United States Government Accountability Office GAO Report to the Committee on Oversight and Government Reform, House of Representatives October 2007 ANABOLIC STEROID ABUSE Federal Efforts to Prevent and Reduce Anabolic Steroid Abuse among Teenagers GAO-08-15 October 2007 ANABOLIC STEROID ABUSE H AccountabilityIntegrityReliability ighlights Federal Efforts to Prevent and Reduce Anabolic Steroid Abuse among Teenagers Highlights of GAO-08-15, a report to the Committee on Oversight and Government Reform, House of Representatives Why GAO Did This Study What GAO Found The abuse of anabolic steroids by There are two categories of federally funded efforts that address teenage teenagers—that is, their use abuse of anabolic steroids. Efforts are either designed to focus on preventing without a prescription—is a health the abuse of anabolic steroids among teenagers or are broader and designed concern. Anabolic steroids are to prevent substance abuse in general—which can include abuse of anabolic synthetic forms of the hormone steroids among teenagers. Two programs that received federal funding during testosterone that can be taken their development and testing, Athletes Training and Learning to Avoid orally, injected, or rubbed on the Steroids (ATLAS) and Athletes Targeting Healthy Exercise & Nutrition skin. Although a 2006 survey Alternatives (ATHENA), are designed to focus on preventing or reducing teen funded by the National Institute on Drug Abuse (NIDA) found that less abuse of anabolic steroids through use of gender-specific student-led than 3 percent of 12th graders had curricula. In addition, there are various research efforts and education and abused anabolic steroids, it also outreach activities that focus on this issue. Two federal grant programs—the found that about 40 percent of 12th Office of National Drug Control Policy’s Drug-Free Communities Support graders described anabolic steroids program and the Department of Education’s School-Based Student Drug as “fairly easy” or “very easy” to Testing program—are designed to support state and local efforts to prevent get. The abuse of anabolic steroids substance abuse in general and may include anabolic steroid abuse among can cause serious health effects teenagers as part of the programs’ substance abuse prevention efforts. In and behavioral changes in 2007, about one-quarter of more than 700 Drug-Free Communities Support teenagers. program grantees reported that they were addressing steroid abuse as one of their program’s objectives. GAO was asked to examine federally funded efforts to address the abuse of anabolic steroids Almost half of the 16 studies GAO reviewed identified certain risk factors and among teenagers and to review behaviors linked to the abuse of anabolic steroids among teenagers. Several of available research on this issue. these studies found connections between anabolic steroid abuse and risk This report describes (1) federally factors such as use of other drugs, risky sexual behaviors, and aggressive funded efforts that address teenage behaviors. Most of the other studies were assessments of the ATLAS and abuse of anabolic steroids, ATHENA prevention programs and in general suggested that the programs (2) available research on teenage may reduce abuse of anabolic steroids and other drugs among high school abuse of anabolic steroids, and athletes immediately following participation in the programs. (3) gaps or areas in need of improvement that federal officials Experts identified gaps in the research addressing teenage abuse of anabolic and other experts identify in research that addresses teenage steroids. Experts identified a lack of conclusive evidence of the sustained anabolic steroid abuse. To do this effectiveness over time of available prevention programs, for example at work, GAO reviewed federal 1 year following participants’ completion of the programs. Experts also agency materials and published identified gaps in the research on the long-term health effects of initiating studies identified through a anabolic steroid abuse as a teenager—including research on effects that may literature review and interviewed be particularly harmful in teens—and in research on psychological effects of federal officials and other experts. anabolic steroid abuse. To view the full product, including the scope and methodology, click on GAO-08-15. For more information, contact Laurie E. Ekstrand at (202) 512-7114 or [email protected]. United States Government Accountability Office Contents Letter 1 Results in Brief 3 Background 4 Some Federally Funded Efforts Are Designed to Focus on Preventing Teenage Steroid Abuse, While Other Efforts Designed to Address Substance Abuse in General May Include Teenagers 9 Research Shows Teenage Anabolic Steroid Abuse Is Linked to Certain Risk Factors and That Prevention Programs May Have Some Short-term Effectiveness 14 Experts Find There Are Gaps in Research on the Sustained Effectiveness of Prevention Programs and on the Long-term Health Effects for Teenagers 