During the initial COVID-19 vaccine rollout, a rare complication called myocarditis was detected, primarily in young males. The incidence of this problem was low and most of the cases were mild. Still, even for people in the highest-risk demographic for vaccine-associated myocarditis, receiving the primary series of the COVID-19 vaccines was safer than getting COVID-19 without having been vaccinated.
Nevertheless, the anti-vaxxer factions seized on this and used it to sow doubt. The phrase “Died Suddenly” became a kind of motto for those looking to spread misinformation about vaccines. There has never been any link between COVID-19 vaccines and sudden cardiac death.
Meanwhile, one of my least favorite cliches during the pandemic was the image of some muscular person flexing for a camera saying that they didn’t need vaccination, because they were just so damn healthy. Nor did I get any joy out of stories of athletes who refused the vaccines on those very grounds, only to die of COVID-19 later.
But, separate from COVID-19-related mortality, I have been curious about the potential for increased mortality risk in people who use anabolic steroids.
Do Anabolic Steroids Really Increase Mortality Among Users?
I have long wondered if researchers could study mortality rates among athletes who were anabolic steroid users (i.e., cheaters/dopers) and glean anything statistically useful. The problem, I figured, was finding a large enough sample that could be tracked for long enough to see the effects play out.
Well, they did it. “They” being Danish research pharmacologists. New research in the JAMA followed 1,189 Danish males who were caught doping, compared to 59,450 matched controls.
Before we get to the reveal, let’s pause to think about the matched controls here. Generally, in retrospective observational studies that match cases (in this case, steroid users) with supposedly similar controls (who did not use steroids), we worry about confounders — that is, subtle ways that the two cohorts are less alike than they appear on paper. (Blinded, randomized trials can overcome this, but in observational studies that find “matched controls” in a database, we can’t be as sure that there are not subtle but meaningful unmeasured differences between two “assembled” groups.) In this case, though, the 1,189 athletes caught taking steroids are likely to be among the healthiest people you could find in any database. I’ll wager that elite athletes who were found to have cheated in sports were at least as healthy (if not healthier) than the 59,450 people whose medical records were used by the researchers as controls in the study. So, if anything, I’d think that the deck was stacked against finding increased mortality in the dopers. Steroids aside, these were people who were in good enough condition that cheating would help them win elite competitions. You get the point.
The findings: steroid users were indeed over 2.8 times more likely to die (all causes) over the following 18 years, compared to matched controls. Among steroid users, one in 36 died during the study window; among controls only one in 103 died during that period. That is a massive difference. So, who died suddenly? Anabolic steroid users.
Also striking, deaths both from natural causes (heart attacks, cancer) and unnatural causes (accidents, homicide, suicide) were higher in the steroid users, compared to controls. That implies that anabolic drug use had both physical and mental effects. For example, it’s known that steroid users have increased risk-taking behaviors.
Whenever I hear of a young and healthy athlete dying suddenly, I tend to worry about a couple of things. The first is whether the deceased had any undiagnosed condition, like a structural heart problem (as was the case for the NBA basketball player Reggie Lewis, who died due to an often deadly condition called hypertrophic cardiomyopathy). The second is to wonder whether drug use had any role. Of course, both can be true in some cases; it could be that one makes the other more dangerous.
Regardless, an athlete’s drive to win should never come at the expense of life. It’s just not worth it. These new data indicate that mortality associated with anabolic steroid use is real, measurable, and not even that unusual.
This piece originally appeared in Inside Medicine.