SERIOUS SUBSTANCES OF ABUSE
From the American Academy of Family Physicians’ 2005 Scientific Assembly, presented September 28 to October 2,
2005, in San Francisco
| THE TAYLOR HOOTON STORY— Donald M. Hooton, MS, Worldwide Strategic Marketing and Business Developer,
Hewlett-Packard Company, Plano, Texas
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| Taylor Hooton: well-liked, well-mannered, intelligent, and popular high school-aged boy; 6 ft 3 in tall and weighed 175 lb;
during fall of junior year in high school, junior varsity baseball coach told Taylor to get bigger to improve chances of
making varsity team; Taylor took coach’s advice but had no specific instructions; during next 3 to 4 mo, Taylor used anabolic
steroids; Taylor gained 30 lb of muscle primarily in upper body and developed classic physical and emotional
signs (eg, mood swings) of steroid use; Taylor’s father absolutely convinced that Taylor’s use of anabolic steroids played
significant role in causing severe depression that resulted in Taylor’s suicide; events leading up to and including Taylor’s
suicide “right out of the medical textbook on steroids”
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| Obtaining steroids: readily available at gyms and on Internet; Taylor paid ≈$400 per cycle of steroids; Taylor took intravenous
(IV) nandrolone (Deca-Durabolin) 300 mg and oral oxymetholone (Anadrol); quality of steroids likely low; common
for adolescents to take 100 mg of anabolic steroids daily; reasons for use include peer pressure, positive feedback
from results, and changes in social group
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| Taylor’s physician visits: family physician lectured on dangers of steroids; drug test results negative, but test did not
screen for steroids; after 6 interviews with psychiatrist, Taylor admitted to use of steroids; psychiatrist instructed Taylor
to take 1 more half-dose of steroids, then to stop; depression common side effect of anabolic steroids and usually worsens
when drug discontinued; 6 wk later, Taylor hung himself
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| PERFORMANCE-ENHANCING DRUGS AND SUPPLEMENTS —Suraj A. Achar, MD, Assistant Clinical Professor of
Family and Preventive Medicine, University of California, San Diego, School of Medicine
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| Introduction: >250,000 adolescents use anabolic steroids in United States; >1 million adults abuse anabolic steroids; steroid
use more common among boys
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| History of use of performance-enhancing drugs: 1950s—anabolic steroids used by Eastern-bloc Olympians; 2 female
swimmers had androgenic changes and underwent sex-change operations (one swimmer sued physician in world court and
won); 1980s—National Collegiate Athletic Association (NCAA) began testing; in late 1980s, suspicious number of European
cyclists died from strokes; epoetin alfa (erythropoietin; EPO; [Epogen]) taken by cyclists and elite athletes to boost
hemoglobin; >50% of athletes participating in 1996 Olympic Games in Atlanta said they were injecting themselves with
somatropin (human growth hormone [hGH])
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| International Olympic Committee (IOC) list of prohibited substances and methods: classes of substances—
stimulants (eg, cocaine, ephedra); anabolic steroids; peptide hormones (eg, hGH); methods—blood doping (ie, injecting
blood from another athlete before competition to increase hemoglobin); hetastarch (hydroxyethyl starch) injections to expand
plasma volume to allow hemoglobin to move better
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| Scope of problem: survey conducted with parental consent found 2% to 3% of eighth graders use anabolic steroids and other
performance-enhancing drugs (50% of users also use hGH)
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| Mechanism of action: some users feel effect on brain (eg, “rush,” resulting in better training); effect on muscle and anticatabolic
effect; increase in muscle mass, blood count, hemoglobin, and heart size; androgenic effects include decreased
sperm count and can last 6 to 9 mo
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| Methods of abuse: stacking—blend of 3 to 5 anabolic steroids; pyramiding—starting low and building up; designer
steroids—eg, tetrahydrogestrinone (THG); injectable; change in body and become undetectable; abuse rates high; 16%
of high school seniors report abusing drugs (4% report using anabolic steroids)
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| Clinical uses of anabolic steroids: chronic obstructive pulmonary disease (COPD); diseases that cause muscle wasting
(eg, end-stage AIDS, cachexia in burn patients); use normal physiologic doses (2-10 mg)
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| Side effects: male-pattern baldness; acne; effect on heart and brain; Finnish study of winning competitive powerlifters—
13% of powerlifters died, compared to 3% of controls; 3 died from suicide, 3 from myocardial infarction, 1 from liver failure;
androgenic anabolic steroid users die 10 to 15 yr earlier than heroin or methamphetamine users (suicide rate higher in steroid
users)
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| Ancillary drugs: clomiphene (Clomid) blocks side effects of anabolic androgenic steroids and helps with sexual impotence;
diuretics
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| Testing: measure testosterone-to-estrogen ratio; androstenedione used to hide use of anabolic steroids; test for drug (eg,
