The Changing Drug Culture: Use and Misuse of Appearance- and Performance-Enhancing Drugs

Awareness of the prevalence of the use of appearance- and performance-enhancing drugs (APEDs) is increasing. Users range from professional athletes and bodybuilders to amateurs and adolescents. Anabolic androgenic steroids (AASs) are the most widely used APEDs, typically for purposes of building muscle mass, in forms that include pills, injections, topical preparations, and transdermal systems. AASs are often used in combination with augmenting drugs taken to enhance androgen production and, for men, to decrease estrogen production. These include aromatase inhibitors, clomiphene, selective estrogen receptor modulators, and human chorionic gonadotropin. Other drugs used with the intention of improving athletic performance include human growth hormone, insulinlike growth factor 1, insulin, erythropoietin, stimulants, diuretics, levothyroxine, and gamma-hydroxybutyrate. Use of APEDs is increasing, with up to 5% of male and 2% of female college athletes using AASs and reports of a more than 20% usage rate among teenagers. Although many of these substances can increase muscle mass when combined with high levels of exercise and specific diets, it is not clear that they improve athletic performance. Furthermore, they are associated with a variety of serious adverse effects. AASs, in particular, can cause hepatotoxicity and acute cardiac events. Behavioral and psychiatric symptoms also can occur.