Review Article

“LONG TERM EFFECT OF ANABOLIC STEROIDS USE ON PHYSICAL AND

MENTAL HEALTH”

Noor Zaman | Term Project | Date 03-06-2024

Project Supervisor: Prof. Dr. Imtiaz Mahmood Tahir

FACULTY OF MEDICAL SCIENCES

COLLEGE OF ALLIED HEALTH PROFESSIONALS
GOVERNMENT COLLEGE UNIVERSITY FAISALABAD
"LONG TERM EFFECT OF ANABOLIC STEROIDS USE
ON PHYSICAL AND MENTAL HEALTH”

ABSTRACT:

Anabolic steroids are a kind of synthetic derivative from testosterone hormones, which help in
muscle buildup and improvement in performance but come along with serious long-term health
hazards. This review tries to bring together available research findings to illustrate extensively
these effects on physical and mental fitness. Physiologically, anabolic steroids cause increased
muscle hypertrophy with significant health implications attached. Some of the common
cardiovascular conditions are hypertension, dyslipidemia and high risk of myocardial infarction.
The endocrine system is marked by hormonal imbalances for example infertility as well as
hypogonadism. Liver damage, indicated by hepatotoxicity, is another critical concern.
Psychologically, there may be mood swings and aggression commonly known as “roid rage.”
Use of this drug leads to addiction and dependence hence patients take it for a long time suffer
from severe mental disorders such as depression or even psychosis. Thus, musculoskeletal
disorders, cardiovascular diseases or chronic endocrine disturbances have a negative impact on
public health. These consequences depend on the dosage, duration of use; age sex and genetic
factors differ among users decide whether they will happen at all or not. There are some ways to
prevent this menace. Introduction prevention programs can reduce the rate at which people start
taking drugs while medical surveillance could tackle physical damages that might occur through
steroid usage. Psychological support/counseling is highly needed for people suffering from
mental illness due steroid abuse. Public health initiatives and policy changes are vital to address
this problem comprehensively. Future studies should focus on patient-specific interventions and
underlying mechanisms to better inform clinical care and public health policies.

Keywords: Anabolic steroids, long-term effects, physical health, mental health,

cardiovascular diseases, endocrine disruption, psychological impact, addiction, prevention
strategies, public health.
1. INTRODUCTION

Athletes and bodybuilders frequently take anabolic-androgenic steroids (AAS), which are
synthetic versions of testosterone, to increase physical performance and improve appearance [1].
Since the 1940s, AAS have become more and more popular; in the United States alone, there are
thought to be between 2.9 and 4.2 million users [2]. AAS are only legally accessible with a
prescription, yet they are widely used and distributed illegally [3]. AAS are widely used,
particularly among young adults and athletes, due to their ease of access via internet pharmacies
and underground markets [4].

AAS are used not just by professional athletes, but also by beginner athletes and bodybuilders to
boost their physical look and outcomes [5]. AAS use among young adults has significantly
increased due to the desire to develop a muscular physique and improve sports performance;
according to some research, up to 4% of high school students have used AAS [6].

1.1. Significance of Long-term Effects on Health

Although much research has focused on the immediate effects of anabolic-androgenic steroids
(AAS) usage, the long-term implications on mental and physical health remain less understood.
AAS usage is linked to a host of health issues, including mental illnesses, liver, and heart disease
[4, 5]. AAS can lead to addiction and dependence, making it crucial to investigate the enduring
consequences of their use. Long-term AAS usage is particularly concerning due to its potential to
cause chronic organ and tissue damage [6]. Prolonged use can result in cardiac muscle
hypertrophy, increasing the risk of heart failure and sudden death. This hypertrophy often leads
to left ventricular hypertrophy, which impairs the heart's ability to pump blood effectively,
exacerbating cardiovascular complications. AAS usage has been associated with arrhythmias,
thrombosis, and myocardial infarction, further escalating cardiovascular risks [7].
The effects on the liver are equally alarming. Chronic AAS use can lead to hepatotoxicity,
manifesting as liver inflammation, fibrosis, and in severe cases, hepatocellular carcinoma. The
liver's role in metabolizing steroids means it is particularly vulnerable to long-term damage,
which can culminate in life-threatening conditions such as liver failure. AAS use also
significantly impacts the endocrine system. Chronic use disrupts the hypothalamic-pituitary-
gonadal axis, leading to hypogonadism, characterized by reduced testosterone production,
infertility, and secondary sexual characteristic atrophy. This hormonal imbalance can persist
even after discontinuation of AAS, causing prolonged health issues. Psychologically, AAS users
are at an increased risk of mood disorders, including depression, anxiety, and aggression, often
referred to as "roid rage." Long-term AAS use can also lead to dependency and addiction, with
withdrawal symptoms mirroring those of other substance use disorders. The structural and
functional changes in the brain associated with AAS use increase the risk of cognitive decline
and mental health disorders. These changes can affect areas of the brain responsible for mood
regulation, decision-making, and impulse control, leading to persistent psychological issues.
Moreover, long-term AAS use can affect musculoskeletal health, leading to conditions such as
tendon ruptures and osteoporosis. The suppression of natural testosterone production can also
reduce bone density, making users more susceptible to fractures. the long-term use of anabolic
steroids poses significant risks to both physical and mental health. It is essential to continue
researching these effects to develop effective mitigation strategies and inform public health
policies. Public health initiatives, education, and comprehensive intervention programs are vital
in addressing the complex health issues associated with long-term AAS use.

1.2. Purpose of the Review Article

The goal of the review article is to present a thorough summary of the long-term impacts of AAS
use on mental and physical health. We want to uncover potential dangers and repercussions
associated with chronic use of AAS by integrating the existing information. Healthcare experts,
athletes, and legislators will be better able to comprehend the effects of AAS usage and create
preventive, intervention, and treatment measures with the use of this knowledge.
The review will concentrate on the risks associated with AAS use, including dependency and
addiction, as well as the impact on liver function, psychiatric problems, cardiovascular health,
and cognitive performance. We will also look at the possible long-term harm to reproduction and
the impact of AAS use on the hypothalamic-pituitary-testicular axis and the endocrine system.
We will also go into the psychological and social elements that influence the use of AAS,
including as peer pressure, body image issues, and the need for social status. We will also look at
the moral ramifications of using AAS, such as the influence on public health and the possibility
of unfair advantage in sporting events.
2. PHYSIOLOGICAL EFFECTS OF ANABOLIC STEROIDS