Epogen) specifically; hGH—detected with blood test; athletes not tested for hGH; can be measured specifically because
only 1 isoform detected if synthetic present (“we have the technology, it’s a matter of using it”)
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| Gene doping: available; plug DNA sequence for muscle building properties into adenovirus; no marker for testing available
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| Marketing of supplements: Dietary Supplement Health and Education Act (DSHEA)—allows supplement manufacturers
to sell drugs over the counter (OTC) without regulations and testing by Food and Drug Administration (FDA); resulted
in increase in sales
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| Performance-enhancing supplements: creatine—studies show 20 g daily can increase bench-pressing performance (ie,
repetitions over time); some aerobic conditioning benefit; no anaerobic benefits seen; side effects may include renal effects
and cramping; may be first drug that “brings our kids into the store”; ephedrine—13,000 complaints filed against
Metabolife; banned by FDA in 2004; caused sentinel deaths (“we can’t explain this event outside of the stimulants”);
RSR13 (efaproxiral)—banned by FDA; used for patients with brain cancer who suffer stroke after removal of cancer;
used by athletes to increase blood vessel supply; CortiSlim—Spanish orange peel containing synephrine; likely to result
in cardiovascular mortality similar to that seen with ephedra
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| Anabolic Steroid Control Act: passed in January 2005; outlawed androstenedione and other prohormones; dehydroepiandrosterone
(DHEA) left on market
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| Steroid testing: many fake drugs sold on Internet; carbon isotope testing used to measure drugs specifically; testing of hair;
tests not performed unless requested; cost ≈$400
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| Questions and answers: human chorionic gonadotropin (hCG)—used by Olympic athletes to cover side effects of anabolic
steroids; patients obtain information from Internet and friends; public often receive wrong or dangerous information;
approach to adolescent with suspected hypogonadism—steroid users can be identified with proper training; management
of steroid users difficult; start with teamwork approach; communicate and share information with coaches to reduce
use; psychologic effects—emotional swings classic side effects of steroids; aggressive behavior (“road rages”) most common
and can result in car racing and homicide; depression after steroid discontinued can last ≥1 yr (6-12 wk after stopping
steroid use most dangerous period); user must be weaned off steroids
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| METHAMPHETAMINE: A GROWING EPIDEMIC —Cathy L. Baldwin-Johnson, MD, Clinical Faculty, University of
Washington, School of Medicine, WWAMI Program, Seattle, and Medical Director, Providence Matanuska Health Care Center,
Wasilla, Alaska
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| Introduction: methamphetamine highly addictive and dangerous; nearly 600% increase in “meth lab” seizures between
1994 and 2000; children commonly present in homes where methamphetamine manufactured; methamphetamine commercially
produced for sale in “super labs”
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| Child abuse: substance abuse causes or exacerbates 7 in 10 child abuse or neglect cases; children whose parents abuse drugs
and alcohol more likely to be abused and neglected; children prenatally exposed to drugs and alcohol more likely to be
abused and neglected; children may be irritable, difficult to feed and console, and may have behavioral issues; problems—
injuries from drug and manufacturing process; diversion of resources; attachment and bonding problems; environmental
dangers; exposure to criminal activity, violence, and parents’ physical and mental illness; methamphetamine use associated
with violence, aggression, pornography, and sexual violence
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| What is methamphetamine? potent nervous system stimulant; similar to cocaine but metabolizes more slowly (can take 2
days to metabolize single dose); can be smoked, sniffed, swallowed, or injected; easily crosses blood-brain barrier; high
street value
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| Methamphetamine manufacturing: quick and easy; meth labs found in residences, barns, motels, and vehicles; household
items (eg, Pyrex kitchenware, tape, aluminum foil) and chemicals (eg, pseudoephedrine [Sudafed], lithium batteries) can be
used; manufacturing 1 lb of methamphetamine generates 5 to 6 lb of toxic waste; fires common; chemicals and byproducts often
flushed down toilet or dumped in drains; other environmental consequences include increased risk to people living at site
of former meth lab because drugs and components penetrate into porous surfaces (eg, linoleum, countertops) and not removable
by surface cleaning; estimated cost of meth lab cleanup $30,000
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| Methamphetamine use: ≈4% of population admitted to trying methamphetamine ≥1 time; highest rate of abuse in young
adults; women more likely to use methamphetamine than cocaine; risk dependent on route of ingestion of drug; health risks
related to solvents include hepatotoxicity, bone marrow toxicity, effects on central nervous system (CNS), effects on kidneys,
