings, using high school athletics, the National Collegiate Athletic Association ("NCAA"), and the World Anti-Doping Agency ("WADA") as examples of amateur sports, as well as the NFL and MLB to contrast the anti-doping policies that exist within the professional sports arena. Section III discusses the frustrations encountered by these policies, using the field of available performance-enhancing drugs as a gauge for the policies' successes and failures. Section IV briefly summarizes the shortcomings of contemporary anti-doping policies, and suggests ways organizations can improve their efforts to eradicate the use of performance-enhancing drugs.

Wichstrom L. Predictors of future anabolic androgenic steroid use. Medicine and Science in Sports and Exercise 38(9): 1578-1583, 2006. (33 refs.)

Purpose: To prospectively study the stability of anabolic androgenic steroid (AAS) use and predictors of AAS use, and to investigate whether AAS use alters the risk of later emotional and behavioral problems. Methods: Survey of a national sample of Norwegian high school students (age 15-19) in 1994 followed up in 1999 (N = 2924). Measures of frequent alcohol intoxication (50+ times per 12 months), cannabis use (12 months), hard drug use (12 months), being offered cannabis, eating problems, conduct problems, sexual debut before age 15, BMI, involvement in power sports, perceived physical appearance, and satisfaction with body parts were obtained. Results: Life-time prevalence of AAS used were 1.9 and 0.8% in the follow-up period. Multivariate logistic regression revealed that future AAS use was predicted by young age, male gender, previous AAS use, involvement in power sports, and frequent alcohol intoxication. AAS use did not predict future emotional or behavioral problems other than reducing the risk of future frequent alcohol intoxication. Conclusion: Frequent alcohol intoxication and involvement in power sports appear to predict future AAS use. At the population level there was little stability in individual AAS use from adolescence to early adulthood. No detrimental effects of AAS use could be detected in this study, but low statistical power limits this conclusion.

Zhou Y; Du GH; Geng MY; Lu ZH. Rapid detection of anabolic steroids in urine by protein arrays. International Journal of Sports Medicine 27(7): 526-532, 2006. (18 refs.)

The pupose of this study was to develop a rapid and sensitive method utilizing the state-of-the-art protein arrays technique to detect urinary anabolic steroids (ASs) in athletes. Three experiments were designed to investigate the feasibility of the protein arrays for ASs testing. Firstly, androgen receptor (AR) and estrogen receptor (ER) protein arrays were prepared on polysaccharide-coated slides to investigate whether they can bind to ASs (affinity tests). Secondly, in comparison to adrenergic receptor (the receptor of beta-blockers) and opioid receptor (the receptor of narcotic analgesics) arrays, AR and ER protein arrays were used to test whether they can determine the ASs positive urine sample specifically (specific binding tests). At last protein arrays were used to estimate qualitatively the ASs in positive urine samples (qualitative tests). From the results of the affinity tests the shape of the dose-dependence curve suggested a positive cooperative binding of ASs with the protein arrays. The AR and ER protein arrays showed affinities for fluorescence labelled testosterone and estradiol that were similar to those of literatures (0.65 vs. 0.89 nM, 5.96 vs. 10.3 nM, respectively). Based on the data, the sensitivity of testing can reach 0.1 nM that was much better than the World Anti-Doping Code (WADA) standard. Specific binding tests showed that the prohibited substance in positive urine samples belonged to the anabolic estrogenic inhibitor of ASs. From the results of qualitative tests, we could estimate that there were anabolic androgenic steroids in the positive urine samples and their concentration was lower than 50 mu M Methyltestosterone. The total time of the test process for ASs in urine needed less than 1 h. In summary, the present study showed that the protein arrays method provided a highly sensitive and rapid alternative to screen urine samples for the detection of the misuse of ASs in athletes and was suitable for testing in both weekly training sessions as well as large-scale competition events.