16 Agency Comments 17 Appendix I Selected Federally Funded Efforts That Address or Can Address Anabolic Steroid Abuse among Teenagers 18 Appendix II Articles Included in GAO’s Review 21 Appendix III GAO Contact and Staff Acknowledgments 23 Table Table 1: Selected Federally Funded Efforts That Address or Can Address Anabolic Steroid Abuse among Teenagers 18 Figures Figure 1: Reported Lifetime Anabolic Steroid Abuse among 12th Graders, 1991-2006 7 Figure 2: Reported Past Year Anabolic Steroid Abuse by Male and Female Adolescents, 2002-2006 8 Page i GAO-08-15 Teenage Abuse of Anabolic Steroids Abbreviations ATHENA Athletes Targeting Healthy Exercise & Nutrition Alternatives ATLAS Athletes Training and Learning to Avoid Steroids CDC Centers for Disease Control and Prevention HHS Department of Health and Human Services MTF Monitoring the Future NIDA National Institute on Drug Abuse NIH National Institutes of Health ONDCP Office of National Drug Control Policy SAMHSA Substance Abuse and Mental Health Services Administration USADA United States Anti-Doping Agency YRBS Youth Risk Behavior Survey This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page ii GAO-08-15 Teenage Abuse of Anabolic Steroids United States Government Accountability Office Washington, DC 20548 October 31, 2007 The Honorable Henry A. Waxman Chairman The Honorable Tom Davis Ranking Member Committee on Oversight and Government Reform House of Representatives The abuse of anabolic steroids1 by teenagers—that is, their use without a prescription—is a health concern. Anabolic steroids are synthetic forms of the hormone testosterone that can be taken orally, injected, or rubbed on the skin. Although a 2006 survey funded by the National Institute on Drug Abuse (NIDA) showed that less than 3 percent of 12th graders had abused anabolic steroids, the survey also showed that about 40 percent of 12th graders described anabolic steroids as “fairly easy” or “very easy” to get. The abuse of anabolic steroids can cause serious health effects and behavioral changes in teenagers. Under U.S. law, anabolic steroids are controlled substances whose manufacture, possession, and use are regulated by the federal government;2 they also cannot be sold legally without a prescription. You asked us to examine federally funded efforts to address the abuse of anabolic steroids among teenagers and to review available research on this issue. In this report, we 1. describe major, federally funded efforts that address teenage abuse of anabolic steroids, 2. describe the available research on teenage abuse of anabolic steroids, and 1We use the term anabolic steroids to refer to anabolic steroids and their precursors, as defined in the Controlled Substances Act. See 21 U.S.C. § 802 (23), (41). 2The Crime Control Act of 1990 amended the Controlled Substances Act to include anabolic steroids. 21 U.S.C. § 812(c), Schedule III (e). Page 1 GAO-08-15 Teenage Abuse of Anabolic Steroids 3. describe gaps or areas in need of improvement that federal officials and other experts identify in research that addresses anabolic steroid abuse among teenagers. We focused our review on the abuse of anabolic steroids by teenagers in grades 8 through 12. To describe federally funded efforts to address anabolic steroid abuse among teenagers, we reviewed databases of federal grant programs.3 We also obtained and reviewed pertinent reports and information from the Web sites of agencies within the Department of Health and Human Services (HHS)—the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA)— as well as the Web sites of the Department of Education (Education) and the Office of National Drug Control Policy (ONDCP). We used these resources to identify federally funded programs,4 research, and education and outreach activities that address—through efforts to either prevent or reduce—anabolic steroid abuse among teenagers. After identifying these efforts, we interviewed and collected information from federal officials to confirm that these efforts are intended to prevent or reduce anabolic steroid abuse among teenagers. Where available, we requested funding information on the federal efforts that we identified.5 To describe the available research on teenage abuse of anabolic steroids, we conducted a systematic review of the published literature on this topic. We identified 16 articles that related to teenage abuse of anabolic steroids and were published from January 1995 through June 2007. To select the articles, we conducted a keyword search using the Dialog Database System,6 a system that searches numerous database files, and reviewed the 3We searched both the Catalog of Federal Domestic Assistance, a database of federal grant programs maintained by the General Services Administration, and the Computer Retrieval of Information on Scientific Projects, a database of research grants funded by the National Institutes of Health. 4We define federally funded programs as including programs that were developed, implemented, or tested using federal funding. 