2.1. Muscle Growth and Strength Enhancement

Athletes and bodybuilders frequently utilize anabolic-androgenic steroids (AAS) to increase

muscle mass and strength. AAS operate by boosting protein synthesis, resulting in increased
muscular mass and strength. This is achieved through several mechanisms, including the
enhancement of nitrogen retention in muscles, leading to an anabolic state conducive to muscle
growth. Strength and muscular mass can be significantly increased by using AAS, especially in
the short term. However, the prolonged use of AAS can disrupt the natural production of
hormones due to the negative feedback loop on the hypothalamic-pituitary-testicular axis,
causing a plateau in muscle growth and strength, and potentially leading to a reduction in muscle
mass and strength. AAS can increase muscle mass as a result of enhanced protein synthesis,
which in turn causes an increase in muscular growth and strength. Additionally, AAS boost the
synthesis of insulin-like growth factor-1 (IGF-1), which promotes the development of stronger
and more muscular tissue. This hormone plays a crucial role in muscle regeneration and repair,
further contributing to increased muscle mass. AAS also elevate testosterone levels, which are
vital for muscle hypertrophy and strength gains. Testosterone, the primary male sex hormone,
enhances muscle protein synthesis and inhibits protein breakdown, leading to net muscle growth.

However, the benefits of AAS use are accompanied by significant risks. Long-term AAS use can
lead to a reduction in the body's natural testosterone production, causing hypogonadism. This
condition is characterized by low testosterone levels, which can lead to decreased muscle mass,
strength, and overall physical performance. Moreover, chronic AAS use can result in the
development of muscle dysmorphia, a psychological condition where individuals perceive
themselves as insufficiently muscular despite significant muscle gains, leading to continued and
potentially harmful use of steroids. In summary, while AAS can significantly enhance muscle
growth and strength in the short term, their long-term use can disrupt hormonal balance, reduce
natural testosterone production, and lead to psychological disorders, highlighting the need for
cautious and informed use.
2.2. Cardiovascular Effects
AAS use has been connected to a number of cardiovascular side effects, such as elevated blood
pressure, heart enlargement, and altered lipid profiles. AAS use can cause a rise in blood
pressure, increasing the chance of cardiovascular disease. The mechanisms underlying this
involve increased blood viscosity and the retention of sodium and water, contributing to
hypertension. Furthermore, the use of AAS may result in myocardial hypertrophy, raising the
possibility of heart failure and unexpected death. This hypertrophy often involves both the left
and right ventricles, impairing cardiac function and leading to arrhythmias. Moreover, using
AAS may alter lipid profiles, raising low-density lipoprotein (LDL) cholesterol and lowering
high-density lipoprotein (HDL) cholesterol, both of which raise the risk of cardiovascular
disease. These changes in lipid metabolism can lead to atherosclerosis, increasing the risk of
coronary artery disease and peripheral vascular disease. The elevated blood pressure and cardiac
output caused by AAS might result in cardiac hypertrophy and lipid profile alterations, among
other cardiovascular effects. Furthermore, AAS may raise the synthesis of inflammatory markers
such as C-reactive protein (CRP), which may elevate the risk of cardiovascular disorders.
Elevated CRP levels indicate systemic inflammation, which is a known risk factor for
atherosclerosis and other cardiovascular conditions.

In addition to these effects, AAS use has been linked to endothelial dysfunction, impairing the
ability of blood vessels to dilate properly. This dysfunction is a precursor to atherosclerosis and
can further exacerbate the risk of cardiovascular events. The chronic use of AAS is also
associated with increased platelet aggregation, which can lead to thrombosis, thereby increasing
the likelihood of stroke and myocardial infarction. Overall, the cardiovascular effects of AAS are
multifaceted, involving a range of mechanisms that collectively heighten the risk of severe
cardiovascular disease. This underscores the need for medical monitoring and intervention for
individuals using or recovering from AAS use to mitigate these significant health risks.

2.3. Endocrine System Disruption

Anabolic androgenic steroids (AAS) profoundly disrupt the endocrine system, primarily by
altering the hypothalamic-pituitary-testicular (HPT) axis. The administration of AAS suppresses
the production of gonadotropin-releasing hormone (GnRH) from the hypothalamus. This
suppression leads to a downstream decrease in the secretion of luteinizing hormone (LH) and
follicle-stimulating hormone (FSH) from the pituitary gland. Consequently, reduced LH and
FSH levels impair the testicular production of testosterone and spermatogenesis, leading to
conditions such as hypogonadism and infertility. AAS use also causes an imbalance in other
hormone levels. The excess androgens introduced by AAS can be aromatized into estrogens,
resulting in elevated estrogen levels in the body. This increase in estrogen can lead to
gynecomastia, characterized by the development of breast tissue in men, and other feminizing
effects such as a higher-pitched voice and fat distribution typically seen in females.

Moreover, prolonged AAS use can cause adrenal gland suppression, affecting cortisol
production. This can lead to an adrenal crisis if AAS use is abruptly stopped, as the body’s
ability to produce natural cortisol is impaired. The endocrine disruption extends to thyroid
function as well, with potential alterations in thyroid hormone levels, which can affect
metabolism and energy balance. These endocrine disruptions are complex and multifaceted,
involving intricate feedback mechanisms. The negative feedback loop created by exogenous
AAS disrupts normal hormonal signaling, which not only affects physical health but also has
significant implications for mental health. Therefore, understanding the full scope of AAS-
induced endocrine disruption is crucial for developing effective treatment and mitigation
strategies. Regular monitoring and endocrine evaluations are recommended for individuals using
or recovering from AAS abuse to manage and mitigate these adverse effects.

