By: Susan E. Matthews

Original Source:

WEDNESDAY, Dec. 19, 2013 — When you think about performance enhancing drugs, professional athletes who have borne the brunt of very public takedowns likely come to mind, such as Lance Armstrong losing his many Tour de France titles or Alex Rodriguez sitting the bench for his discrepancies this fall. But while these men may steal the headlines, professional athletes are only a small percentage of the 3 million people affected by performance enhancing drugs, according to a scientific statement released by the Endocrine Society in Endocrine Reviews on Tuesday.

A committee of scientists from diverse backgrounds, led by Shalender Bhasin, MD, director of the research program in men’s health at Brigham and Women’s Hospital in Boston, reviewed the problems and challenges facing performance enhancing drug (PED) abuse in their statement, which urged doctors to start more research on the topic while raising public awareness. The most common PED is anabolic-androgenic steroids, though other human growth hormones, insulin, stimulants, and thyroid hormones are included in the category, the authors noted.

The statement estimates that more people abuse PEDs than have type 1 diabetes or HIV in the United States, but notes that the number of resources for preventing and treating the problem fall short.

“I continue to be amazed at how prevalent it is in the subculture of teenage athletes, as well as some of the body-building sports,” said Nicholas Fletcher, MD, assistant professor of orthopedic surgery at Emory University.

Athletes’ Problems Mask the Problem

While athletes may take PEDs over short-term periods to help bulk up or excel at a specific competition, average users tend to take them for extremely extended periods of time. In contrast, non-professional athletes tend to take them to look better, since the drugs help them add muscle while losing fat. In order to maintain this, however, they must be taken for longer, which raises the likelihood that they’ll become addicted; in fact, the researchers estimated that a full one third of the three million users are reliant on the drugs.

One of the largest misconceptions about performance enhancing drugs is that they’re banned in professional sports only because they’re unethical, not because they’re unsafe. To be clear, they’re unsafe, though more about that later.

“Users are assuming it’s different because they’re not using it for evil reasons,” said Loren Wissner Greene, MD, a clinical associate professor in the endocrinology division at New York University’s Langone Medical Center.

“[PED users] see these athletes as being very successful, and they assume part of it is due to steroids,” said Alan Rogol, MD, PhD, professor of pediatrics from the University of Virginia and co-author of the statement. While athletes are more likely to take them for shorter spurts rather than years, fans don’t wait to see the long-term consequences, Dr. Rogol said. “No one wants to know how an athlete is doing 20 years after he or she retires,” he said.

PEDs cause a long-term hormonal imbalance, the effects of which seem to be quite dangerous. Physically, it suppresses testosterone production and can lead to infertility. It also warps cholesterol levels, which can have serious implications for heart health, while simultaneously causing a hormonal imbalance.

The drugs are likely to have devastating consequences on emotional health, causing depression and risky behavior, as well as mood and psychiatric problems. Past research into the psychological effects has been quite troubling — Dr.  Bhasin cited a small study conducted in 2000 that tracked 34 steroid users. Of those individuals, 32 percent of users died from suicide, 26 percent from homicide, and 35 percent from accidents. Subsequent studies have also concluded that people who take PEDs have earlier mortality, the researchers noted.

“The issue is that over years, it does become a public health problem,” Rogol said.

How to Combat a Hidden Epidemic

The full extent of the medical ramifications of PEDs, however, is unknown because they are understudied. It’s unethical to conduct randomized control trials with the drugs because they are known to be harmful, the researchers said. What may be possible, however, are observational studies that rely on recruited people who already take the substances. Another reason the ramifications are still unclear is that the researchers concluded that widespread abuse of the drugs did not start until the 1980s and 1990s, meaning that very few people who have used them are over age 50, Bhasin said.

While there’s plenty of research and academic discussion about the ethical issues surrounded PEDs, less is known about the medical issues, Dr. Greene noted.

One of the biggest barriers to providing the appropriate medical attention to people suffering from performance enhancing drug addiction and abuse is the lack of attention they receive, Bhasin said. Unlike other serious drugs, like heroin, cocaine or alcohol, PED abuse typically doesn’t land people in the emergency room, he said.

Additionally, people taking the drugs are less likely to bring them up to their doctors during appointments, and it isn’t always easy to tell if someone may be abusing them, Fletcher said. The researchers found that 56 percent of steroid users had never told their doctor that they took the drugs.

“We urge they tell their doctors all of the things they’re taking,” Rogol said, be they PEDs, over-the-counter supplements, or prescribed drugs. Only when doctors knows the full story are they able to treat patients correctly, he emphasized.

The work could also convince people to be more scrupulous with their prescribing of drugs like testosterone, Rogol said. Many PEDs are obtained illegally, however, Bhasin said, and it’s still unclear where they’re coming from.

The scientific statement noted that one-fifth of users start taking them by age 18-19, which makes this a ripe issue for expanding education initiatives. Fletcher also noted that sports coaches should be sure to talk to their athletes about their health and safety.

“At the end of the day, these are kids, and the majority of them won’t have a professional or even college career,” he said.