Problematic alcohol use linked to legal performance-enhancing substances

Reviewed by Emily Henderson, B.Sc.Sep 1 2020

A new study published in the journal Pediatrics found that young adults aged 18-26 who used legal performance-enhancing substances were significantly more likely to report several problematic alcohol use and drinking-related risk behaviors seven years later. This relationship was especially strong among men.

The study, which analyzed a sample of over 12,000 U.S. participants from the National Longitudinal Study of Adolescent Health (Add Health), highlights the need for more research and government oversight and regulation of legal performance-enhancing substances.

The results from our study are concerning given the common use of legal performance-enhancing substances among young people, particularly boys and men."

Kyle T. Ganson, PhD, MSW, Study Lead Author and Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto

Performance-enhancing substances can be legal, such as creatine monohydrate or protein powders, or illegal, such as anabolic-androgenic steroids.

Research has consistently shown adverse health and social outcomes due to the illegal use of unprescribed steroid use, but few studies have been conducted to identify outcomes associated with legal performance-enhancing substance use.

The researchers found that men who used legal performance-enhancing substances were more likely to experience five alcohol use problems and risk behaviors.

This included binge drinking, getting hurt or engaging in risky behaviors while under the influence of alcohol, experiencing legal problems while under the influence of alcohol, continued alcohol use despite emotional or physical health problems, and reduced activities and socialization that interfered with alcohol use.

"Risky alcohol use is a serious problem for adult men, who have higher rates of death associated with alcohol use compared to women," said Dr. Ganson. "Problematic alcohol use ultimately impedes economic and employment success, and increases health care and law enforcement costs."

Ganson hypothesizes that the social pressure that boys and men feel to achieve a lean and muscular body type may explain the different results between genders. "For most boys and men, this body ideal is unattainable, leading to performance-enhancing substance use," he says. "This body image contrasts with the thin ideal for girls and women."

There are other reasons to be concerned about legal performance-enhancing substances as well.

"Legal performance-enhancing substances are unregulated by the Food and Drug Administration," said senior author Jason M. Nagata, MD, MSc, assistant professor at the University of California, San Francisco's Department of Pediatrics.

"These substances are also commonly mislabeled and may contain harmful ingredients, such as anabolic steroids, which can lead to heart, liver, and kidney problems and worsen mental health."

An earlier study, led by Dr. Nagata and published in JAMA Pediatrics, also showed a relationship between legal performance-enhancing substances and later use of illegal anabolic-androgenic steroids.

The study's authors say health professionals and policy makers need to adjust their practices and goals to account for the gateway-like relationship they have observed between alcohol use and legal performance-enhancing substances.

"Health professionals should screen for these behaviors and counsel young people about potential health risks," says Ganson. "We also need state and federal policymakers to begin to take these substances seriously and recognize the adverse effects they have on youth."

Several states, including Massachusetts, California, and New York are making efforts to regulate the sale of these substances to young people.

"These legislative efforts are a great start and we need to get them passed into law," says Ganson. "I hope that we see more efforts from federal regulators."