Anabolic Androgenic Steroids: Emerging Use Disorder, Mechanisms of Action, and Clinical Considerations for Pharmacotherapy

Anabolic androgenic steroids (AAS) are synthetic versions of testosterone that are frequently used as performance-enhancing drugs. Over the past few decades, these drugs have become more popular and readily available through online clinics and retail outlets. At the same time, increasing evidence has demonstrated their addictive potential and the likely emergence of an AAS use disorder. In addition to their impact on reward pathways, which is similar to that of other addictive substances, AAS have an addiction-related unique mechanism involving hormonal dysregulations of the hypothalamic-pituitary-gonadal axis that frequently result in long-term post-use hypogonadism, prompting patients to develop tolerance and continue to use AAS despite harms. In caring for patients with a likely AAS use disorder, a multidisciplinary care team is needed, including professionals in the fields of psychiatry, addiction medicine, and endocrinology, to screen for and treat body or muscle dysmorphia (if present) and hypogonadism, and to mitigate unwanted consequences of AAS use by using primary care and harm-reduction methods.