Evidence-Based Reviews

Bodybuilding’s dark side: Clues to anabolic steroid use

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His friends had taught him to self-inject AAS at age 15; he admitted that he was also occasionally self-injecting the opioid analgesic nalbuphine intravenously because of “pain in my ‘delts’ from military presses.”

During his cycles, Aaron experienced hypomanic symptoms, including euphoria, prominent irritability, increased libido, decreased need for sleep, and grandiosity. “I feel invincible,” he said. His aggressive outbursts had worsened with increasing AAS doses; in addition to attacking the motorist, he also had been physically violent with his girlfriend. “She’s scared of me when I’m on juice,” he conceded.

During the withdrawal phase after stopping each cycle, Aaron described prominent depression with anhedonia, hypersomnia, loss of libido, and suicidal ideation. “I once almost jumped off a bridge after my fourth cycle,” he admitted. “I couldn’t wait to get on my next cycle to feel good again.” His depressions were also characterized by body-image obsessions; he would regularly spend at least 1 hour a day examining his musculature in a mirror, and sometimes refused to go out in public because he “was getting too small.”

Perhaps most disturbing was his increasing use of opioids. In addition to self-injecting nalbuphine, he also ingested oral opioids such as oxycodone almost daily. He mentioned that several of his friends in the gym had progressed from injecting nalbuphine to injecting morphine or heroin, and he knew two bodybuilders who had died from apparently unintentional opioid overdoses.

Aaron said his parents, teachers, and non-bodybuilding friends were unaware of this history. He claimed his parents were proud that their son had apparently eschewed drugs and alcohol to pursue a healthy athletic lifestyle.


In our experience with treating substance abusers, we find that AAS users may be the least likely to disclose their drug use to clinicians. In a recent study,1 20 of 36 AAS users (56%) reported they had never revealed their AAS use to any physician. When asked to rate their trust in sources of information about AAS, 17 of 42 AAS users (40%) said they trusted information from their drug dealers at least as much as information from any physician they had seen.

Some expressed contempt for physicians as “geeks” or “pencil-necks” who could not comprehend the body-building lifestyle. They gave doctors high marks on knowledge of tobacco, alcohol, and ordinary “street drugs” but much lower ratings on AAS knowledge. Other investigators have shown that many clinicians are unfamiliar with AAS.2,3

AAS users embrace these beliefs for two other reasons. First, to admit to AAS use is to admit that one’s muscularity and physical prowess is the result of taking a drug; there is no comparable motivation to withhold information about, say, one’s use of marijuana or cocaine.

Second, AAS users are much less likely than other substance abusers to view their behavior as pathologic. We have argued that our culture is partially to blame.4 Americans pay to watch 300-lb football linemen and AAS-using movie stars. Makers of cars, computers, and electronics do not hesitate to advertise their products as “on steroids,” but they would never claim their products were “on cocaine.” In this climate, it is easy to forget that AAS use is an illicit substance abuse.

Box 2

How to calculate fat-free mass index (FFMI)

Formula: FFMI = (W x (100 - BF)/100)H2 + 6.1 x (1.8 - H)

W = weight in kilograms

BF = body fat percentage

H = height in meters

Obtain height in meters and weight in kilograms. Ideally, measure body fat using calipers, electrical impedance, or some other method. Alternately, estimate body fat by visual inspection:

  • 20% = average 30-year-old American man
  • 10% = quite lean
  • 5% = approaching lowest body fat normally attainable

FFMI values for American men:

20 = average

22 = visibly muscular

25 = approximate maximum attainable by a lean individual without using drugs

Example 1

Young male weightlifter is 69 inches tall, weighs 175 lbs, and is moderately lean, with body fat of 10%; he denies AAS use

H = 69 inches x .0254 meters/inch = 1.75 m

H2= 1.75 x 1.75 = 3.06 m2

W = 175 pounds x 0.454 kilograms/lb = 79.5 kg

Therefore, FFMI = (79.5 x (100-10)/100)/3.06 + 6.1 x (1.8 - 1.75) = 23.7

This degree of muscularity can be attained without using AAS

Example 2

Young male weightlifter is 66 inches tall, weighs 175 lbs, and is very lean, with body fat of 6%; he also denies AAS use

H = 66 inches x .0254 meters/inch = 1.68 m

H2= 1.68 x 1.68 = 2.82 m2

W = 175 pounds x 0.454 kilograms/lb = 79.5 kg

Therefore, FFMI = (79.5 x (100-6)/100)2.82 + 6.1 x (1.8 - 1.68) = 27.2

This level of muscularity is extremely unlikely without drugs. Patient is almost certainly lying and should be gently confronted, especially if other symptoms (Table 2) suggest AAS use

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