Performance & Image Enhancing Drugs in Syringe Exchange:

Implications for Practice

Martin Chandler Inter Agency Drug Misuse Database (IAD) Manager

Centre for Public Health Liverpool John Moores University

Objectives

• To explore recent findings on the prevalence of AAS use amongst NeX clients in the UK• Discuss possible reasons why the prevalence appears to be changing• Review the pharmacology and use of AAS and associated substances (PIEDs), including legal issues• Discuss the key dangers in AAS use • Review and discuss the implications for practice

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Year of Presentation/Attendance

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New AS injecting clients

New other injecting clients

AS injecting clients

Other injecting clients

‘‘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)

Results of the “straw poll” of Syringe Results of the “straw poll” of Syringe Exchanges in the UKExchanges in the UK

•15 responses, representing a total of 36(ish!) syringe exchange sites around the UK (Not including sites reporting directly to the IAD)

• All sites report an increase in the number of new injectors using AAS

• All sites report a perception of the average age decreasing (but few can prove it)

• Many sites reporting 17 year old clients, some suggestion of younger clients but unconfirmed

• Some sites reporting younger AAS users who train in isolation

Anabolic steroid injectors in contact with Anabolic steroid injectors in contact with syringe exchange schemes in Cheshire & syringe exchange schemes in Cheshire &

Merseyside Merseyside 600% increase in new steroid injectors between 1991 and 2001600% increase in new steroid injectors between 1991 and 2001

1,800% increase in the number of individual anabolic steroid injectors 1,800% increase in the number of individual anabolic steroid injectors

At the largest Merseyside agency:At the largest Merseyside agency:

60% increase in the number of anabolic steroid injectors between 60% increase in the number of anabolic steroid injectors between 2002 and 20062002 and 2006

Agency based sites in Cheshire & Merseyside are reporting 70-80% Agency based sites in Cheshire & Merseyside are reporting 70-80% of of newnew clients as AAS users. One site has nearly 90%. clients as AAS users. One site has nearly 90%.

““Tip of the Iceberg”Tip of the Iceberg”

The extent of peer distribution is unknown but in just one site on The extent of peer distribution is unknown but in just one site on Merseyside there are four clients taking an average of 3-500 Merseyside there are four clients taking an average of 3-500 packspacks per visit….each.per visit….each.

Why is this happening?Why is this happening?

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Internet Sites for Steroid UseInternet Sites for Steroid Use

Internet Sites for Steroid UseInternet Sites for Steroid Use

Internet Sites for Steroid UseInternet Sites for Steroid Use

What are Anabolic Steroids?What are Anabolic Steroids?

How are they used?How are they used?

DefinitionDefinition

•Mimic the effects of testosteroneMimic the effects of testosterone

•Testosterone - anabolic & androgenicTestosterone - anabolic & androgenic

•Anabolic - growth & development of tissue Anabolic - growth & development of tissue

•Androgenic - secondary male sexual Androgenic - secondary male sexual characteristicscharacteristics

•Not to be confused with corticosteroids Not to be confused with corticosteroids (School surveys in the USA)(School surveys in the USA)

Clinical usesClinical uses

•Aplastic anaemiasAplastic anaemias•Muscle wastingMuscle wasting

•Trauma/burnsTrauma/burns•HIV/AIDSHIV/AIDS

•Post menopausal osteoporosis Post menopausal osteoporosis •HRT for men HRT for men •Delayed male pubertyDelayed male puberty•Male contraceptiveMale contraceptive•Rarely indicated or used – Rarely indicated or used – supercededsuperceded by by other drugs or not part of the diagnosis other drugs or not part of the diagnosis (Depression vs Male menopause)(Depression vs Male menopause)

Performance enhancement Performance enhancement (or image enhancement)(or image enhancement)

•Increase lean body mass/decrease body fat Increase lean body mass/decrease body fat ratioratio

