History Of Anabolic Steroid Use Research Articles

(081) Fertility Trends in Men with Prior History of Anabolic Steroid Use: Results from a Standardized Treatment Regimen

Abstract Introduction The management of infertility in men who have previously used anabolic steroids poses a complicated clinical challenge. Addressing the infertility issues in this specific population requires a comprehensive approach that considers the underlying physiological alterations caused by anabolic steroid use and tailors treatment interventions accordingly to restore and optimize reproductive function. In this study, we report an analysis of sperm parameter recovery and fertility outcomes in men who had azoospermia or severe oligospermia caused by anabolic steroid use and underwent a standardized treatment regimen for recovery of spermatogenesis. Objective The study aims to assess the longitudinal trends in sperm concentrations, determine the proportion of men achieving normozoospermia, and evaluate subsequent pregnancy rates in this specific population. Additionally, the study seeks to identify potential predictors for improved semen parameters and successful pregnancy outcomes. Methods A retrospective analysis of the period spanning from 2018 to 2022 was conducted on a cohort of men with a prior history of anabolic steroid use who complained of infertility. The standardized treatment approach involved the cessation of testosterone replacement therapy (TRT) and the administration of a combination regimen comprising clomiphene citrate and human chorionic gonadotropin (hCG) for a minimum of 3 to 6 months. Following adequate treatment, men were contacted in March 2023 to determine the most up-to-date pregnancy outcomes. Statistical analysis was performed utilizing SPSS, employing univariate logistic regression analysis to establish a predictive mathematical model. The level of statistical significance was defined as p < 0.05. Results A total of 45 men (median age 37 years, IQR 32-45) met inclusion criteria for this analysis. Median duration of prior T use was 4 years (IQR 1.3-10), with the two most common modalities consisting of injection therapy (43.5%) and oral therapy (34.8%). Median initial sperm concentration was 0 million/cc (IQR 0-1.15), and 23 (51.1%) men initially presented with azoospermia. The median duration of combination hCG/clomid therapy was 5 months (IQR 3-12). In initially azoospermic men (N:23), 5 were lost to follow-up, 6 (33.3%) progressed to severe oligospermia (<5 million/cc), 6 (33.3%) to oligospermia (<15 million/cc), 1 (5.6%) to normozoospermia (>15 million/cc), and 5 (27.8%) remained azoospermic following medical treatment for 6 months. Among the 24 couples who responded to the follow-up call, a total of 9 (37.5%) achieved a successful subsequent pregnancy. Of these, 33.3% (3 couples) used assisted reproductive technology (ART), while 66.7% (6 couples) conceived naturally. On logistic regression analysis, no significant predictors for improved sperm parameters or successful pregnancy were identified. Conclusions Despite the implementation of appropriate treatment regimens, a significant proportion of men with a prior history of anabolic steroid use continue to exhibit severe oligospermia, with more than half failing to demonstrate substantial improvement in their semen parameters even after undergoing a six-month medical treatment protocol. Moreover, only a fraction of men, estimated to be 1 in 6, achieve normozoospermia following medical treatment after anabolic steroid use. Future work should continue to explore predictors for improved sperm parameters on follow-up as well as subsequent successful pregnancy in men with prior history of anabolic steroid use. Disclosure No.

