Original Article
Use of Multiple Drugs among Adolescents Who Use Anabolic Steroids
N Engl J Med 1993; 328:922-926April 1, 1993
- Abstract
Background
Because adolescent users of anabolic steroids are concerned with increasing muscle size and strength, they may be unique among substance users and unlikely to use other drugs. Alternatively, if the factors that cause the use of anabolic steroids are similar to those associated with the use of other substances, adolescents who use anabolic steroids would be expected to report use of other drugs as well.
Methods
We administered a questionnaire based on the 1989 Secondary School Health Risk Survey and the 1990 Youth Risk Behavior Survey of the Centers for Disease Control and Prevention to 1881 students enrolled in compulsory health-science classes (mean [±SD] age, 14.9 ±1.0 years) in the Richmond County, Georgia, school system.
Results
A higher percentage of boys (6.5 percent) than girls (1.9 percent, P ≤ 0.001) reported using anabolic steroids without a doctor's prescription. Among ninth-grade students, 5.4 percent of boys and 1.5 percent of girls reported using anabolic steroids (P ≤ 0.001). Among users of anabolic steroids, 25 percent reported sharing needles to inject drugs. The frequency of anabolic-steroid use was significantly (P<0.001) associated with the frequency of use in the previous 30 days of cocaine (r = 0.44), injectable drugs, alcohol (r = 0.23), marijuana (r = 0.42), cigarettes (r = 0.25), and smokeless tobacco (r = 0.40). On the basis of multiple regression analysis, the use of marijuana, shared needles, smokeless tobacco, and cocaine accounted for 33 percent of the variation in anabolic-steroid use among the ninth-grade students.
Conclusions
In our study, adolescent users of anabolic steroids were likely to use other drugs as well, and many were sharing needles.
Media in This Article
Table 1
Characteristics of 1881 Students in Ninth-Grade Health-Science Classes and Frequency of Anabolic-Steroid Use.Table 2
Substance Use and Risk-Taking Behavior with Regard to AIDS and HIV, as Reported by 1881 Adolescents.Article Activity
- Article
It is estimated that 1 million people in the United States are spending more than $100 million a year on black-market anabolic steroids1-3. Habitual use of anabolic steroids to enhance muscle size for cosmetic reasons and to improve strength and endurance for competitive purposes is increasing4. Some 250,000 U.S. high-school seniors have used anabolic steroids, and the use of anabolic steroids by adolescents is increasing3-10. Five to 11.1 percent of males and as many as 2.5 percent of females surveyed have used anabolic steroids4,10. Adolescents who use these substances most frequently are apt to be participating in football and wrestling. However, Johnson et al.8 reported a small portion of male adolescents who used anabolic steroids without engaging in activities such as weight lifting to promote increases in muscle size. Buckley et al.7 found that the students who used anabolic steroids frequently were likely to have begun to use these drugs at a younger age.
These studies suggest that adolescents who begin using anabolic steroids at young ages often continue to use several types of anabolic steroids for extended periods and that they share behavior, perceptions, and opinions that are consistent with habituation or psychological dependence7,10-13. Steroids affect mood as well as the physique and may induce complications similar to those associated with other misused drugs, such as cocaine, marijuana, and alcohol3,12. The relation of anabolic-steroid use to other drug use remains unclear. Users of steroids may be unique among substance users because they often have an attitude that the body is a “temple” and do not use alcohol and marijuana because they believe that these substances will harm their health10. Alternatively, if the mechanisms of anabolic-steroid use are similar to those of other substance use,14 users of anabolic steroids would also be expected to report the use of multiple drugs.
The protocol of injecting steroids represents an increased level of commitment to drug use, which often leads anabolic-steroid users to engage in behavior similar to that of other adolescent substance abusers11. For example, since insulin needles cannot be used for steroid injections, adolescents must obtain larger-gauge needles through the black market11. As with other illicit, injectable drugs, the use of anabolic steroids by adolescents becomes an even more critical health issue because of its potential for contributing to the spread of the human immunodeficiency virus (HIV) through the sharing of contaminated needles15,16.
In this study we examined the relation of anabolicsteroid use to the use of other drugs, including cocaine, marijuana, alcohol, cigarettes, and smokeless tobacco. In addition, we sought to determine the degree to which young adolescents reported the use of injectable drugs and the percentage that reported sharing needles. Finally, we also attempted to evaluate the relation between previous education about HIV and the use of anabolic steroids.
