Why do some bodybuilders and athletes take dietary supplements?

Some bodybuilders and athletes use dietary supplements to try to improve their strength, muscle mass, and energy. However, many of these types of products contain harmful ingredients. Also, for some substances, including glutamine, choline, methoxyisoflavone, quercetin, zinc/magnesium aspartate, nitric oxide, and L-arginine, there’s no clear evidence that they improve athletic performance.

What dietary supplements are banned by the NCAA?

The National Collegiate Athletic Association (NCAA) maintains a list of banned substances and explains that some dietary supplements may contain banned substances not listed on the product labels. BMPEA (a phenethylamine) and DMAA (dimethylamylamine) are two examples of substances banned by the NCAA. More information on BMPEA and DMAA is given below.

Are dietary supplements necessary?

Most of us can meet all of our nutritional needs from food. Health care providers will recommend a supplement if needed—for example, vitamin D if you don’t get much sun and are low on vitamin D, or vitamin B12 if you have difficulty absorbing vitamin B12 from food (including many people over 50 and those with pernicious anemia or digestive disorders) or if you follow a vegan or vegetarian diet that does not include adequate levels of vitamin B12.

What is creatine?

Creatine is an amino acid produced by the body and a popular dietary supplement. It may somewhat enhance the effects of exercise on strength, muscle mass, and endurance. But creatine can have some short-term side effects, and its long-term effects haven’t been well studied.

Is creatine safe?

There have been reports that creatine may impair liver and kidney function. Creatine has also been linked to an increased risk of compartment syndrome, a condition where pressure builds in a muscle compartment and prevents blood flow. People at risk of kidney problems should check with their health care providers before using creatine and be carefully monitored while using it.

There are no data documenting the safety of creatine in children or adolescents. The American Academy of Pediatrics and the American College of Sports Medicine warn that teens should not use performance-enhancing supplements, including creatine, because of the possible health risks.

Do performance-enhancing dietary supplements work?

Studies have looked at a variety of supplements used for bodybuilding or to improve physical performance, including glutamine, choline, methoxyisoflavone, quercetin, zinc/magnesium aspartate, nitric oxide, and L-arginine. There’s no clear evidence these supplements improve athletic performance.

The results of studies on beta-alanine, an amino acid found in food and dietary supplements, are mixed but generally don’t show that it improves athletic performance significantly.

Are bodybuilding supplements safe?

• Dangerous hidden ingredients are an increasing problem in products promoted for bodybuilding, the U.S. Food and Drug Administration (FDA) warns. Consumers may unknowingly take products laced with prescription drug ingredients, controlled substances, and other ingredients.
• Bodybuilding supplements often are adulterated with anabolic steroids that are modified variants of male hormones designed to increase muscle mass.
• Liver injury from taking bodybuilding dietary supplements has increased in recent years. Bodybuilding products are the most common cause of liver injury linked to herbal and dietary supplement use.
• Products containing the stimulants BMPEA or DMAA can cause serious health problems.
  • Supplements labeled as containing the herb Acacia rigidula often contain BMPEA, although BMPEA isn’t in the herb and isn’t a dietary ingredient.
  • DMAA-containing products marketed as dietary supplements are illegal. In 2013, the FDA began taking action to remove these products from the market. However, DMAA is still found in some products marketed as supplements, including under different names, such as geranium oil.
• Some dietary supplements may interact with drugs or other supplements. Some vitamins and minerals are harmful at high doses. Talk with your health care provider before using a dietary supplement for bodybuilding or endurance.

Appearance and performance enhancing drugs (APEDs) are most often used by males to improve appearance by building muscle mass or to enhance athletic performance. Although they may directly and indirectly have effects on a user’s mood, they do not produce a euphoric high, which makes APEDs distinct from other drugs such as cocaine, heroin, and marijuana. However, users may develop a substance use disorder, defined as continued use despite adverse consequences.

Anabolic-androgenic steroids, the best-studied class of APEDs (and the main subject of this report) can boost a user’s confidence and strength, leading users to overlook the severe, long-lasting, and in some cases, irreversible damage they can cause. They can lead to early heart attacks, strokes, liver tumors, kidney failure, and psychiatric problems. In addition, stopping use can cause depression, often leading to resumption of use.

Because steroids are often injected, users who share needles or use nonsterile injecting techniques are also at risk for contracting dangerous infections such as viral hepatitis and HIV.

