Appearance Image- and Performance-Enhancing Drug Users.pdf

Appearance/Image- and Performance-Enhancing Drug Users
A Forensic Approach
Monia Lusetti, MD,* Manuela Licata, PhD,* Enrico Silingardi, MD,*
Alessandro Bonsignore, MD,† and Cristian Palmiere, MD‡
Abstract: Image- and performance-enhancing drugs include a wide
range of substances used to promote physical changes to enhance appear-
ance. Anabolic androgen steroids are the most widely used image- and
performance-enhancing drugs along with a wide variety of additional sub-
stances. The aim of this study was to identify the pathological changes
pertaining to the cardiovascular system possibly involved in the death
and characterize the substances associated with steroid use and their possi-
ble role in the death. A series of deaths involving image- and performance-
enhancing drug users were selected. Nandrolone and testosterone were the
most frequently identified steroids. The most commonly illegal drugs
found were tetrahydrocannabinol, cocaine, and methadone. Antidepres-
sants, opioids, benzodiazepines, and barbiturates were also found. These
findings highlight that results obtained from postmortem investigations
should be meticulously evaluated to understand the weight that each iden-
tified substance may have played in the death process and exclude any al-
ternative causes of death.
Key Words: anabolic androgen steroids, autopsy,
image- and performance-enhancing drugs, psychoactive drugs, toxicology
(Am J Forensic Med Pathol 2018;00: 00–00)
Image- and performance-enhancing drugs include a wide range
of substances used to promote physical changes to enhance ap-
pearance, increase musculature, and improve athletic perfor-
mance, as well as perceived social opportunity, self-confidence,
and self-esteem.1
Anabolic androgen steroids are the most widely used class of
illicit image- and performance-enhancing drugs in competitive
athletics, recreational sports, and bodybuilding, generally used
to augment muscle mass. However, numerous studies have consis-
tently shown that anabolic androgen steroids users typically ingest
a wide variety of additional drugs, including other image- and
performance-enhancing drugs and classic drugs of abuse as well
as analgesic and psychiatric drugs without medical prescription.1–3
Uncontrolled anabolic androgen steroid abuse by adult athletes,
professionals, and amateurs, whether taking part in sporting events or
not, may be responsible for an increased incidence of cardiac deaths.
This concerns mainly weightlifters and bodybuilders taking very high
anabolic androgen steroid doses, often in combination with other
image- and performance-enhancing drugs and illicit drugs.2,4
On the other hand, the fact that anabolic androgen steroid
users may assume a bewilderingly large number of image- and
performance-enhancing drugs invarious forms, individually, simulta-
neously, and invarious temporal combinations and sequences, as well
as classic drugs of abuse, renders the interpretation of morphological
and toxicological findings in fatal cases extremely difficult.5
Exhaus-
tive macroscopic, microscopic, and toxicological investigations
are mandatory in the evaluation of sudden unexpected deaths in-
volving suspected image- and performance-enhancing drug users.
The study presented herein (case series) focuses on postmortem
findings in a series of deaths involving image- and performance-
enhancing drug (anabolic androgen steroid) users that underwent
forensic investigations. Our aim was 2-fold: to identify the mor-
phological changes pertaining to the cardiovascular system possi-
bly involved in the pathogenesis of death and characterize the
substances associated with anabolic androgen steroid use and
their possible role in the occurrence of death.
MATERIALS AND METHODS
A retrospective review was performed of cases between 2010
and 2018 to identify deaths with anabolic androgen steroid use.
Five cases (all males; mean age, 33 years) who had undergone fo-
rensic investigations were selected.
All cases included in this study originated from forensic
practice and were admitted to the mortuary because of sudden, un-
expected, and unwitnessed death. Personal data and medical re-
cords, when available, were collected from families, clinical
patient databases, general practitioners, and local health services.
According to available medical records, all these cases were void
of any “officially” medically prescribed drug treatment at the time
of death, including anabolic androgen steroid. Circumstantial ele-
ments (personal data collected from relatives and friends as well as
house searches carried out by authorities) confirmed image- and
performance-enhancing drug (including anabolic androgen ste-
roid) use in all cases.
Systematic toxicological analysis included blood ethanol
level determination, as well as general screening for volatile and
nonvolatile drugs, poisons, and metabolites. Anabolic androgenic
steroid screening (qualitative determination) was essayed in urine
samples using recommended techniques for this analysis.
RESULTS
Table 1 summarizes the main results obtained in the selected
cases. External examinations and autopsies allowed prominent
muscular masses and various degrees of testicular atrophy to be
noticed. At heart dissection, most coronary arteries were normal
or revealed only slight intima thickening in their subepicardial
portion. Scattered fatty streaks, as well as intima and media thick-
ening, occasionally characterized the coronaries. Acute myocar-
dial infarction was not observed in any of these subjects.
The main myocardial and coronary artery histological find-
ings consisted of myocardial interstitial fibrosis (2 cases) and
Manuscript received May 1, 2018; accepted June 26, 2018.
From the *Section of Legal Medicine, Department of Diagnostic Medicine,
Clinical Pathology and Public Health, University of Modena and Reggio
Emilia, Modena; and †DISSAL, University of Genova, Genova, Italy; and
‡CURML, University Center of Legal Medicine, Lausanne, Switzerland.
This study was not financially supported.
Reprints: Cristian Palmiere, MD, CURML, Chemin de la Vulliette 4, 1000,
Lausanne 25, Switzerland. E-mail: cristian.palmiere@chuv.ch.
The authors report no conflict of interest.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/18/0000–0000
DOI: 10.1097/PAF.0000000000000424
ORIGINAL ARTICLE
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018 www.amjforensicmedicine.com 1
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

