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Web Design by Gravity Works. Program effects were estimated with the conditional regression model using individuals and schools as units of analyses. Follow-up measures were used as the dependent variables, while preintervention measures and program exposure were independent variables.

Program effects were the difference between control and experimental groups at follow-up, adjusted for the preintervention assessment.

Ethnicity and father's education differed between groups at the baseline assessment. All analyses were repeated, with age, ethnicity, and father's education used as covariates in the regression model.

School-level effects were analyzed because participants were clustered within each school's football team. Whether the subject was a senior was a covariate in the long-term follow-up analyses to control for the difference in measurement time and the possible differences between graduating and remaining students.

For season's-end effects, all cohorts were combined, while cohorts 1 and 2 were combined for the long-term effects, as 1-year follow-up data are available only for these cohorts. A variety of sport supplements, AS, alcohol, and each illicit drug's use were measured and analyzed by single items.

The remainder of the individual questionnaire items were combined to represent constructs for the analyses, as is common in health research.

The program was designed as a primary prevention intervention to reduce the incidence of new AS users ie, the number of athletes who began using AS after baseline assessments. Comparisons between experimental and control groups used logistic regression analysis. For school-level analysis, we assessed cumulative percentages of new users, examining effects with the conditional model using ordinary regression analysis.

The same analyses were conducted on the cumulative index of new sport supplement use and drinking and driving behavior. The cumulative sport supplement index was a combination of various sport supplements excluding vitamins and minerals.

Differences in the experimental and control groups were incorporated in these analyses by weighting the frequencies of new users and nonusers among groups. The intervention measured new and cumulative use of AOD, sport supplements, and drinking and driving behavior.

We assessed an illicit drug index by calculating the sum of dichotomized responses ever used vs never used for marijuana, amphetamines, and narcotics. Because alcohol is not legal for adolescents, we included alcohol and illicit drugs as an AOD index in the analyses, and then assessed the estimated effects with the conditional model using ordinary regression analysis.

All schools were retained in the follow-up periods. Student attrition was expected from 3 sources: team withdrawal, school transfer, or study withdrawal. Only study withdrawal was potentially modifiable by investigators. A total of adolescent athletes were enrolled in the study and assessed at baseline.

Because football rosters shrink during the first few weeks of school owing to dropouts from quitting or injury , precise estimates of the total subject pool are not available.

The 1-year follow-up retention rate was consistent with the annual retention rate in Portland Public Schools We achieved a comparable retention among cohorts 1 and 2, postseason to 1-year follow-up: Mean age for each cohort was between 15 to 16 years 3-cohort mean, 15 years 5 months.

Table 2 shows demographics for subjects who took both the preseason questionnaire and the end-of-season questionnaire. Group differences were tested with t tests for the continuous variables and χ 2 tests for categorical variables.

Baseline equivalence was assessed for each construct. Outcomes were not altered when baseline differences, including age, were used as covariates.

The analyses used 1-tailed significance for the program effects, justified by the positive findings detected in the pilot and cohort 1 findings. This study substantiates the benefits of a sex-specific, sports team—centered approach to improve adolescent health risks and behaviors.

In addition, ATLAS is the first intervention to achieve a significant reduction in new AS use, with more than twice as many new AS users in the control group after the football season.

However, durable reductions in the intention to use AS a likely predictor of future drug use 35 of those in the experimental group remained lower at the 1-year follow-up. Corroborating these program effects are improved nutrition behavior and less use of sport supplements.

This latter finding may be important in deterring AS use, as sport supplements that claim athletic enhancement were highly correlated with performance-enhancing drug use in this study.

Previous methods to reduce AS and other substance abuse in sports have relied on cognitive education and drug testing. The ATLAS program's format is based on social learning theory 43 and uses an established social unit the sports team to redirect the students' goal-directed behavior.

With team-centered programming, content can be sex-specific and address the causes and risks of substance abuse unique to male adolescents. The success of this intervention model is supported by the findings that ATLAS-trained athletes believed their teammates were more reliable sources of information about AS, drugs, nutrition, and strength training than control teammates, and coaches of the experimental group were perceived as more intolerant of AS use.

There are limitations to the investigation. Study power was limited as AS use was lower than expected. Participation was voluntary, requiring active student and parental consent. Questionnaires were confidential but not anonymous; research staff not school personnel or parents could identify respondents through codes.

Thus, some students who used or were considering using AS may have been reluctant to enroll. Alternatively, these students may have enrolled in the study but not admitted to drug use. For these reasons, we expected and observed a lower base rate of AS use than in anonymous, point prevalence surveys.

Curriculum time differed between the first and later cohorts, with a reduction in class contact hours. However, program content remained similar in scope. Furthermore, the team format allows reinforcement of classroom materials during other team sessions so that curriculum time underestimates the effect of the intervention.

Although this reduction could be detrimental to an intervention's efficacy, 26 substantial improvements were maintained. Also, despite small differences in age of the cohorts, outcomes, assessed as a covariate, were not age-related. High school athletes are an important group for health promotion and AOD prevention.

The ATLAS program demonstrates widespread and sustained 1-year drug prevention and health promotion effects for male adolescent athletes. Sex-specific, sports team—centered education is a new paradigm that can favorably influence adolescent behavior.

This project was supported by grant DA from the National Institute on Drug Abuse, Bethesda, Md Dr Goldberg. We thank Angela Lapin, MA, for substantial help with the manuscript development, preparation, and revision. Reprints: Linn Goldberg, MD, Oregon Health Sciences University, SW Sam Jackson Park Rd, Portland, OR e-mail: goldberl ohsu.