2.4. Liver Damage

The use of anabolic-androgenic steroids (AAS) has been associated with significant
modifications in the structure and function of the liver. These changes can manifest in both
biochemical and structural alterations that can have serious health consequences. One of the
primary indicators of liver damage is the increase in liver enzymes, such as aspartate
transaminase (AST) and alanine transaminase (ALT). Elevated levels of these enzymes in the
bloodstream are often used as biomarkers to assess liver function, and their increase can indicate
hepatocellular damage due to the use of AAS. Additionally, these biochemical changes, AAS can
cause structural alterations in the liver. These alterations include the development of hepatic
cysts and tumors, such as hepatocellular adenomas and, in more severe cases, hepatocellular
carcinoma. These tumors can be benign or malignant, and their growth is often stimulated by the
synthetic hormones present in AAS. The formation of liver cysts can further complicate liver
function and potentially lead to more severe liver diseases if left untreated.
AAS use also promotes liver damage by increasing inflammatory markers, such as C-reactive
protein (CRP). Elevated CRP levels are indicative of inflammation and have been correlated with
an increased risk of liver injury. This inflammation can exacerbate liver damage and contribute
to a cycle of ongoing liver injury. Furthermore, AAS usage can lead to oxidative stress by
increasing the production of reactive oxygen species (ROS). ROS are highly reactive molecules
that can cause significant cellular damage, including lipid peroxidation, protein oxidation, and
DNA damage. The elevated ROS levels in the liver can overwhelm the organ's antioxidant
defenses, leading to oxidative stress and further liver damage. In conclusion, the use of AAS
poses a significant risk to liver health by causing both biochemical and structural changes. The
elevation of liver enzymes, the formation of cysts and tumors, the increase in inflammatory
markers, and the rise in reactive oxygen species all contribute to the potential for severe liver
damage. Long-term use of AAS can lead to chronic liver conditions, emphasizing the need for
awareness and monitoring among users.

3. PSYCHOLOGICAL EFFECTS OF ANABOLIC STEROIDS

3.1. Mood Swings and Aggression

The use of anabolic-androgenic steroids (AAS) has been linked to significant behavioral and
emotional changes, including increased frustration and aggression. These substances can cause
users to experience dramatic mood swings, shifting rapidly from happiness to sadness, and
becoming more abrasive and antagonistic. This phenomenon is often referred to as "roid rage," a
condition characterized by extreme irritability, anger, and outbursts of aggression.

Studies have shown that individuals using AAS are more likely to exhibit aggressive behaviors
and engage in violent acts. The heightened aggression and irritability can lead to conflicts in
various aspects of life, including social interactions, workplace environments, and personal
relationships. For instance, an individual under the influence of AAS might react
disproportionately to minor annoyances, leading to strained relationships and potentially
resulting in social isolation. The mood fluctuations associated with AAS use are not limited to
negative emotions. Users may also experience periods of euphoria and heightened confidence,
which can further complicate their emotional state. The rapid cycling between these extreme
moods can be exhausting and confusing, both for the individual and those around them. The
unpredictability of these mood swings can cause significant distress and impair the individual's
ability to maintain stable relationships and function effectively in their daily life.

Apart from aggression and mood swings, AAS use can contribute to other psychological issues
such as anxiety, paranoia, and even psychosis. These conditions can exacerbate the user's
emotional instability and increase the risk of engaging in harmful behaviors. Long-term AAS
users may also experience chronic depression and suicidal ideation, especially when they attempt
to stop using the drugs. The psychological dependence on AAS, coupled with the withdrawal
symptoms, can make it challenging for individuals to cease usage without professional help. The
impact of AAS on mental health underscores the need for awareness and education about the
potential psychological risks associated with these substances. Individuals considering AAS use
should be informed about the possible emotional and behavioral consequences, and those already
using AAS should be encouraged to seek support and treatment to mitigate these effects.

3.2. Addiction and Dependence

Anabolic-androgenic steroids (AAS) use can lead to significant addiction and dependence, much
like other substance use disorders. The addiction to AAS is characterized by continued use
despite the presence of adverse physical, psychological, and social consequences. This
compulsive use is often driven by the desire to enhance physical appearance and performance,
leading to a distorted self-image and a reliance on the drugs to maintain perceived
improvements. Several studies indicate that AAS users may experience a range of withdrawal
symptoms when they stop using the substances. These symptoms include severe depression,
heightened anxiety, irritability, and pronounced fatigue. Additionally, users may face insomnia,
loss of appetite, decreased libido, and in severe cases, suicidal ideation. The intensity of these
withdrawal symptoms can vary based on the duration and dosage of AAS use.

The addiction and dependence associated with AAS use often create a challenging cycle of
continued use. Individuals attempting to quit may relapse due to the overwhelming withdrawal
symptoms, the psychological dependence on the drug to maintain body image, and social
pressures within certain subcultures, such as bodybuilding and competitive sports. This cycle can
be exacerbated by underlying mental health issues, such as body dysmorphic disorder or low
self-esteem, which AAS users might be attempting to self-medicate. Long-term AAS use can
lead to significant changes in brain chemistry, particularly affecting neurotransmitter systems
like dopamine and serotonin, which are associated with reward and mood regulation. These
changes can further entrench addiction and make recovery more difficult. Therefore, addressing
AAS addiction often requires comprehensive treatment approaches, including psychological
counseling, medical intervention, and support groups to address both the physical and
psychological aspects of dependence.

Understanding the complex nature of AAS addiction and dependence is crucial for developing
effective prevention and treatment strategies. Public health campaigns aimed at educating young
athletes and fitness enthusiasts about the risks of AAS, coupled with accessible treatment
programs, can help mitigate the widespread issue of AAS addiction.

3.3. Psychiatric Disorders

The use of anabolic-androgenic steroids (AAS) has been linked to a variety of psychiatric
disorders, significantly impacting mental health. Research has shown that individuals who use
AAS are at an increased risk for experiencing severe anxiety and depression. These mental
health issues are not just transient but can lead to long-term psychological consequences.
Anxiety in AAS users often manifests as heightened levels of stress, panic attacks, and an overall
sense of unease that can interfere with daily functioning. Similarly, depression linked to AAS use
can be profound, leading to feelings of hopelessness, a lack of interest in previously enjoyed
activities, and severe mood swings.

One of the most concerning aspects of AAS-induced psychiatric disorders is the potential for
suicidal ideation and behavior. Studies have indicated that the depressive symptoms associated
with AAS use can escalate to such a degree that users may contemplate or attempt suicide. This
is particularly alarming given the relatively young age of many AAS users, who may not have
the coping mechanisms or support systems in place to manage these intense psychological
effects. AAS use has been associated with psychotic episodes, which can be characterized by
delusions and hallucinations. Delusions may involve irrational beliefs or paranoia, such as
thinking that others are out to get them or believing in their own invincibility. Hallucinations can
include seeing or hearing things that are not present, which can be extremely distressing and
dangerous. These psychotic symptoms can lead to impaired judgment and risky behaviors,
further complicating the individual's mental health status.

