Prevalence of AAS‐Positive Samples at Drug Abuse Laboratory Sweden Between 2014 and 2023 and Sub‐Study of Dual Use of AAS and Narcotics
Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
Doping Control Laboratory, MU Clinical Pharmacology, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
Drugs of Abuse Laboratory, MU Clinical Pharmacology, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
ABSTRACT
It is of interest to investigate trends in AAS usage profile. Here we aimed to retrospectively study the prevalence of AAS‐positive samples based on 21,172 consecutive analyses from routine AAS testing 2014–2023. Moreover, 310 urine samples from 2022 to 2023 were reanalyzed for a broader AAS panel as well as for the presence of narcotics. Between 2014 and 2023, the frequency of reported AAS‐positive samples varied between 6% and 11%, with no trend discerned. The prevalence of samples containing several AAS also shows a similar distribution. The most common AAS detected were consistently testosterone, nandrolone, and drostanolone. Of the 310 urine samples reanalyzed, 80 male and 6 female samples were positive for AAS. Thirteen of the samples showed T/E 4–10, indicative of testosterone use, with no other AAS. Consequently, 4% of the samples might have been reported as false negatives. Of the AAS‐positive samples, amphetamine was found in 10% and 0% of the male and female samples, respectively. Cannabis was more often detected in AAS‐positive female samples (50%) than in male samples (25%), whereas cocaine was more commonly detected in male than in female samples (33 versus 17%). The prevalence of cannabis and amphetamine was like previous AAS studies conducted in Sweden, whereas the presence of cocaine in male samples was substantially higher. Co‐use of AAS and narcotics is a well‐known problem and highlights the importance of preventive actions and education/awareness of AAS.
Graphical
Throughout 2014–2023, over 20,000 AAS analyses have been conducted at the drug of abuse laboratory, Karolinska University Hospital. Approximately 20% and 2% of the samples have been positive for AAS, with no trends of increase or decrease. Around 50% of the AAS‐positive samples were also positive for narcotics (year 2022–2023), with gender differences; cocaine and cannabis being more frequent in AAS‐positive male and female samples, respectively.
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Article notes
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Revised 2025 Aug 22; Received 2025 Mar 25; Accepted 2025 Sep 13; Issue date 2025 Dec.
1.Introduction
Anabolic androgenic steroids (AAS) are used for their muscle‐enhancing effects and are considered a public health concern [1]. The use of AAS is associated with endocrine adverse effects including gynecomastia, testicular atrophy, and androgen‐induced hypogonadism [2, 3]. Moreover, AAS may lead to hypercholesterolemia, platelet aggregation, and thickness of the left ventricular interventricular septum [3, 4, 5], all risk factors for cardiovascular events. The long‐term effects of AAS use are not well known but have been associated with increased mortality rates and cardiovascular morbidity [6, 7].
In Sweden it has been estimated that 30,000–100,000 persons, mainly men, are using AAS [8, 9]. It has been reported that men and women use on average 2.9 and 1.6 AAS substances, respectively [10, 11]. The number of AAS found simultaneously in samples from Swedish police cases increased between the years 1999 and 2009 [12]. However, the trend for how many AAS men and women have used over the last years has to our knowledge not been followed up.
Endogenous AAS, such as testosterone (T), is popular due to its anabolic potency and with fewer side effects than other AAS [13]. In World Anti‐Doping Agency (WADA) testing laboratories, a urinary T/epitestosterone (T/E) > 4 is indicative of exogenous T intake and triggers further analyses for confirmation. However, in testing for illicit T use outside WADA laboratories, higher T/E thresholds are applied, which could lead to reporting many false negatives [14].
In addition to anabolic substances, other performance‐enhancing drugs are abused. Moreover, drugs are used to mitigate the adverse effects of the steroids, e.g., aromatase inhibitors and estrogen receptor antagonists to prevent gynecomastia, 5α‐reductase inhibitors for AAS‐induced alopecia [15]. Additionally, the co‐use of narcotics, i.e., cocaine, cannabis, and amphetamine, has been associated with AAS use [12, 16]. In a study from 2010, 73% of the subjects with confirmed use of AAS were also using narcotic substances, of which cannabis was the most common [17]. It is not known to what extent AAS users use narcotics today.