Steroids are popularly associated with doping by elite athletes, but since the 1980s, their use by male non-athlete weightlifters has exceeded their use by competitive athletes. Their use is closely associated with disordered male body image—most specifically, muscle dysmorphia.

Anabolic-androgenic steroids, often shortened to "anabolic steroids," "steroids," or "androgens," are the most widely misused APED. These are synthetic substances similar to the male sex hormone testosterone. They promote the growth of skeletal muscle (anabolic effects) and the development of male sexual characteristics (androgenic effects) in both males and females.

These compounds are sometimes used medically to treat delayed puberty and muscle loss due to disease and to treat low levels of testosterone in men with an associated medical condition. Anabolic androgenic steroids can also improve feelings of well-being and increase bone strength, but are not approved for these purposes. However, testosterone-supplementation therapy is an increasingly common treatment for mood and sexual performance problems associated with male aging, and it is controversially being prescribed even for younger men.

Note that in the context of this report, anabolic steroids refer only to the non-prescribed use (misuse) of testosterone and testosterone-like substances by athletes and non-athlete bodybuilders. This research report will not cover image enhancers, such as dermal fillers, Botox, or the skin tanner, melanotan.

Non-steroidal anabolics, include insulin, insulin-like growth hormone (IGF), and human growth hormone (HGH)—substances that are produced by the human body and are prescribed for legitimate medical uses but also sometimes misused for performance enhancement.

Ergo/thermogenics are compounds used to decrease body fat or to promote leanness versus muscle mass in endurance athletes. The three main categories of ergo/thermogenics are:

• Xanthines: compounds that increase attention and wakefulness and suppress appetite. Examples are caffeine, the asthma drug theophylline, and theobromine—a substance found in chocolate, coffee, and tea.
• Sympathomimetics: drugs that are similar in structure and action to epinephrine and norepinephrine—natural chemicals in the body that increase heart rate, constrict blood vessels, and raise blood pressure. An example is ephedrine, which is derived from the ephedra plant. Ephedrine/ephedra used to be included in dietary supplements that promoted weight loss, increased energy, and enhanced athletic performance. In 2004, the FDA banned the U.S. sale of dietary supplements containing ephedrine/ephedra due to various possible health risks including cardiovascular and nervous system effects.
• Thyroid hormones: substances that regulate metabolism by altering the function of the thyroid. Cytomel is an example.

Nutritional/dietary supplements are substances purchased legally from nutritional stores or via the internet that are often taken in combination with other APEDS. Creatine, which boosts exercise capacity, is one common example.

In the United States, dietary supplements containing steroid precursors such as tetrahydrogestrinone (THG) and androstenedione previously could be purchased legally without a prescription. Athletes took steroid precursors in an effort to boost testosterone levels. Less is known about the side effects of steroid precursors, but if large quantities of these compounds substantially increase testosterone levels in the body, then they also are likely to produce the same side effects as anabolic steroids themselves. The purchase of these supplements, with the notable exception of dehydroepiandrosterone (DHEA), became illegal after the passage of the Anabolic Steroid Control Act of 2004, which amended the Controlled Substances Act.

What are anabolic steroids?

Anabolic steroids are synthetic (man-made) versions of testosterone. Testosterone is the main sex hormone in men. It is needed to develop and maintain male sex characteristics, such as facial hair, deep voice, and muscle growth. Women do have some testosterone in their bodies, but in much smaller amounts.

What are anabolic steroids used for?

Health care providers use anabolic steroids to treat some hormone problems in men, delayed puberty, and muscle loss from some diseases. But some people misuse anabolic steroids.

Why do people misuse anabolic steroids?

Some bodybuilders and athletes use anabolic steroids to build muscles and improve athletic performance. They may take the steroids orally, inject them into muscles, or apply them to the skin as a gel or cream. These doses may be 10 to 100 times higher than doses used to treat medical conditions. Using them this way, without a prescription from a health care provider, is not legal or safe.

What are the health effects of misusing anabolic steroids?

Misuse of anabolic steroids, especially over a long period of time, has been linked to many health problems, including

• Acne
• Stunted growth in teens
• High blood pressure
• Changes in cholesterol
• Heart problems, including heart attack
• Liver disease, including cancer
• Kidney damage
• Aggressive behavior

In men, it can also cause

• Baldness
• Breast growth
• Low sperm count/infertility
• Shrinking of the testicles

In women, it can also cause

• Changes in your menstrual cycle (period)
• Growth of body and facial hair
• Male-pattern baldness
• Voice deepening

Are anabolic steroids addictive?

