From Medicine & Science in Sports & Exercise?
Anabolic Androgenic Steroids: A Survey of 500 Users
Andrew B. Parkinson; Nick A. Evans
Abstract and Introduction
Purpose: The use of anabolic androgenic steroids (AAS) to increase muscle size and strength is widespread. Information regarding self-administered AAS used nonmedically to enhance athletic performance or improve physical appearance is sparse and poorly documented. The purpose of this study is to identify current trends in the drug-taking habits of AAS users.
Methods: An anonymous self-administered questionnaire was posted on the message boards of Internet Web sites popular among AAS users.
Results: Of the 500 AAS users who participated in the survey, 78.4% (392/500) were noncompetitive bodybuilders and nonathletes; 59.6% (298/500) of the respondents reported using at least 1000 mg of testosterone or its equivalent per week. The majority (99.2%) of AAS users (496/500) self-administer injectable AAS formulations, and up to 13% (65/500) report unsafe injection practices such as reusing needles, sharing needles, and sharing multidose vials. In addition to using AAS, 25% of users admitted to the adjuvant use of growth hormone and insulin for anabolic effect, and 99.2% (496/500) of users reported subjective side effects from AAS use.
Conclusions: This survey reveals several trends in the nonmedical use of AAS. Nearly four out of five AAS users are nonathletes who take these drugs for cosmetic reasons. AAS users in this sample are taking larger doses than previously recorded, with more than half of the respondents using a weekly AAS dose in excess of 1000 mg. The majority of steroid users self-administer AAS by intramuscular injection, and approximately 1 in 10 users report hazardous injection techniques. Polypharmacy is practiced by more than 95% of AAS users, with one in four users taking growth hormone and insulin. Nearly 100% of AAS users reported subjective side effects.
Anabolic androgenic steroids (AAS) are synthetic derivatives of testosterone. According to surveys and media reports, the illegal use of these drugs to increase muscle size and strength is widespread. In 1991, data from the National Household Survey on Drug Abuse indicated that there were more than one million AAS users in the United States and that the lifetime use was 0.9% for males and 0.1% for females. Despite the fact that AAS were added to the list of Schedule III Controlled Substances in 1990, recent data suggest that AAS use has increased. Current estimates indicate that there are as many as three million AAS users in the United States and that 2.7-2.9% of young American adults have taken AAS at least once in their lives. Surveys in the field indicate that AAS use among community weight trainers attending gyms and health clubs is 15-30%[5,16,22] and that the majority of AAS users are noncompetitive recreational bodybuilders or nonathletes, who use these drugs for cosmetic purposes rather than to enhance sports performance.
There is a growing body of evidence that AAS have positive anabolic actions on the musculoskeletal system, influencing lean body mass, muscle size, strength, protein metabolism, bone metabolism, and collagen synthesis.[3,4,8,11,21,26,27] Skeletal muscle is a primary target tissue for the anabolic effects of AAS. Supraphysiological doses of testosterone administered to healthy young men over periods lasting 10-20 wk increase lean body mass, muscle size, and strength, with or without exercise.[3,4,27] The anabolic effect of testosterone is dose dependent, and significant increases in muscle size and strength only occur with doses of 300 mg?wk-1 and higher.[4,27] Such supraphysiological doses elevate mean serum testosterone concentrations above normal values to over 1000 ng?dL-1.
The testosterone-induced increase in muscle size and strength is due to a dose-dependent hypertrophy that results from an increase in cross-sectional area of muscle fibers and an increase in myonuclear number. Evidence suggests that these morphometric effects are the result of a testosterone-induced increase in muscle protein synthesis.[11,26,28] AAS also enhance collagen synthesis (21) and increase bone mineral density. The anabolic effect of AAS is mediated primarily by androgen receptors in skeletal muscle. The androgen receptor regulates the transcription of target genes that may control the accumulation of DNA required for muscle growth. It has also been suggested that AAS exert several complementary anabolic actions, including a psychoactive effect on the brain, glucocorticoid antagonism, and stimulation of the growth hormone (GH)-insulin-like growth factor-1 (IGF-1) axis.
In the United States, AAS are classed as Schedule III Controlled Substances, and possession of these drugs without a prescription is illegal. Many sporting organizations have banned the use of these performance-enhancing drugs. Fearing legal consequences or a sporting ban, AAS users rarely disclose their drug-taking habits. As a result, information on the self-administered AAS used nonmedically to enhance athletic performance or improve physical appearance is relatively sparse. Several observational studies have surveyed the unsupervised drug habits of AAS users in "natural" settings.[5,9,23,24] This kind of study is subject to selection bias because AAS users are recruited on a voluntary basis, and information bias may arise when the participants recall their experience. Nevertheless, field studies of AAS users are a valid source of information regarding self-administered AAS regimens. Consistencies and similarities between several published surveys support and validate the results.
Recently, the Internet has become a valuable tool for researchers desiring to gain an in-depth understanding of particular individuals or groups. Previous studies have documented the validity of Web-based surveys by comparing them with identical studies in the real world, suggesting that the validity and reliability of data obtained online are comparable to those with classic methods.[6,7] With these factors in mind, we developed a Web-based survey to gain in-depth insight into the dosing patterns, regimens, demographics, accessory drug use, and side effects common among AAS users. Inherent in this type of study is a selection bias due to the nonrepresentative nature of the Internet as well as through self-selection of participants. However, given the goals of our study, this was not a confounding variable.
The purpose of this study is to identify current trends in the drug-taking habits of AAS users and to improve our understanding of this widespread phenomenon. Our hypothesis was that despite the risk of side effects, drug doses are increasing and the use of adjuvant anabolic agents like GH or insulin is gaining popularity.