The development of multiple drug use among anabolic-androgenic steroid users: six subjective case reports

The development of early combined drug use starting with AAS

John had a difficult childhood. He felt that he did not receive any love from his mother since she did not bother much about him. He was also subjected to sexual abuse by a relative. He was slender during his teens and bullied by his classmates. For this reason he began training at a gym at the age of 16. His goal was to increase both his strength and his body mass. After four years of training, at the age of 20, one of his gym mates advised him to start taking AAS to enhance the effects of the training, which he did. He soon noticed considerable effects on his training and also enhanced emotional well-being.

After using AAS for some time, he took the advice of some more experienced gym mates and began taking anti-estrogens in order to prevent gynecomastia. He also started using ephedrine, other bronchodilators and dietary supplements that contained ephedrine in order to make him more energetic and to enable him to train harder. He felt both psychologically and physically well when taking ephedrine and started using this even when not using AAS. He also began taking testosterone releasers to speed up his own hormone production. The tough training regimen he now followed led to pain in his muscle insertions and ligaments, which prompted him to begin also taking analgesics. John trained regularly and heavily, sometimes several times a day.

His social interactions became increasingly limited to other AAS users and his knowledge about the drugs and their effects grew rapidly. As a child he was very shy, particularly in relation to girls. He had no contact with girls but instead developed sexual fantasies that occupied a great deal of his time and that has continued into adulthood. When he was twenty-four years of age, he met a woman at the gym and they embarked on a relationship, which was a new experience for him.

In this period of life, the most important thing for him was training at the gym and his life became increasingly focused upon medication, diet and training. In order to train even more, he began using amphetamines; he felt that this helped him to keep alert during training. His experience was that amphetamines allowed him to train even harder. Amphetamines made him feel good mentally but also led to difficulties in relaxing after training. He therefore began taking hashish and benzodiazepines to help him wind down and sleep better. He was now using amphetamines more frequently because he found them to be wonderful for recreational use. John had previously drunk alcohol sparsely but now began using alcohol more frequently to help him sleep and as recreation at the weekends.

Altogether, John was taking fourteen human and veterinary AAS products during a period of five years (oral: oxymetholone, stanozolol, methandrostenolone and methenolone acetate; injected: trenbolone acetate, testosterone blends, boldenone, nandrolone esters, methenolone and stanozolol). Throughout the training period he ate or drank dietary supplements (e.g. protein and various products containing protein, creatine and ephedra) with the purpose of enhancing the effects of training.

Initially, John felt the positive effects from his AAS use far outweighed the negative. He describes increased self-confidence, improved libido and affirmation from both men and women in his surroundings. However, despite using various medications to counteract psychological and physical problems, he experienced more and more negative effects. He experienced testicle shrinkage, skin lesions and potency problems. He also began to experience hallucinations, depression, mood swings, aggressiveness and feelings of persecution. His sexual fantasies also became more marked.

By the age of 25, after five years of AAS abuse, he was tested for AAS use at the gym at which he trained. His regimen at this time included nandrolone decanoate and amphetamine. When the tests proved positive, he was barred from the gym. John cites this as the stimulus for his increasing use of amphetamine and alcohol, although he discontinued both training and AAS. His use of other drugs of abuse and alcohol worsened, with associated severe social problems. His company ran out of business, his girlfriend left him, he failed to pay his rent and he became destitute. It was in this situation that he sought help from the addiction clinic, mainly because of his psychological problems.

The development of late combined drug use starting with AAS

Joe grew up with his biological parents. He was and remains very close to his mother but was often beaten by his father, with whom he had a very remote relationship. Joe describes his upbringing as very strict because of his father's principles. At school he was often afraid and teased for being small. However, he completed his schooling with top grades. In his early teens, he was prescribed analgesics for frequent headaches and he has continued to take them ever since.

At 16 years of age, he started training at the bench press at a gym and, at the same age, he began drinking alcohol. He drank a fair amount of alcohol in his late teens but, because he felt it impaired his training, he decided to completely quit alcohol in his early twenties. When he was 21 years of age, he felt he had reached a plateau in his training. A friend told him to try AAS to enhance his training. His first course consisted of oral AAS (stanozolol, oxymetholone and testosterone undecanoate) and the associated rapid improvement in strength he experienced prompted him to continue using AAS.