Even though they don't cause a high, anabolic steroids can be addictive. You can have withdrawal symptoms if you stop using them, including

• Fatigue
• Restlessness
• Loss of appetite
• Sleep problems
• Decreased sex drive
• Steroid cravings
• Depression, which can sometimes be serious and even lead to suicide attempts

Behavioral therapy and medicines can be helpful in treating anabolic steroid addiction.

Testosterone was first synthesized in Germany in 1935 and was used medically to treat depression. Professional athletes began misusing anabolic steroids during the 1954 Olympics, when Russian weightlifters were given testosterone. In the 1980s, anabolic steroid use began to extend into the general population, and young men began using these substances, sometimes to enhance athletic performance but in most cases to improve personal appearance.

Most anabolic steroid users are male non-athletes aiming to improve their appearance by building muscle, and use of steroids is strongly tied to a male body image disorder called muscle dysmorphia (see “Who uses anabolic steroids?"). Just as female body image disorders have been linked to unrealistic portrayals of the female form in fashion magazines and popular culture, muscle dysmorphia in males is linked to exaggerated physiques in action movies and other media over the past three decades.

Congress passed the Anabolic Steroid Act of 1990 to respond to the increasing levels of illicit traffic in steroids. This Act identified anabolic steroids as a separate drug class and categorized over two dozen drugs as controlled substances. The Act also gave a four-part definition of this drug class, which allowed for flexibility in controlling new anabolic steroids as they were synthesized. In 2004, Congress enacted the Anabolic Steroid Control Act of 2004, which banned over-the-counter steroid precursors; increased penalties for making, selling, or possessing illegal steroid precursors; and provided funds for preventative educational efforts.

Other countries, such as Mexico and some European nations, where steroids are available without prescription, are the main sources of illegal steroids smuggled into the United States. Less common illicit sources include diversion from legitimate sources (e.g., thefts or inappropriate prescribing) or production within clandestine laboratories.

The vast majority of people who misuse steroids are male non-athlete weightlifters in their 20s or 30s. Contrary to popular belief, only about 22 percent of anabolic steroid users started as teenagers. Anabolic steroid use is less common among females, since fewer women desire extreme muscularity and the masculinizing effects of steroids.

Males who are more likely to use steroids tend to have poor self-esteem, higher rates of depression, more suicide attempts, poor knowledge and attitudes about health, greater participation in sports emphasizing weight and shape, greater parental concern about weight, and higher rates of eating disorders and substance use. Steroid misuse is associated with muscle dysmorphia, a behavioral disorder in which men think that they look small and weak, even if they are large and muscular (see “Why are anabolic steroids misused?”).

Some people who misuse steroids have experienced physical or sexual abuse. In a study of 506 male users and 771 male nonusers of anabolic steroids, users were significantly more likely than nonusers to report being sexually abused in the past. Similarly, female weightlifters who had been raped were found to be twice as likely to report use of anabolic steroids or another purported muscle-building drug, compared with those who had not been raped. Moreover, almost all females who had been raped reported that they markedly increased their bodybuilding activities after the attack. They believed that being bigger and stronger would discourage further attacks because men would find them either intimidating or unattractive.

It is difficult to estimate the true prevalence of steroid misuse in the United States because many surveys that ask about illicit drug use do not include questions about steroids. However, the annual Monitoring the Future study, a NIDA-funded survey of drug use and attitudes in middle and high school students across the United States, shows that past-year use of steroids has generally declined among 8th and 10th graders, after peaking in 2000. Past-year steroid use among 12th graders increased from 2011 to 2015, although use significantly declined from 2015 to 2016. The 2017 rate of use among 12th graders holds relatively steady.

Past Year Anabolic Steroid Use Among Middle and High School Students, 2007-2017

Anabolic steroids increase lean muscle mass when used in conjunction with weight training. The aim, for non-athlete weightlifters, is typically improvement of appearance. As mentioned in “Who uses anabolic steroids?” steroid use is often associated with a form of male body dysmorphic disorder called muscle dysmorphia, a preoccupation with the perceived inadequate size of their muscles.

As a result, some users report taking anabolic steroids to increase confidence and because they feel that they are at a point where they can no longer get bigger through weight training alone. Most users report that anabolic steroids help them achieve their ideal body.

