THE MEDICAL PRESCRIPTION OF ANABOLIC STEROIDS

Anthony Millar, Lewisham Sports Medicine Clinic, Sydney, Australia

This is a version of a paper presented at the VIth International Conference on the Reduction of Drug Related Harm in Florence, March 1995.

The expansion of anabolic steroid usage has occurred in spite of law enforcement and educational attempts . This presentation details the results of a programme devoted to harm reduction rather than total abolition. Anabolic steroids were prescribed to a group of athletes with no prior history of their use and they were followed for up to 5 years . Following physical examination all participants had their lean and fat masses estimated. Blood was taken for estimation of liver enzymes, total cholesterol, HDL-cholesterol, triglycerides and bilirubin. The athletes were instructed in methods of training to failure . Dietary advice was given to ensure -an adequate carbohydrate intake . Protein and other supplements were forbidden. The initial course was methenolone 20 mg daily and was of 7 weeks' duration. At the end of the course, lean and fat masses were reassessed and blood examinations were repeated. A further course was not given for at least 7 weeks after the first course ended. The materials for subsequent courses were discussed with the athlete to allow further education and a sense of involvement in decision-making. The average weight gain was 2 .8 kg. Lean mass increased 3 .7 kg and fat mass reduced I kg. Some rises in AST, ALT and total cholesterol occurred and HDL levels decreased . These changes reversed in 44 weeks . A failure to gain is discussed and the common reasons are failure to train heavily, inadequate diet, intercurrent illness, shift work and emononal disturbances . Some 51% of athletes took no further steroids beyond the first course. This harm-reduction approach is practical and easily implemented. It gives an opportunity for one-on-one education to challenge that in the gym and establishes the doctor as a reputable contact for discussion particularly when new wonder substances come on stream .

Drug use in sport has been a prevalent problem ever since the introduction of competition. The Greeks used dietary preparations, mushrooms and other sub stances to improve performance (Cszaky, 1972, pp. 117-23). There was little evidence that it did so, but that in no way restricted their use.

Interest in drugs in sport has continued down through the centuries with multiple substances being used and little research done on their effects. The major product of this century in the sports-drug field has been the anabolic steroid. This is the only substance in which there is evidence that a beneficial effect is produced and results since their introduction tend to support this view. Records for power events have improved considerably and much of this must be due to the use of anabolic agents for strength development.

The drug testing industry that has grown up as a result of this is strong evidence that those in charge sporting competitions believe that drugs work in spite of their frequently repeated statements that 'n beneficial affect can be obtained'.

With reference to anabolic steroids, the American College of Sports Medicine (1977) once stated 'that they were useless and did not produce any affect and yet 10 years later have completely reversed that decision (American College of Sports Medicine 1984). The use of the drugs has spread throughout the community and they are now in all areas where strength development is important and muscle bulk achievement is paramount.

Anabolic steroids are used with reckless abandon. They are provided by black marketeers whose sole interest is the maintenance of profit and whose knowledge of the correct dose, side effects and the way in which benefits can be assessed is minimal. This has resulted in an industry with multiple reports of damage resulting from anabolic steroids. Most of these reports are badly supported by technical evidence. The example of liver cancer is an excellent example. Most cases reported in the early days were in patients who had haemopoietic disease and this would end in malignant changes irrespective of whether steroids were used or not (Haupt and Rovere,1984). They were being used on these occasions as a medical treatment. There were very few liver cancers reported in athletes. In the cases described all appear to have been supplied by black marketeers in doses that are far beyond the needs of any athlete and the purity of these substances cannot be assessed.

Research of animals shows that anabolic steroids do not cause cancer, but once cancer has started they certainly stimulate the growth rate (Lesna and Taylor,1986) The media have overlooked all these negative factors to promote the positive and exciting view that anabolic steroids cause cancer. There is likewise no evidence that they cause heart disease or many of the problems that are ascribed to them.

To try and counter this problem, anabolic steroids were prescribed in a medical situation taking into consideration the material used and the needs of the athletes, their training programmes and dietary situations. This programme was started in 1987 and continued for 3 years. Only people who had not previously used anabolic steroids were admitted to the study. All patients were medically examined, their body composition estimated by electrical impedance and blood was taken for the assessment of liver enzymes, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), alkaline phosphatase (AP), and cholesterol, triglyceride, bilirubin and highdensity-lipoprotein (HDL)-cholesterol levels. All athletes were advised to train to failure. They must train a minimum of 4 days a week, preferably. It was stressed that it was important to reach the stage of failure so that only two or three repetitions were possible at the load used. They were forbidden to use protein supplements. They were instructed to eat carbohydrate food as their main diet. They were also instructed to eat a high carbohydrate meal within an hour to an hour and half of finishing training. Their characteristics are shown in Table 1.

TABLE 1: Patient numbers, age, height, weight and percentage body fat and lean body mass

The initial course for all athletes was the prescripion of methenolone acetate for a 7-week period using 140 mg/week. They were given printed sheets detailing the effects of anabolic steroids and the need to work hard and to eat correctly. They were reviewed at the end of 7 weeks and at that time the blood parameters were re-tested and their body fat and lean mass once again estimated.