Fertility outcomes in men with prior history of anabolic steroid use

To study sperm parameters recovery and fertility outcomes in men with azoospermia or severe oligospermia caused by anabolic steroid use who underwent a standardized treatment regimen for spermatogenesis recovery. A retrospective analysis of a cohort of men with a prior history of anabolic steroid use and infertility complaints (between 2018 and 2022) was conducted. The standardized treatment approach involved discontinuing testosterone replacement therapy and administering a combination regimen of clomiphene citrate and human chorionic gonadotropin for a minimum of 3 to 6 months. The main outcome measures included changes in sperm parameters, predominantly sperm concentration, and subsequent pregnancy outcomes. A total of 45 men (median age 37 years, IQR 32-45) met the inclusion criteria for this analysis. Median duration of prior T use was 4 years (IQR 1.3-10), with the 2 most common modalities consisting of injection therapy (43.5%) and oral therapy (34.8%). The median initial sperm concentration was 0 million/cc (IQR 0-1.15), and 23 (51.1%) men initially presented with azoospermia. The median duration of combination human chorionic gonadotropin/clomid therapy was 5 months (IQR 3-12). In initially azoospermic men (N: 23), 5 were lost to follow-up, 6 (33.3%) progressed to severe oligospermia (<5 million/cc), 6 (33.3%) to oligospermia (<15 million/cc), 1 (5.6%) to normozoospermia (>15 million/cc), and 5 (27.8%) remained azoospermic after medical treatment for 6 months. Among the 24 couples who responded to the follow-up call, a total of 9 (37.5%) achieved a successful subsequent pregnancy. Of these, 33.3% (3 couples) used assisted reproductive technology, whereas 66.7% (6 couples) conceived naturally. On logistic regression analysis, no significant predictors for improved sperm parameters or successful pregnancy were identified. Despite appropriate treatment regimens, a significant proportion of men with a prior history of anabolic steroid use continue to exhibit severe oligospermia, with more than half showing limited improvement in semen parameters after 6 months of treatment. Only a fraction of men achieves normozoospermia after treatment. Further research is needed to explore predictors for improved sperm parameters and successful pregnancy outcomes in men with a history of anabolic steroid use.

One-year minimum follow-up results following distal biceps tendon repair using tension slide technique

Background Tears of the distal biceps tendon are unusual and most often result from an injury or lifting a heavy object. These tears are usually complete and the muscle is separated from the bone and retracted back, causing weakness in supination and mid-prone elbow flexion. We present our results of patients undergoing repairs of these tears using the tension slide technique through a single longitudinal anterior incision who were followed up for a minimum of 1 year. Patients and methods A total of 17 patients with acute distal biceps tendon rupture were treated surgically by two surgeons, at two independent centers, using the tension slide technique (Arthrex) between 2017 and 2019. Patients were evaluated retrospectively at a minimum of 1-year follow-up using the patient-reported outcomes Quick Disabilities of the Arm, Shoulder, and Hand (DASH), Oxford elbow score (OES) and EQ-5D-5L. Results The average age at the time of injury was 49 years. All patients were right-hand dominant. Eleven injuries were on the right and remaining on the left side. All patients were males, and there was no documented history of anabolic steroid use. The average time to surgery, following injury, was 6 weeks. The mean postoperative DASH score was 4.4, the average OES was 49.17, and mean European quality of life five dimension (EQ5D) Vas was 84. The elbow range of motion (ROM) was comparable to the healthy contralateral side. There were no reported major complications, although we did have two (11%) minor complications: one case with delayed wound healing and the second patient with a delayed infection, treated with oral antibiotics for 14 days. Conclusions The utilization of the tension slide technique for repair of acute distal tendon biceps rupture using Endobutton and interference screw is safe. The complications were minor, and the function was excellent as reflected with OES and DASH scores.

SAT-047 Adoption of an Age Adjusted Testosterone Reference Range Reduces Referrals to Endocrine Clinic and New Prescriptions of Testosterone

Testosterone levels decline with age. However, until recently well defined harmonised age and/or obesity (BMI <30kg/m2) adjusted reference ranges did not exist.1 There is also a lack of international consensus on whether an age adjusted reference range (RR) should be used to define the syndrome of hypogonadism in men. Our local referral guideline suggests referral to endocrinology is appropriate if morning testosterone is <9.4nmol/L similar to the Endocrine Society Clinical Practice Guideline.2 In mid 2018 our laboratory adopted the published all men age adjusted RR1. We sought to; i) investigate clinic referrals before and after adoption of the all men age adjusted RR and, ii) to model the impact on referrals and prescription of testosterone replacement therapy (TRT) had we adopted either the lower limit of either all men or non-obese age adjusted RR as our referral criteria. Despite similar numbers of testosterone levels being measured in the laboratory, referrals to endocrine clinic for investigation of male hypogonadism fell by 52% (n=101 vs 48) in the one year following the introduction of the new age adjusted RR, with a corresponding reduction in prescriptions for testosterone. Mean testosterone concentration (6.7±2.5 vs 6.4±3.9nmol/L [mean±SD], NS), and age (51±13.9 vs 50±17.9 years, NS) of individuals referred were similar before and after the change of RR. Of the 101 patients referred for investigation of hypogonadism prior to the new RR mean testosterone concentrations were 8.5±4.5, 7.3±4.1, 6.8±3.6, 6.7±2.1 & 6.6±1.6nmol/L, with 39, 71, 39, 40 & 17% of the 87 patients seen in clinic being prescribed TRT in age groups 19-39 (n=28), 40-49 (n=7), 50-59 (n=33), 60-69 (n=20) &70-79 (n=6) respectively, excluding those with a history of anabolic steroid use or Klinefelter’s syndrome. Mean BMI was 30.9±4.4kg/m2, which was similar between age groups. Had the lower limit of normal of the all men testosterone RR been employed as our referral criteria in the preceding year, 23.8% (24/101) of referrals would not have met referral criteria, and 26.2% (n=11/42) of those receiving a prescription would potentially not have received a trial of TRT. In contrast, had the non-obese age adjusted RR had been adopted for all men 13.9% (14/101) of referrals would not have met referral criteria and, of those prescribed testosterone, 2.4% (n= 1/42) would not have received a trial of TRT. In conclusion, adoption of the all men age adjusted RR for testosterone has been associated with a significant fall in referrals for investigation of male hypogonadism. However, modelling of historical clinic data would suggest that some non-obese individuals miss out on a therapeutic trial of TRT, especially if the all men, rather than non-obese, age adjusted RR is adopted. Reference: (1) Travison et al, J Clin Endocrinol Metab, 2017,102(4):1161-1173, (2) Bhasin S et al,. J Clin Endocrinol Metab. March 2018;103(5):1715-1744.

