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U.S. Anti-Doping Agency (USADA)

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Use of Performance-Enhancing Drugs More Prevalent than Type 1 Diabetes or HIV Infection

Spirit of Sport – July 2014
A Scientific Statement published by the Endocrine Society highlights the prevalence of performance-enhancing drug use and the associated public health risks.

As a member of the Endocrine Society’s Scientific Task Force (SSTF), USADA’s Chief Science Officer, Dr. Larry Bowers, was an author of the scientific statement, “Adverse Health Consequences of Performance-Enhancing Drugs,” published in the Endocrine Society journal, Endocrine Reviews. The SSTF compiled a multitude of research and documentation on a variety of performanceenhancing drugs (PEDs) and the associated health effects, with a focus on anabolic-androgenic steroids (AAS). Most notably, the statement asserted that:

With at least three million PED users in the U.S. alone, PED use ranks ahead of type 1 diabetes and HIV infection in prevalence, and yet the resources allocated to address PED use as a public health problem are negligible in comparison to these diseases.

According to the statement, “Neither the medical community nor policymakers appreciate that most PED users are not competitive athletes, but rather non-athlete weightlifters.” This widespread misconception that PED use is limited to the elite athlete population has distracted attention from the public health issue created by PED use.

Another widespread misperception noted in the statement is the belief that PEDs are safe or associated with manageable adverse effects, which has contributed to the growing use of PEDs, especially among non-athletes. The unregulated sale of dietary supplements on the Internet has also greatly increased the illicit use of AAS, as more and more products are manufactured and advertised to this market.

The statement points out that the adverse health effects of PED use remain “understudied and underappreciated,” as the resources to study PEDs primarily are used on detection and deterrence.

One reason is because widespread illicit use of PEDs did not appear until the 1980’s and 1990’s, meaning the majority of users are still under the age of 50 and the full scope of the long-term effects of PED use have yet to surface. Additionally, all current medical evidence of health consequences has emerged from case-control studies, case reports, and retrospective surveys, as randomized trials in the dosages that users tend to take are not possible due to ethical concerns. Yet even with these limited resources, many adverse health effects of PED use were expounded upon within the SSTF’s statement.

PED use has been linked to an increased risk of death as well as a wide variety of cardiovascular, psychiatric, metabolic, endocrine, neurologic, infectious, hepatic, renal, and musculoskeletal disorders. Users of high doses of AAS may be more susceptible to rage, antisocial and violent behaviors, and suicidality.

Of all AAS users, the statement indicates that 30% may develop AAS dependence. These longterm users might develop potentially irreversible cognitive deficits and some may never regain normal testosterone levels. If these long-term high dosage AAS users attempt to stop using, they will likely experience depressive symptoms during withdrawal.

The statement highlighted two areas of concern which require more research. One concern is PED users combining AAS with other drugs, including opiates and non-steroidal anti-inflammatory drugs. These “PED cocktails” allow athletes to engage in extremely intense training exercises in the face of a previous injury, thus greatly increasing the risk for further muscle and joint injury.

The second concern is the possible interaction of AAS with central nervous system (CNS) injuries, especially in those with repeated mild head trauma, usually found in soldiers and football players. The armed forces do not test for AAS, and while football players may be tested for AAS, there is a lack of comparable data on concussive injuries.

This mounting evidence of adverse effects related to PED use provides “a strong justification for the need to improve methods for detecting illicit PED use and eliminating abuse by both athletes and non-athletes.” This statement emphasizes that PED use is a “serious public health problem.”

Randomized trials of PEDs are not possible due to ethical concerns, and most controlled lab studies test AAS doses that are much lower than the supra-physiologic doses often used by illicit users. Due to this, the statement recommends a variety of observational studies and registries to determine the prevalence of PED use in non-athletes and the long-term health effects. Therapeutic trials to treat AAS withdrawals are advised as well, as there is proof that some adverse cardiovascular effects may be at least partially reversible following AAS abstinence. Finally, the statement suggests developing innovative approaches to enhance public awareness of the serious health consequences of PED use.

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