The psychiatric disorders linked to AAS use are multifaceted and can exacerbate pre-existing
mental health conditions or lead to the development of new disorders. The biochemical effects of
AAS on the brain, including alterations in neurotransmitter systems such as serotonin and
dopamine, are thought to underpin these psychological changes. Chronic use of AAS can disrupt
the natural balance of these chemicals, leading to mood disturbances and cognitive impairments.
It is crucial for healthcare providers to be aware of these potential psychiatric effects when
treating individuals who use or have used AAS. Early detection and intervention can help
mitigate some of the severe psychological consequences. Psychological counseling, psychiatric
care, and support groups can be integral parts of a comprehensive treatment plan to address the
mental health needs of AAS users.

3.4. Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a mental condition characterized by a distorted perception
of one’s body image and an obsession with perceived physical flaws. This disorder leads
individuals to become excessively concerned about their appearance, often focusing on minor or
imagined imperfections. The use of anabolic-androgenic steroids (AAS) has been increasingly
connected to the development and exacerbation of BDD. Individuals who use AAS may develop
a distorted body image, believing that their bodies are inadequate despite being muscular or well-
built. This obsession often drives them to continue using the drug in pursuit of an ideal physique,
even in the face of significant negative physical and psychological consequences.

The prevalence of BDD among AAS users is notably higher compared to the general population.
Research suggests that AAS users with BDD are more likely to engage in risky behaviors to
enhance their muscle size and definition. These behaviors can include excessive exercising,
restrictive dieting, and the continuous use of steroids despite adverse health effects. The fixation
on achieving a perfect body can lead to a cycle of steroid dependence, where the user feels
compelled to use increasing amounts of the drug to attain their desired physique. The
psychological effects of AAS use can intensify the symptoms of BDD. The euphoria and
increased self-confidence initially experienced with steroid use can quickly turn into anxiety,
irritability, and mood swings. These mood disturbances can exacerbate the obsessive thoughts
and compulsive behaviors associated with BDD, creating a vicious cycle that is difficult to break.
The individual’s quality of life may significantly deteriorate as they become more consumed by
their perceived flaws and the relentless pursuit of an unattainable body image. The physical
consequences of prolonged AAS use can also impact mental health. Long-term steroid use is
associated with a range of adverse effects, including cardiovascular problems, liver damage, and
endocrine disorders. These health issues can further contribute to the distress and body
dissatisfaction experienced by individuals with BDD, reinforcing their dependence on steroids to
cope with their insecurities.

Treatment for individuals with BDD and AAS dependence typically involves a combination of
psychotherapy and medical intervention. Cognitive-behavioral therapy (CBT) is particularly
effective in addressing the distorted body image and obsessive thoughts characteristic of BDD.
In severe cases, pharmacological treatments, such as selective serotonin reuptake inhibitors
(SSRIs), may be prescribed to help manage symptoms. It is crucial for healthcare providers to
adopt a holistic approach, addressing both the psychological and physical aspects of the disorder
to support recovery and improve the individual’s overall well-being. In conclusion, the
relationship between anabolic-androgenic steroids and body dysmorphic disorder is complex and
multifaceted. The use of AAS can trigger and exacerbate BDD symptoms, leading to a harmful
cycle of dependence and deteriorating mental health. Understanding this connection is essential
for developing effective treatment strategies and providing comprehensive care for those affected
by both conditions.

3.5. Eating Disorders

Anabolic-Androgenic Steroids (AAS) use has been linked to the development of various eating
disorders, including anorexia and bulimia nervosa. This association is particularly prevalent
among individuals who use AAS to enhance their physical appearance and athletic performance.
The drive for a muscular and lean physique can lead to unhealthy behaviors centered around
food intake and body weight management. Users of AAS often become intensely focused on
their diet and body composition, striving to achieve an idealized body image. This preoccupation
can manifest as restrictive eating, where individuals severely limit their caloric intake to reduce
body fat while maintaining muscle mass. Such restrictive behaviors may resemble those seen in
anorexia nervosa, where there is an intense fear of gaining weight and a distorted body image.
AAS users may also engage in purging behaviors, including self-induced vomiting and the
misuse of laxatives or diuretics. These behaviors are similar to those observed in bulimia
nervosa, where individuals cycle between episodes of binge eating and compensatory behaviors
to prevent weight gain. The pressure to maintain a certain body shape and size can drive AAS
users to adopt these harmful eating practices. The psychological effects of AAS, such as mood
swings, irritability, and anxiety, can exacerbate the risk of developing eating disorders. The
anxiety and obsession with body image can create a cycle where individuals continually strive
for an unattainable physical ideal, leading to further psychological distress and disordered eating
patterns.

Studies have shown that the prevalence of eating disorders is higher among AAS users compared
to non-users, highlighting the significant impact of AAS on mental health. The combination of
psychological pressure, societal expectations, and the pharmacological effects of steroids can
create a potent risk factor for the development of eating disorders. Addressing the psychological
effects of AAS, including the risk of eating disorders, requires a comprehensive approach.
Healthcare providers should be aware of the signs and symptoms of disordered eating in
individuals using AAS and provide appropriate interventions. This may include counseling,
nutritional guidance, and mental health support to address both the physical and psychological
aspects of AAS use. Early intervention and education about the risks associated with AAS and
the importance of healthy body image perceptions can help prevent the development of eating
disorders in at-risk populations. Promoting awareness about the potential psychological
consequences of AAS use is crucial in mitigating these adverse effects and supporting the overall
well-being of individuals.

3.6. Cognitive Impairment

The use of anabolic-androgenic steroids (AAS) has been connected to cognitive impairment,
which includes reduced attention, memory, and executive functioning. Studies indicate that AAS
users often exhibit deficits in various cognitive domains, such as verbal learning and memory,
visuospatial abilities, and information processing speed. These impairments may be due to the
neurotoxic effects of AAS on the brain, particularly in regions such as the hippocampus and
prefrontal cortex, which are critical for cognitive functions. One study conducted by Lundholm
et al. (2010) found that AAS users performed worse on memory and executive function tests
compared to non-users. The neuropsychological deficits observed in AAS users could be
attributed to alterations in neurotransmitter systems, oxidative stress, and neuroinflammation
caused by prolonged steroid use.