Extreme cardiac hypertrophy in bodybuilders: Mechanical assessment of diastolic alteration

This study aimed to evaluate the effect of bodybuilding (a combination of training and anabolic steroids abuse) on left ventricular diastolic function and, more specifically, on underlying mechanisms that characterize this function (e.g. filling pressure, relaxation and twist-untwist mechanics). Participants ( n = 44; aged 20 to 45 years) were from healthy sedentary population (SED, n = 15), strength-training athletes who had no history of anabolic steroid use (FOR, n = 15) and bodybuilders who had history of anabolic steroid use (AAS, n = 14). Each participant underwent 2D-strain echocardiography assessment to study morphological and functional parameters. Both the AAS and FOR groups had a concentric hypertrophy of the left ventricle. However, it was more severe in the AAS group. Left ventricular diastolic function was also significantly altered in the AAS group ( P < 0.05) as indicated by a decrease in E wave velocity and E/A ratio, a decrease in relaxation (E’ and SrL diastolic), an increase of filling pressure (i.e. an increase of SIDI), as well as a decrease in twist (in relation to decrease of apical rotation) and untwist velocities. Bodybuilding in conjunction with use of anabolic steroids induces concentric hypertrophy of the left ventricle and adversely alters left ventricular diastolic function.

Surgical treatment of pectoralis major muscle rupture with adjustable cortical button

ObjectiveTo assess the tendon reconstruction technique for total rupture of the pectoralis major muscle using an adjustable cortical button. MethodsProspective study of 27 male patients with a mean age of 29.9 (SD=5.3 years) and follow-up of 2.3 years. The procedure consisted of autologous grafts taken from the semitendinosus and gracilis tendons and an adjustable cortical button. Patients were evaluated functionally by the Bak criteria. ResultsThe surgical treatment of pectoralis major muscle tendon reconstruction was performed in the early stages (three weeks) in six patients (22.2%) and in 21 patients (77.8%), in the late stages. Patients operated with the adjustable cortical button technique obtained 96.3% excellent or good results, with only 3.7% having poor results (Bak criteria). Of the total, 85.2% were injured while performing bench press exercises and 14.8%, during the practice of Brazilian jiu-jitsu or wrestling. All weight-lifting athletes had history of anabolic steroid use. ConclusionThe early or delayed reconstruction of ruptured pectoralis major muscle tendons with considerable muscle retraction, using an adjustable cortical button and autologous knee flexor grafts, showed a high rate of good results.

