Summary
Objectives: To consolidate scientific data on adolescent hormone abuse, particularly anabolic steroids, including prevalence and behavioral correlates of use, performance-enhancing effects, adverse effects, and interventions that have been used in an attempt to reduce hormone abuse. Recent data relevant to the use of dietary supplements that possess intrinsic androgenic/anabolic activity or that serve as precursors to more potent anabolic steroids or their active metabolites also are reviewed. Barriers and challenges to the design and implementation of an effective nationwide intervention strategy also are discussed.
Methods: Literature searches were conducted in the MEDLINE and Nexis databases for English-language articles published between 1975 and February 2003 using the search terms adolescent/adolescence or student or athlete in combination with anabolic, steroid, dietary supplements, erythropoietin, or growth hormone, and prevalence, epidemiology, adverse effects, doping in sports or substance abuse detection. A total of 1163 citations were identified and 503 were retrieved for analysis. Additional references were culled from the bibliographies of these references.
Results: Survey data indicate that middle and high school students have been using anabolic steroids since the mid-1970s. National surveys conducted since 1991 indicate that use is increasing in high school students, particularly among females, among whom it may be considered a subset of disordered eating habits and physique-altering drug abuse. Use is highest among athletes and clusters with the abuse of other drugs. Short-term use of low to moderate doses of compounds classified as anabolic steroids increase muscle strength in previously trained athletes; studies analyzing higher dose regimens typically used for performance enhancement have not been conducted. The anabolic steroid precursors androstenedione and dehydroepiandrosterone (DHEA) have not been demonstrated to significantly increase serum testosterone in males or to improve strength; many other precursors are available that have not been adequately evaluated in the peer-reviewed literature. Androstenedione does significantly increase serum testosterone concentrations in women. Erythropoietin clearly enhances aerobic performance; data are lacking on the effect of human growth hormone on strength or performance in normal adolescents or athletes.
Conclusions: Illicit anabolic steroid use is on the rise in adolescents, and effective interventions are needed. Drug testing is legal, but too expensive for widespread application. Structured, gender-specific, multidimensional educational interventions used in the athletic team setting have been effective in reducing anabolic steroid use and improving decision-making. A successful nationwide approach will require focused educational efforts tailored to the school community in conjunction with further research on key variables, and possibly requiring legislative and/or regulatory approaches to limit availability of anabolic steroid precursors that are currently freely available over the counter as dietary supplements.
RECOMMENDATIONS
The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA directives and policy at the 2003 AMA Annual Meeting:
- The AMA will collaborate with the Hormone Foundation, the United States Anti-Doping Agency, the National Institute on Drug Abuse, interested medical specialty societies, and other relevant stakeholders on a nationwide campaign designed to reduce the prevalence of adolescent hormone abuse and to foster the development of healthy behaviors and fair competition. (Directive)
- The AMA supports legislation designed to reclassify anabolic steroid precursors that are currently protected by the Dietary Supplement and Health Education Act as prescription drugs subject to the Controlled Substances Act. (Directive)
- AMA Policy H-470.972 (AMA Policy Database), Medical and Nonmedical Uses of Anabolic-Androgenic Steroids, is amended as follows: The AMA (1) reaffirms its concern over the nonmedical use of drugs among athletes, its belief that drug use to enhance or sustain athletic performance is inappropriate, its commitment to cooperate with various other concerned organizations, and its support of appropriate education and rehabilitation programs; (2) reaffirms its support of increased criminal penalties enacted as a part of the Anti-Drug Abuse Act of 1988 and its support of state legislation that addresses the problem of misprescribing; (3) reaffirms its willingness to work closely with sports groups, coaches, team owners, amateur and professional athletes, and parents; (4) continues to endorse the public and professional education campaign of the FDA; (5) supports making available to practicing physicians, legislators, sports organizations, educators, adolescents, and the public existing and proposed educational materials and model state legislation on the nonmedical use of anabolic steroids; (6) supports identifying and widely disseminating information on successful initiatives and activities to curtail the problem of nonmedical use; (7) encourages survey efforts that provide a better understanding of the nature and prevalence of nonmedical use; (8) actively encourages further research on short- and long-term health effects, and encourages reporting of suspected adverse effects to the FDA; and (9) supports continued efforts to work with sports organizations to increase understanding of health effects and to discourage use of steroids on this basis. (Policy)
- The AMA will continue to monitor trends in adolescent hormone abuse including the apparent use of growth hormone, recombinant human erythropoietin, and its analogues. (Directive)
- The AMA will renew its effort to revise the Dietary Supplement and Health Education Act. (Directive)
The CSA wishes to acknowledge the contributions as authors for this report of individuals from the following institutions.
- Division of Health Promotion and Sports Medicine (ATHENA Program)
Oregon Health Sciences University - University of Virginia, Charlottesville
- Medical College of Virginia
- Maine Medical Center
- M.M.C Research Institute
NOTE: A revised version of this report has been published. Dickinson B, Goldberg L, Elliot D, Spratt D, Rogol AD, Fish LH. Hormone abuse in adolescents and adults. a review of current knowledge. Endocrinologist. 2005;15-115-125. (April)
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