ventricular hypertrophy (left ventricular or left and right ventricu-
lar hypertrophy, 3 cases) (Fig. 1). Occasional myocyte necrosis
within the left ventricle was observed.
Nandrolone and testosterone were the most frequently identi-
fied anabolic androgen steroids. The most commonly drugs found
were non–medically prescribed tetrahydrocannabinol (4 cases),
non–medically prescribed methadone (2 cases), non–medically
prescribed opiates (2 cases), and non–medically prescribed benzo-
diazepines (2 cases). Ethanol, cocaine, non–medically prescribed
barbiturate, and non–medically prescribed antidepressants were
observed in 1 case.
In all cases, the morphological findings along with the toxi-
cological data were considered sufficient to explain the death as
related to the cardiac effects of anabolic androgen steroid abuse in-
dividually considered or in combination with drug concentrations
potentially causing the death.
DISCUSSION
For years, individual case reports and small case series in
both clinical and forensic literature have described a variety of
possible anabolic androgen steroid effects on the cardiovascu-
lar system such as cardiomyopathy, arrhythmias, myocardial
infarction, and cerebrovascular accidents, as well as coagula-
tion abnormalities in known or suspected users. Larger con-
trolled studies have more recently supported these findings in
the clinical setting.2,3,5–9
TABLE 1. Main Results Obtained in the Selected Cases
Case
Main Toxicological Findings
(Blood and/or Urine)
Main Macroscopic and
Microscopic Findings
Case 1
Male, 32 y
Nandrolone* (urine)
Testosterone* (urine)
Methadone (blood 74 ng/mL)
EDDP (blood 32 ng/mL)
Citalopram (blood 143 ng/mL)
Clozapine (blood 165 ng/mL)
Venlafaxine (blood 118 ng/mL)
Lorazepam (blood 55 ng/mL)
Phenobarbital (blood 11 μg/mL)
THC (blood 3.3 μg/L)
Prominent muscular masses
Left ventricular hypertrophy
Heart 390 g
Myocardial fibrosis within
the left ventricle
Testicular atrophy
Case 2
Male, 32 y
Boldenone* (urine)
Clomiphene* (urine)
Methenolone* (urine)
Oxandrolone* (urine)
Stanozolol* (urine)
Lorazepam (blood 45 ng/mL)
Heart 360 g
Fatty streaks, intima and media thickening
within the coronary arteries
Testicular atrophy
Case 3
Male, 33 y
Methadone (blood 1.38 μg/mL)
Cocaine (blood 1.48 μg/mL)
Left ventricular hypertrophy
Heart 425 g
Myocyte necrosis involving
groups of myocytes
Case 4
Male, 39 y
Nandrolone* (urine)
Total morphine (blood 206 ng/mL)
Free morphine (blood 180 ng/mL)
Left and right ventricular hypertrophy
Heart 480 g
Myocardial fibrosis within the left ventricle
Myocyte necrosis involving groups of myocytes
Testicular atrophy
Case 5
Male, 29 y
Nandrolone* (urine)
Total morphine (blood 113 ng/mL)
Free morphine (blood 21 ng/mL)
Ethanol (blood 1.2 g/L)
Heart 340 g
Testicular atrophy
*Qualitative determination.
THC indicates tetrahydrocannabinol.
FIGURE 1. Myocardial interstitial fibrosis as observed in case 1
(hematoxylin-eosin stain).
Lusetti et al Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018
2 www.amjforensicmedicine.com © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Polypharmacy (use of multiple substances or agents in a
complex drug regimen), including use of legal and illegal sub-
stances, is common among image- and performance-enhancing
drug users. In anabolic androgen steroid users, this phenomenon
typically presents as a range of ancillary substances designed to
complement the effects of and counteract the unwanted side effects
of anabolic androgen steroids (or other image- and performance-
enhancing drugs taken simultaneously, eg, antiestrogens). The most
common substances include other hormones (human growth hor-
mone, insulinlike growth factor 1, thyroid hormones, and insulin),
stimulants (amphetamine, ephedrine, pseudoephedrine, and espe-
cially β-agonist clenbuterol), drugs supposed to stimulate testos-
terone (anabolic androgen steroid augmenting drugs) or growth
hormone secretion (peptidic growth hormone secretagogues)
and decrease estrogen production, drugs for weight or fluid loss
(diuretics, laxatives), and numerous other agents.5,10–12
It is worth noting that anabolic androgen steroid users fre-
quently ingest avariety of “dietary supplements” or “nutraceuticals”
in addition to the aforementioned drugs. Although these supple-
ments are typically sold over the counter without regulation, numer-
ous recent studies have shown that certain supplements actually
contain potent androgens or other image- and performance-
enhancing drugs such as clenbuterol. Conversely, a sizable propor-
tion of drugs sold on the street or over the Internet as supposedly
genuine androgens may be mislabeled, impure, or simply counter-
feit. Thus, an individual's actual total burden of image- and
performance-enhancing drug exposure may differ substantially
from what he/she believes to have ingested.3
Numerous studies have also shown that illicit anabolic andro-
gen steroid users frequently assume classic drugs of abuse in addi-
tion to anabolic androgen steroids. These include opioids/opiates,
cocaine, and tetrahydrocannabinol, as well as other licit and illicit
analgesic and psychoactive drugs. The mixture of pharmacologi-
cally distinct substances seems to be a common feature among
image- and performance-enhancing drugs/anabolic androgen
steroid users. It has been observed that the consumption of il-
licit psychoactive drugs among anabolic androgen steroid users
is primarily associated with pathological anabolic androgen
steroid users, for example, those who also engage in excessively
long cycling.3,5,10,13–15
Thieme and Büttner16
reported that a substantial number of