rhabdomyolysis, and neuropsychologic issues; inhalation of iodine particles causes mucous membrane irritation and respiratory
distress; risk for corrosive gastroenteritis, CNS toxicity, renal toxicity; risk for malnutrition, infection, poor hygiene,
acute coronary syndromes, arrhythmias, cardiomyopathies, endocarditis, and respiratory symptoms; “meth mouth”—related
to malnutrition and poor dental hygiene; users also tend to grind teeth; direct chemical and toxic effects on teeth and gums; adverse
effects on pregnancy; dermatologic effects from injecting drug and picking at skin; look for cerebral hemorrhages if patients
present with seizures; users tend to become anxious, hallucinate, become paranoid, and may have permanent brain
damage
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| Effects of methamphetamine: causes mood swings, agitation, and loss of appetite; damages dopamine- and serotonin-producing
cells; brain scan performed on long-term users after abstinence showed little or no improvement in cognitive testing
and gross and fine motor skills; affects ability to feel happiness without drug; affects parenting skills; increased
tolerance; withdrawal—severity depends on time and amount used; addiction often requires specialized treatment
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| Methamphetamine and pregnancy: women using methamphetamine may also be using tobacco, cocaine, alcohol, and
marijuana; patient may not be receiving prenatal care or proper nutrition; increase in maternal blood pressure (BP) and
heart rate (HR) can result in placental vasoconstriction; methamphetamine passes through placenta and results in elevated
fetal BP, fetal tachycardia, dysrhythmia, and fetal brain effects; babies born to methamphetamine users tend to be smaller
in head circumference, length, and weight; higher risk for fetal distress, death in uterus and after birth, and premature delivery;
malformation may be associated with methamphetamine use; babies at higher risk for bloodborne diseases (eg,
hepatitis B and C and HIV) if mothers injecting methamphetamine; higher rates of sudden infant death syndrome (SIDS);
babies can have withdrawal symptoms and may be more difficult to parent; cognitive deficits and language and behavioral
changes extend into early school years
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| Testing for neonatal drug exposure: testing maternal urine detects use within last 1 to 3 days; first urine from baby often
difficult to obtain, but fastest and cheapest way; meconium testing detects use during second half of pregnancy; testing
hair in newborns not shown effective
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| Methamphetamine and children: teenagers perceive methamphetamine as safer and easier to use than cocaine; meth lab
exposure—poor feeding; exposure to needles and firearms; ≤80% of children removed from meth labs test positive on
urine toxicity screen within 2 hr (10%-50% of children from homes of methamphetamine users); effects include hepatotoxicity,
renal toxicity, and behavior changes; drug absorption causes rapid HR and high BP
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| Management of methamphetamine intoxication in emergency department: basic laboratory work-up; imaging studies
recommended if patient has pulmonary symptoms or trauma; computed tomography (CT) of head mandatory if patient has
neurologic symptoms; low index of suspicion for cardiac disease; treatment—mostly supportive; cooling if patient hyperthermic;
aggressively treating agitation may improve hypertension and tachycardia; use IV vasodilators; do not use selective
β-blocker; treat evidence of myocardial ischemia; treat seizures; be highly suspicious of rhabdomyolysis (treat any signs)
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| Management of inadvertent exposure: decontamination process; determine which chemicals present; supportive care; baseline
laboratory studies; nontraumatic decontamination process for children may include clean clothes and cleansing hair and
skin with soap and water; children should be screened for drugs within 2 hr of being removed with laboratory test that detects
minute levels (eg, 25-50 ng/mL); test hair sample within 3 to 30 days after removal from meth lab; baseline assessment;
long-term follow-up recommended because children at high risk for organ injury and injury to brain and to development;
multidisciplinary approach; placement in permanent safe home
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| Role of family physician: recognize use in communities; educate physicians, communities, and legislators; consider forming
local drug endangerment task force
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| Questions and answers: limiting access to pseudoephedrine—resulted in decrease in “mom and pop” labs; can be purchased
on Internet; not only answer; prevention—prevent use with early education in schools; screening children—
quantity detected on test not particularly important because no normal range of methamphetamine for babies and children;
methamphetamine-induced psychosis—evidence of permanent brain injury even in patients who stopped methamphetamine
(consider whether psychosis predated methamphetamine use)
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Educational Objectives
| The goal of this program is to educate the listener about abuse of performance-enhancing drugs and methamphetamine. After
hearing and assimilating this program, the participant will be better able to:
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 | 1. Discuss anabolic androgenic steroid use by adolescents.