Increasing muscle mass may also promote strength, which can improve performance in certain types of sports. More benefit is seen for strength-dependent sports (weightlifting, shot-put throwing, football) than for sports that require speed, agility, flexibility, and/or endurance.

Anabolic steroid users also report that their muscles recover faster from intense strain and muscle injury. Research in animals has not conclusively supported this belief, with some showing that anabolic steroids can enhance recovery from certain types of muscle damage, but others finding no benefit in taking anabolic steroids to enhance muscle recovery.

Anabolic steroid users report using an average of about 11 APEDs per year. They are also more likely than non-steroid users to take supplements such as protein powders and creatine; estrogen blockers; ergo/thermogenics, such as caffeine or ephedrine; medications for erectile dysfunction; and other hormones such as insulin, thyroid hormones, and human growth hormone.

Some anabolic steroids are taken orally, others are injected intramuscularly, and still others are provided in gels or creams that are applied to the skin. Many users start with the oral form and then progress to injectable forms, since the latter causes less liver damage. However, oral steroids clear more rapidly from the body, often making this the preferred route for users concerned with drug testing. Doses taken by people misusing these substances can be 10 to 100 times higher than the doses used to treat medical conditions.

Commonly Misused Steroids

Oral Steroids

• Anadrol (oxymetholone)
• Anavar (oxandrolone)
• Dianabol (methandienone )
• Winstrol (stanozolol)
• Restandol (testosterone undecanoate)

Injectable Steroids

• Deca-Durabolin (nandrolone decanoate)
• Durabolin (nandrolone phenpropionate)
• Depo-Testosterone (testosterone cypionate)
• Agovirin (testosterone propionate)
• Retandrol (testosterone phenylpropionate)
• Equipoise (boldenone undecylenate)

Cycling, stacking, pyramiding, and plateauing

Steroids are often used in patterns called "cycling." This involves taking multiple doses of steroids over a specific period of time, stopping for a period, and starting again. People who misuse steroids also typically "stack" the drugs, meaning that they take two or more different anabolic steroids, mix oral and/or injectable types, and sometimes even take compounds that are designed for veterinary use. The belief is that different steroids interact to produce an effect on muscle size that is greater than the effects of each drug individually, a theory that has not been tested scientifically.

Another common mode of steroid misuse is referred to as "pyramiding," which typically involves taking them in a cycle of six to 12 weeks, tapering gradually rather than starting and finishing a cycle abruptly. At the beginning of a cycle, the person starts with low doses of the drugs being stacked and then slowly increases the doses. In the second half of the cycle, the doses are slowly decreased to zero. This is sometimes followed by a second cycle in which the person continues to train but without drugs. Steroid users believe that pyramiding allows the body time to adjust to the high doses, and the drug-free cycle allows the body's hormonal system time to recuperate.

A technique called "plateauing" may also be used, whereby steroids are staggered, overlapped, or substituted with another type of steroid to avoid developing tolerance. As with stacking, the effects of pyramiding, cycling, and plateauing have not been substantiated scientifically.

A variety of side effects can occur when anabolic steroids are misused, ranging from mild effects to ones that are harmful or even life-threatening. Most are reversible if the user stops taking the drugs. However, others may be permanent or semi-permanent.

Most data on the long-term effects of anabolic steroids in humans come from case reports rather than formal epidemiological studies. Serious and life-threatening adverse effects may be underreported, especially since they may occur many years later. One review found 19 deaths in published case reports related to anabolic steroid use between 1990 and 2012; however, many steroid users also used other drugs, making it difficult to show that the anabolic steroid use caused these deaths. One animal study found that exposing male mice for one fifth of their lifespan to steroid doses comparable to those taken by human athletes caused a high frequency of early deaths.

Possible Health Consequences of Anabolic Steroid Misuse

Cardiovascular System

Steroid use has been associated with high blood pressure; decreased function of the heart’s ventricles; and cardiovascular diseases such as heart attacks, artery damage, and strokes, even in athletes younger than 30. Steroids contribute to the development of cardiovascular disease partly by increasing the level of low-density lipoprotein (LDL) and decreasing the level of high-density lipoprotein (HDL). High LDL and low HDL levels increase the risk of atherosclerosis, a condition in which fatty substances are deposited inside arteries and disrupt blood flow. If blood is prevented from reaching the heart or brain, the result can be a heart attack or stroke, respectively. Steroids also increase the risk that blood clots will form in blood vessels, potentially disrupting blood flow and damaging the heart muscle, so that it does not pump blood effectively.