The aim of this study was to assess potential trends in AAS use in Sweden using medical statistics data from our drug of abuse laboratory between 2014 and 2023. Moreover, to identify the dual intake of AAS and narcotics (cannabis, amphetamine, cocaine), analyses of 310 urine samples from our drug of abuse laboratory were performed using WADA‐accredited initial testing procedure (ITP) GC–MSMS and LC‐MSMS methods.
2.Materials and Methods
2.1.Clinical Samples for Retrospective AAS Analyses 2014–2023
The study is based on 21,172 test results from our routine AAS analyses of “out of sport samples” (UAAS)—as described below, conducted 2014–2023, at the Drug Abuse Laboratory, Medical Unit of Clinical Pharmacology, Karolinska University Hospital (Stockholm, Sweden). The reason for ordering AAS analyses varies; many of the samples are from workplace testing or from healthcare samples. Drug testing at workplaces includes AAS since it is illegal according to Doping Law in Sweden (1991:1969) [18]. The healthcare samples originate from healthcare providers in Sweden, e.g., from people in drug addiction programs, patients with suspicious AAS use, etc. In addition, the Drug of Abuse Laboratory has increased the number of samples for AAS testing from forensic laboratories outside of Sweden. In Table 1, the fraction of samples from different stakeholders over the years is presented.
| Number of samples tested | Stakeholders (% from H, W, F) | AAS‐positive total n (%) | Mean numbers AAS/sample (max) | T only n (% pos) | Top 3 AAS detected | |
|---|---|---|---|---|---|---|
| 2014 | 1776 | N/A | 108 (6%) | 1.23 (5) | 45 (42%) | T, N, B |
| 2015 | 2261 | N/A | 255 (11%) | 1.72 (6) | 55 (23%) | T, N, D |
| 2016 | 2104 | N/A | 219 (10%) | 1.44 (5) | 54 (25%) | N, T, D |
| 2017 a | 2079 | 53, 46, 0 | 228 (11%) | 1.51 (8) | 60 (26%) | N, T, D |
| 2018 a | 2151 | 39, 55, 7 | 202 (9%) | 1.47 (5) | 54 (27%) | D, N, T |
| 2019 a | 2047 | 28, 57, 15 | 216 (11%) | 1.35 (7) | 55 (25%) | N, D, T |
| 2020 a | 2106 | 32, 53, 15 | 212 (10%) | 1.29 (4) | 53 (25%) | N, T, D |
| 2021 a | 3535 | 36, 41, 23 | 216 (6%) | 1.37 (6) | 64 (30%) | T, D, N |
| 2022 a | 2366 | 29, 53, 18 | 244 (10%) | 1.39 (4) | 89 (36%) | T, N, D |
| 2023 a | 2456 | 29, 46, 25 | 261 (11%) | 1.29 (4) | 72 (28%) | T, N, D |
The UAAS analysis was performed using ISO 15189 accredited GC–MS/MS that includes 13 exogenous AAS, T, and epitestosterone, as described in Petterson et al. [19]. Briefly, to 1 mL of urine, an internal standard (ISTD) mixture (Epitestosterone‐d3, T‐d3, methyl‐T‐d3) was added to all urine samples and hydrolyzed with β‐glucuronidase from Escherichia coli (Roche, Basel, Switzerland) at 50°C for 60 min. The steroids were extracted, derivatized, and run on an Agilent G7000C mass spectrometer as described by Mullen et al. [20]. In each batch, there was a water blank, a negative quality control, a calibrator for the endogenous steroids (T = 50 ng/mL and E = 5 ng/mL), one quality control (T and E), and two exogenous calibrators (100 and 10 ng/mL). The LOD for T and E is 3 ng/mL, and values below 3 ng/mL were assigned to 3 ng/mL when calculating the T/E ratio.
Samples reported as positive when concentrations > 10 ng/mL for exogenous AAS, except for nandrolone and boldenone where 15 and 30 ng/mL are lower reporting limits, respectively. Concentrations > 100 ng/mL are reported as > 100 ng/mL as the quantitative interval of the method is 3–100 ng/mL. For T detection, a T/E > 10 with an accompanying > 250 T/Luteinizing Hormone (nmol/units) is reported as positive. In 2017 and forward, T positive samples were not reported if another AAS was detected in the sample.