Tratamento cirúrgico da ruptura do tendão do músculo peitoral maior com botão cortical ajustável

ObjectiveTo assess the tendon reconstruction technique for total rupture of the pectoralis major muscle using an adjustable cortical button. MethodsProspective study of 27 male patients with a mean age of 29.9 (SD=5.3 years) and follow‐up of 2.3 years. The procedure consisted of autologous grafts taken from the semitendinosus and gracilis tendons and an adjustable cortical button. Patients were evaluated functionally by the Bak criteria. ResultsThe surgical treatment of pectoralis major muscle tendon reconstruction was performed in the early stages (three weeks) in six patients (22.2%) and in 21 patients (77.8%), in the late stages. Patients operated with the adjustable cortical button technique obtained 96.3% excellent or good results, with only 3.7% having poor results (Bak criteria). Of the total, 85.2% were injured while performing bench press exercises and 14.8%, during the practice of Brazilian jiu‐jitsu or wrestling. All weight‐lifting athletes had history of anabolic steroid use. ConclusionThe early or delayed reconstruction of ruptured pectoralis major muscle tendons with considerable muscle retraction, using an adjustable cortical button and autologous knee flexor grafts, showed a high rate of good results.

Synchronous giant hepatic adenoma in siblings-A case report and brief literature review

ABSTRACTA 47-year-old woman was referred to our department for a hepatic mass. She denied history of hepatitis or alcohol consumption and regular oral contraceptive use, except for the emergency contraceptive pill taken once a decade ago. Hepatitis B surface antigen and anti-hepatitis C antibody were negative, α-fetoprotein was within normal limit. CT scan revealed an enormous mass measuring 26.0×16 5×13 0 cm that almost totally replaced the right hepatic lobe. The neoplasm was completely resected and pathologically diagnosed as hepatic adenoma. Literature review indicates this is the largest hepatic adenoma reported so far. At the same time, clinical examination also revealed a hepatic mass in the patient's 42-year-old brother, which was pathologically confirmed as hepatic adenoma, too. He denied history of anabolic steroid use. Immunohistochemical analysis revealed the subtypes of both tumors as the inflammatory hepatic adenoma. Literature review indicates this is the first report of synchronous hepatic adenomas in siblings.

Functional outcomes and complications after surgical repair of triceps tendon rupture.

The purpose of this study was to present the functional outcomes and complications after primary repair of triceps tendon ruptures (TTR). A retrospective review was performed on eight patients (six males, two females) who underwent transosseous suture repair for TTR. Mayo elbow score, range of motion, muscle strength and patient satisfaction were evaluated after at least 1-year follow-up. The mean age of the patients was 25.1 years (range 16-42). The mechanism of injury was a sports injury in three patients, simple fall (fall on outstretched hand) in four and motorcycle accident in one patient. Two patients had associated radial head fracture, and one had a radial head fracture and trochlear fracture, and one patient had a medial epicondyle fracture. In two patients the diagnosis was missed at the initial admission to ED (delay, 20 and 75 days). Only one patient, who was a bodybuilder, had a history of anabolic steroid use, and the rest had no underlying disease or a predisposing factor for TTR. One of the patients with radial head fracture (displaced three parts) underwent simultaneous fixation using two headless screws. Patients were followed up for a mean of 18.8 months (range 12-26). At the final follow-up, all patients were satisfied with the treatment and the Mayo elbow score was excellent in six patients and good in two patients. There was 5° extension loss in two patients. Triceps muscle strength was 5/5 in all patients. Ulnar nerve entrapment occurred in one patient, so ulnar nerve release and anterior transposition were performed 3 months after surgery. Posterior interosseous nerve palsy occurred in one patient who underwent simultaneous radial head fracture fixation, but eventually returned back to normal 3 months postoperatively. All patients returned to their previous level of activity and occupation. Transosseous suture technique is a safe and effective treatment method for acute TTR with a low rate of complications and excellent functional outcomes. Retrospective case series, Level IV.

Rodent and Human Trials of the Testosterone Modulating Experimental Nutraceutical Taxadrol

Background: Testosterone therapy is commonly used by individuals dealing with testosterone deficiency (TD). TD affects older men and athletes with a history of anabolic steroid use. In this study a novel nutraceutical product, Taxadrol, was tested in rodents and human subjects to assess toxicity and activity as a testosterone therapy. Materials: Taxadrol, consisting of a proprietary mixture of natural products, was tested for toxicity and efficacy in rodents and humans. Results: Rodents examined at 10, 17, 24 and 7 days post withdrawal of Taxadrol were found to have increases in free and total testosterone compared to control animals when given 4 and 8 mg/kg doses. An average of 180% improvement in testosterone levels were also noted in two human subjects who ingested a 30 mg per day dose of Taxadrol. Conclusion: Increases in free and total testosterone were noted in rodent models with no signs of toxicity. Taxadrol was additionally shown to effectively raise testosterone levels in two male athletes with no major side effects.

