Harm Reduction Harm Reduction 20082008: IHRA’s : IHRA’s 1919thth International ConferenceInternational ConferenceT d A Gl b l A hT d A Gl b l A hTowards A Global ApproachTowards A Global Approach

Anabolic steroids and associated drugs:Anabolic steroids and associated drugs: Public health implications and harm reduction

Jim McVeighJim McVeighJim McVeighJim McVeighReader in Substance Use EpidemiologyReader in Substance Use Epidemiology

Liverpool John Moores UniversityLiverpool John Moores Universityp yp y

Presentation outlinePresentation outline

P l f b li t idP l f b li t idPrevalence of anabolic steroid usePrevalence of anabolic steroid use

Reasons for useReasons for useReasons for useReasons for use

Adverse effectsAdverse effects

How and what drugs are usedHow and what drugs are used

B i t i tB i t i tBarriers to serviceengagementBarriers to serviceengagement

Models of interventionModels of interventionModels of interventionModels of intervention

The extent of anabolicThe extent of anabolicThe extent of anabolic The extent of anabolic steroid use in thesteroid use in thesteroid use in the steroid use in the

general populationgeneral populationgeneral populationgeneral population

The extent of anabolic steroid use in the The extent of anabolic steroid use in the general populationgeneral population

United StatesUnited States studies showstudies show 44% to% to 66% (range of% (range of 33% to% to 1212%) of high%) of high

general populationgeneral population

United StatesUnited States studies show studies show 44% to % to 66% (range of % (range of 33% to % to 1212%) of high %) of high school males using anabolic steroids at some time in their life. school males using anabolic steroids at some time in their life. Estimates as high as Estimates as high as 3 3 million Americansmillion Americans

CanadaCanada ((19961996) more than ) more than 8383,,000 000 young people had usedyoung people had used

AustraliaAustralia ((19971997) lifetime prevalence amongst high school males ) lifetime prevalence amongst high school males 33..22% % d f ld f l 11 22%%and females and females 11..22%%

PolandPoland ((20062006) Internet survey ) Internet survey 66..22% among males and % among males and 22..99% among % among femalesfemalesfemales females

DenmarkDenmark ((19981998) Estimates vary from ) Estimates vary from 1010,,000 000 to to 5050,,000000+ anabolic + anabolic steroid userssteroid users

United Kingdom United Kingdom ((20062006//0707) anabolic steroid lifetime prevalence of ) anabolic steroid lifetime prevalence of 197197,,000 000 ((165165,,000 000 –– 234234,,000000))

3000

2500

2000

Clie

nts

New AS injecting clients

New other injecting clients

1500

Num

ber

of C AS injecting clients

Other injecting clients

1000

N

0

500

01991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year of Presentation/Attendance

‘All’ & ‘new’ clients attending agency based SEPs in ‘All’ & ‘new’ clients attending agency based SEPs in Cheshire & Merseyside (1991 to 2005)Cheshire & Merseyside (1991 to 2005)

Pressures on males to initiate anabolic Pressures on males to initiate anabolic t idt idsteroid usesteroid use

ExternalExternal –– social &social & InternalInternalExternal External social & social & culturalcultural

Media pressureMedia pressure

InternalInternal

Negative body imageNegative body imageMedia pressureMedia pressure

Sporting influencesSporting influences

E i id tiE i id ti

SelfSelf--esteemesteem

Pubertal timingPubertal timingEconomic considerationsEconomic considerations

Parental influenceParental influenceBody Dysmorphia Disorder Body Dysmorphia Disorder (BDD)(BDD)

Peer pressurePeer pressure

“ achieving your full potential is the ultimate battle of“ achieving your full potential is the ultimate battle of…achieving your full potential is the ultimate battle of …achieving your full potential is the ultimate battle of mind over body…”mind over body…”

“ th t f f t t l i fl“ th t f f t t l i fl“...the purest form of sport…no external influences or “...the purest form of sport…no external influences or arbitrary rules, the results are purely down to myself”arbitrary rules, the results are purely down to myself”

40 40 years of Action Manyears of Action Man“The Public Health Response”“The Public Health Response”

Reasons for use & effects experiencedReasons for use & effects experienced

Reasons for use:Reasons for use: Effects experienced:Effects experienced:Reasons for use:Reasons for use:

Improve bodybuildingImprove bodybuildingEffects experienced: Effects experienced:

Faster training recoveryFaster training recovery 88.9%88.9%Increase muscleIncrease muscle

Improve performanceImprove performanceIncreased muscle massIncreased muscle mass 87.6%87.6%