2.2.Sub‐Study—Detection of AAS and Narcotics 2022–2023
Urine samples (n = 310) left over from the Drug of Abuse laboratory, originally subjected to UAAS testing in a healthcare setting, were collected from the 30th of November 2022 to the 16th of June 2023. The samples were anonymized for all information except gender without a key to deanonymize them. The samples were from men (n = 269), women (n = 35), and 6 samples of unknown gender (from patients with hidden identity). Urine samples were stored at −20°C prior to GC–MS/MS (2 mL) and for LC–MS/MS (3 mL). The samples were all analyzed with both the WADA‐accredited GC–MS/MS and LC–MS/MS ITP method as described below. Samples with less than 5 mL urine were excluded (n = 101) as the volume would not be sufficient to run on all methods.
2.3.Sub‐Study—LC/MSMS ITP Method
WADA‐accredited routine method for screening of sports samples was used to reanalyze the presence of narcotics (amphetamine, cocaine) and the AAS (trenbolone, stanozolol) in the sub‐study (n = 310 samples).
The method has been described in [19] and detects, among others, amphetamine, cocaine, and some AAS (e.g., trenbolone, stanozolol). Briefly, urine samples (2 mL in a falcon tube and approximately 0.5–1 mL in an Ellerman tube) were thawed to room temperature. ISTD and β‐glucuronidase in 1 M potassium phosphate buffer, pH 6.5, were added to the urine samples in falcon tubes, and the mixture was hydrolyzed at 50°C for 60 min. After cooling to room temperature, 100 μL of formic acid was added to each sample. The samples were then subjected to a solid phase extraction (SPE) clean‐up, and the eluates were reconstituted in 200 μL of 10% MeOH (aq.). After this, the samples were vortexed and centrifuged. The samples were then run on a Q Exactive or Q Exactive Focus from Thermo Fisher (Waltham, MA, USA).
Verifications of trenbolone, stanozolol (including the metabolites 3‐OH‐stanozolol, 16β‐OH‐stanozolol, and N‐glucuronide‐stanozolol) and cocaine and the cocaine metabolite benzoylecgonine were done with a second injection using instrument methods including parallel reaction monitoring (PRM) for the compounds of interest. Ion ratio and retention time (RT) were evaluated according to WADA [21].
2.4.Sub‐Study—Chiral LC–MS/MS Analysis of Levo‐ and Dextro‐Amphetamine
All sub‐study samples containing amphetamine when analyzed with the ITP LC–MS/MS method were subjected to chiral LC–MS/MS analysis for the detection of levo‐amphetamine (l‐amphetamine) and dextro‐amphetamine (d‐amphetamine) using the WADA‐accredited direct injection method used for the confirmation procedure (CP). Fifty microliters of urine was used, to which the internal standard, amfetamine‐d5, was added and 50 μL of mobile phase A. The samples were vortexed and centrifuged prior to analysis. The analysis was performed using a LUX 3 μm AMP, 150 × 3.0 mm from Phenomenex (Torrance, CA, USA) at a column temperature of 40° C. Mobile phase A consisted of 0.025% ammonia in water and mobile phase B of 0.025% ammonia in MeOH: H2O (95:5). The used flowrate was 0.5 mL/min and the gradient started at 44% of B for 2 min and after that ramped up to 58% of B over the next 15 min and finally went back to 44% of B and re‐equilibrated the column for 3 min. The same mass system was used as for the ITP but this time with an inclusion list with normalized collision energy set to 40 for both amphetamine and ISTD. The analysis was performed in positive mode and the resolution for the PRM experiment was set to 17,500, automatic gain control was set to 2e5, maximum injection time to 64 ms, and isolation window 1.0 m/z.
2.5.Sub‐Study—GC‐MSMS ITP Method
WADA‐accredited method for initial screening of sports samples was used to reanalyze the endogenous steroids T and E, as well as to the presence of the AAS described on the WADA prohibited list [22], and cannabis in the sub‐study of n = 310 urine samples. The GC‐MSMS ITP analysis includes detection of endogenous steroid profile (e.g., T/E), > 60 exogenous AAS and long‐term metabolites.