antihypertensive drugs of various classes were found in a series
of relevant doping cases. The presumptive correlation between an-
abolic androgen steroid misuse and self-treatment of cardiovascular
side effects was explicitly confirmed by detailed user statements.
Westerman et al17
observed that illegal drug use may occur in
nearly all subjects before starting testosterone use. These authors
highlighted that their own conclusions appeared to contrast others
that had suggested testosterone as a plausible gateway to other
drug abuse.14,18
In a report by Lood et al,14
polydrug abuse including analge-
sics, antidepressants, hypnotics, and other neuroleptics was found
in 60% of urine samples obtained from anabolic androgen steroid
users. According to the authors, all these substances are likely
used as medical treatment for different side effects associated with
anabolic androgen steroid use. Moreover, polydrug abuse in ana-
bolic androgen steroid users would support the hypothesis of ana-
bolic androgen steroid use as a gateway to other drug abuse and
chronic anabolic androgen steroid intake as a risk factor for
opioid dependence.
Current medicolegal literature pertaining to sudden death in
image- and performance-enhancing drug users consists mainly
of single case reports or small case series in anabolic androgen ste-
roid users. In most situations, the cause of death was considered
cardiac in origin based on the results of all investigations and
the exclusion of alternative causes of death, thus supporting the
hypothesis that cardiovascular changes possibly induced by
chronic anabolic androgen steroid use may play a role in the path-
ogenesis of death. On the other hand, postmortem case series fo-
cusing on polydrug and anabolic androgen steroid/image- and
performance-enhancing drug users have rarely been reported in
the forensic setting.7,19–28
In a case series including 24 anabolic androgen steroid users
described by Darke et al,29
the most common direct cause of death
was drug toxicity. In 23 of 24 cases, psychoactive substances other
than steroids were detected. The most prevalent drugs were psycho-
stimulants (cocaine, methamphetamine, MDMA). Opioids/opiates
(morphine, codeine, oxycodone, tramadol, and pholcodine) were
detected in 37.5% of cases, with morphine present in all cases. Ben-
zodiazepines were detected in nearly half of all cases, most com-
monly diazepam. Venlafaxine was present in 1 case, whereas no
cases tested positive for cannabis.
As stated previously, the fact that anabolic androgen steroid
users may assume other image- and performance-enhancing drugs
in various forms, individually, simultaneously, and in various tem-
poral combinations and sequences, as well as classic drugs of
abuse, renders the interpretation of morphological findings in fo-
rensic cases quite challenging. For instance, chronic cocaine abuse
has been demonstrated to be associated with increased left ventric-
ular mass index and wall thickness. Left ventricular hypertrophy
may provide an additional substrate facilitating the develop-
ment of myocardial ischemia and/or fatal arrhythmia in cocaine
abusers.5,30
Maceira et al31
observed a decreased systolic function
of both left and right ventricles, an increased left ventricular mass,
and the presence of local fibrosis in 71% of a cohort of 94 consec-
utive cocaine abusers, with a probability of left ventricular systolic
function related to mean duration of cocaine abuse.
The results of the study presented herein tend to confirm
clinical observations on this topic and corroborate previous
suggestions of associations between image- and performance-
enhancing drug/anabolic androgen steroid use and the con-
sumption of a wide range of other licit and illicit substances.
On the other hand, the main limitations of our study must be
clearly outlined and considered. The most important is the small
study sample, which may limit the possibility of drawing conclu-
sions based on a very limited number of studied cases, although
comparable with other researches examining the same topic.
The second limitation concerns the fact that several other fac-
tors, such as genetics, could theoretically be involved in the path-
ogenesis of sudden death in image- and performance-enhancing
drug/anabolic androgen steroid users. These factors were not con-
sidered in our research and should be taken into account in the fu-
ture when assessing the possible “pathways” leading to cardiac
events in such forensic population.
Third, as already highlighted by Petersson et al,26
most cases
of sudden death among individuals younger than 40 years are sub-
jected to forensic examinations even in the absence of obvious
signs of unnatural death, although forensic autopsy and toxicol-
ogy are not systematic in these situations.
Moreover, toxicological analyses regarding performance-
enhancing drugs/anabolic androgen steroids/illicit drugs are usu-
ally performed on the suspicion of the forensic pathologists.
As a consequence, additional cases of sudden deaths in
performance-enhancing drug/anabolic androgen steroid users
might have been missed in our research, because of either lack
of toxicological investigations or the fact that some cases could
have been diagnosed with terminal cardiac event in the clinical
setting, with no forensic investigations, or even in the forensic set-
ting with no toxicological investigations/no anabolic androgen
steroid research.
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018 Performance-Enhancing Drug Users
© 2018 Wolters Kluwer Health, Inc. All rights reserved. www.amjforensicmedicine.com 3

