Providers may still be working on a protocol for treating young athletes using anabolic steroids, but practitioners and scientific literature have evidence-based methods for preventing and identifying performance enhancing substance use (PES) in sports, as well as some limited treatment suggestions.
The following recommendations apply not just to pediatricians and sports medicine specialists. "Get away from the perception that this is an adolescent problem [only]," said Harrison Pope, MD, a psychiatrist at McLean Hospital who has authored several articles on PES use. Most users are men in their 20's and 30's, including weekend warriors, he notes. "Nobody else is watching them -- no parents, no coaches. They're independent people and the clinician may be the only person who sees that individual."
Prevention
"These are not recreational [drugs], they're goal-directed," said Michelle LaBotz, MD, who co-authored an American Academy of Pediatrics 2016 clinical report on PES use. So she advises providers suggest other strategies for athletes to achieve their goals besides using PES; "don't say don't use, but steer them towards good nutrition, recovery, a resistance training program."
School-based educational programs may complement medical care in the future, according to a new study in Frontiers in Psychology evaluating a media literacy campaign. "The findings of the school 6-month intervention suggest that it was effective in eliciting positive attitude changes in students' views of illegal PAES and doping substances. More importantly, the intervention also seemed to exert an effect on reducing students' self-reported use of legal PAES," the authors wrote. "Efficacious anti-doping interventions in school settings are a viable way to reach a large audience of young people and, hopefully, reinforce their anti-doping beliefs and attitudes."
More research on this approach is needed, according to the study's authors and the authors of a 2016 article, who wrote: "The efficacy of education about PED use as a preventative measure (overall) needs further study."
Diagnosis
"A diagnosis can be made by watching a patient walk through the door," Pope said.
But if patients do not walk through the door looking like Stewie Griffin in this episode of "Family Guy," diagnosing PES use is more complicated. Start by asking them about weightlifting and fitness, "and work from there to supplements," Pope suggests. "Talk and get the patient to elaborate." If you start to suspect PES use, continue the conversation.
Avoid an interrogating tone because many users are ashamed and afraid of divulging their use. "You've got to explore the issue sympathetically," Pope cautions.
Be prepared, he adds: "Just have some familiarity with the substances, supplements especially ... basic familiarity with the language and those drugs and how one can get them." Citing his own experience, he adds: "Once they realize I am familiar with the disorder, then they open up."
Providers who are not knowledgeable should refer patients to colleagues who are, Pope said.
Providers seeing adolescents should mine for acne and violent outbursts, LaBotz said, and ask parents if they have noticed mood changes. Anxiety could be another sign, indicating patients are taking a stimulant they get from a friend; Adderall abuse has emerged in sports, for example.
Pope said another sign to look out for is a ruptured tendon, especially in the patient's upper body, citing a study he co-authored in 2015.
Providers can leverage pre-participation evaluations, which are required by many school districts and recreational sports organizations for kids to play; they "may represent the only healthcare provider encounter in a given year" for athletes, according to a 2015 article published in American Journal of Sports Medicine. "The medication history (in particular) provides an opportunity for the physician to query athletes about anabolic steroid, stimulant, or illicit drug use."
Treatment
The lack of scientific literature notwithstanding, LaBotz cautions against instructing steroid users to quit using cold-turkey: "That's when their mood goes into the deepest, darkest places and there's a withdrawal phenomenon." She recommends primary care providers refer users to endocrinology and mental health specialists.
UptoDate also has advice: "A man who wishes to stop abusing androgens should be encouraged to do so but warned that he will become hypogonadal for up to several months before he recovers endogenous gonadotropin secretion and testicular function," according to UptoDate's page on athlete PES use. "He should be monitored every few months until recovery occurs. Human chorionic gonadotropin (hCG) should not be prescribed."
A few recent articles support motivational interviewing for pediatric patients, which can cultivate within them "motivation for avoiding or altering drug use behavior," wrote the authors of a recent review in American Journal of Lifestyle Medicine. "At the same time, this process builds confidence in the athlete's ability to enhance their natural ability through undergoing puberty and utilizing evidence-based nutrition and physical training regimens."
"There is little research available to guide counselling (sic) and psychiatric approaches to treatment of athletes who abuse drugs," according to a 2016 article in International Review of Psychiatry. "However, motivational interviewing approaches may be used since athletes may often present in the pre-contemplation stage of change."
"Providers," the authors added, "should also assess for and treat comorbid mental illness."
To treat patients using dietary supplements, "don't overstate the danger," LaBotz said, citing creatine's relatively harmless profile as an example. "They all know people that are taking it that are doing perfectly fine."
Indeed: "Exaggeration of evidence on one side or another will do little to dissuade an athlete intent on using and will likely erode trust," Katherine Newsham, PhD, a St. Louis University physical therapy and athletic training professor, wrote in a recent editorial.
LaBotz instead recommends counseling patients that these supplements are not effective and not a shortcut to athletic success, and lack FDA oversight. "Then counsel kids, point out a different way to achieve their goals," LaBotz added. (Make sure parents are aware of potential contamination, especially with supplements ordered online, LaBotz and Pope said.)
Informing athletes about long-term dangers is recommended, however, if athletes are using steroids. "But that may fall on deaf ears because if you are 18 and want to get big in a hurry, you are not worried about a heart attack later in life," Pope warned.
Studies and polls back Pope up. "Many athletes choose to dope despite being aware of the possible consequences," according to the American Journal of Lifestyle Medicine review. "By definition, outperforming others is a goal of competitive athletics and thus, [PES] use may be perceived as rational behavior in a competitive athlete's mind."
This is where treatment really gets nebulous. Young patients often admit their use to a provider confidentially from their parents, and these athletes "may have no interest in getting treated," Pope said. "But you've got to keep confidentiality as long as it's not too dangerous."
And how do you know if it's not too dangerous? Rob Garibaldi was in college when he committed suicide a decade ago. The baseball player's psychiatrist kept his steroid use confidential from his parents after he opened up to the doctor, according to the book Suicide Squeeze.
"He was no longer responsible for himself," Rob's mother told author William Kashatus. "He was delusional and may well have been suicidal from the combination of all the drugs." She acknowledged the doctor-patient confidentiality principle but nevertheless was angry with the psychiatrist for not informing her.
This is anecdotal evidence, but what should Garibaldi's psychiatrist have done?
Perhaps the answer lies in the research.