The method is described here briefly; for more detail, see [20]. ISTD mixture was added to 2 mL urine samples and hydrolyzed with β‐glucuronidase from E. coli (Roche, Basel, Switzerland), and subsequently, the steroids were extracted with a tert‐butyl methyl ether (TBME) liquid–liquid extraction. The TBME was evaporated, and the steroids were transferred to vials using acetone and subsequently evaporated. The samples were then trimethylsilyl derivatized with a mix of N‐methyl‐N‐(trimethylsilyl) trifluoroacetamide, ethanethiol, and ammonium iodide at 80°C for 30 min. Each sample was run on an Agilent G7000C mass spectrometer (Santa Clara, CA, USA). In every batch of samples, there were a urine blank, a calibrator for the endogenous steroids, a calibrator for seven exogenous steroids, one high, and one low quality control (QC). T and epitestosterone concentrations were determined with a single point calibration, where values below 1 ng/mL were assigned to 1 ng/mL. Exogenous steroids were evaluated according to the WADA technical document [23]. Substances with a minimum reporting limit, such as nandrolone and boldenone, were quantified in ng/mL with a one‐point calibration and identified as positive > 15 and 30 ng/mL, respectively.
Samples were identified as positive on cannabis when delta‐9‐tetrahydrocannabinol (THC) was present and showing a peak with RT and ion ratio in accordance with the International Standard for Laboratories [21].
3.Results and Discussion
3.1.Retrospective AAS Analyses 2014–2023
The proportion of samples tested positive for AAS at the drug of abuse laboratory between 2014 and 2023 varied between 6% and 11% (Table 1). The result shows no changes in the prevalence of samples positive for AAS.
The mean numbers of different AAS found in the positive samples over the years are consistent, between 1.23 and 1.47, indicating a constant AAS use pattern in the last 10 years (Table 1). Sporadic samples with > 5 AAS have been found evenly over the years, of which one sample contained as many as 8 AAS. However, the doses of AAS used during these years are not known and could not be estimated, since in UAAS testing absolute concentrations > 100 ng/mL are reported as > 100 ng/mL.
An average of 20% of the male samples tested were positive for AAS (range 16%–22%), whereas in female samples, on average, 2% were tested positive, (Figure 1). For > 50% of the samples, the sex was, however, unknown. The result aligns with previous estimations that AAS is 10 times more common among men than women in Sweden [8].
Monitoring drug testing results is considered a reasonable indicator of AAS prevalence over time. First, as many of the samples are positive for AAS, there is a high chance to discern changes in the proportion of AAS tested positive. Other data that also point towards a stable usage profile of AAS are the numbers of custom seizures in Sweden, where similar amounts have been confiscated over the last 5 years. Moreover, surveys to Swedish high school and college students have shown that around 1% self‐report having used AAS between 2004 and 2023, with a peak in 2007 [24]. These numbers are of interest as an AAS use is often initiated in adolescents and young adults [2, 16, 25], even though lately illicit use of AAS has increasingly been initiated among middle aged men [26].
The number of samples including only T appears to be vary over the years (23%–42% of the positive samples), but with no trend of increase over the years (Table 1). The number of people using only T might even be higher as probably some individuals have been reported as false negatives using a T/E > 10. In addition to T, nandrolone and drostanolone have been the most commonly detected AAS throughout the years. This agrees with other findings and reports outside of sports [2, 16, 27]. Trenbolone and oxandrolone have also been reported as common AAS in men and women, respectively [27, 28]. It is possible that some people subjected to drug testing might cease their AAS use and therefore the detection rate of trenbolone and oxandrolone, both with short half‐lives, is lower.
Conclusively, the use of AAS in the Swedish society appears to be stable, i.e., how many are tested positive at the drug of abuse laboratory and how many AAS are used simultaneously. It is possible that the peak in AAS usage was seen around 2015, as studies prior to 2015 point towards an increase in reporting and detection in the Nordic countries [1, 12]. One reason for not seeing an increase in AAS usage, despite the easy availability of AAS and aggressive marketing campaigns on social media [29] might be that doping preventive actions may have been effective. In addition to legislative actions, doping prevention in the society relies primarily on education and information interventions. In Sweden, preventive measures have been initiated by the research center STAD (Stockholm Prevents Alcohol and Drug Problems) in the form of a multicomponent program [30]. A well‐known barrier to effective doping prevention includes a lack of knowledge about doping among different stakeholders [31]. Unfortunately, healthcare staff's knowledge about AAS is poor and sometimes judgmental [32, 33]. Consequently, AAS users seek medical advice through online forums. Improving healthcare staff's knowledge about AAS is important as well as educating on how to better deal with AAS users [34].