Globally considered, all these limitations might have led to
underestimate the effective role that anabolic androgen steroids
might play in the pathogenesis of sudden cardiac deaths and there-
fore limit the accuracy of our research.
From a forensic point of view, sudden and unexpected deaths
in suspected image- and performance-enhancing drug/anabolic
androgen steroid users raise significant issues pertaining to the in-
terpretation of morphological findings and toxicological results.
The toxicological identification of anabolic androgen ste-
roids, anabolic androgen steroid releasers/boosters, blood pressure
regulators, diuretics, psychostimulants, opiates/opioids, tetrahy-
drocannabinol, benzodiazepines, and antidepressants in the same
blood/urine samples, along with the macroscopic and microscopic
identification of potentially significant cardiovascular abnormali-
ties, must be intensely evaluated in order to assign the proper
weight to each of these findings in the pathogenesis of death.
Potentially significant morphological changes pertaining to
the myocardium and coronary arteries may be observed in fatali-
ties involving chronic anabolic androgen steroid/ image- and
performance-enhancing drug users. The high incidence of polydrug
abuse in these cases corroborates the observation that image- and
performance-enhancing drugs/anabolic androgen steroids are com-
monly taken together with other drugs of abuse, which is in accor-
dance with the drug abuse pattern of the average drug user/addict,
and confirms that these individuals are at high risk of death
by intoxication.
Results obtained from postmortem investigations should
therefore be meticulously evaluated in order to understand the
weight that each identified substance may have played in the oc-
currence of death.
Based on the above, it is challenging to identify the most suit-
able forensic “strategy” to decide in which cases anabolic androgen
steroids and other image- and performance-enhancing drugs should
be screened in situations of sudden cardiac death or when anabolic
androgen steroid use should be considered a contributing factor in
the cause/pathogenesis of death in sudden cardiac death cases.
Numerous steroid-related pathophysiological mechanisms
may play a role in determining a cardiac pathology and predispose
young individuals to myocardial injury and subsequent sudden
cardiac death. Based on the reviewed literature and our own find-
ings, we strongly support the hypothesis that sudden cardiac death
cases should always be investigated from a forensic point of view
and always include broad toxicological investigations preceded,
when possible, by a careful evaluation of personal information
(clinical data and anamnestic data), in order to identify possible
cases of anabolic androgen steroid consumption, as already em-
phasized by former researchers.20,21,32
REFERENCES
1. Hildebrandt T, Harty S, Langenbucher JW. Fitness supplements as a
gateway substance for anabolic-androgen steroid use. Psychol Addict
Behav. 2012;26:955–962.
2. Nieschlag E, Vorona E. Doping with anabolic androgenic steroids (AAS):
adverse effects on non-reproductive organs and functions. Rev Endocr
Metab Disord. 2015;16:199–211.
3. Kanayama G, Pope HG Jr. Illicit use of androgens and other hormones:
recent advances. Curr Opin Endocrinol Diabetes Obes. 2012;19:211–219.
4. Alizade E, Avcı A, Fidan S, et al. The effect of chronic anabolic-androgenic
steroid use on Tp-E interval, Tp-E/Qt ratio, and Tp-E/Qtc ratio in male
bodybuilders. Ann Noninvasive Electrocardiol. 2015;20:592–600.
5. Pope HG Jr, Kanayama G, Hudson JI. Risk factors for illicit
anabolic-androgenic steroid use in male weightlifters: a cross-sectional
