Correspondence
Anabolic–Androgenic Steroids as a Gateway to Opioid Dependence
N Engl J Med 2000; 342:1532May 18, 2000
- Article
To the Editor:
Athletes who abuse anabolic–androgenic steroids may go on to abuse opioid agonist–antagonists such as nalbuphine1-3 or even classic opioids such as heroin.2,3 We studied this phenomenon among patients treated at Sunrise House, a private inpatient facility for substance-dependence treatment in northern New Jersey. Among 227 men admitted for dependence on heroin or other opioids in 1999, we found that 21 (9.3 percent) had a history of anabolic–androgenic steroid use. In contrast, among 197 men admitted for opioid dependence in 1990, only 1 (0.5 percent) reported prior use of anabolic–androgenic steroids (P<0.001 by two-tailed Fisher's exact test).
None of the 21 men in 1999 reported any form of substance abuse or dependence before their use of anabolic–androgenic steroids. The mean (±SD) age at the time of their first use of anabolic–androgenic steroids was 20.9± 2.4 years and the age at the time of their first use of opioids was 27.0±4.0 years. The information they provided strongly suggests that they were introduced to opioids through anabolic–androgenic steroid use and the bodybuilding subculture: 17 of the 21 men (81 percent) first purchased opioids from the same drug dealer who had sold them anabolic–androgenic steroids; 14 (67 percent) were introduced to opioids by a fellow bodybuilder; 18 (86 percent) claimed that they first used opioids to counteract insomnia and irritability induced by anabolic–androgenic steroids; and 14 (67 percent) had used opioids to counteract depression associated with withdrawal from anabolic–androgenic steroids. All 21 of the men reported at least one of these four attributes.
Demographically, these men appeared atypical for opioid users; they all lived in suburban New Jersey and reported a mean household income of $69,800 (range, $38,000 to $145,000). They reported serious associated morbidity. Since the time of their first use of opioids, 15 (71 percent) had been charged with possession of a controlled substance or prescription fraud; 5 (24 percent) had served time in prison, including 1 for attempted murder; and 7 (33 percent) had made at least one suicide attempt. In the 1 to 11 months since their discharge from Sunrise House, 17 (81 percent) have relapsed into opioid use, and 2 (10 percent) have committed suicide.
These findings suggest an alarming trend: that anabolic–androgenic steroids may serve as “gateway” drugs to opioid dependence, with substantial associated morbidity and even mortality. Although our study cannot establish that anabolic–androgenic steroid use per se led to opioid dependence in these men, the data we report strongly suggest this interpretation. Alternatively, what we observed might be specific to our facility, but our facility is in a region not noted for unusually high rates of either anabolic–androgenic steroid use or opioid dependence. Progression from anabolic–androgenic steroid use to opioid dependence deserves further exploration as a public health problem.
3 ReferencesDrew Arvary
Sunrise House, Lafayette, NJ 07848Harrison G. Pope, Jr., M.D.
Harvard Medical School, Boston, MA 021151
McBride AJ ,Williamson K ,Petersen T . Three cases of nalbuphine hydrochloride dependence associated with anabolic steroid use. Br J Sports Med 1996;30:69-70
CrossRef | Web of Science | Medline2
Wines JD Jr ,Gruber AJ ,Pope HG Jr ,Lukas SE . Nalbuphine hydrochloride dependence in anabolic steroid users. Am J Addict 1999;8:161-164
CrossRef | Web of Science | Medline3
Pope HG Jr, Phillips KA, Olivardia R. The Adonis complex: the secret crisis of male body obsession. New York: Free Press, 2000.
- Citing Articles (31)
Citing Articles
1
Yvonne Lood, Arne Eklund, Mats Garle, Johan Ahlner. (2012) Anabolic androgenic steroids in police cases in Sweden 1999–2009. Forensic Science International
CrossRef2
Bernd Lenz, Christian P. Müller, Christina Stoessel, Wolfgang Sperling, Teresa Biermann, Thomas Hillemacher, Stefan Bleich, Johannes Kornhuber. (2011) Sex hormone activity in alcohol addiction: Integrating organizational and activational effects. Progress in Neurobiology
CrossRef3
Gen Kanayama, James I. Hudson, Harrison G. Pope. (2010) Illicit anabolic–androgenic steroid use. Hormones and Behavior 58:1, 111-121
CrossRef4
Gen Kanayama, Kirk J. Brower, Ruth I. Wood, James I. Hudson, Harrison G. Pope Jr. (2009) Anabolic
androgenic steroid dependence: an emerging disorder. Addiction 104:12, 1966-1978
CrossRef5
Gen Kanayama, James I. Hudson, Harrison G. Pope. (2009) Features of men with anabolic-androgenic steroid dependence: A comparison with nondependent AAS users and with AAS nonusers. Drug and Alcohol Dependence 102:1-3, 130-137
CrossRef6
Gen Kanayama, James I. Hudson, Harrison G. Pope. (2008) Long-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: A looming public health concern?. Drug and Alcohol Dependence 98:1-2, 1-12
CrossRef7
Ruth I. Wood. (2008) Anabolic–androgenic steroid dependence? Insights from animals and humans. Frontiers in Neuroendocrinology 29:4, 490-506
CrossRef8