Reduced cognitive performance in AAS users may cause issues with relationships and day-to-
day living. Impairments in attention and memory can lead to difficulties in managing everyday
tasks, maintaining employment, and fulfilling social responsibilities. For example, an individual
with decreased attention span may struggle to focus on conversations, leading to
misunderstandings and conflicts in personal relationships. Additionally, memory impairments
can result in forgetfulness, affecting one's ability to remember important dates, appointments,
and responsibilities, further complicating social and occupational functioning. The cognitive
deficits associated with AAS use can exacerbate other psychological issues such as depression,
anxiety, and aggression. The interplay between cognitive impairments and these psychological
conditions can create a vicious cycle, where cognitive difficulties contribute to psychological
distress, and vice versa. This can lead to a decline in overall mental health and well-being,
making it challenging for individuals to cope with everyday stressors and demands. The
cognitive impairments linked to AAS use are significant and multifaceted, affecting various
aspects of cognitive functioning and daily life. Addressing these impairments through
appropriate medical and psychological interventions is crucial for improving the quality of life of
AAS users and mitigating the adverse effects on their mental health.

3.7. Sleep Disturbances

The use of anabolic-androgenic steroids (AAS) has been closely linked to a variety of sleep
disorders, including sleep apnea and insomnia. These conditions can severely impact the overall
quality of life for users. One of the significant sleep disturbances associated with AAS is sleep
apnea. Sleep apnea is a serious condition characterized by repeated interruptions in breathing
during sleep. This can lead to fragmented sleep and reduced oxygen levels in the blood, causing
significant daytime fatigue and other health issues. Studies have shown that AAS users are at a
higher risk of developing obstructive sleep apnea due to the influence of these substances on
muscle growth, including the muscles around the airway, which can lead to their abnormal
enlargement and contribute to airway obstruction during sleep.
Insomnia, another common sleep disturbance among AAS users, involves difficulty in falling
asleep, staying asleep, or waking up too early and not being able to get back to sleep. Insomnia
can be acute or chronic and can lead to various negative outcomes such as impaired cognitive
function, mood disturbances, and decreased overall functioning. The stimulant effects of certain
steroids can increase the level of alertness and restlessness, thereby making it difficult for users
to achieve restful sleep. The poor-quality sleep resulting from these disturbances can
significantly affect daily functioning. Chronic sleep deprivation can lead to impaired cognitive
performance, decreased productivity, and increased susceptibility to mental health issues such as
depression and anxiety. Additionally, the lack of restorative sleep can hinder physical recovery
and performance, which is particularly detrimental for athletes and bodybuilders who rely on
optimal recovery for peak performance.

The exact mechanisms through which AAS induce sleep disturbances are not entirely understood
but are believed to involve several factors. Hormonal imbalances caused by AAS can disrupt the
natural sleep-wake cycle. For instance, elevated levels of androgens can interfere with the
production of melatonin, a hormone that regulates sleep. Moreover, AAS can induce changes in
neurotransmitter systems, such as the serotonin and dopamine pathways, which play crucial roles
in mood regulation and sleep patterns. Long-term use of AAS and the resulting sleep
disturbances can have severe health consequences. Chronic sleep apnea, if left untreated, can
lead to cardiovascular issues such as hypertension, heart attacks, and stroke. Persistent insomnia
can increase the risk of developing psychiatric disorders, including major depressive disorder
and generalized anxiety disorder. Therefore, it is crucial for AAS users to be aware of these risks
and seek appropriate medical advice to manage and mitigate these potential health issues. So, the
use of anabolic-androgenic steroids is strongly associated with significant sleep disturbances,
including sleep apnea and insomnia. These conditions can profoundly impact the quality of life,
daily functioning, and long-term health of users. Understanding the risks and mechanisms behind
these sleep issues is essential for developing effective strategies to prevent and treat them.
4. Long-term Health Implications

4.1. Musculoskeletal Complications

Anabolic steroid use has been connected to a number of musculoskeletal issues, such as
osteoporosis, muscular strains, and ruptured tendons [2, 33]. Prolonged use of these drugs may
increase the risk of tendon rupture, especially in the Achilles, quadriceps, and rotator cuff
tendons [34]. Muscle rips and strains can also be caused by an excessive amount of strain on the
muscles [9].

Additionally, the use of anabolic steroids has been linked to a higher risk of osteoporosis,
especially in older persons [35]. Increased risk of fractures and osteoporosis can result from the
reduction of natural testosterone production, which also lowers bone density [36].

4.2. Cardiovascular Diseases

Anabolic steroid use has been connected to a number of cardiovascular conditions, such as
myocardial infarction, cardiac hypertrophy, and hypertension [37, 38]. Long-term use of these
drugs may raise the risk of high blood pressure, which in turn raises the risk of myocardial
infarction and cardiac hypertrophy [34].

Furthermore, it has been shown that using anabolic steroids increases the risk of heart attack and
sudden heart failure [4]. The use of these drugs may interfere with the cardiovascular system's
normal operation, raising the risk of cardiovascular illnesses [39].

4.3. Endocrine Disorders

Anabolic steroid use can cause a number of endocrine diseases by interfering with the endocrine
system's normal function [40]. Extended use of these drugs may result in hypogonadism, a
condition marked by a reduction in the body's natural synthesis of testosterone [2].

The use steroids can interfere with the normal function of the endocrine system, resulting in a
variety of endocrine disorders [40]. Long-term use of these medications may lead to
hypogonadism, a disorder characterized by a decrease in the body's normal production of
testosterone [2].

4.4. Mental Health Disorders

A number of mental health conditions, such as sadness, anxiety, and psychotic episodes, have
been connected to the use of anabolic steroids [24, 41]. Long-term usage of these drugs may
raise the chance of depression, which in turn may raise the danger of anxiety and psychotic
episodes [13].
Furthermore, the use of anabolic steroids has been linked to a higher risk of violence and
aggression, especially in people with a history of mental health issues [42]. The use of these
drugs raises the risk of mental disorders by interfering with the brain's normal function [32].

5. Factor Influencing Long-term Effects

5.1. Dosage and Duration of Use

The dose and duration of anabolic steroid use have a major impact on long-term physical and
mental health. High doses and longtime usage are linked to more severe and long-lasting
deleterious effects [27]. According to a research in the Journal of Clinical Endocrinology and
Metabolism, anabolic steroid users who used higher dosages for longer periods of time had more
severe hepatic and cardiovascular side effects than those who used lower doses for shorter
periods of time [2]. Furthermore, the mode of administration—oral versus injectable—may have
an effect on how severe the long-term effects are [9].