Joe combined AAS with ephedrine and other ephedra preparations to perk himself up. He also took dietary supplements such as protein powder and other protein supplements, creatine, nutritional replacements and multivitamins. He learned from other AAS users at the gym that he could also add anti-estrogens and testosterone releasers in order to counteract the unwanted effects of AAS. He has had to use a number of medications to counteract what he believed to be side effects from his AAS use and hard gym training, including analgesics for pain from over-training, benzodiazepines for insomnia, and analgesics for headaches and pain in muscles and joints.

He combined a painkiller containing codeine with water in a plastic bottle from which he drank continually while at the gym so that he could train harder and longer.

He also took muscle relaxants immediately after a training session. Altogether, he used thirteen different AAS medications during 16 years of AAS abuse (oral: fluoxymesterone, methandrostenolone, methenolone acetate, oxymetolone, stanozolol and testosterone undecanoate; injected: nandrolone esters, stanozolol, several testosterone injections, testosterone blends and trenbolone acetate).

He felt that his self-confidence was much improved when using AAS and he described experiencing better control of his feelings so that he never felt afraid when he was in a confrontational situation. He became stronger and gained weight and felt that his healing capacity was improved. With time, however, the negative effects increased in number and severity. He had previously found it easy to mix with girls. Now he became markedly jealous, had violent mood swings, outbreaks of aggression and frequent depression. He also describes an emotional numbness in relation to others. The physical problems included wear and tear of his joints, testicular atrophy, gynecomastia, acne, blood in his urine, kidney pain and infected skin lesions. The cost of supporting his drug use also continued to rise, leading to criminal behaviour.

At the age of 30, he began using other drugs of abuse, including amphetamines and cocaine. Initially, he took these drugs to increase his ability to train but later he also started taking them at parties for recreational purposes. His other drugs of abuse increased rapidly in number and he began using hashish as well. He sought treatment because of his narcotics use and for the troubling physical and psychological problems he believed were derived from AAS.

The early development of a complex usage of hormone preparations

Sune had good contact with his father and siblings during his childhood, but contact with his mother was not as good and he describes her as having alcohol and psychological problems. Sune had many friends at school and has maintained contact with several of them later in life. He was never bullied or the victim of any kind of violence. The only problem he recalls from childhood was that he became aggressive rather easily.

He began training at a gym with some friends at about 15 years of age and, when he was 16, he and some friends became curious about whether AAS would give supplementary effects. Even before he began trying AAS, Joe had started using various dietary supplements such as protein and creatine. The first AAS he bought was a testosterone product that was to be injected into the buttock. He experienced clear positive results from this, predominantly as an increase in weight and strength. He noted, however, that he became more irritable. He soon began using AAS more steadily. He used oral AAS (methandrostenolone, stanozolol), injectible varieties (nandrolone esters, different testosterone blends and trenbolone cyclohexylmethylcarbonate) and a fluid form of AAS (unknown name) that could be administered as drops under the tongue.

He later combined AAS with growth hormone and insulin. He took these hormones hoping that this combination would produce even quicker muscle growth. He also started using an anti-estrogen so as to reduce the risk of gynecomastia and testosterone releasers to enhance his own hormone production. Other substances that were added later were ephedrine, prohormones, anticatabolics and testosterone boosters. He was able to train harder and more frequently while using AAS; however, pain in his muscle insertions and joints soon developed. He therefore started taking analgesics in order to be able to train despite the pain.

When he started using hormones, he also started taking protein and creatine supplements and various plant steroid compounds. After four years of abuse and 10 different human steroid products, when he was about 20 years old, his regimen consisted of AAS drugs (nandrolone ester, methandrostenolone) in combination with insulin, testosterone releasers and ephedrine.

Sune experienced mainly positive effects from AAS, particularly in the beginning. He mentioned increased strength and weight gain above all but also a feeling of attractiveness to girls. His sexual drive was considerably increased after the debut of AAS. Sune was, however, at that time also troubled by hair growth on his back, skin lesions between his shoulder and chest musculature, acne, potency problems, testicular atrophy and a cough that bothered him particularly after taking testosterone preparations. He had also suffered serious psychological problems such as pathological jealousy, mood swings, depression and aggressiveness. Several times he had become so angry that he smashed up the furniture at his parents' house. He also attempted to commit suicide. Sune also sometimes had memory problems and his fixation with his body was greatly increased. His parents contacted the addiction clinic because they felt their son's personality had undergone such a radical change.