5The efforts that we discuss in this report may not represent all federally funded activities that address anabolic steroid abuse among teenagers but reflect those efforts mentioned by federal officials with whom we consulted. We were unable to determine the extent of total federal funding for programs that address teenage anabolic steroid abuse because, in some instances, funding information covers more than prevention of teenage anabolic steroid abuse. 6We searched using the keywords anabolic steroids, abuse, addiction, teen, youth, adolescent, prevent, and treat. Page 2 GAO-08-15 Teenage Abuse of Anabolic Steroids resulting article titles and abstracts to identify whether the articles focused on teenage abuse of anabolic steroids. We did not select articles that were international works, based on reviews of other articles or research, position papers, policy statements, or federal agency program documents. The references we make to articles refer strictly to those that we reviewed. To describe the gaps or areas in need of improvement in research that addresses teenage abuse of anabolic steroids as identified by experts, we interviewed experts in anabolic steroid abuse and reviewed relevant literature. We interviewed federal officials from CDC, NIDA, SAMHSA, and Education, as well as other experts from universities and professional associations. We reviewed research articles identifying gaps or areas in need of improvement as part of our systematic review of the literature. We conducted the work for our review from January 2007 through September 2007 in accordance with generally accepted government auditing standards. Results in Brief There are two categories of federally funded efforts that address teenage abuse of anabolic steroids. Efforts are either designed to focus on preventing the abuse of anabolic steroids among teenagers or are broader and designed to prevent substance abuse in general—which can include abuse of anabolic steroids among teenagers. Two programs that received federal funding during their development and testing, Athletes Training and Learning to Avoid Steroids (ATLAS)7 and Athletes Targeting Healthy Exercise & Nutrition Alternatives (ATHENA), are designed to focus on preventing or reducing teen abuse of anabolic steroids. In addition, there are various research efforts and education and outreach activities that focus on this issue. For example, in addition to steroid-related research, since 2000 NIDA has provided nearly $500,000 in funding for a variety of education and outreach activities including a multimedia educational initiative intended to prevent anabolic steroid abuse among teenagers. Two federal grant programs—ONDCP’s Drug-Free Communities Support program and Education’s School-Based Student Drug Testing program— 7ATLAS—the acronym for the prevention program named Athletes Training and Learning to Avoid Steroids—originally stood for Adolescents Training and Learning to Avoid Steroids, which was the title of the NIDA research grants that supported the program’s development. For this reason, some published research describing the program, as listed in appendix II, for example, refers to ATLAS as Adolescents Training and Learning to Avoid Steroids. Page 3 GAO-08-15 Teenage Abuse of Anabolic Steroids are designed to support state and local efforts to prevent substance abuse in general and may include anabolic steroid abuse among teenagers as part of the programs’ substance abuse prevention efforts. In 2007, about one- quarter of more than 700 Drug-Free Communities Support program grantees reported that they were addressing steroid abuse as one of their program’s objectives. Almost half of the 16 studies we reviewed identified certain risk factors and behaviors linked to the abuse of anabolic steroids among teenagers. Several of these studies found connections between anabolic steroid abuse and risk factors such as use of other drugs, risky sexual behaviors, and aggressive behaviors. Most of the other studies we reviewed were assessments of the ATLAS and ATHENA prevention programs. In general, these studies suggested that the programs may reduce abuse of anabolic steroids and other drugs among high school athletes immediately following participation in the programs. Experts identified gaps in the research that addresses anabolic steroid abuse among teenagers. Experts identified a lack of conclusive evidence of sustained effectiveness over time of available prevention programs, for example at 1 year following participants’ completion of the programs. Experts also identified gaps in the research on the long-term heath effects of initiating anabolic steroid abuse as a teenager—including research on effects that may be particularly harmful in teenagers—and in the research on psychological effects. HHS and Education provided technical comments only, which we incorporated into the report as appropriate. Background The abuse of anabolic steroids differs from the abuse of other illicit substances. When users initially