cohort study. Biol Psychiatry. 2012;71:254–261.
6. Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of
performance-enhancing drugs: an endocrine society scientific statement.
Endocr Rev. 2014;35:341–375.
7. Joseph JF, Parr MK. Synthetic androgens as designer supplements.
Curr Neuropharmacol. 2015;13:89–100.
8. Shamloul RM, Aborayah AF, Hashad A, et al. Anabolic steroids
abuse-induced cardiomyopathy and ischaemic stroke in a young male
patient. BMJ Case Rep. 2014;26:1–3.
9. Akçakoyun M, Alizade E, Gündoğdu R, et al. Long-term anabolic
androgenic steroid use is associated with increased atrial electromechanical
delay in male bodybuilders. Biomed Res Int. 2014;2014:1–8.
10. Van Hout MC, Kean J. An exploratory study of image and
performance enhancement drug use in a male British South Asian
community. Int J Drug Policy. 2015;26:860–867.
11. Albertson TE, Chenoweth JA, Colby DK, et al. The changing drug culture:
use and misuse of appearance and performance enhancing drugs.
FP Essent. 2016;441:30–43.
12. Ip EJ, Trinh K, Tenerowicz MJ, et al. Characteristics and behaviors
of older male anabolic steroid users. J Pharm Pract. 2015;
28:450–456.
13. Hildebrandt T, Lai JK, Langenbucher JW, et al. The diagnostic dilemma
of pathological appearance and performance enhancing drug use.
Drug Alcohol Depend. 2011;114:1–11.
14. Lood Y, Eklund A, Garle M, et al. Anabolic androgenic steroids
in police cases in Sweden 1999–2009. Forensic Sci Int. 2012;
219:199–204.
15. Bersani FS, Santacroce R, Coviello M, et al. Cannabis: a self-medication
drug for weight management? The never ending story. Drug Test Anal.
2016;8:177–179.
16. Thieme D, Büttner A. Cardiovascular alterations associated with doping.
Herz. 2015;40:410–416.
17. Westerman ME, Charchenko CM, Ziegelmann MJ, et al.
Heavy testosterone use among bodybuilders: an uncommon cohort
of illicit substance users. Mayo Clin Proc. 2016;91:
175–182.
18. Arvary D, Pope HG Jr. Anabolic-androgenic steroids as a gateway to opioid
dependence. N Engl J Med. 2000;342:1532.
19. Montisci M, El Mazloum R, Cecchetto G, et al. Anabolic androgenic
steroids abuse and cardiac death in athletes: morphological and
toxicological findings in four fatal cases. Forensic Sci Int. 2012;217:
e13–e18.
20. Fineschi V
, Riezzo I, Centini F, et al. Sudden cardiac death during anabolic
steroid abuse: morphologic and toxicologic findings in two fatal cases of
bodybuilders. Int J Legal Med. 2007;121:48–53.
21. Fineschi V
, Baroldi G, Monciotti F, et al. Anabolic steroid abuse and cardiac
sudden death: a pathologic study. Arch Pathol Lab Med. 2001;125:
253–255.
22. Thiblin I, Mobini-Far H, Frisk M. Sudden unexpected death in a female
fitness athlete, with a possible connection to the use of anabolic androgenic
steroid (AAS) and ephedrine. Forensic Sci Int. 2009;184:e7–e11.
23. Far HR, Ågren G, Thiblin I. Cardiac hypertrophy in deceased users of
anabolic androgenic steroids: an investigation of autopsy findings.
Cardiovasc Pathol. 2012;21:312–316.
24. Di Paolo M, Agozzino M, Toni C, et al. Sudden anabolic steroid
abuse-related death in athletes. Int J Cardiol. 2007;114:114–117.
25. Petersson A, Garle M, Holmgren P, et al. Toxicological findings and
manner of death in autopsied users of anabolic androgenic steroids.
Drug Alcohol Depend. 2006;81:241–249.
26. Petersson A, Garle M, Granath F, et al. Morbidity and mortality in patients
testing positively for the presence of anabolic androgenic steroids in
connection with receiving medical care. A controlled retrospective cohort
study. Drug Alcohol Depend. 2006;81:215–220.
Lusetti et al Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018
4 www.amjforensicmedicine.com © 2018 Wolters Kluwer Health, Inc. All rights reserved.