Increased strengthIncreased strength 83.9%83.9%Train longerTrain longer

Prevent injuryPrevent injuryImproved performance 78.7%Improved performance 78.7%

Faster recovery after injuryFaster recovery after injury 70 9%70 9%Prevent injuryPrevent injury

Increase strengthIncrease strength

S dS d

Faster recovery after injuryFaster recovery after injury 70.9%70.9%

Decreased body fatDecreased body fat 56.1%56.1%Speed up recoverySpeed up recovery More self confidentMore self confident 52.3%52.3%

Adverse effectsAdverse effectsAdverse effectsAdverse effects

Use of steroids in high doses has been Use of steroids in high doses has been associated with a diverse number of negative associated with a diverse number of negative effects on physical and mental healtheffects on physical and mental health

These include: cosmetic effects, reproductive These include: cosmetic effects, reproductive dysfunction liver disease cardiovasculardysfunction liver disease cardiovasculardysfunction, liver disease, cardiovascular dysfunction, liver disease, cardiovascular disease, anxiety, aggression, depression and disease, anxiety, aggression, depression and dependencedependencedependencedependence

Limitations of evidenceLimitations of evidence

SelfSelf--reports and case reports (many with incomplete reports and case reports (many with incomplete clinical history)clinical history)clinical history)clinical history)

Naturalistic/crossNaturalistic/cross--sectional/casesectional/case--control/prospective control/prospective h t dih t diresearch studiesresearch studies

Limited number of RCTs using “moderate” doses of a Limited number of RCTs using “moderate” doses of a single steroid (Do the studies reflect “realsingle steroid (Do the studies reflect “real--life” steroid life” steroid use?)use?)

Extrapolating from clinical populations Extrapolating from clinical populations

Animal models (can demonstrate that effects are Animal models (can demonstrate that effects are ((compoundcompound--specific, but can we translate data to specific, but can we translate data to humans?)humans?)

Biological plausibilityBiological plausibility

The easy ones …

•AcneFemaleFemale••Menstrual Menstrual

• Male pattern baldness (paradoxically, increased growth of body hair)

irregularitiesirregularities••Clitoral enlargementClitoral enlargementincreased growth of body hair)

• Gynaecomastia (also associated with, HCG and spironolactone)

gg••Smaller breastsSmaller breasts••Reproductive Reproductive HCG and spironolactone)

Infection via injection

ppdysfunctiondysfunction••Deepening of voiceDeepening of voice

• Decreased production of sperm and shrinking of the testicles

p gp g••Body/facial hairBody/facial hair

• Virilisation in women

Common anabolic steroidsCommon anabolic steroids

Most commonly used drugs in Most commonly used drugs in conjunction with anabolic steroidsconjunction with anabolic steroidsconjunction with anabolic steroidsconjunction with anabolic steroids

DrugDrug % used% used DrugDrug % used% usedlast yearlast year

HCGHCG 22.422.4last yearlast year

CocaineCocaine 11.811.8Growth HormoneGrowth Hormone 21.221.2TamoxifenTamoxifen 17.617.6

EcstasyEcstasy 3.53.5CannabisCannabis 2.42.4

ClenbuterolClenbuterol 11.811.8EphedrineEphedrine 9 49 4

AmphetamineAmphetamine 1.21.2EphedrineEphedrine 9.49.4DiureticsDiuretics 7.17.1InsulinInsulin 5 95 9InsulinInsulin 5.95.9GHBGHB 3.53.5NalbuphineNalbuphine 1 21 2

Sample of Sample of 85 85 anabolic steroid users anabolic steroid users attending Merseyside syringe exchangesattending Merseyside syringe exchangesNalbuphine Nalbuphine 1.21.2

IGFIGF--11 1.21.2

attending Merseyside syringe exchangesattending Merseyside syringe exchanges

36 36 year old male using for over year old male using for over 11 11 yearsyearsCase studyCase study

y gy g yyInjected Injected 50 50 times in the previous yeartimes in the previous yearHad informed his GP but not received any drug relatedHad informed his GP but not received any drug relatedHad informed his GP but not received any drug related Had informed his GP but not received any drug related services or informationservices or informationInformation accessed from trainer, internet and magazinesInformation accessed from trainer, internet and magazines, g, gIn the previous year he had used: In the previous year he had used:

Nandrolone decanoateNandrolone decanoateSustanon 250Stanozolol

Growth hormone Growth hormone ClenbuterolClenbuterolStanozolol

Testosterone cypionateT t t i t

HCG HCG TamoxifenTamoxifenTestosterone propionate

Boldenone undecanoateM th d t l

TamoxifenTamoxifenEphedrineEphedrineDiureticsDiureticsMethandrostenolone

Oxymetholone

DiureticsDiureticsCocaineCocaine

Why is it difficult Why is it difficult yyto provide harmto provide harmto provide harm to provide harm

reduction toreduction toreduction to reduction to b li t idb li t idanabolic steroid anabolic steroid users?users?