Hormonal System

Steroid use disrupts the normal production of hormones in the body. Changes that can be reversed include decreased sperm production, decreased function of the testes (hypogonadism) that leads to low testosterone levels, and shrinking of the testicles (testicular atrophy). Irreversible changes include male-pattern baldness and breast development (gynecomastia) in men. Anabolic steroids may also act upon the hormone system to increase the risk of testicular cancer, especially when steroids are used in combination with insulin-like growth factor.

In females, anabolic steroids cause masculinization. Specifically, breast size and body fat decrease, the skin becomes coarse, and the voice deepens. Women may experience excessive growth of body hair but lose scalp hair. With continued administration of steroids, some of these effects become irreversible. It is commonly believed that anabolic steroids will produce irreversible enlargement of the clitoris in females, although there are no studies on this.

Infections

Many people who inject anabolic steroids may use nonsterile injection techniques or share contaminated needles with other users. This puts these steroid users at risk for acquiring life threatening viral infections, such as HIV and hepatitis B and C. In addition, animal models indicate that anabolic steroids suppress the immune system, which could worsen infections.

Liver

Steroid misuse has been associated with liver damage, tumors, and a rare condition called peliosis hepatis, in which blood-filled cysts form in the liver. The cysts can rupture, causing internal bleeding and even death in rare cases.

Musculoskeletal System

Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during puberty and adolescence. These rising levels of testosterone also provide the signals to stop growth. When a child or adolescent takes anabolic steroids, the resulting artificially high sex hormone levels can prematurely signal the bones to stop growing.

Evidence suggests that weightlifters who misuse anabolic steroids have stiffer tendons, which could lead to an increased risk for tendon injury.

Skin

Steroid misuse can cause acne, hair loss on the head, cysts, and oily hair and skin. Users who inject steroids may also develop pain and abscess formation at injection sites.

Anabolic steroids can also produce jaundice, or yellowing of the skin or eyes, as a result of damage to the liver.

Aggression

Case reports and small studies indicate that anabolic steroids increase irritability and aggression, although findings may be confounded by personality traits that are overrepresented in steroid users (i.e., antisocial, borderline, and histrionic personality disorder) and use of other drugs. People who misuse anabolic steroids report more anger than nonusers, as well as more fights, verbal aggression, and violence toward their significant others, sometimes called "roid rage." One study suggests that the mood and behavioral effects seen during anabolic-androgenic steroid misuse may result from secondary hormonal changes.

Scientists have attempted to test the association between anabolic steroids and aggression by administering high steroid doses or placebo for days or weeks to human volunteers and then assessing behavioral symptoms. In one such study, researchers found that testosterone over a six week period was associated with increased aggression, as assessed by a questionnaire and computer-based model of aggressive behavior. In addition, high steroid doses produced greater feelings of irritability and aggression than placebo, although the effects appear to be highly variable across individuals, and other studies have not shown that effect. One possible explanation, according to the researchers, is that some but not all anabolic steroids increase irritability and aggression.

Psychiatric Disorders

Anabolic steroid users are more likely than nonusers to report anxiety. Moderate to high doses of anabolic steroids are also associated with major mood disorders such as mania, hypomania, and major depression. In one study, manic symptoms were not uniform across individuals, with most showing little psychological change, whereas a few demonstrated prominent effects.

Other Drug Use

Anabolic steroid users are more likely to use drugs such as marijuana, prescription opioids, cocaine, or heroin. In a study of men admitted to treatment for opioid use disorders, 25 percent reported prior use of anabolic steroids. Some described first learning about opioids from friends at the gym, and that they first purchased opioids from the same person who had sold them the anabolic steroids. In a study of anabolic steroid users dependent upon the injectable opioid analgesic nalbuphine, most reported that they began using nalbuphine to treat pain from weightlifting injuries. They also described widespread use of nalbuphine in their gyms.

Research also indicates that some users might turn to other drugs to alleviate some of the negative effects of anabolic steroids. For example, a study of 227 men admitted in 1999 to a private treatment center for addiction to heroin or other opioids found that 9.3 percent had previously misused anabolic steroids. Of these, most reported using opioids to counteract insomnia, irritability, depression, and withdrawal from anabolic steroids.

