Q: How would I know if my body-building friend is abusing steroids?

Q: How would I know if my body-building friend is abusing steroids?

A: Anabolic steroids are one of several substances abused as a performance-enhancing-drug. The goal of this abuse is to enhance athletic performance and/or improve physical appearance. Other PEDs include growth hormone, drugs or techniques to increase red blood cell count (this may include blood transfusions, medications that stimulate red blood cell production, others), and many other substances (including certain recreational drugs).

Androgenic steroids are what many people think of when they say anabolic steroids (in this article I will simply use the term "steroids"); you can think of these as testosterone-like substances. These are either naturally occurring or synthetically made hormones that stimulate the body to increase lean muscle mass and decrease body fat.

Steroid abuse is common, and it is not limited to professional athletes. One study noted that steroid abuse was higher among recreational athletes than professional athletes (18 percent vs. 13 percent), possibly due to professional athletes' concern for testing and "getting caught." A report from the Centers for Disease Control and Prevention in 2013 noted that more than 3 percent of all high school students had taken steroids without a doctor's prescription at least once, and this was more common in males than females. The average onset of steroid abuse is late teens to early 20s, the years where concerns about body image, competitiveness and peer pressure are often very pronounced.

Unlike many other drugs of abuse, steroids do not give an immediate "high" feeling of euphoria, but the enhancement they give people from their altered physical appearance and/or physical performance can be just as addicting. More than one in three people who abuse steroids become physically dependent on them, manifested by drug cravings and withdrawal symptoms when they are stopped.

Steroid abusers get their drugs from the internet, coaches, other athletes, trainers and sometimes even medical professionals. Steroids may be injected (so they have all the risks of any IV/IM drug abuse), ingested, or even absorbed through the skin from certain cream or gel formulations. Like with so many drugs of abuse, it is common that someone starts them at low doses "to see what effect they will have." This may progress to escalating doses, increasing doses in crescendo fashion with periods of abstinence (pyramiding) and/or combining different types of steroids (stacking).

Anabolic steroids have been banned by the World Anti-Doping Agency for good reason; they can have significant adverse medical consequences. These include heart problems (for example cardiac hypertrophy, where the heart wall muscles become overly "thick"), increased formation of blood clots (including the complications of these such as pulmonary embolism), liver disease, kidney disease and/or neuropsychiatric issues. These complications can be severe and even life-threatening. Acne is another possible side effect from steroid abuse.

In addition, males that abuse steroids will often develop hypogonadism (small, decreased functioning testicles since the steroids they take cause their testicles to stop normal production of testosterone) and/or breast enlargement (the increased level of hormones cross-react with hormone receptors in the breasts, causing growth). Women who abuse steroids may develop excess hair growth (facial hair, excess body hair) and deepening of their voice.

The neuropsychiatric symptoms are most commonly noted by friends and family of steroid abusers. "Roid rage," where the patient develops bursts of anger and rage (think "the Hulk") is the symptom commonly portrayed on TV, but there are many types of neuropsychiatric symptoms that are more common. These include mood changes, risk-taking behavior (potentially including criminal behavior), depression, agitation and/or others.

Although many types of anabolic steroids can be found from testing of body fluids (blood and/or urine), this type of testing most often occurs in relationship to sports (think about the Major League Baseball and Olympic doping scandals), and other competitive situations (for example, body building, etc.). For most steroid abusers, their drug abuse only comes to light when it is suspected based on symptoms.

Patients who abuse steroids need counseling, often in a group environment like with other substance abusers, to help them quit. They need to be monitored medically for the potential affects that may have occurred from their abuse, as well as for possible complications from withdrawal (which can include exacerbation of depression and even suicidal tendencies).

Steroid abuse should be considered in at-risk people (athletes, those with body perception issues, etc.), with an increased suspicion if they display certain behavior changes (mood changes, depression, aggressive behavior, irritability, etc.), have rapid changes in muscle mass and/or develop certain physical characteristics (acne or behavior changes in either sex, small testicles and/or large breasts in men, hair growth and/or deepening voice in women). If you suspect steroid abuse in a friend or loved one, encourage them to seek counseling. As with any substance abuse, be sure you are being supportive of their journey to better health but are not enabling their addiction.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com