3.2.Detection of AAS 2022–2023
In order to study the prevalence of various anabolic substances among Swedish AAS users, samples originally subjected to UAAS analyses were reanalyzed using WADA‐accredited methods. The top three most common AAS in this study were T, drostanolone, and stanozolol (Table 2). Stanozolol and T were most often present in the female samples, whereas drostanolone was most often detected in male samples. Notably, stanozolol was not in the top three in the UAAS statistics, which could be due to the long‐term metabolite N‐glucuronide‐stanozololidentified in the LCMSMS method not being included in the UAAS method.
| Male | Female | Total | % of total | |
|---|---|---|---|---|
| Testosterone | 53 | 4 | 57 | 29 |
| Testosterone (T/E > 10) | 37 | 3 | 40 | 20 |
| Testosterone (T/E 4–10) | 16 | 1 | 17 | 9 |
| Drostanolone | 28 | 0 | 28 | 15 |
| Stanozolol | 16 | 4 | 20 | 11 |
| Trenbolone | 16 | 1 | 17 | 9 |
| Nandrolone | 11 | 0 | 11 | 6 |
| Metandienone | 9 | 2 | 11 | 6 |
| Methyltestosterone | 10 | 0 | 10 | 5 |
| Mesterelone | 6 | 0 | 6 | 3 |
| Oxymetholone | 4 | 2 | 6 | 3 |
| Boldenone | 5 | 0 | 5 | 3 |
| Methasterone* | 5 | 0 | 5 | 3 |
| Metenolone | 3 | 0 | 3 | 2 |
| DHCMT | 3 | 0 | 3 | 2 |
| Methylstenbolone* | 3 | 0 | 3 | 2 |
| Oxandrolone | 2 | 0 | 2 | 1 |
| Stenbolone* | 1 | 0 | 1 | 1 |
| Mestanolone* | 1 | 0 | 1 | 1 |
Of the 310 urine samples analyzed, 86 samples contained AAS (80 male samples and 6 female samples), with an average of 2.3 AAS/sample (range 1–7) for men and 1.8 (range 1–3) AAS for women. The number was somewhat higher when WADA methods for AAS were employed as compared to UAAS results (Table 1). This is because more AAS and metabolites are included in the WADA ITP method, and particularly due to the lower threshold set for T (i.e., T/E > 4). The numbers of AAS/sample appear to be lower in male samples herein as compared to previous studies [11]. However, in Börjesson et al., many AAS users were recruited via Anti‐Doping hotline, i.e., people more prone to contact the healthcare may be those using more AAS.
3.3.Detection of T 2022–2023
Fifty‐seven samples displayed a T/E > 4 (Table 2). Seventeen of the samples had a T/E ratio > 4, but below the positive cut‐off criteria of 10 used in drug testing. Thirteen of these samples had a T/E between 4 and 10 unaccompanied by any other AAS, i.e., would have been reported as negative in a UAAS analysis, as mimicked by our previous study using the same study design [19]. It is unknown how many of these 13 samples originate from individuals having naturally high T/E or elevated due to T doping. Population data available on the natural variation of T/E ratios have been performed on large cohorts of athlete samples (n = 4885) where ~4% exhibited a T/E ratio greater than four [35]. However, such a population is only representative of athletes that are being tested multiple times. In addition, there might be use of T doping in these samples, adding to the number of samples with T/E > 4. With that said, within that study population of the T/E variation, 1/130 samples had a T/E ratio > 6 [35]; in our study, the mean T/E value for the samples with T/E 4–10 was 5.5 (SD 1.3), closer to six, which means that most samples are likely to be positive for T doping. Finally, Lood et al. found about 56% of samples with T/E ratios between 4 and 12 to be positive for T doping when confirmed with isotope ratio mass spectrometry [14]. Notably, three female samples showed a T/E > 10, which is most likely due to the injection of T preparations, as transdermal application does not result in T/E > 10 [36].