•Increase size and strengthIncrease size and strength

•Increase aggressionIncrease aggression

•Increase staminaIncrease stamina

•Increase sex driveIncrease sex drive

Nandrolone DecanoateNandrolone Decanoate

Commonly used Anabolic SteroidsCommonly used Anabolic Steroids

MethandrostenoloneMethandrostenolone

OxandroloneOxandrolone

OxymetholoneOxymetholone

MethenoloneMethenolone

StanozololStanozolol

Sustanon 250Sustanon 250

FormeboloneFormebolone

BoldenoneBoldenone

Testosterone CypionateTestosterone Cypionate

Testosterone EnanthateTestosterone Enanthate

Testosterone PropionateTestosterone Propionate

Testosterone UndecanoateTestosterone Undecanoate

MethyltestosteroneMethyltestosterone

Common anabolic steroidsCommon anabolic steroids

Common anabolic steroidsGeneric Common trade names Inject OralNandrolone Deca, Anabolin Methandrostenolone Dianabol *Methandienone Pronabol *Oxandrolone Anavar *Oxymetholone Anadrol, Anapalon *Norethandrolone Nilevar Methenolone Primobolan *Stanozolol Stromba, Winstrol *Fluoxymesterone Halotestin *Sustanon Sostenon Formebolone Esiclene Boldenone Equipoise Testosterone Cypionate Testex Leo, Testex Testosterone Enanthate Testoviron Testosterone Propionate Testovis Testosterone Undecanoate Andriol, Restandol Methyltestosterone Android *

* Indicates C17 alpha-alkylated

Nandrolone DecanoateNandrolone Decanoate

Most commonly used injectable steroidMost commonly used injectable steroid

Relatively low androgenic properties so Relatively low androgenic properties so does not aromatise easilydoes not aromatise easily

Not C17 alpha alkylated so not strongly Not C17 alpha alkylated so not strongly associated with liver dysfunctionassociated with liver dysfunction

Associated with fluid retention.Associated with fluid retention.

Available in 25mg/ml to 200mg/mlAvailable in 25mg/ml to 200mg/ml

Therapeutic dosageTherapeutic dosageMale:Male: 50-100mg per week50-100mg per weekFemale:Female: 50mg every 3 weeks50mg every 3 weeks

Typical dosageTypical dosageMale:Male: 200-400mg per week200-400mg per weekFemale:Female: 50-100mg per week50-100mg per week

MethandrostenoloneMethandrostenolone

Usually referred to as Dianabol and almost Usually referred to as Dianabol and almost identical to Methandienone (Pronabol).identical to Methandienone (Pronabol).

C17 alpha alkylatedC17 alpha alkylated

Short acting – half-life: 3.2 to 4.5 hoursShort acting – half-life: 3.2 to 4.5 hours

Dramatic gains in size & strength reported but Dramatic gains in size & strength reported but associated with hypertension, aromatisation, associated with hypertension, aromatisation, male pattern baldness & acne.male pattern baldness & acne.

Virilisation occurs easily in womenVirilisation occurs easily in women

Available in range of tablets – usually 5mgAvailable in range of tablets – usually 5mgTherapeutic dosageTherapeutic dosage2-5mg daily. 6 weeks on, 4 weeks off2-5mg daily. 6 weeks on, 4 weeks offTypical dosageTypical dosageMale:Male: 15-30mg per day15-30mg per dayFemale:Female: 10-20mg per day10-20mg per day

Generic Common trade names

Clenbuterol Clenbuterol Spiropent, Ventolase Spiropent, Ventolase

Growth Hormone Growth Hormone Somatropin Somatropin

Chorionic Gonadotrophin Chorionic Gonadotrophin HCG HCG

Insulin Insulin Actrapid, monotard, humulin Actrapid, monotard, humulin

Insulin Like Growth Factor 1 Insulin Like Growth Factor 1 IGF IGF (Long R3)(Long R3)

Tamoxifen Tamoxifen NolvadexNolvadex

Performance Enhancing DrugsPerformance Enhancing Drugs & common trade names& common trade names

Fakes & CounterfeitsFakes & Counterfeits

•Many products contain active ingredients Many products contain active ingredients different to that labelled or at significantly different different to that labelled or at significantly different strengths strengths