Goffredo Guarino, Santi Spampinato. (2008) Nandrolone decreases mu opioid receptor expression in SH-SY5Y human neuroblastoma cells. NeuroReport 19:11, 1131-1135
CrossRef9
Sanna Kurling, Aino Kankaanpää, Timo Seppälä. (2008) Sub-chronic nandrolone treatment modifies neurochemical and behavioral effects of amphetamine and 3,4-methylenedioxymethamphetamine (MDMA) in rats. Behavioural Brain Research 189:1, 191-201
CrossRef10
Folke Sjöqvist, Mats Garle, Anders Rane. (2008) Use of doping agents, particularly anabolic steroids, in sports and society. The Lancet 371:9627, 1872-1882
CrossRef11
Fia Klötz, Anna Petersson, Dag Isacson, Ingemar Thiblin. (2007) Violent crime and substance abuse: A medico-legal comparison between deceased users of anabolic androgenic steroids and abusers of illicit drugs. Forensic Science International 173:1, 57-63
CrossRef12
Jason P. Caplan, Lucy A. Epstein, Davin K. Quinn, Jonathan R. Stevens, Theodore A. Stern. (2007) Neuropsychiatric Effects of Prescription Drug Abuse. Neuropsychology Review 17:3, 363-380
CrossRef13
Kristina Magnusson, Mathias Hallberg, Jonas Bergquist, Fred Nyberg. (2007) Enzymatic conversion of dynorphin A in the rat brain is affected by administration of nandrolone decanoate. Peptides 28:4, 851-858
CrossRef14
Bodo Melnik, Thomas Jansen, Stephan Grabbe. (2007) Abuse of anabolic-androgenic steroids and bodybuilding acne: an underestimated health problem. JDDG 5:2, 110-117
CrossRef15
Cheryl A. Frye, Alicia Babson, Alicia A. Walf. (2007) Self-administration of 3α-androstanediol increases locomotion and analgesia and decreases aggressive behavior of male hamsters. Pharmacology Biochemistry and Behavior 86:2, 415-421
CrossRef16
Cheryl A. Frye. (2007) Some rewarding effects of androgens may be mediated by actions of its 5α-reduced metabolite 3α-androstanediol. Pharmacology Biochemistry and Behavior 86:2, 354-367
CrossRef17
Kayo Takahashi, Mathias Hallberg, Kristina Magnusson, Fred Nyberg, Yasuyoshi Watanabe, Bengt L??ngstr??m, Mats Bergstr??m. (2007) Increase in [11C]vorozole binding to aromatase in the hypothalamus in rats treated with anabolic androgenic steroids. NeuroReport 18:2, 171-174
CrossRef18
Evelyne Célérier, Therese Ahdepil, Helena Wikander, Fernando Berrendero, Fred Nyberg, Rafael Maldonado. (2006) Influence of the anabolic-androgenic steroid nandrolone on cannabinoid dependence. Neuropharmacology 50:7, 788-806
CrossRef19
Anna Petersson, Mats Garle, Per Holmgren, Henrik Druid, Peter Krantz, Ingemar Thiblin. (2006) Toxicological findings and manner of death in autopsied users of anabolic androgenic steroids. Drug and Alcohol Dependence 81:3, 241-249
CrossRef20
Kristina Magnusson, Mathias Hallberg, Anna M.S. Kindlundh Högberg, Fred Nyberg. (2006) Administration of the anabolic androgenic steroid nandrolone decanoate affects substance P endopeptidase-like activity in the rat brain. Peptides 27:1, 114-121
CrossRef21
Heiko Striegel, Perikles Simon, Steffen Frisch, Kai Roecker, Klaus Dietz, Hans-Hermann Dickhuth, Rolf Ulrich. (2006) Anabolic ergogenic substance users in fitness-sports: A distinct group supported by the health care system. Drug and Alcohol Dependence 81:1, 11-19
CrossRef22
R. C.W. Hall. (2005) Psychiatric Complications of Anabolic Steroid Abuse. Psychosomatics 46:4, 285-290
CrossRef23
Adam J Trenton, Glenn W Currier. (2005) Behavioural Manifestations of Anabolic Steroid Use. CNS Drugs 19:7, 571-595
CrossRef24
MARILYN Y. McGINNIS. (2004) Anabolic Androgenic Steroids and Aggression: Studies Using Animal Models. Annals of the New York Academy of Sciences 1036:1, 399-415
CrossRef25
Gen Kanayama, Harrison G. Pope, Geoffrey Cohane, James I. Hudson. (2003) Risk factors for anabolic-androgenic steroid use among weightlifters: a case–control study. Drug and Alcohol Dependence 71:1, 77-86
CrossRef26
Evelyne Célérier, Maryam T Yazdi, Anna Castañé, Sandy Ghozland, Fred Nyberg, Rafael Maldonado. (2003) Effects of nandrolone on acute morphine responses, tolerance and dependence in mice. European Journal of Pharmacology 465:1-2, 69-81
CrossRef27
C.A Frye, M.E Rhodes, R Rosellini, B Svare. (2002) The nucleus accumbens as a site of action for rewarding properties of testosterone and its 5α-reduced metabolites. Pharmacology Biochemistry and Behavior 74:1, 119-127
CrossRef28
Kirk J. Brower. (2002) Anabolic steroid abuse and dependence. Current Psychiatry Reports 4:5, 377-387
CrossRef29
Ann-Sophie Lindqvist, Pia Johansson-Steensland, Fred Nyberg, Claudia Fahlke. (2002) Anabolic androgenic steroid affects competitive behaviour, behavioural response to ethanol and brain serotonin levels. Behavioural Brain Research 133:1, 21-29
CrossRef30
Pia Johansson-Steensland, Fred Nyberg, Loris Chahl. (2002) The anabolic androgenic steroid, nandrolone decanoate, increases the density of Fos-like immunoreactive neurons in limbic regions of guinea-pig brain. European Journal of Neuroscience 15:3, 539-544
CrossRef31
Anna M. S. Kindlundh, Jonas Lindblom, Lena Bergström, Jarl E. S. Wikberg, Fred Nyberg. (2001) The anabolic-androgenic steroid nandrolone decanoate affects the density of dopamine receptors in the male rat brain. European Journal of Neuroscience 13:2, 291-296
CrossRef