Editor's Note: Back in July , when the preliminary study was published, I stated that I'd be "eagerly awaiting the long-term outcomes. DeAngelis, MD.

Goldberg L , MacKinnon DP , Elliot DL , Moe EL , Clarke G , Cheong J. The Adolescents Training and Learning to Avoid Steroids Program : Preventing Drug Use and Promoting Health Behaviors.

Arch Pediatr Adolesc Med. Artificial Intelligence Resource Center. Select Your Interests Customize your JAMA Network experience by selecting one or more topics from the list below. Save Preferences. Privacy Policy Terms of Use. X Facebook LinkedIn. This Issue.

Citations View Metrics. Share X Facebook Email LinkedIn. April Linn Goldberg, MD ; David P. MacKinnon, PhD ; Diane L. Elliot, MD ; et al Esther L. Moe, PhD ; Greg Clarke, PhD ; JeeWon Cheong, MA.

Author Affiliations Article Information From the Department of Medicine, Oregon Health Sciences University, Portland Drs Goldberg, Elliot, and Moe ; the Department of Psychology, Arizona State University, Tempe Dr MacKinnon and Ms Cheong ; and the Center for Health Research, Kaiser Permanente, Portland, Ore Dr Clarke.

visual abstract icon Visual Abstract. Subjects and methods. Study design. View Large Download. He noted that younger athletes may be more prone to using human growth hormone.

Younger athletes are at risk for performance-enhancing substance use because they often fail to consider the long-range effects of these substances. It is important to note that performance-enhancing substance use is not limited to professional or elite athletes.

An Internet search for human growth hormone or anabolic steroids will yield millions of hits, Green said. In fact, non-athletes may be at highest risk. When educating patients about these agents, it is important to communicate that all performance-enhancing substances have adverse events, and although some are simply annoying, others can be life-threatening.

For example, anabolic steroids have a variety of risks affecting multiple organ systems, according to Michael G. Steroids can affect the cardiovascular system, increasing the risk of myocardial infarction and stroke, and lowering HDL while increasing LDL, he said.

Steroids can influence the hepatobiliary system, and can promote the growth of benign and malignant liver tumors. Steroids also can impact other body systems. Furthermore, anabolic steroids can cause musculoskeletal problems, causing tendon degeneration and rupture.

In young athletes, they can promote premature closure of the growth plates. These substances can decrease testosterone levels, cause testicular atrophy, baldness and acne, according to Ciccotti.

Although most stimulants are relatively benign, like caffeine, some can have detrimental effects, said Andrew M. Tucker, MD, medical director of sports medicine at Medstar Union Memorial Hospital in Baltimore, and head team physician for the Baltimore Ravens.

Most concerning is that some stimulants negatively affect the cardiovascular system — raising blood pressure and potentially inducing arrhythmias, according to Tucker. Some supplements can have adverse events, according to David G.

Liddle, MD, assistant professor, Vanderbilt Sports Medicine, Vanderbilt Internal Medicine at Vanderbilt University in Nashville, Tenn. However, the damage can be permanent. Many of the supplements containing protein, amino acids and vitamins are safe.

Despite these risks, there is no clear evidence that these substances significantly improve performance, Ciccotti said. There is some evidence that suggests that the combination of anabolic steroids and strength training may facilitate gains in size and strength compared with athletes who are not using steroids; however, those gains are lost when the drugs are stopped, he said.

For example, with steroids, the athlete may have a sudden and dramatic increase in muscle mass accompanied by severe acne and increasingly aggressive behavior.

In men, physicians will see baldness and gynecomastia. In women, there may be genital changes, increased muscle mass and male patterned hair, whether baldness or growth. Athletes may be taking human growth hormone if they suddenly develop dental problems like large gaps between their teeth and gain a large amount of weight in a short time, he said.

Performance-enhancing substance testing programs are an integral part of competition, ensuring fair play for all participants.

But detecting these agents can be challenging. For instance, certain drugs have short half-lives, making them difficult to detect. For instance, endurance sports, which require the delivery of more oxygen to muscles, testing must detect substances that increase hemoglobin, such as erythropoietin.

That is never going to stop. WADA and other organizations have responded to this issue by requiring random, in- and out-of-competition testing of both blood and urine. Clearly, testing is an effective deterrent as is evidenced by the waning popularity of anabolic steroids.

Because it is not detectable with current urine screening, human growth hormone is harder to spot. Under its new collective bargaining agreement, the NFL will now perform random blood tests for human growth hormone. Tucker hopes that someday the technology will evolve to allow for urine screening for human growth hormone as well.

The most effective anti-doping programs incorporate education, which targets athletes, parents, trainers, therapists and coaches. Orthopedists are in a unique position to help in this regard.

Even physicians need to keep learning. Orthopedists may be especially important in educating the adolescent population. They do not have a lot of routine health-type things, and most of them have already had their vaccinations, so really, from about 10 years old to about 18 years, the do not see doctors very often.

The one time they do see doctors is when they get hurt and they might see their orthopedist. With all of the attention given to athletes who dope, fighting performance-enhancing substance use may seem overwhelming.

There will always be athletes willing to use them, and there will always be manufacturers willing to develop new agents that evade detection.

But the fact is that the vast majority of athletes want to compete fairly. The keys to success are education and ensuring fair, consistent, top-of-the-line scientific testing programs that are tough on athletes who use performance-enhancing substances and that elevate clean athletes, he said.

Fortier LA, et al. J Bone Joint Surg Am. Michael G. Ciccotti, MD, can be reached at the Rothman Institute at Jefferson, Chestnut St.