Unlike most illicit drug use, misuse of anabolic steroids most commonly begins in young adulthood rather than adolescence. But steroid use in teens is of concern, especially since the hormonal systems they interact with play a critical role in brain development during these years. In adolescent rodents, exposure to anabolic steroids increased neuronal spine densities in the hippocampus and amygdala—brain regions involved in learning and emotions (e.g., aggression), respectively. Four weeks after withdrawal, these increases in neuronal spine densities returned to normal in the amygdala, but not in the hippocampus. This suggests that pubertal steroid exposure could produce long-lasting structural changes in certain brain regions.

Teens who use anabolic steroids may also be at increased risk for some cognitive side effects compared with adults. For example, males who begin using anabolic steroids during the teen years show increased impulsivity and decreased attention, compared to men who began using steroids in their adult years. In adolescent rats, anabolic steroid exposure is associated with electrolytic imbalances, hyperactivity, anxiety, and increased sympathetic autonomic modulation (e.g., fight or flight response) during adulthood, even when steroid use was discontinued during adolescence. In addition, adolescent male hamsters given anabolic steroids show increased aggression, even after steroid use is discontinued. These aggressive effects are paralleled by changes in levels of serotonin and androgen receptors in the rodent brain.

Anabolic steroids act at androgen receptors to influence cellular functioning and gene expression. In addition to regulating pathways involved in the development of male characteristics, activation of androgen receptors also produces rapid increases in calcium levels within skeletal muscle, heart, and brain cells. Calcium plays important roles in neuronal signaling.

Research with human cells demonstrates that anabolic steroids also interact with certain types of GABAA receptors, which could mediate the increased anxiety reported by steroid users. In addition, animal studies show that anabolic steroids increase serotonin levels in brain regions involved in mood and dopamine levels in reward-related brain regions. Chronic use of anabolic steroids has also been shown to cause dysfunction of these reward pathways in animals. Specifically, rats given twice daily nandrolone injections for four weeks showed loss of sweet preference (a sign of reward dysfunction) that was accompanied by reductions of dopamine, serotonin, and noradrenaline in the nucleus accumbens, a reward-related brain region.

An undetermined percentage of steroid users may develop a steroid use disorder. Substance use disorders are defined by continued use despite adverse consequences; for steroid users, these may include physical or psychological problems such as breast growth (in men), sexual dysfunction, high blood pressure, excessive fats in the blood, heart disease, mood swings, severe irritability, or aggressiveness. Anabolic steroid users also may give up other important activities for fear that they will miss workouts, violate their dietary restrictions, or be prevented from using steroids. Steroid users also typically spend large amounts of time and money obtaining the drugs, and they may try to reduce or stop anabolic steroid use without success—possibly due to depression, anxiety about losing muscle mass, or and other unpleasant effects of withdrawal.

Withdrawal from steroids occurs when an individual develops dependence. A review of the research suggests that about 32 percent of people who misuse anabolic steroids become dependent. Symptoms of dependence can include tolerance, which is needing to take more steroids to achieve the same effects. Another indicator of dependence is withdrawal once anabolic steroid use stops. Withdrawal symptoms can include fatigue, restlessness, loss of appetite, insomnia, reduced sex drive, and steroid cravings. The most dangerous of the withdrawal symptoms is depression, because it sometimes leads to suicide attempts.

Although non-athlete weightlifters account for the bulk of anabolic steroid misuse, occasional steroid use by professional and Olympic athletes to improve performance or cheat in competition ("doping") has done the most to raise awareness of steroid misuse. The World Anti-Doping Agency (WADA) was founded in 1999 to consistently apply anti-doping policies across sports organizations and governments around the world. Non-compliant organizations can face sanctions such as event cancellation, loss of WADA funding, or ineligibility to host events.

Refinements in drug testing have improved the ability to detect anti-doping violations, resulting in increased numbers of reported violations over recent years. For example, the discovery of long-term steroid metabolites has lengthened the drug detection window, making it more difficult for athletes to pass drug tests by simply discontinuing steroid use just prior to an event. In addition, more sensitive technologies have allowed detection of lower metabolite thresholds.

Although testing procedures are now in place to deter steroid use among professional and Olympic athletes, new designer drugs constantly become available that can escape detection and put athletes willing to cheat one step ahead of testing efforts. To detect early use of designer steroids and provide more accurate baseline standards for each athlete, testing laboratories store data from each drug testing sample. These samples are then used as reference points for future testing, thereby eliminating the possibility that a person tests positive simply because he or she has naturally elevated levels of testosterone when compared to the general population. Long-term use of designer steroids suppresses levels endogenous steroids in urine samples, which could be the first indication that an athlete is taking a designer steroid.