27. Hausmann R, Hammer S, Betz P. Performance enhancing drugs
(doping agents) and sudden death—a case report and review of the
literature. Int J Leg Med. 1998;111:261–264.
28. Martinez-Quintana E, Saiz-Udaeta B, Marrero-Negrin N, et al.
Androgenic anabolic steroid, cocaine and amphetamine abuse and adverse
cardiovascular effects. Int J Endocrinol Metab. 2013;11:e8755.
29. Darke S, Torok M, Duflou J. Sudden or unnatural deaths involving
anabolic-androgenic steroids. J Forensic Sci. 2014;59:1025–1028.
30. Brickner ME, Willard JE, Eichhorn EJ, et al. Left ventricular hypertrophy
associated with chronic cocaine abuse. Circulation. 1991;84:1130–1135.
31. Maceira AM, Ripoll C, Cosin-Sales J, et al. Long term effects
of cocaine on the heart assessed by cardiovascular magnetic
resonance at 3T. J Cardiovasc Magn Reson. 2014;16:26.
32. Frati P, Busardò FP, Cipolloni L, De Dominicis E, Fineschi V
, Anabolic
androgen steroid (AAS) related deaths: autoptic, histopathological and
toxicological findings. Curr Neuropharmacol. 201513 :146–159.
Am J Forensic Med Pathol • Volume 00, Number 00, Month 2018 Performance-Enhancing Drug Users
© 2018 Wolters Kluwer Health, Inc. All rights reserved. www.amjforensicmedicine.com 5

Appearance Image- and Performance-Enhancing Drug Users.pdf

Recommended

Recommended

More Related Content

Similar to Appearance Image- and Performance-Enhancing Drug Users.pdf

Similar to Appearance Image- and Performance-Enhancing Drug Users.pdf (20)

More from Holly Fisher

More from Holly Fisher (20)

Recently uploaded

Recently uploaded (20)

Appearance Image- and Performance-Enhancing Drug Users.pdf