5.2. Age and Gender

Age and gender have a significant impact on the long-term effects of anabolic steroids use.
Given their continued physical and mental growth, adolescents and young adults may be more
vulnerable to the harmful effects of anabolic steroids [43]. Compared to adult males, teenage
boys who used anabolic steroids had more severe consequences on their mental health, such as
anxiety and depression, according to a study published in the Journal of Psychiatric Research
[35]. Moreover, the long-term effects of the drug may differ for men and women; men may
experience more severe effects on the heart and liver, while women may experience more severe
effects on the reproductive system and hormones [2].
5.3. Genetic Predispositions
One possible factor contributing to the long-term impacts of anabolic steroid use is genetic
predisposition. People who have a family history of certain illnesses, like mental illness or
cardiovascular disease, may be more vulnerable to the harmful consequences of anabolic steroids
[27]. According to a research in the Journal of Clinical Endocrinology and Metabolism, people
who are genetically predisposed to cardiovascular disease were found to have more severe
cardiovascular side effects when using anabolic steroids than people who are not [9].
Furthermore, the response to anabolic steroids and their long-term consequences can be
influenced by genetic differences in hormone metabolism and receptor sensitivity [2].

5.4. Concurrent Substance Abuse

The long-term consequences of using anabolic steroids can be made worse by concurrent
substance addiction, including abuse of alcohol, tobacco, or other narcotics. The use of many
drugs, or polypharmacy, might raise the possibility of negative side effects and medication
interactions, which can result in longer-term consequences that are more severe and persistent
[27]. According to a study that was published in the Journal of Psychiatric Research, people who
used anabolic steroids with other drugs had worse mental health consequences than people who
used them alone, such as anxiety and depression [36]. Moreover, using drugs concurrently can
raise your chance of addiction and mental health issues.

6. Mitigation Strategies

6.1. Education and Prevention Programs

Programs for prevention and education are crucial for reducing the long-term negative impacts of
anabolic steroid usage on mental and physical health. These initiatives can be put into practice in
a number of contexts, such as communities, educational institutions, and medical facilities. These
initiatives seek to:
 Increase public knowledge of the dangers and repercussions of anabolic steroid use [27].
 Give precise information regarding the impact of anabolic steroids on mental and
physical well-being [2].
 Promote healthy living choices and alternate strategies for reaching fitness objectives [9].
  Recognize and assist anyone who could be using anabolic steroids at risk [43].

6.1.1. Effective education and prevention programs can be achieved through:

 Engaging seminars and workshops [44]
 Internet resources and social media campaigns[32]
 Working together with role models and influencers[7]
 Incorporation into health education initiatives and school curricula[45]

6.2. Medical Monitoring and Intervention

Incorporation the long-term negative impacts of anabolic steroid usage on mental and physical
health must be lessened through medical supervision and intervention. A key role for healthcare
practitioners is in:

 Recognizing and treating the use of anabolic steroids and associated health problems [2].

 Providing care and treatment for associated medical conditions [32].

 Watching for any unfavorable reactions and negative effects [43].

 Directing people to receive specialized assistance and services[46]

6.2.1. Effective medical monitoring and intervention can be achieved through:

 Frequent screenings and check-ups for health [7]
 Working together with interdisciplinary teams and specialists[47]
 Protocols for treatment and management based on evidence[48]
 Referrals to specialty treatments including mental health and cardiology[49]
 Tailored treatment programs and aftercare [2].
 Keeping an eye out for possible adverse effects and drug interactions [50].
 Resources and assistance for people and their families[51]
 Instruction on risk management and safe usage[52]
6.3. Psychological Support and Counseling
Counseling and psychological support are crucial for reducing the long-term negative impacts of
anabolic steroid use on mental health. Professionals in mental health can offer the following
services:
 Evaluation and diagnosis of mental health issues connected to the use of anabolic steroids
[2].
 Evidence-based treatments, including motivational interviewing and cognitive-behavioral
therapy [53].
 Assistance and direction for people and their families [51]
 Advisory regarding special services and resources[54]

6.3.1. Effective psychological support and counseling can be achieved through:

 Sessions of both individual and group therapy [55]
 Family counseling and assistance [56]
 Working together with diverse teams and healthcare providers[57]
 Making a recommendation for specialist resources, like support groups and addiction
treatment [58].

7. Conclusion

7.1. Recap of key findings

The substantial long-term impacts of anabolic steroid use on both physical and mental health
have been brought to light by this review. According to available data, using anabolic steroids
may raise the risk of infectious diseases [40], cause liver damage [5], renal damage [41], and
cause cardiovascular disease [2]. Additionally, the use of anabolic steroids has been linked to a
number of mental health conditions, such as anxiety, depression, and psychotic episodes [53, 59,
and 40]. Anabolic steroid use can also result in addiction and dependence [60], with users
suffering withdrawal symptoms after stopping the medication.
7.2. Implications for public health and policy
The long-term consequences of using anabolic steroids have a big impact on public policy and
health. Policymakers and medical professionals need to be aware of the dangers of anabolic
steroid usage and take action to prevent and treat health problems brought on by anabolic
steroids [61]. Increasing knowledge and instruction regarding the dangers of anabolic steroid
usage is one way to do this, especially for athletes and young people [62]. In addition, authorities
should think about tightening laws governing the use and sale of anabolic steroids [63] and
promoting research and therapy initiatives [64].

7.3. Areas for future research

Even though the substantial long-term repercussions of anabolic steroid use have been brought to
light by this assessment, several areas still need more investigation. Future research ought to look
at how anabolic steroid usage affects particular groups of people, like women and teenagers [59],
as well as any possible connections between anabolic steroid use and other issues related to drug
use. Research should also concentrate on creating efficient programs for the prevention and
treatment of anabolic steroid use, which should include pharmacological and behavioral
treatments [65].