The development of body fixation and a complex usage of hormone preparations

Bill describes his childhood in glowing terms. He had good contact with his parents and a younger sister. He was very active in sports such as football, ice hockey, boxing and tae kwando while he was growing up. After leaving home at the age of 15, he stopped these sports and took up training at a gym instead. His training became so intense and time-consuming that his schoolwork began to suffer. He completed his schooling with poor grades.

After a few years of training, he became increasingly focused on competing in the field of bodybuilding. Bill had read about AAS and, while he was thinking about starting to compete, he felt he needed to begin taking AAS so as to increase his body size, since he believed everyone in elite level bodybuilding was using AAS. He was 20 years old when he began taking AAS. The first course consisted of oral methandrostolone and injections of testosterone blends. He described the positive effects as including increased body bulk and strength as well as a powerful "pump" feeling, particularly in his biceps, when he was training. He described the feeling when the blood pumped into a specific muscle as almost orgasmic. He also described increased libido and significantly enhanced self-confidence that meant he "felt like a king in the town". He sought out fights because it gave him a "good feeling" when others were afraid of him. Bill soon became preoccupied with his AAS use and began reading more about preparations, training and AAS. He found advice that prompted him to start using testosterone releasers for speeding up his own hormone production.

He had previously begun using dietary supplements such as protein and creatine and now he added other compounds. His strength and body bulk increased but he wanted to become even bigger. He now began using a combination of AAS and other hormone preparations such as growth hormone, insulin and IGF-1 (Insulin growth factor 1).

During the four years of AAS use, he used a total of nine different human and veterinary AAS preparations: oral AAS consisting of methandrostenolone, stanozolol and testosterone undecanoate and injectible AAS in the form of boldenone, nandrolone ester, various testosterone blends and trenbolone acetate. The whole time that Bill was training, he used stimulants such as ephedrine and sometimes bronchodilators to reduce fat and fluid in the muscle tissues. He has also tested other drugs of abuse such as amphetamines and hashish at parties and has used alcohol occasionally.

The second to last course he took, which included nandrolone esters, testosterone blends, growth hormone, insulin, and testosterone releasers, resulted in such a drastic drop in blood sugar level that he was hospitalized. The first time he sought help at the addiction clinic he described himself as severely depressed. The reason he gave was that he had gone from weighing 128 kg to, as he said, "only 124 kg". He said he could not imagine going back to his old gym where everyone would see how "small he had become". In order to gain weight quickly he therefore began his last course of AAS. During this course, he had such drastic physical and psychological problems that he decided to completely stop using AAS.

Altogether, he suffered a range of physical problems such as breast development, acne, skin lesions, testicular atrophy, reduced libido and fatigue. Psychologically, he felt depressed, with mood swings, increased aggressiveness, panic attacks and pronounced body fixation. Sometimes, under the influence of AAS, he would wander around the streets of his hometown looking for fights because he felt himself to be invincible. While using AAS, he developed a criminal career and was sentenced several times for various acts of violent crime.

The development of the use of enhancing drugs and an extreme body fixation

Irene describes her childhood as very problematic. She felt she was pushed aside as a child because her brothers always came first. She also experienced sexual harassment by a close relative and was bullied in school. In her early teens, she became increasingly fixated with her body, constantly asking others what they thought of it. Irene completed her schooling with poor grades.

As a teenager she was very active in several sports and at the age of 17 she began training at a gym as a complement to her handball training. She felt good and she believed that her body became more beautiful thanks to the tough gym training. She soon quit her other sports and decided to begin gym training to compete in bodybuilding. She was then convinced that a prerequisite for success in this sport was the use of AAS, and this led to her AAS debut at the age of 20. The first course, which lasted three months, consisted of stanozolol injections. She felt that, once she had begun using AAS, her body fixation intensified. During the second course, she took not only AAS injections but also growth hormone (hGH). Her psychological problems, with mood swings, anxiety and irritation, worsened.