Conclusively, the result confirms a previous study with a similar study approach that analyzing the most common AAS is considered good enough when testing outside of sport where the “rather free than convict” approach is applied [19]. This is opposite to sport testing where extremely low concentrations of AAS might lead to a conviction in accordance with the principle of strict liability. In addition to urine samples, dried blood spots (DBS) are an innovative matrix in anti‐doping testing and have shown promising results for doping testing at gyms [37]. Using DBS might also increase the chances of detecting individuals using illicit T ester preparations despite non‐elevated T/E.
3.4.AAS and Co‐Use of Narcotics
3.4.1.Amphetamine
In total (n = 56) samples contained amphetamine when analyzed with the ITP method, of which 47, 7, and 2 samples were from male, female, and unknown gender, respectively. Several Attention Deficit Hyperactivity Disorder (ADHD) medicines available in Sweden are based on d‐amphetamine (Elvanse, Attentin), whereas street amphetamine is a racemate containing both d‐ and l‐amphetamine. In drug abuse reporting, the relative amount of l‐amphetamine > 1% is indicative of illicit amphetamine use [38]. Chiral analyses of the amphetamine samples revealed that 44% (n = 25) of the amphetamine‐containing samples detected l‐amphetamine between 1% and 79%.
Of the 80 AAS‐positive male samples, 8 samples (10%) contained a relative amount of l‐amphetamine > 1% (Table 3). This number is lower compared to a previous study among Swedish police cases, where 15% of the AAS‐positive samples' illicit use of amphetamine was reported [17]. Even a higher number, as 30% amphetamine findings in AAS‐positive cases, has been reported [12]. However, in the former studies, the analytical discrimination between legal and illicit amphetamine was not performed. But before 2014, the therapeutic use of d‐amphetamine was not so common in Sweden, and hence the results could be comparable.
| Males | Females | |||
|---|---|---|---|---|
| Amphetamine+ | Amphetamine− | Amphetamine+ | Amphetamine− | |
| AAS+ | 8 (3%) | 72 (27%) | 0 | 6 (17%) |
| AAS− | 17 (6%) | 172 (64%) | 7 (20%) | 22 (63%) |
| Cannabis+ | Cannabis− | Cannabis+ | Cannabis− | |
| AAS+ | 20 (7%) | 60 (22%) | 3 (9%) | 3 (9%) |
| AAS− | 48 (18) | 141 (52%) | 4 (11%) | 25 (71) |
| Cocaine+ | Cocaine− | Cocaine+ | Cocaine− | |
| AAS+ | 26 (10%) | 54 (20%) | 1 (3%) | 5 (14%) |
| AAS— | 35 (13%) | 154 (57%) | 6 (17%) | 23 (66%) |
In some of the samples, ADHD medicines, e.g., methylphenidate, were found in addition to the street amphetamine (data not shown). Even though these ADHD medicines are legal if prescribed by clinicians, it is possible to buy these drugs on the black market; hence, illicit use of ADHD drugs in those without street amphetamine cannot be ruled out.
The reason for dual intake of amphetamine and AAS could be in addition to reducing fatigue and increasing alertness, also to induce weight loss, i.e., for image‐enhancing purposes [39]. Moreover, some individuals with ADHD may use AAS for “self‐medication” purposes [40].
As opposed to male samples, amphetamine was not detected in any of the AAS‐positive female urine samples (Figure 2).
3.4.2.Cannabis
Cannabis was detected in 68 and 7 male and female samples, respectively. Of the 80 AAS‐positive male samples, cannabis was present in 20 (25%) (Table 3). The proportion of samples including both AAS and cannabis is somewhat lower than Swedish studies conducted > 10 years ago, where dual use of AAS and cannabis was reported in ~35% [12, 17] of forensic male samples in Sweden. The reason cannabis findings were considerably lower here is not known. AAS users report that cannabis helps to wind down after strength training sessions and to improve sleep [39, 41], and many of the healthcare samples are not necessarily from gym goers.
Of 6 AAS‐positive female samples, 3 contained cannabis (50%), being significantly more common than in male samples (OR = 3.0, p < 0.001, Fisher's exact test), (Figure 2). This is a higher frequency than in previous studies [10, 42] and does not corroborate previous findings that cannabis use is similar among male and female AAS users [10].