Methods
Subjects
This study was approved by the Human Assurance Committee of the Medical College of Georgia and the Board of Education of Richmond County, Georgia. In November 1990, we administered an anonymous standardized questionnaire, based on the questionnaire used by the Centers for Disease Control and Prevention (CDC) for the 1989 Secondary School Health Risk Survey,17-19 to all students (n = 1881) in the compulsory ninth-grade health-science classes in Richmond County. The characteristics of the students are described in Table 1Table 1
Characteristics of 1881 Students in Ninth-Grade Health-Science Classes and Frequency of Anabolic-Steroid Use.. Like the National Center for Health Statistics, the CDC uses the following classifications for race: black, white, Native American or Alaskan Native, Asian or Pacific Islander, and other. Because people with a Hispanic ethnic background often belong to different racial groups, membership in the Hispanic or Latino ethnic group is measured with a separate question20. Most of the students we surveyed were in the ninth grade, but other students who had not yet taken health education were also in the class. The mean (±SD) age of the students was 14.9 ±1.0 years.Questionnaire
We used a modified version of the 1989 edition of the CDC's Secondary School Health Risk Survey21-23. This survey was designed for the school-based epidemiologic surveillance of adolescents' knowledge, attitudes, and behaviors related to health risks and has not been tested for test-retest reliability24. However, acceptable levels of internal reliability have been found for most of the scales in the questionnaire21-26. Ten questions assessing the frequency of substance use from the CDC's 1990 Youth Risk Behavior Survey were added to the questionnaire18. These two questionnaires have been used extensively by the CDC to measure risk-taking behavior among adolescents attending public schools.
Variables
Two questions from the 1990 CDC Youth Risk Behavior Survey asked respondents whether they had ever “injected (shot up) cocaine, heroin, or other illegal drugs into your body” and whether they had done so in the past 30 days. Subjects were also asked “In the last 30 days, have you shared needles used to inject (shoot up) any drugs?” Two questions asked how many times respondents had used any form of cocaine, including powder, crack, or freebase, “during your life” and “during the last 30 days” (Table 2Table 2
Substance Use and Risk-Taking Behavior with Regard to AIDS and HIV, as Reported by 1881 Adolescents.). Four questions assessed the use of alcohol, marijuana, cigarettes, and smokeless tobacco during the previous month. Anabolic-steroid use was assessed with the following question: “During your life, how many times have you taken steroid pills or shots without a doctor's prescription?” (Table 2). We also asked whether the student had received education about the acquired immunodeficiency syndrome (AIDS) and HIV in school before the introduction of the current curriculum. Sixty-eight percent (n = 1274) responded yes to this question. The frequency of behavior placing the adolescent at risk for AIDS or HIV was assessed by asking, “During the last month, how many times have you engaged in any behavior that would increase your chance of getting the AIDS/HIV infection?” with forced-choice responses ranging from 0 times to 9 or more times (Table 2). This was placed as the last item in the questionnaire, so the students' responses to this question would be prompted by all previous questions about knowledge, attitudes, and behavior.Statistical Analysis
Both continuous and ordinal data are summarized as means ±SD for simplicity of interpretation. Because the AIDS-HIV risk-taking scale and the scales assessing substance use were positively skewed, the means and standard deviations should be interpreted with caution. Moreover, since the variables were measured on ordinal scales and were not normally distributed, pairwise associations were tested with the Spearman rank-correlation coefficient (r) and chi-square tests. All variables found to be significantly associated with the frequency of use of anabolic steroids were then analyzed with stepwise multiple regression analysis, with forward inclusion of the independent variables27.
Categorical variables were treated as indicator variables in the regression model. The change in the R2 (the percentage of the variation explained) when each variable was added to the model was examined to assess the clustering of substance use by anabolic-steroid users. Because of the time frames attached to the questions measuring the use of anabolic steroids as compared with the use of other substances, the correlation and regression analyses should be reviewed as covariational relations and not as cause-and-effect relations. The regression analysis was conducted only on the data for the ninth-grade students.
Results
The proportion of students who reported that they had ever used anabolic steroids was 4.2 percent. Among those who had used anabolic steroids, the frequency of use was evenly distributed across the categories, ranging from 1 to 2 times to 40 or more times (Table 1). A significantly higher percentage of boys than girls and of Hispanic than non-Hispanic adolescents reported the use of anabolic steroids (Table 3Table 3
Frequency of Use of Anabolic Steroids among 1813 Adolescents According to Sex, Hispanic Background, Previous AIDS-HIV Education, and Injection-Drug Use.). The Hispanic students were distributed among all four racial groups (Table 1). When we controlled for racial group, the difference in anabolic-steroid use between Hispanics and non-Hispanics was significant (P ≤ 0.001) only among white students. Students who had previously received education about AIDS and HIV in school were less likely to have used anabolic steroids. Students in the 9th grade reported less use of anabolic steroids than students in the 10th through 12th grades. However, the correlation between the frequency of use of anabolic steroids and the grade in school was low (r = 0.13, P<0.001). Among the ninth-grade students, 5.4 percent of the boys and 1.5 percent of the girls (P<0.001) reported the use of anabolic steroids. No other racial or demographic differences were associated with the use of anabolic steroids in this sample of students.Among the students who had used anabolic steroids, 24.7 percent reported that they had shared needles to inject drugs during the previous 30 days. However, 30.6 percent of anabolic-steroid users who had not received school-based education about AIDS and HIV had shared needles, as compared with 18.9 percent of anabolic-steroid users who had received such education.