Drug Testing and Nutritional Supplements

Athletes taking over-the-counter nutritional supplements may believe that such products are safe. However, nutritional supplements are not subjected to the same pre-approval requirements and quality tests as FDA-approved medications. For example, some supplements advertised to promote weight loss have been found to contain banned stimulants such as ephedrine or clenbuterol. Other research shows that supplements sometimes contain prohormones or anabolic steroids. In a study looking at 634 nutritional supplements from 13 different countries, 15 percent included some type of prohormone not listed on the label. Another study showed that some non-labeled prohibited substances could be detected by drug tests up to 144 hours later.

Nutritional supplements sometimes contain banned substances that are not indicated in their labels. The FDA notes that consumers should be wary if a product meets any of these criteria:

• products claiming to be alternatives to FDA-approved drugs or to have effects similar to prescription drugs
• products claiming to be a legal alternative to anabolic steroids
• products that are marketed primarily in a foreign language or those that are marketed through mass e-mails
• sexual enhancement products promising rapid effects such as working in minutes to hours, or long-lasting effects such as 24 hours to 72 hours
• products that provide warnings about testing positive in performance enhancement drug tests

According to WADA’s codes, athletes are responsible for any prohibited substance found in their samples, regardless of whether ingestion was intentional or unintentional. However, sanctions may be reduced or avoided if the athlete can demonstrate that the substance was ingested through no significant fault or negligence on his/her part, or in some circumstances where the athlete did not intend to enhance performance.

Research suggests that high school athletes are less likely to use steroids if their peers and parents disapprove, indicating that peers and parents can be strong partners in prevention efforts.

However, research shows that simply teaching students about steroids' adverse effects does not convince adolescents that they will be adversely affected, nor does such instruction discourage young people from taking steroids in the future. Presenting both the risks and benefits of anabolic steroid use is more effective in convincing adolescents about steroids' negative effects, apparently because the students find a balanced approach more credible.

Research also indicates that some adolescents misuse steroids as part of a pattern of high-risk behaviors such as drinking and driving, carrying a gun, driving a motorcycle without a helmet, and using other illicit drugs. This suggests that a prevention program should focus on comprehensive high-risk behavior screening and counseling among teens who use anabolic steroids.

NIDA-Funded Prevention Research Helps Reduce Steroid Misuse

A more sophisticated approach has shown promise for preventing steroid misuse among players on high school sports teams. The Adolescents Training and Learning to Avoid Steroids (ATLAS) program is showing high school football players that they do not need steroids to build powerful muscles and improve athletic performance. By educating student athletes about the harmful effects of anabolic steroids and providing nutrition and weight-training alternatives to steroid use, the ATLAS program has increased football players' healthy behaviors and reduced their intentions to misuse steroids. In the program, coaches and team leaders teach the harmful effects of anabolic steroids and other illicit drugs on immediate sports performance and discuss how to refuse offers of drugs.

Studies show that one year after completion of the program, compared with a control group, ATLAS-trained football student athletes in 15 high schools had:

• less use of anabolic steroids and less intention to misuse them in the future
• less misuse of alcohol, amphetamines, and narcotics
• less misuse of "athletic enhancing" supplements
• less likelihood of engaging in hazardous behaviors such as drinking and driving
• better knowledge about anabolic steroid, alcohol, and marijuana effects; better knowledge of alternatives to steroid misuse; greater confidence in athletic abilities; and improved nutritional behaviors

People who use steroids often do not seek treatment for their use, with one study reporting that 56 percent of users had never told their physician about their use. This could be because users feel their physician lacks knowledge about anabolic steroids. In addition, many internet sites devoted to anabolic steroids and other APEDs challenge the professionalism of health care providers and offer their own medically questionable advice on the use of APEDs. This makes it important for health care providers to be educated on the signs and symptoms of steroid use in their patients.

Current views recommend that treatment for steroid use address the underlying causes of the steroid use. This can include:

• psychological therapies (and possibly medications) for muscle dysmorphia
• endocrine therapies to restore function in those suffering from hypogonadism and to alleviate symptoms of depression
• antidepressants for those whose depression does not respond to endocrine therapies
• pharmacological and psychosocial treatments for patients who are also dependent on opioids, which appear to also be effective in alleviating signs of anabolic steroid dependence