She soon began experiencing more physical problems, such as clitoris enlargement, hair loss and yellowing of her skin. In the six years during which she used hormones, she used four different types of AAS (oral: methandrostenolone and stanozolol; injected: methenolone enanthate and stanozolol). She also took several courses that included hGH. Early on in her AAS use, she also used ephedrine and other preparations to reduce subcutaneous fat and fluid in the muscles (e.g. bronchodilators and a drug which contained a combination of ephedrine, caffeine and aspirin).

Irene trained far harder after starting to take hormones. Sometimes she would train several times a day, which led to pains in her muscle insertions. She began taking analgesics in order to continue training despite the pain. She became much stronger after starting to use AAS, and she then preferred to train with men. Because she was afraid of building up fat or retaining fluid, she has only occasionally used dietary supplements over the years and, when she has done so, has primarily taken protein supplements. She tested creatine but stopped because of weight gain. Irene was just over 26 when she stopped using AAS after a final course consisting of oral methenolone acetate, an ephedra preparation, ephedrine tablets and bronchodilators.

Irene describes the positive effects she experienced with AAS as increased muscle bulk, a harder body and a psychological boost including improved self-confidence. However, she also notes psychological problems that at times were considerable, such as jealousy, extreme body fixation, powerful mood swings, aggressiveness and recurrent depression including suicidal fantasies.

She has tried various anti-depressant medications, all of which she discontinued because she felt they made her retain fluid. She has also undergone breast enhancement surgery and her voice became deep. Irene describes how she became very popular among men and she had an increased sex drive leading to unfaithfulness. She has lived in several partnerships but all of them broke up because of her body fixation and her extreme jealousy, which often led to maltreatment of partners. Irene sought treatment at the addiction clinic for her psychological problems, particularly for her fixation with her body. Before she came to the clinic she had met several doctors but had not found them helpful since they knew so little about AAS.

The development of oscillating drugs of abuse and AAS use

Sonja grew up with her biological mother and an older sister. Their parents divorced when the girls were very young and their mother refused to allow them to meet their father. Sonja describes her upbringing as slack. Their mother was described by Sonja as selfish and the girls were allowed to do as they pleased. Her schooling was rife with problems and she quit school at the age of fourteen. She found it difficult to concentrate in class and often fought with her teachers and with other students. Sonja became more interested in sports after leaving school and involved herself in several, including running and swimming.

She travelled overseas to work at the age of 17 and remained there for one and a half years. After this, she returned home and met a man who was using other drugs of abuse. Her contact with him was her gateway into drug use, and he introduced her to amphetamine. Sonja then stopped all her sports and instead developed quite a severe problem with drug use, including heroin and other opiates, amphetamines and analgesics. Later, she also included hashish and cocaine.

At the age of 21, she met a man who was using AAS. Under his influence, she also started to train at the gym. Since she wanted to have a larger and stronger body, she began using AAS (oral methandrostenolone), and she discontinued her use of drugs of abuse. Sonja's self-confidence improved and she felt generally good taking AAS, which led her to continue with testosterone undecanoate and stanozolol. While taking this course, she noticed that her skin became greasier, her hair looked unwashed, and she had more acne, mood swings and outbreaks of aggression. She was now training seven days a week at the gym, sometimes twice a day. She began to take dietary supplements such as protein, creatine, vitamins and sometimes CLA (Conjugated Linoleic Acid) to keep her weight under control.

Her aggressiveness worsened after starting AAS use and she increasingly frequently got into fights in order to find release for these feelings. She began walking around town looking for someone to fight with because fighting gave her a sense of satisfaction. She felt she was truly alive on these occasions. She bought herself a dog, which she also beat when it did not behave. During her nine months of AAS use, she used oral methandienone, testosterone undecanoate and stanozolol. She also took ephedrine and clenbuterol before training. After a drug-free period she once again began taking other drugs of abuse, although in smaller quantities than before.

She finally stopped taking AAS after encountering problems such as pain and acne but above all because of her aggression and suicide attempts. She was also arrested several times for her involvement in fights. She had previously been sentenced for theft but her criminality increased markedly after she began using AAS. She was then sentenced for drugs of abuse and doping offences. She sought treatment for her drug problem, which had increased to include ecstasy, amphetamines, buprenorfin and benzodiazepines.