Following a steroid-free period equal in length t the length of the course, a second course was discussed with those who wished to undertake it. Th anabolic agent used then was determined after considering the athletes' view and the availability o material. No black market sources were used and a no time did the total dosage exceed 500"mg/week No course lasted more that 9 weeks and all courses were preceded and followed by estimation of blood levels of liver enzymes and HDL in 'particular, and also an estimation of body fat and lean body mass.

Table 2: Biochemical parameters before and after first steriod course

Changes in blood parameters are listed in Table 2. Of the athletes attending some 64% were weight training for body building as their main activity. They were casual athletes who trained initially for the pleasure and occasionally competed in competitions. Many felt that their body size and shape were inadequate. They were too thin and would not be noticed favourably by their colleagues and particularly potential sexual partners. Some had attended for the development of strength to improve their chosen sport, particularly football and body contact activities. There were a significant number of people who were homosexual and had a more intense interest in improving their body image. The older people in the group aged 3540 were motivated by an urge to tone up the body and a desire not to become fat.

Weight and body composition analysis showed gains in lean mass of up to 9 kg on the first course. The mean weight gain was 2.1 kg. There was a significant loss of fat in those with body fat levels 16% and over. The failure to gain weight was generally the result of inadequate training programmes and an unsatisfactory diet. Frequency of patient consultations varied, the mean period between visits over the whole length of the course being 5 months. The modal value was 7 months. The variety of anabolic agents and their frequency of use and the doses used are shown in Table 3.

Table 3: Steroids used and average weekly doses

It is apparent that there is a need for a new approach to anabolic steroid use. The old concepts that it is extremely dangerous and that 'death is just around the corner' once you start the course need to be eliminated. Health education has failed dramatically to improve the situation. It has only led to the development of users and non-users and the users are castigated by the non-users, forcing them underground where no contact is made with them. Their sole source of information is their peers in the gym, together with the occasional dealer. Unless something is done to improve this we will not be able to reduce the amount of steroids used.

The number of athletes attending the programme doubled in the third year as a consequence of the publication of a government report on 'Drugs in Sport'. Like all reports it recommended a punitive approach with no help for the athletes and it did not accept that something could be done with smaller doses on a more regular basis with medical help. There is no likelihood that steroids will ever be eliminated and the community has its option of fighting an expensive war against these drugs, or alternativeIy accepting the least worse option, that is, of medical prescription which will lead to lower doses, better effects and less side effects.

In this programme over half of those who attended did not continue beyond the first course. Fifteen per cent of that group regarded the doses as far too low. Thirty-five per cent consciously decided not to proceed as they were disappointed with their effects and worried about side effects. The remainder had reached a target weight, or alternatively had reached that stage of the season where they could no longer concentrate on weight training and were involved in their regular sporting programmes. The athletes themselves altered over the period. Initially there were demands for rapid results and the need for higher doses, particularly injectable materials. As the personal education programme continued, there was more understanding that results cannot be produced rapidly and that steroids do not produce the results if the athlete does not train heavily. Many stated that they were training heavily, but eventually found a partner and realised that that caused an increase in workloads and their original workload had not been as high as was desired. Once the better results came there was less demand for more steroids.

Side effects were not a problem because of the small doses used. Of the alterations occurring in the blood, ALT and HDL levels were excellent markers for use. The changes in cholesterol, although statistically significant, were not of clinical significance.

This programme has shown that it is possible to manage athletes who wish to use anabolic steroids with a progressive graduated programme in which the doses used are far less than those needed when the material is prescribed by black marketeers. This programme has shown a minimal amount of side effects. Changes in the blood are reversed over a short period of time and results for the patient are satisfactory and lead to a relatively short history of steroid intake.

The management of doses has been such that the athletes have not experienced the highs and lows that occur with large doses administered by black marketeers and this has, in turn, led to less demand for more and more drugs. There is a need for an educated medical profession to be able to discuss the pharmacology and endocrinology of the substances in a knowledgeable way so that the athletes will understand that their 'bibles' are incorrect and the results can be obtained without large amounts.

It is highly unlikely that the dire side effects described years ago are likely to occur because, to date, there has been no significant longer term problem with anabolic steroids that has been documented in the literature; it is reasonable to maintain a guarded graduated programme for a relatively short period of time in which side effects and dangers are minimal.

Anthony Millar, Lewisham Sports Medicine Clinic, 1-7West Street, Petersham 2049, NSW, Australia.

REFERENCES

American College of Sports Medicine(1977) . Position on the use and abuse of anabolic-androgenic steroids in sport. Medical Sci. Sports Ex 9: 11-13.

American College of Sports Medicine (1984) . Position on the use and abuse of anabolic-androgenic steroids insport. Medical Sci. Sports Ex 19: 13-18.

Cszaky TZ (1972) . Doping. Journal of Sports Medicine and Physical Fitness 12: 117-23.

Haupt HA, Rovere GD (1984) . Anabolic steroids: a review of the literature. American Journal of Sports Medicine 1 2: 469-84.

Lesna M, Taylor W (1986) . Liver lesions in BALB/C mice induced by anabolic androgens with and without pre-treatment with diethylnitrosamine. Journal of Steroid Biochemistry 24: 449-53.