In general, the more frequently these adolescents used anabolic steroids, the more likely they were to use one or more other drugs (Table 4Table 4
Spearman Rank-Correlation Coefficients (r) for Reported Substance Use and Risk-Taking Behavior with Regard to AIDS and HIV.). The use of anabolic steroids was moderately strongly associated with the frequency of use of cocaine, marijuana, and smokeless tobacco, as indicated by correlation coefficients ranging from 0.40 to 0.44. Weaker correlations were found with the frequency of cigarette smoking, alcohol use, AIDS-HIV risk-taking behavior, and age (Table 4). Anabolic-steroid use was also significantly associated with injection-drug use and the use of shared needles to inject drugs during the previous 30 days (Table 3).Among the ninth-grade students only, all variables found to be significantly associated with the use of anabolic steroids were analyzed with multiple regression analysis to determine which group of factors explained the highest percentage of the variation in the frequency of use (Table 5Table 5
Multiple Regression Analysis of Frequency of Anabolic Steroid Use in the Subsample of Ninth-Grade Students.). Five variables explained significant amounts of additional variation in anabolic-steroid use when added to the regression model. This analysis revealed substantial clustering of other drug-use behaviors among users of anabolic steroids. Cocaine use was the strongest factor covarying with anabolic-steroid use, explaining 20.4 percent of the variation in the frequency of use. In descending order of magnitude, the following variables also explained significant amounts of additional variation in anabolic-steroid use (P<0.001): marijuana use (7.6 percent), shared-needle use (3.5 percent), and smokeless-tobacco use (1.2 percent). Previous AIDS-HIV education was a significant predictor of anabolic-steroid use, but the magnitude of the change in R2 was too small to be meaningful. The first four variables in the model explained 32.7 percent of the variation in the frequency of use of anabolic steroids.Discussion
In previous studies, 5 to 11 percent of adolescent boys and 1 to 2.5 percent of adolescent girls reported using anabolic steroids4-10. In our study, 6.5 percent of boys and 1.9 percent of girls reported the use of anabolic steroids. Among ninth-grade students, 5.4 percent of boys and 1.5 percent of girls reported use of anabolic steroids. Our data also suggest that a substantial number of young adolescents have used injection drugs, probably anabolic steroids, and one quarter of anabolic-steroid users have shared needles to inject drugs during the past 30 days. Earlier studies suggested that those who first use anabolic steroids by 15 years of age make up the largest single group of high-school seniors who report the use of these drugs7,11. Our data confirm these reports but suggest that anabolic-steroid use probably begins even earlier.
Our study relied on the validity of the students' own reports as measures of their drug use. We used a questionnaire that had been developed by the CDC and used extensively in school-based populations. That the prevalence of use of anabolic steroids in this population was similar to the rates found in other studies adds credibility to our results.
Almost one quarter of the students who reported using anabolic steroids in our study also reported sharing needles, a practice that places them at risk for HIV and other viral infections. Anabolic-steroid users who reported that they had previously received education about AIDS in school reported sharing needles less frequently than those who had not received such education about AIDS and HIV. Thus, there are young adolescents who are using injectable forms of anabolic steroids without recognizing the risk of HIV transmission. They may not perceive themselves as being at risk for infection because they perceive themselves as invulnerable. They may also believe that they will not become infected because the people with whom they are sharing needles are not seen to be “real” drug users, such as those who inject heroin. Finally, users may believe they are at low risk for infection because steroids are not harmful but, rather, health-enhancing7,10,11. Regardless of the explanation for the sharing of needles, our data confirm that this practice may serve as a route for the transmission of HIV among adolescents15,16.
We found significant associations between the use of anabolic steroids and the use of marijuana, cocaine, cigarettes, smokeless tobacco, and alcohol. Particularly disturbing were the strong relations we found between the use of anabolic steroids and the concomitant use of mood-altering substances. The relation between smokeless tobacco products and anabolic steroids has been documented before28.
Educational interventions concerning the effects of anabolic steroids are just beginning to be described in the literature29-33. Like similar strategies to decrease alcohol consumption among adolescents,34 interventions that only provide information about the negative effects of anabolic steroids have little effect. Behavioral change and interventions designed to teach risk-reduction and risk-avoidance skills that are specifically targeted to these users must be employed, since many of them are likely to engage in more than one type of high-risk behavior.
Source Information
From the Departments of Pediatrics (R.H.D., G.S.) and Internal Medicine (C.N.), Medical College of Georgia, Augusta; the Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock (V.I.R.); and the Department of Pediatrics, University of Alabama at Birmingham (C.S.A.).
Address reprint requests to Dr. DuRant at the Section of General Pediatrics and Adolescent Medicine, Department of Pediatrics, CE-112, Medical College of Georgia, Augusta, GA 30912.
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