Anabolic Androgenic Steroids: A Survey of 500 Users

Andrew B. Parkinson; Nick A. Evans


Med Sci Sports Exerc. 2006;38(4):644-651. 

In This Article


This study profiles a sample of 500 AAS users and represents the largest and most in-depth survey of this kind to date. Whereas the results presented here lend support to previous surveys, there are some striking differences suggesting a worrying trend that current AAS users are taking greater health risks than observed a decade ago.

AAS use is not a practice unique to elite athletes seeking to enhance performance. Four out of five steroid users (78.4%) in this study were noncompetitive athletes, recreational bodybuilders, and nonathletes who self-administered AAS for cosmetic reasons with the sole intention of improving physical appearance. Nearly 60% of steroid users in this sample were younger than 30 yr of age, and approximately one in four steroid users stated that they began using AAS during their teenage years. These findings suggest that body image presents a significant concern in young males who resort to AAS use as a means of enhancing physical appearance. Over 40% of this sample admitted to habitual steroid use for longer than 4 yr, and 10% report chronic AAS use lasting = 10 yr.

As might be expected with self-administered drug use, steroid doses reported in this survey varied widely, ranging from 70 to 6000 mg·wk-1 of testosterone or its equivalent. Remarkably, nearly 60% of steroid users this sample reported using a dose of at least 1000 mg·wk-1. Comparing current data with that from previous studies indicates that self-administered AAS doses may have increased during the past decade. The majority of AAS users in a survey published in 1997 (9) reported a weekly dose = 500 mg, whereas in the current sample, the majority of users take at least 1000 mg·wk-1. Although historical controls make comparisons difficult, there may be a trend among AAS users toward increasing doses that greatly exceed the recommended therapeutic doses used for testosterone replacement therapy.[1]

Of AAS users in the current sample, 95% reported combining two or more different formulations of AAS simultaneously, a practice known as steroid "stacking," in order to meet the large supraphysiological doses that are required to elicit a significant anabolic response in skeletal muscle. Recent scientific studies support AAS users' theory that "the bigger the dose, the bigger the muscle".[8] The anabolic effect of testosterone is dose dependent, and androgen receptors can be upregulated by exposure to exogenous AAS.[4,15,26] Nearly 100% of those surveyed reported using injectable formulations to facilitate their suprapharmacological dose regimens. Typical drug combinations reported by steroid users this sample are shown in Table 10 .

Nine out of 10 steroid users reported self-administering AAS in "drug cycles," typically using steroids for periods of 4-20 wk. The time interval between steroid cycles, or "off-cycle," is more variable. Whereas regular users take a 4- to 6-wk drug holiday to "clear the system," less frequent users may remain drug-free for several months. One half of steroid users this sample reported using the drugs for 6 months or more per year. Only a small proportion (6%) of steroid users admitted to a continuous drug use for 52 wk of the year.

Nearly 100% (496/500) of this sample reported subjective side effects with AAS use. Seventy percent experienced three or more adverse symptoms. The most common subjective side effects were acne, testicular shrinkage, insomnia, sexual dysfunction, injection site pain, striae, fluid retention, mood alterations, and gynecomastia. Five of the nine most common side effects reported were experienced by more than 50% of survey participants, with acne and testicular atrophy being reported in nearly two thirds of users. Although it is not possible to confirm or evaluate subjective AAS-induced side effects reported during a self-administered survey, it is evident that these complications were bothersome enough to be recognized by users. None of the participants admitted to suffering any serious complications as result of AAS use. Because the majority of steroid users admitted to polypharmacy, with more than 50% of users simultaneously taking several AAS formulations and up to five other accessory drugs, it may be difficult to pinpoint an individual medication as the direct cause of adverse symptoms.

In previous surveys,[5,9] 88 and 96.4% of steroid users reported subjective side effects, and data suggest that the prevalence of side effects increases with increasing doses and number of AAS taken concurrently.[5] AAS-induced adverse effects do not deter users from taking increasingly larger doses of AAS. Rather than reducing AAS use, a common practice is to self-administer additional medications to alleviate or prevent AAS-induced side effects.

Furthermore, these AAS users often begin in their teen years and continue on a habitual path of use for many years. Chronic AAS users have been shown to have a mortality rate 4.6 times higher than non-AAS users.[20] The data from this study suggest that AAS users are not only using higher doses than previously documented, but are also staying on the drugs for longer periods of time, increasing their risk of potentially severe health complications in the long term.

Close to 100% of steroid users surveyed admitted to self-administering AAS by intramuscular injection, and one half of this sample reported experiencing injection site pain. Several factors may contribute to injection-related complications, including a lack of training in sterile injection technique, the use of poor quality bootleg and veterinary products, and the frequent large-volume injections needed to sustain a megadose drug regimen. Of the steroid users surveyed, approximately 1 in 10 reported hazardous injection practices: 13% reported reusing needles, 8.2% admitted to sharing multidose vials, and 1% reported sharing needles with another steroid user. These unsafe injection practices may be explained by a lack of available injection equipment and a lack of education in sterile injection techniques.

The majority (89%) of steroid users surveyed reported obtaining drugs from illegal sources; only 11% obtained AAS legally with a physician's prescription. Although some illegally acquired drugs may be from legitimate pharmaceutical manufacturers, there is a growing bootleg industry supplying drugs of questionable quality, content, and sterility. Seventy percent of steroid users purchased drugs via the Internet, and more than 50% reported the use of bootleg AAS manufactured in illicit laboratories. More than one third of users (37.4%) had obtained drugs manufactured in Mexico, where most AAS are produced by veterinary pharmacies.