begin to abuse anabolic steroids, they typically are not driven by a desire to achieve an immediate euphoria like that which accompanies most abused drugs such as cocaine, heroin, and marijuana. The abuse of anabolic steroids is typically driven by the desire of users to improve their athletic performance and appearance— characteristics that are important to many teenagers. Anabolic steroids can increase strength and boost confidence, leading users to overlook the potential serious and long-term damage to their health that these substances can cause. In addition, the methods and patterns of use for anabolic steroids differ from those of other drugs. Anabolic steroids are most often taken orally or injected, typically in cycles of weeks or months (referred to as “cycling”), rather than continuously. Cycling involves taking Page 4 GAO-08-15 Teenage Abuse of Anabolic Steroids multiple doses of anabolic steroids over a specific period of time, stopping for a period, and starting again. In addition, users often combine several different types of anabolic steroids to maximize their effectiveness (referred to as “stacking”). While anabolic steroids can enhance certain types of performance or appearance, when used inappropriately they can cause a host of severe, long-term, and in some cases, irreversible health consequences. The abuse of anabolic steroids can lead to heart attacks, strokes, liver tumors, and kidney failure. In addition, because anabolic steroids are often injected, users who share needles or use nonsterile injection techniques are at risk for contracting dangerous infections, such as HIV/AIDS and hepatitis B and C. There are also numerous side effects that are gender-specific, including reduced sperm count, infertility, baldness, and development of breasts among men; and growth of facial hair, male-pattern baldness, changes in or cessation of the menstrual cycle, and deepened voice among women. There is also concern that teenagers who abuse anabolic steroids may face the additional risk of halted growth resulting from premature skeletal maturation and accelerated puberty changes. The abuse of anabolic steroids may also lead to aggressive behavior and other psychological side effects. Many users report feeling good about themselves while on anabolic steroids, but for some users extreme mood swings also can occur, including manic-like symptoms leading to violence. Some users also may experience depression when the drugs are stopped, which may contribute to dependence on anabolic steroids. Users may also suffer from paranoia, jealousy, extreme irritability, delusions, and impaired judgment stemming from feelings of invincibility. Two national surveys showed increasing prevalence in teenage abuse of steroids throughout the 1990s until about 2002 and a decline since then (see fig. 1). One of these two national surveys, the Monitoring the Future (MTF) survey, is an annual survey conducted by the University of Michigan and supported by NIDA funding.8 The MTF survey measures drug use and attitudes among students in grades 8, 10, and 12, and asks several questions about the use of and attitudes towards anabolic steroids, such as perceived risk, disapproval, and availability of anabolic steroids. The 8The MTF survey is administered to nationally representative samples of public and private secondary school students throughout the United States. In 2006, sample sizes were about 17,000, 16,600, and 14,800 in 8th, 10th, and 12th grades, respectively. In all, about 48,500 students in 410 secondary schools participated in the 2006 survey. Page 5 GAO-08-15 Teenage Abuse of Anabolic Steroids survey’s questions are designed to assess respondents’ use of steroids in the last 30 days, the past year, and over the course of the respondent’s lifetime. Questions about steroid use were added to the study beginning in 1989. The most recent results from this survey showed that in 2006, 2.7 percent of 12th graders said they had used anabolic steroids without a prescription at least once. The second national survey, the Youth Risk Behavior Survey (YRBS), is a biennial survey conducted since 1991 by CDC.9 The YRBS is part of a surveillance system consisting of national, state, and local surveys of students in grades 9 through 12. These surveys collect information about a wide variety of risk behaviors, including sexual activity and alcohol and drug use. The most recent available national YRBS survey—conducted in 2005—asked one question related to lifetime steroid use without a prescription, which showed that 3.3 percent of 12th graders had used steroids at least once. 9The sampling frame for the 2005 national YRBS survey consisted of all public and private schools with students in at least one of grades 9 through 12 in the 50 states and the District of Columbia. For the 2005 national YRBS survey, 13,953 questionnaires were completed in 159 schools by a nationally representative sample of students in grades 9 through12. Page 6 GAO-08-15 Teenage Abuse of Anabolic Steroids