MISINFORMATIONMISINFORMATIONMISINFORMATIONMISINFORMATIONMISTRUSTMISTRUSTMISTRUSTMISTRUST

MYTHOLOGYMYTHOLOGYMYTHOLOGYMYTHOLOGYPROPHYLACTIC LIESPROPHYLACTIC LIESPROPHYLACTIC LIESPROPHYLACTIC LIES

“There is no conclusive “There is no conclusive scientific evidence that scientific evidence that

extremely large doses ofextremely large doses ofextremely large doses of extremely large doses of anabolicanabolic--androgenic steroids androgenic steroids a abo ca abo c a d oge c ste o dsa d oge c ste o dseither aid or hinder athletic either aid or hinder athletic

performance”performance”

ACSM, 1976ACSM, 1976

Statement still in effect in the midStatement still in effect in the midStatement still in effect in the mid Statement still in effect in the mid 1980s1980s

“Although there is still little“Although there is still littleAlthough there is still little Although there is still little available evidence regarding the available evidence regarding the g gg g

long term health effects of long term health effects of anabolic steroids, many current anabolic steroids, many current

or potential anabolic steroidor potential anabolic steroidor potential anabolic steroid or potential anabolic steroid users unfortunately mistake users unfortunately mistake yy

absence of evidence for absence of evidence for id f b ”id f b ”evidence of absence”evidence of absence”

Y liY li 20002000Yesalis, Yesalis, 20002000

MISINFORMATION, MYTHOLOGY& PROPHYLACTIC LIESMISINFORMATION, MYTHOLOGY& PROPHYLACTIC LIESnot restricted to the anabolic steroid using communitiesnot restricted to the anabolic steroid using communities…not restricted to the anabolic steroid using communities…not restricted to the anabolic steroid using communities

Many healthcare professionals base their views regarding Many healthcare professionals base their views regarding the long term health effects of anabolic steroids on a the long term health effects of anabolic steroids on a limited number of individual case reports. limited number of individual case reports.

“Untoward health events in “Untoward health events in individuals using individuals using

performance & imageperformance & imageperformance & image performance & image enhancing drugs do notenhancing drugs do notenhancing drugs do not enhancing drugs do not

necessarily prove causality necessarily prove causality by those drugs”by those drugs”

What can we do?What can we do?What can we do?What can we do?

S ringe e changeS ringe e changeSyringe exchangeSyringe exchangeNurse led servicesNurse led servicesNurse led servicesNurse led servicesMedical led serviceMedical led serviceOutreachOutreachSSSpecialist targetingSpecialist targeting

Harm reduction messagesHarm reduction messagesLook at motivation for useLook at motivation for useExisting health statusExisting health statusDosage Dosage –– smallest smallest –– do not adopt other users regimesdo not adopt other users regimesgg p gp gStacking Stacking –– minimal benefitminimal benefitCyclesCycles –– limit the on cyclelimit the on cycle –– ensure off cycleensure off cycleCycles Cycles limit the on cycle limit the on cycle ensure off cycleensure off cycleDrugs to combat side effects Drugs to combat side effects –– if you need them if you need them -- too high too high dosage of steroidsdosage of steroidsdosage of steroidsdosage of steroidsInjecting Vs OralInjecting Vs OralDangers of recreational drug useDangers of recreational drug useDangers of recreational drug useDangers of recreational drug useInjecting techniquesInjecting techniquesTraining Nutrition & SleepTraining Nutrition & SleepTraining, Nutrition & SleepTraining, Nutrition & SleepCounterfeit & fakes Counterfeit & fakes –– check check –– if in doubt don’t useif in doubt don’t useW f id ff t i l di t ti l f i it bilit &W f id ff t i l di t ti l f i it bilit &Warn of side effects including potential for irritability & Warn of side effects including potential for irritability & aggressionaggression

Contact detailsContact detailsJi M V i hJi M V i hJim McVeighJim McVeigh

Reader in Substance Use EpidemiologyReader in Substance Use EpidemiologyCentre for Public HealthCentre for Public Health

Liverpool John Moores UniversityLiverpool John Moores UniversityCastle House, North StreetCastle House, North Street

Liverpool, LLiverpool, L3 23 2AY AY p ,p ,Tel: Tel: 0151 231 45120151 231 4512

email: j mcveigh@ljmu ac ukemail: j mcveigh@ljmu ac ukemail: j.mcveigh@ljmu.ac.ukemail: j.mcveigh@ljmu.ac.ukwww.cph.org.ukwww.cph.org.uk