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| 2. Describe effects of performance-enhancing drugs, eg, creatine.
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| 3. Discuss psychologic effects of steroid use.
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| 4. List risks to children of methamphetamine users and manufacturers.
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| 5. Assess and treat methamphetamine exposure or intoxication.
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Discussed on This Program
Clomiphene citrate [Clomid, Milophene, Serophene]
Creatine monohydrate Dehydroepiandrosterone (DHEA)
Ephedra sinica (ma huang)
Epoetin alfa (erythropoietin; EPO) [Epogen, Procrit]
Gonadotropin, chorionic, human (hCG)
Hetastarch (hydroxyethyl starch; HES) [Hespan, Hextend, Voluven]
Methamphetamine HCl (desoxyephedrine HCl) [Desoxyn]
Nandrolone decanoate [Deca-Durabolin]
Oxymetholone [Anadrol-50]
Pseudoephedrine HCl (d-isoephedrine HCl) (several trade names)
Somatropin (human growth hormone) [Biotropin, Genotropin, Genotropin Miniquick, Humatrope, Norditropin, Nutropin,
Nutropin AQ, Nutropin Depot, Saizen, Serostim, Tev-Tropin]
Suggested Reading
Berning JM et al: Anabolic steroid usage in athletics: facts, fiction, and public relations. J Strength Cond Res 18:908,
2004; Dhar R et al: Cardiovascular toxicities of performance-enhancing substances in sports. Mayo Clin Proc 80:1307,
2005; Drug Enforcement Administration (DEA) et al: Implementation of the Methamphetamine Anti-Proliferation Act;
thresholds for retailers and for distributors required to submit mail order reports; changes to mail order reporting requirements.
Final rule. Fed Regist 68:57799, 2003; Ellender L et al: Sports pharmacology and ergogenic aids. Prim Care
32:277, 2005; Gambelunghe C et al: Testing for nandrolone metabolites in urine samples of professional athletes and sedentary
subjects by GC/MS/MS analysis. Biomed Chromatogr 16:508, 2002; Gunter TD et al: Drug and alcohol treatment
services effective for methamphetamine abuse. Ann Clin Psychiatry 16:195, 2004; Hohman M et al: Methamphetamine
abuse and manufacture: the child welfare response. Soc Work 49:373, 2004; Hutin YJ et al: Multiple modes of hepatitis A
virus transmission among methamphetamine users. Am J Epidemiol 152:186, 2000; Irvine GD et al: The environmental
impact and adverse health effects of the clandestine manufacture of methamphetamine. NIDA Res Monogr 115:33, 1991;
Irving LM et al: Steroid use among adolescents: findings from Project EAT. J Adolesc Health 30:243, 2002; Kristiansen
M et al: Dietary supplement use by varsity athletes at a Canadian university. Int J Sport Nutr Exerc Metab 15:195, 2005;
Mecham N et al: Unintentional victims: development of a protocol for the care of children exposed to chemicals at methamphetamine
laboratories. Pediatr Emerg Care 18:327, 2002; Parssinen M et al: Increased premature mortality of competitive
powerlifters suspected to have used anabolic agents. Int J Sports Med 21:225, 2000; Person EC et al: Structural
determination of the principal byproduct of the lithium-ammonia reduction method of methamphetamine manufacture. J
Forensic Sci 50:87, 2005; Pline KA et al: The effect of creatine intake on renal function. Ann Pharmacother 39:1093,
2005; Thiblin I et al: Anabolic androgenic steroids and suicide. Ann Clin Psychiatry 11:223, 1999; Trenton AJ et al: Behavioural
manifestations of anabolic steroid use. CNS Drugs 19:571, 2005; Trout GJ et al: Sports drug testing--an analyst's
perspective. Chem Soc Rev 33:1, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Mr. Hooton and Drs. Achar and Baldwin-Johnson were recorded in San Francisco at the 2005 Scientific Assembly, presented
September 28 to October 3, 2005, by the American Academy of Family Physicians (AAFP). The Audio-Digest
Foundation thanks the speakers and the AAFP for their cooperation in the production of this program.
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