3.4.3.Cocaine
Cocaine was found in 69 samples, 61 male and 8 female samples, respectively. Of the 80 AAS‐positive male samples, 26 (33%) also contained cocaine (Table 3). It was significantly more likely to find cocaine in an AAS‐positive than in an AAS‐negative sample (OR = 2.0, p < 0.05, Fisher's exact test). A study also noted that cocaine was used more broadly by AAS users than by those not using AAS (13% versus 5%) [12]. Notably, a significantly higher prevalence of co‐use was observed herein than in Lood et al. Considering that cocaine findings in general increase in Sweden [43], it might not be surprising that cocaine also increases in subpopulations such as AAS users.
Already in 1993 a significant association between the use of anabolic steroids and the abuse of cocaine among adolescents was reported [44]. Cocaine use is linked to cardiotoxicity, and one may assume that dual use of cocaine and AAS increases the risks for cardiovascular events [45, 46]. Moreover, animal studies suggest that AAS induce the sensitization of cocaine particularly in adolescents. Subsequently, the high co‐incidence of AAS and cocaine observed here may be of clinical concern.
Of the 6 AAS‐positive female samples, only one was positive for cocaine. The detection frequency was two times higher in male samples (OR = 2.1, p < 0.05, Fisher exact test), (Figure 2). Thus, cocaine use among AAS users seems to be predominantly a male concern.
To summarize the narcotic findings, ~50% of the AAS male and female users also used narcotic agents. Most AAS‐positive samples (n = 26) contained only one of the narcotics tested for, and in three samples the AAS findings were accompanied by amphetamine, cannabis, and cocaine. It has been reported that people using AAS > 2 years are more likely to combine their AAS with illicit drugs compared to short‐term AAS users [47]. AAS‐associated co‐use of narcotics may be dangerous for several reasons, not only for the increased risk of developing serious medical adverse side effects, but also increased risky behaviors including violence [48]. Moreover, the co‐use of narcotics can be considered a confounder when interpreting AAS‐induced side effects, making it challenging to study the long‐term effects of AAS [49].
4.Limitations and Considerations
AAS users are a heterogeneous group, and the sample population studied here is not representative of all AAS users. This study population does not overall constitute gym‐goers or people engaged in strength training, where many AAS studies traditionally have been done. Nevertheless, the retroactive trend analyses include samples with various clinical issues, as well as workplace testing and hence comprise a heterogeneous group, with no dropouts or selection bias, as may be the case with survey studies. There is, moreover, a strength in that the results are based on detection rather than self‐reporting. Another limitation is that some samples might be from the same individual, as some are tested regularly in healthcare settings. Caution must be exercised when drawing any conclusions on sex differences in AAS and co‐use of narcotics because of the small number of female samples.
5.Conclusions
Here we have shown that there were no obvious changes in how many AAS‐positive samples were reported at our drug of abuse laboratory during the last 10 years. The numbers of AAS found in some samples could be high; these were consequent over the years. Thirteen samples display T/E between 4 and 10, and are not positive for any other AAS, indicative of false negative reporting in UAAS testing. It is well known that many AAS users are co‐using narcotics for various reasons, and when investigating the prevalence of narcotics in AAS‐positive samples, some notable findings were discerned. The cocaine use among male AAS users was considerably higher than previous reports in Sweden (33 versus 13%). Moreover, in female samples, AAS and cannabis were more often detected together compared to male samples. Considering the high proportion of narcotics, particularly cocaine, among AAS users should motivate authorities to increase preventive efforts in Sweden and strengthen the interventions to combat the AAS use in general and AAS‐related narcotic use in particular.
Conflicts of Interest
The authors declare no conflicts of interest.
Untitled section
Bohlin K., Villén T., Hopcraft O., Pohanka A., and Ekström L., “Prevalence of AAS‐Positive Samples at Drug Abuse Laboratory Sweden Between 2014 and 2023 and Sub‐Study of Dual Use of AAS and Narcotics,” Drug Testing and Analysis 17, no. 12 (2025): 2421–2428, 10.1002/dta.3955.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
References
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Associated Data
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.