Foreign-made, veterinary, and bootleg drugs may be of inferior quality and dubious sterility, thereby increasing the potential for injection-related and other health complications. Furthermore, unregulated bootleg drugs may be subject to mislabeling, and such products may not contain the drug concentration listed on the label. The growing reliance on potentially mislabeled bootleg drugs may partly explain why the self-administered AAS doses in this survey are higher than those reported previously.

Drug use by AAS users is not limited to anabolic steroids. More than 95% of AAS users admit to taking a mix of muscle-shaping drugs and accessory medications ( Table 7 ) in addition to "stacking" different types of steroids. Accessory drugs are used for a variety of reasons, such as adjuvant anabolic effects, stimulants, fat loss, and medications to combat the side effects of AAS.

Compared with previous surveys, the proportion of AAS users taking GH and insulin as adjuvant anabolic agents has increased. In a 1997 survey, 12% of steroid users reported using GH, and 2% had used insulin.[9] A striking observation from the current study is that 25% of the steroid users admit to the unsupervised use of both GH and insulin. The anabolic effects of GH on target tissues are not direct, but are the result of increased production of IGF-1 in the liver and peripheral tissues.[25] Nearly 10% of AAS users surveyed report using recombinant injectable IGF-1 preparations in their anabolic arsenal. The prevalence of IGF-1 use has not been previously documented among AAS users. In addition to the effects mediated by IGF-1, GH is a powerful stimulant of lipolysis in central and peripheral adipose cells.[12] Whereas the true effectiveness of GH as a potent anabolic substance remains in question, powerful nutrient-partitioning and fat-loss properties have been documented.[25] Long-term GH administration in normal individuals may lead to cardiac instability, hypertension, development of insulin resistance, and possibly type 2 diabetes.[25]

Unsupervised insulin regimens reported by AAS users in this study typically consisted of a fast-acting insulin (Humulin R, Humalog) formulation self-administered after a postworkout meal. Some users report using a glucometer to minimize their risk of unwanted hypoglycemic events. The anabolic effect of insulin is manifest by an artificially induced hyperinsulinemic state that increases amino acid transport into muscles inhibiting protein breakdown and stimulating overall bulk protein synthesis when in the presence of concomitant hyperaminoacidemia.[2]

The reported use of thermogenic stimulants like ephedrine, caffeine, and clenbuterol is similar to that found by a previous survey;[9] however, the use of thyroid medications to aid in fat loss has risen from 2% to more than 45%. The use of yohimbine and dinitrophenol (DNP) has not previously been documented in AAS users. Yohimbine is an α2-adrenergic receptor blocker that indirectly increases epinephrine and norepinephrine levels and functions as a fat-loss agent. DNP is a powerful uncoupling agent of oxidative metabolism that functions by inhibiting the oxidative production of adenosine triphosphate, causing a substantial increase in metabolic activity and heat production. This drastic increase in metabolic activity and heat production has led to hyperthermia and death with overdose of DNP.[18]

Accessory medications are also taken to alleviate AAS-induced side effects. Almost 100% of AAS users in our study complained of one or more side effects, and more than 95% reported taking medications to treat these effects. More than half of the participants noted taking clomiphene, antiaromatases, and tamoxifen, with nearly 40% using human chorionic gonadotropin (HCG). Clomiphene and HCG are commonly used to reverse the endogenous testosterone suppression experienced by users, in an effort to "kick start" natural hormone production at the end of a steroid cycle and reverse testicular atrophy. Tamoxifen and antiaromatase medications block or alleviate the symptoms of gynecomastia that result from the aromatization of testosterone to estrogen. Antiaromatases are also used to alleviate the inevitable fluid retention of heavy androgen use.

It is noteworthy that some of these "accessory" drugs are potentially much more dangerous than AAS. The unsupervised use of insulin, diuretics, stimulants, and thyroxine can precipitate a number of medical emergencies.[8] Little if any information exists with regards to the myriad of possible interactions and increased health risks of these polypharmaceutical practices. During the evaluation of a known or suspected steroid user, it is of paramount importance that the physician take a detailed drug history, keeping in mind the widespread use of these accessory medications.

Despite evidence that AAS users are taking increasing health risks with respect to drug megadoses, accessory medications, unsafe injection practices, and illicit drug sources, 6 out of 10 (61.4%) of steroid users surveyed indicated that they were concerned about the potential health ill effects of their AAS use. Although this may seem somewhat contradictory, it is supported by the observation that a similar proportion (64.4%) of steroid users undergo routine health checks and/or laboratory screenings. Only 37% of those surveyed, however, report discussing their AAS use with a physician. This barrier to communication between AAS users and their physicians may exist for several reasons, such as fear of legal consequences, the stigma of illegal drug use, and a perceived lack of physician knowledge regarding AAS. Nevertheless, more than 90% of steroid users surveyed noted that they would prefer to use AAS legally and under the supervision of a knowledgeable physician. It is possible that medically supervised AAS use could deter some of the emerging dangerous trends of unsupervised AAS use and possibly decrease the likelihood of preventable health complications.

There are some limitations to this self-selected, self-reported survey. Recruiting AAS users on a voluntary basis exposes this kind of study to selection bias, and information bias may arise when the participants recall their experience. Our findings cannot be generalized to all AAS users, and current data cannot easily be compared with previous studies or historical controls. However, AAS users present a difficult group to assess, and studies reporting the unsupervised drug habits of AAS users are relatively few. Despite the limitations, consistencies and similarities between this study and previously published surveys support and validate the results.


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