Bilateral Simultaneous Traumatic Upper Arm Compartment Syndromes Associated with Anabolic Steroids

BackgroundAcute compartment syndrome, a surgical emergency, is defined as increased pressure in an osseofascial space. The resulting reduction of capillary perfusion to that compartment requires prompt fasciotomy. Treatment delay has a poor prognosis, and is associated with muscle and nerve ischemia, resultant infarction, and late-onset contractures. ObjectivesWe report a case of traumatic bilateral upper limb acute compartment syndrome associated with anabolic steroids, requiring bilateral emergency fasciotomies. Case ReportA 25-year-old male bodybuilder taking anabolic steroids, with no past medical history, presented to the Emergency Department 25 min after a road traffic accident. Secondary survey confirmed injuries to both upper limbs with no distal neurovascular deficit. Plain radiographs demonstrated bilateral metaphyseal fractures of the distal humeri. Within 2 h of the accident, the patient developed clinical features that were consistent with bilateral upper arm compartment syndrome. Bilateral fasciotomies of both anterior and posterior compartments were performed, confirming clinical suspicion. ConclusionWe suggest consideration of a history of anabolic steroid use when evaluating patients with extremity trauma.

Hepatocellular adenomas in men: MRI findings in four patients

To demonstrate both MRI and histopathological findings of hepatocellular adenomas (HCAs) in men. HCAs in four men are reported. All patients underwent MR studies at 1.5T including serial gadolinium-enhanced gradient echo imaging. Three men had solitary non-hemorrhagic adenomas that exhibited a uniform capillary blush with no central scar, and uniform fading of the tumor to near isointensity with the liver parenchyma by one minute. One of the subjects had uniform fat content as shown by uniform low signal on out-of-phase images. One patient had a solitary hemorrhagic adenoma that measured 17 cm in diameter and was heterogeneous on all sequences. Two of the four patients had a history of anabolic steroid use, and in the other two patients no underlying explanation for the tumor was found. Although three of the four patients had tumors that exhibited uniform homogeneous tumor blush and rapid fading of enhancement, because HCAs are rare in men and resemble hepatocellular carcinoma (HCC) in appearance, our findings suggest that histological confirmation of HCAs may not be avoidable in men.

SURGICAL REPAIR OF PECTORALIS MAJOR RUPTURE

HISTORY: 22 year old male bodybuilder with history of anabolic steroid use with acute onset of left chest pain while bench pressing. Complains of pain and weakness with attempted bench press. PHYSICAL EXAM: Muscular young male. Gross deformity of left pectoralis musculature with loss of normal pectoralis contour. Full range of motion of left shoulder. Weakness in internal rotation and adduction. (photo of patient) DIFFERENTIAL DIAGNOSIS: Partial vs complete rupture of pectoralis major muscle TEST AND RESULTS: MRI of left chest/upper humerus demostrates complete rupture through the musculotendinous portion of sternal head of pectoralis major muscle. Intact tendon insertion of sternal head and intact clavicular head of pectorilis major. (images) FINAL DIAGNOSIS: Complete tear of sternal head of pectoralis major muscle through musculotendinous junction TREATMENT: Surgical repair of sternal head of pectoralis major muscle (surgical photos)