References:

1. Pope Jr, H.G., et al., The lifetime prevalence of anabolic‐androgenic steroid use and dependence
in Americans: Current best estimates. The American journal on addictions, 2014. 23(4): p. 371-
377.
2. Kaufman, M.J., et al., Brain and cognition abnormalities in long-term anabolic-androgenic
steroid users. Drug and alcohol dependence, 2015. 152: p. 47-56.
3. Miech, R.A., et al., Monitoring the Future National Survey Results on Drug Use, 1975-2022:
Secondary School Students. Institute for Social Research, 2023.
4. Lincoff, A.M., et al., Cardiovascular safety of testosterone-replacement therapy. New England
Journal of Medicine, 2023. 389(2): p. 107-117.
5. Takyar, V. and A. Stolz, Spectrum of drug induced liver injury caused by anabolic androgenic
steroids abuse. Current Hepatology Reports, 2019. 18: p. 417-424.
6. Pope Jr, H.G. and G. Kanayama, Anabolic–androgenic steroids, in Drug abuse and addiction in
medical illness: Causes, consequences and treatment. 2012, Springer. p. 251-264.
7. Baggish, A.L., et al., Cardiovascular toxicity of illicit anabolic-androgenic steroid use.
Circulation, 2017. 135(21): p. 1991-2002.
8. Wood, R.I. and K.G. Wallin-Miller, Neurobiology of anabolic-androgenic steroid abuse, in
Oxford Research Encyclopedia of Neuroscience. 2019.
9. Bhasin, S., et al., Effect of testosterone replacement on measures of mobility in older men with
mobility limitation and low testosterone concentrations: secondary analyses of the Testosterone
Trials. The lancet Diabetes & endocrinology, 2018. 6(11): p. 879-890.
10. Maior, A.S., et al., Chronic users of supraphysiological doses of anabolic androgenic steroids
develop hematological and serum lipoprotein profiles that are characteristic of high
cardiovascular risk. International Journal of Sport and Exercise Science, 2011. 3(2): p. 27-36.
11. Gregersen, I., et al., Elevated interleukin 8 and matrix metalloproteinase 9 levels are associated
with myocardial pathology in users of anabolic-androgenic steroids. European Journal of
Preventive Cardiology, 2024: p. zwae126.
12. Van Breda, E., et al., Androgenic anabolic steroid use and severe hypothalamic-pituitary
dysfunction: a case study. International journal of sports medicine, 2003. 24(03): p. 195-196.
13. Hauger, L.E., Hooked on Hormones: Long-term anabolic androgenic steroid use and
dependence. 2020.
14. Bjørnebekk, A., Long-term anabolic androgenic steroid use is associated with deviant brain
aging Astrid Bjørnebekk1, PhD, Tobias Kaufmann2, 3 PhD, Lisa E. Hauger1, PhD, Sandra
Klonteig1, Ingunn R. Hullstein4, Lars T. Westlye2, 5, 6, PhD The Anabolic Androgenic Steroid
Research Group, Section for clinical addiction research, the Division of Mental Health and
Addiction, Oslo University Hospital, Oslo, Norway.
15. Modlinski, R. and K.B. Fields, The effect of anabolic steroids on the gastrointestinal system,
kidneys, and adrenal glands. Current sports medicine reports, 2006. 5(2): p. 104-109.
16. Tavares, A.S.R., et al., Impact of anabolic steroid consumption on biochemical and
hematological parameters in bodybuilders: A systematic review and evidence gap mapping.
Performance Enhancement & Health, 2024: p. 100280.
17. Zahaki-Jamil, M. and F. Rahmani-Nia, The Impact of Anabolic–Androgenic Steroids Use on the
Liver Enzymes (ALT, AST, ALP) and Hematologic Parameters in Male Bodybuilders. Journal of
Advances in Medical and Biomedical Research, 2016. 24(104): p. 29-38.
18. Kocar, I., et al., The effect of testosterone replacement treatment on immunological features of
patients with Klinefelter's syndrome. Clinical & Experimental Immunology, 2000. 121(3): p. 448-
452.
19. Hartgens, F. and H. Kuipers, Effects of androgenic-anabolic steroids in athletes. Sports medicine,
2004. 34: p. 513-554.
20. Vorona, E. and E. Nieschlag, Abuse of Anabolic Androgenic Steroids (AAS) for Doping, in
Andrology: Male Reproductive Health and Dysfunction. 2023, Springer. p. 585-597.
21. Kanayama, G., et al., Treatment of anabolic–androgenic steroid dependence: Emerging evidence
and its implications. Drug and alcohol dependence, 2010. 109(1-3): p. 6-13.
22. BELCHIOR SANTOS, J.P., et al., NEUROLOGICAL CONSEQUENCES OF ABUSIVE USE OF
ANABOLIC-ANDROGENIC STEROIDS. Brazilian Journal of Surgery & Clinical Research, 2020.
32(2).
23. Piacentino, D., et al., Anabolic-androgenic steroid use and psychopathology in athletes. A
systematic review. Current neuropharmacology, 2015. 13(1): p. 101-121.
24. Ponce, O.J., et al., The efficacy and adverse events of testosterone replacement therapy in
hypogonadal men: a systematic review and meta-analysis of randomized, placebo-controlled
trials. The Journal of Clinical Endocrinology & Metabolism, 2018. 103(5): p. 1745-1754.
25. Bjørnebekk, A., et al., Cognitive performance and structural brain correlates in long-term
anabolic-androgenic steroid exposed and nonexposed weightlifters. Neuropsychology, 2019.
33(4): p. 547.
26. Morrison, T.R., L.A. Ricci, and R.H. Melloni Jr, Anabolic/androgenic steroid administration
during adolescence and adulthood differentially modulates aggression and anxiety. Hormones
and behavior, 2015. 69: p. 132-138.
27. Kanayama, G., J.I. Hudson, and H.G. Pope Jr, Anabolic-androgenic steroid use and body image
in men: a growing concern for clinicians. Psychotherapy and Psychosomatics, 2020. 89(2): p. 65-
73.
28. Harris, M.A., T. Alwyn, and M. Dunn, Symptoms of muscle dysmorphia between users of
anabolic androgenic steroids with varying usage and bodybuilding experience. European Journal
of Health Psychology, 2019.
29. Alharbi, F.F., et al., Knowledge, attitudes and use of anabolic-androgenic steroids among male
gym users: A community based survey in Riyadh, Saudi Arabia. Saudi Pharmaceutical Journal,
2019. 27(2): p. 254-263.
30. Mędraś, M., A. Brona, and P. Jóźków, The central effects of androgenic-anabolic steroid use.
Journal of addiction medicine, 2018. 12(3): p. 184-192.
31. McCullough, D., et al., How the love of muscle can break a heart: Impact of anabolic androgenic
