Anabolic–Androgenic Steroids as a Gateway to Opioid Dependence
Athletes who abuse anabolic-androgenic steroids may go on to abuse opioid agonist-antagonists such as nalbuphine or even classic opioids such as heroin.
We studied this phenomenon among patients treated at Sunrise House, a private inpatient facility for substance-dependence treatment in northern New Jersey. Among 227 men admitted for dependence on heroin or other opioids in 1999, we found that 21 (9.3 percent) had a history of anabolic-androgenic steroid use. In contrast, among 197 men admitted for opioid dependence in 1990, only 1 (0.5 percent) reported prior use of anabolic-androgenic steroids).
None of the 21 men in 1999 reported any form of substance abuse or dependence before their use of anabolic-androgenic steroids. The mean (±SD) age at the time of their first use of anabolic-androgenic steroids was 20.9±2.4 years and the age at the time of their first use of opioids was 27.0±4.0 years. The information they provided strongly suggests that they were introduced to opioids through anabolic-androgenic steroid use and the bodybuilding subculture: 17 of the 21 men (81 percent) first purchased opioids from the same drug dealer who had sold them anabolic-androgenic steroids; 14 (67 percent) were introduced to opioids by a fellow bodybuilder; 18 (86 percent) claimed that they first used opioids to counteract insomnia and irritability induced by anabolic-androgenic steroids; and 14 (67 percent) had used opioids to counteract depression associated with withdrawal from anabolic-androgenic steroids. All 21 of the men reported at least one of these four attributes.
Demographically, these men appeared atypical for opioid users; they all lived in suburban New Jersey and reported a mean household income of $69,800 (range, $38,000 to $145,000). They reported serious associated morbidity. Since the time of their first use of opioids, 15 (71 percent) had been charged with possession of a controlled substance or prescription fraud; 5 (24 percent) had served time in prison, including 1 for attempted murder; and 7 (33 percent) had made at least one suicide attempt. In the 1 to 11 months since their discharge from Sunrise House, 17 (81 percent) have relapsed into opioid use, and 2 (10 percent) have committed suicide.
These findings suggest an alarming trend: that anabolic-androgenic steroids may serve as "gateway" drugs to opioid dependence, with substantial associated morbidity and even mortality. Although our study cannot establish that anabolic-androgenic steroid use per se led to opioid dependence in these men, the data we report strongly suggest this interpretation. Alternatively, what we observed might be specific to our facility, but our facility is in a region not noted for unusually high rates of either anabolic-androgenic steroid use or opioid dependence. Progression from anabolic-androgenic steroid use to opioid dependence deserves further exploration as a public health problem.
Lafayette, NJ 07848
Harrison G. Pope, Jr., M.D.
Harvard Medical School
Boston, MA 02115
N Engl J Med. 2000 May 18;342(20):1532.