Anabolic steroids in sport and exercise

Part I. History and Incidence of Use Chapter 1. Anabolic-Androgenic Steroids: A Historical Perspective and Definition Charles D. Kochakian and Charles E. Yesalis Endocrine Function of the Testis Androgens: Multiplicity of Male Hormones Anabolic Activity Partial Dissociation of Anabolic Activity From Androgenic Activity Anabolic Steroids Anabolic-Androgenic Steroids Therapeutic and Other Applications Veterinary Applications Summary References Chapter 2. History of Anabolic Steroid Use in Sport and Exercise Charles E. Yesalis, Stephen P. Courson, and James E. Wright Olympic Sports Female Athletes National Doping Programs Professional Football College High School Other Sports Conclusions References Chapter 3. Incidence of Anabolic Steroid Use: A Discussion of Methodological Issues Charles E. Yesalis, Michael S. Bahrke, Andrea N. Kopstein, and Camille K. Barsukiewicz Investigative Journalism Government Investigations Drug Testing Surveys Current Trends Methodological Issues Recommendations References Chapter 4. Prevention of Anabolic Steroid Use Linn Goldberg and Diane L. Elliot Scope of the Problem Drug-Testing Policy Educational Strategies AS Education: The ATLAS Study The ATLAS Program Conclusions References Part II. Effects, Dependence, and Treatment Issues Chapter 5. Effect of Anabolic Steroid Use on Body Composition and Physical Performance Karl E. Friedl Variations in Physiological Response to Anabolic Steroids Comparing Anabolic Steroid Dose and Effects Empirical Strength Studies Composition of Steroid-Induced Body Weight Gain Body Composition Changes After Cessation of Anabolic Steroid Use Neuromuscular and Neuropsychological Effects of Anabolic Steroid Use Sustainment of Androgenicity During Demanding Physical Training Countermeasures for Stress-Induced Catabolic Hormones Improved Aerobic Endurance Performance Conclusions References Chapter 6. Effects of Anabolic Steroids on Physical Health Karl E. Friedl Distinctions Between Types and Doses of Anabolic Steroids Case Reports of Adverse Effects in Anabolic Steroid-Using Athletes Suspected Disease Associations Stroke: A New Association With Anabolic Steroids Prostate: An Androgen Target and Potential for Disease Musculoskeletal Injuries Problems Indirectly Associated With Anabolic Steroids Research on Health Effects Conclusions References Chapter 7. Women and Anabolic Steroids Diane L. Elliot and Linn Goldberg Normal Physiological Effects of Testosterone in Women and Men Prevalence of Anabolic Steroid Use in Females Physical Effects of Anabolic Steroids on Women Psychological Effects of Anabolic Steroids on Females DHEA: A Weak Androgen Physique-Altering Drug Use References Chapter 8. Psychological Effects of Endogenous Testosterone and Anabolic-Androgenic Steroids Michael S. Bahrke Anabolic Steroids and Aggressive Behavior in Animals Effect of Endogenous Testosterone Levels on Human Moods and Behaviors Estrogen-Related Aggression Contraceptive Studies and Moods Effects of Anabolic Steroids on Athletes' Moods and Behavior Effects of Anabolic Steroids on Psychological Dependence and Withdrawal Methodological Issues Conclusions References Chapter 9. Anabolic Steroids: Potential for Physical and Psychological Dependence Kirk J. Brower The Nature of Drug Abuse and Dependence Evidence for Dependence on Anabolic Steroids Mechanisms of Anabolic Steroid Dependence Predictors of Anabolic Steroid Dependence Course of Dependence on Anabolic Steroids Prevention and Treatment References Chapter 10. Assessment and Treatment of Anabolic Steroid Abuse, Dependence, and Withdrawal Kirk J. Brower Identification and Assessment Treatment of Withdrawal Conclusions References Chapter 11. Legal Aspects of Anabolic Steroid Use and Abuse Carol Cole Kleinman and C.E. Petit Direct Legal Consequences of Steroid Abuse Indirect Legal Consequences of Steroid Abuse: Criminal Behavior The Proper Role of the Legal System Regarding Steroid Abuse References Part III. Testing and Societal Alternatives Chapter 12. Evolution and Politics of Drug Testing Jim Ferstle The Year of Scandals History of Drug Testing The Roots of Modern Drug Testing Challenges and Limitations in Drug Testing Causes for Criticism of Drug Testing Possible Solutions Outside the IOC Athletes' Rights in Drug Testing 1984: The L.A. Cover-Up More Secrets Testing Issues in Pro and U.S. Collegiate Sports Politics and Pharmacological Warfare Drug Testing and the Media References Chapter 13. Drug Testing and Anabolic Steroids R. Craig Kammerer Blood or Urine Testing? Structures, Chemistry, and Metabolism Technology of Anabolic Steroid Testing Philosophy of Anabolic Steroid Testing Costs of Anabolic Steroid Testing Circumventing Positive Test Results Use of Other Substances Future Directions in Anabolic Steroid Testing References Chapter 14. Societal Alternatives Charles E. Yesalis, Michael S. Bahrke, and James E. Wright Legalization: An End to Hypocrisy? Interdiction: A Question of Cost-Effectiveness Education: Is Anybody Listening? Conclusion: Our Values Must Change References