steroids on skeletal muscle hypertrophy, metabolic and cardiovascular health. Reviews in
Endocrine and Metabolic Disorders, 2021. 22(2): p. 389-405.
32. Kanayama, G. and H.G. Pope, Anabolic Steroid Use Disorders: Diagnosis and Treatment.
Textbook of Addiction Treatment: International Perspectives, 2021: p. 307-323.
33. Guzzoni, V., H.S. Selistre-de-Araújo, and R. de Cássia Marqueti, Tendon remodeling in response
to resistance training, anabolic androgenic steroids and aging. Cells, 2018. 7(12): p. 251.
34. Nieschlag, E. and E. Vorona, Doping with anabolic androgenic steroids (AAS): Adverse effects
on non-reproductive organs and functions. Reviews in Endocrine and Metabolic Disorders, 2015.
16(3): p. 199-211.
35. Casavant, M.J., et al., Consequences of use of anabolic androgenic steroids. Pediatric Clinics of
North America, 2007. 54(4): p. 677-690.
36. Wenbo, Z. and Z. Yan, The Uses of Anabolic Androgenic Steroids Among Athletes; Its Positive
and Negative Aspects-A Literature Review. Journal of Multidisciplinary Healthcare, 2023: p.
4293-4305.
37. Baggish, A.L., et al., Long-term anabolic-androgenic steroid use is associated with left
ventricular dysfunction. Circulation: Heart Failure, 2010. 3(4): p. 472-476.
38. Kanayama, G., et al., Ruptured tendons in anabolic-androgenic steroid users: a cross-sectional
cohort study. The American journal of sports medicine, 2015. 43(11): p. 2638-2644.
39. Torrisi, M., et al., Sudden cardiac death in anabolic-androgenic steroid users: a literature
review. Medicina, 2020. 56(11): p. 587.
40. Loeza, A.C., Bullying victimization as a predictor of anabolic-androgenic steroid abuse in a
nationally representative sample of adolescent males. 2018, Appalachian State University.
41. Pope Jr, H.G. and G. Kanayama, Neurobiology and treatment of anabolic-androgenic steroid-
related disorders. Brady KT, Levin FR, Galanter MC, Kleber DH, editos. The American
Psychiatric Association Publishing Textbook of Substance Use Disorder Treatment. Washington,
DC: American Psychiatric Association, 2021: p. 315-31.
42. Langli, S., Long-term anabolic-androgenic steroid use, aggression and executive functions. 2015.
43. Navidinia, M. and P. Ebadi, Medical consequences of long-term anabolic-androgenic steroids
(AASs) abuses in athletes. Biomed. Res. Tokyo, 2017. 28: p. 5693-5701.
44. Garcia-Argibay, M., The relationship between the big five personality traits, impulsivity, and
anabolic steroid use. Substance Use & Misuse, 2019. 54(2): p. 236-246.
45. Merz, F., United Nations Office on Drugs and Crime: World Drug Report 2017. 2017. SIRIUS-
Zeitschrift für Strategische Analysen, 2018. 2(1): p. 85-86.
46. Tauchen, J., et al., Medicinal use of testosterone and related steroids revisited. Molecules, 2021.
26(4): p. 1032.
47. Liu, J.-D. and Y.-Q. Wu, Anabolic-androgenic steroids and cardiovascular risk. Chinese medical
journal, 2019. 132(18): p. 2229-2236.
48. Bhasin, S., et al., Testosterone therapy in men with hypogonadism: an endocrine society clinical
practice guideline. The Journal of Clinical Endocrinology & Metabolism, 2018. 103(5): p. 1715-
1744.
49. Evans, N.A., Current concepts in anabolic-androgenic steroids. The American journal of sports
medicine, 2004. 32(2): p. 534-542.
50. Scarth, M., Cognitive and psychological mechanisms of anabolic androgenic steroid dependence.
2024.
51. Hauger, L.E., L.T. Westlye, and A. Bjørnebekk, Anabolic androgenic steroid dependence is
associated with executive dysfunction. Drug and alcohol dependence, 2020. 208: p. 107874.
52. McCarty, D. and D.M. Donovan, The national drug abuse treatment clinical trials network: from
2000 to 2020 and beyond. Journal of Substance Abuse Treatment, 2020. 112: p. 1-3.
53. Hauger, L.E., et al., Anabolic androgenic steroid dependence is associated with impaired
emotion recognition. Psychopharmacology, 2019. 236: p. 2667-2676.
54. Gomides, L., et al., Neurological consequences of abusive use of anabolic-androgenic steroids.
Tempus–Actas de Saúde Coletiva, 2019. 13(1): p. 102-122.
55. Almutairi, A.M.M., Principles of drug addiction treatment. Int J Med Dev Ctries, 2021. 5(2): p.
1523-7.
56. Mark, T.L., et al., Spending on mental and substance use disorders projected to grow more
slowly than all health spending through 2020. Health Affairs, 2014. 33(8): p. 1407-1415.
57. de Brito, V.M.A. and J.P. Dias, Prevalence of use of dietary supplements and other substances by
medical students in Salvador, Bahia, 2020. Rev Med (São Paulo), 2023. 102(1): p. 200696.
58. Phillips, K., Mental illness is not anyone’s fault: A review of NAMI, the national alliance on
mental illness. Journal of Consumer Health on the Internet, 2020. 24(1): p. 75-81.
59. Kanayama, G., H.G. Pope, and J.I. Hudson, Associations of anabolic-androgenic steroid use with
other behavioral disorders: an analysis using directed acyclic graphs. Psychological medicine,
2018. 48(15): p. 2601-2608.
60. Canton, H., United Nations Office on drugs and crime—UNODC, in The Europa Directory of
International Organizations 2021. 2021, Routledge. p. 240-244.
61. Piacentino, D., et al., Anabolic androgenic steroids used as performance and image enhancing
drugs in professional and amateur athletes: Toxicological and psychopathological findings.
Human Psychopharmacology: Clinical and Experimental, 2022. 37(1): p. e2815.
62. Silver, M.D., Use of ergogenic aids by athletes. JAAOS-Journal of the American Academy of
Orthopaedic Surgeons, 2001. 9(1): p. 61-70.
63. Bates, G., J. McVeigh, and C. Leavey, Looking beyond the provision of injecting equipment to
people who use anabolic androgenic steroids: Harm reduction and behavior change goals for
UK policy. Contemporary Drug Problems, 2021. 48(2): p. 135-150.
64. Knox, J., et al., Reduction in non-abstinent World Health Organization (WHO) drinking risk
levels and drug use disorders: 3-year follow-up results in the US general population. Drug and
alcohol dependence, 2019. 201: p. 16-22.
65. Bacon, D., Achieving Long-Term Recovery Outcomes for Substance Use Disorders. Perspectives
on Critical Issues, 2021: p. 225.