•40 products tested: 37.5% not as stated 40 products tested: 37.5% not as stated (Germany)(Germany)

•4 products tested: 43%-73% of stated dosage 4 products tested: 43%-73% of stated dosage (Liverpool)(Liverpool)

•14 products tested: Between 0-169% of stated 14 products tested: Between 0-169% of stated dosage (Wales)dosage (Wales)

(Ritsch & Musshoff 2000, McVeigh and Lenehan 1994, Perry, 1995(Ritsch & Musshoff 2000, McVeigh and Lenehan 1994, Perry, 1995

Common physical side effects of Common physical side effects of anabolic steroidsanabolic steroids

•Acne Acne •Heart disease Heart disease •HypertensionHypertension•Liver disordersLiver disorders•Blood disordersBlood disorders•Sexual/reproductive Sexual/reproductive dysfunctiondysfunction•Hormone imbalanceHormone imbalance•HairHair•InfectionsInfections

Potential side effectsPotential side effectsGender specificGender specific

MaleMale•GynaecomastiaGynaecomastia.•Testicular atrophyTesticular atrophy•Male pattern baldnessMale pattern baldness•Increased body hairIncreased body hair

Potential side effectsPotential side effectsGender specificGender specific

FemaleFemale•Menstrual irregularitiesMenstrual irregularities•Clitoral enlargementClitoral enlargement•Smaller breastsSmaller breasts•Reproductive dysfunctionReproductive dysfunction•Deepening of voiceDeepening of voice•Body/facial hairBody/facial hair

•AggressionAggression•DepressionDepression•AnxietyAnxiety•Social/behavioural problemsSocial/behavioural problems•Mood swingsMood swings•InsomniaInsomnia•?Psychosis?Psychosis•?Violence?Violence•?Dependence?Dependence•?Suicide?Suicide

Potential psychological side effects of Potential psychological side effects of anabolic steroidsanabolic steroids

• DietDiet- Changes in physique come from the dietChanges in physique come from the diet- Should watch out for high levels of sugars and Should watch out for high levels of sugars and

saturated fats “Eat clean” (Lipid levels)saturated fats “Eat clean” (Lipid levels)

• TrainingTraining- Needs to be consistent and well though out Needs to be consistent and well though out - Only a signal for the body to adaptOnly a signal for the body to adapt- Damages the bodyDamages the body

• RecoveryRecovery-This is when the body adapts (grows)This is when the body adapts (grows)- Most forgotten aspect but crucial to successMost forgotten aspect but crucial to success- Reduced time on cycleReduced time on cycle

The cornerstones of an exercise The cornerstones of an exercise programprogram

Anabolic steroids: Legal statusAnabolic steroids: Legal status•1/9/96 - Came under Misuse of Drugs Act 1/9/96 - Came under Misuse of Drugs Act (previously under the Medicines Control Act (previously under the Medicines Control Act

•Named steroids (46) plus chemical definitionNamed steroids (46) plus chemical definition

•Clenbuterol/HGH/HCG also covered by legislationClenbuterol/HGH/HCG also covered by legislation

•Class C Schedule 4 part 1Class C Schedule 4 part 1

•Simple possession in medicinal form - legalSimple possession in medicinal form - legal

•Supply, possession with intent to supply - illegalSupply, possession with intent to supply - illegal

•Max penalty - 14 years and/or unlimited fineMax penalty - 14 years and/or unlimited fine

•Import/export license required - not personal use Import/export license required - not personal use in in medicinalmedicinal form form

Anabolic steroids: Legal statusAnabolic steroids: Legal statusThe definition of "medicinal product" is provided by section 130 of the The definition of "medicinal product" is provided by section 130 of the Medicines Act 1968 as Medicines Act 1968 as "any substance or article which is manufactured, "any substance or article which is manufactured, sold, supplied, imported or exported for use wholly or mainly .... as an sold, supplied, imported or exported for use wholly or mainly .... as an ingredient in the preparation of a substance . . . which is to be ingredient in the preparation of a substance . . . which is to be administered . . . for a medicinal purpose."administered . . . for a medicinal purpose." "Medicinal purpose" means "Medicinal purpose" means one or more of the following:one or more of the following:

(1 ) treating or preventing disease;(1 ) treating or preventing disease;(2) diagnosing disease or ascertaining the existence, degree or extent of (2) diagnosing disease or ascertaining the existence, degree or extent of a physiological condition;a physiological condition;(3) contraception;(3) contraception;(4) inducing anaesthesia;(4) inducing anaesthesia;(5) otherwise preventing or interfering with the normal operation of a (5) otherwise preventing or interfering with the normal operation of a physiological function, whether permanently or temporarily, and whether physiological function, whether permanently or temporarily, and whether by way of terminating, reducing or postponing, or increasing or by way of terminating, reducing or postponing, or increasing or accelerating, the operation of that function or in any other way.accelerating, the operation of that function or in any other way.

Sub-paragraph (5) provides the basis on which anabolic steroids are Sub-paragraph (5) provides the basis on which anabolic steroids are classed as a medicinal product.classed as a medicinal product.

Steroid users in Syringe Exchange:Steroid users in Syringe Exchange:Implications for practiceImplications for practice

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Opiates

Stimulants

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SES visits per year (mean) by drug groupSES visits per year (mean) by drug group(Cheshire & Merseyside 1991 –2005)(Cheshire & Merseyside 1991 –2005)

• Sterile equipment/basic hygiene/safe Sterile equipment/basic hygiene/safe disposaldisposal

•Correct equipmentCorrect equipment

•max. 2ml syringemax. 2ml syringe

•21g x 1.5” (green) or 23g x 1.25” (blue)21g x 1.5” (green) or 23g x 1.25” (blue)

•Double amount of needles providedDouble amount of needles provided

•Rotation of sitesRotation of sites

•Needle = quickly / injection = slowlyNeedle = quickly / injection = slowly

Information for anabolic steroid injectorsInformation for anabolic steroid injectors

Information for anabolic steroid injectors Information for anabolic steroid injectors Sites for intramuscular injectionsSites for intramuscular injections

Sciatic Sciatic nervenerve

Barriers to engagement with AAS clientsBarriers to engagement with AAS clients

Don’t perceive themselves as drug usersDon’t perceive themselves as drug usersConflict with other client groupsConflict with other client groupsTrustTrustAwareness of serviceAwareness of serviceAccessibilityAccessibilityValue placed on servicesValue placed on servicesLack of expertise/specialist knowledgeLack of expertise/specialist knowledgeCompeting information sourcesCompeting information sourcesReduced opportunity to build relationshipsReduced opportunity to build relationshipsUnclear care & referral pathwaysUnclear care & referral pathwaysLack of hierarchy of harm reductionLack of hierarchy of harm reduction

General Practitioner contact with General Practitioner contact with anabolic steroid usersanabolic steroid users

•43% of steroid users had informed their GP of 43% of steroid users had informed their GP of their anabolic steroid usetheir anabolic steroid use•22% were receiving regular medical checks from 22% were receiving regular medical checks from their GPtheir GP•45% of those not receiving medical checks would 45% of those not receiving medical checks would pay for this service if available pay for this service if available (Lenehan & McVeigh 1996)(Lenehan & McVeigh 1996)

•32% 32% had informed their GP of their anabolic had informed their GP of their anabolic steroid usesteroid use•Only 15% had received health related Only 15% had received health related information regarding anabolic steroid use from information regarding anabolic steroid use from their GPtheir GPSample of 85 anabolic steroid users attending Merseyside syringe exchanges Sample of 85 anabolic steroid users attending Merseyside syringe exchanges September 2005 – February 2006September 2005 – February 2006

Public health responses Public health responsesPublic health responses

Basic syringe exchange provisionBasic syringe exchange provision

Few other interventions available across the countryFew other interventions available across the country

Some examples of good practice relating to clinics, Some examples of good practice relating to clinics, outreach and servicesoutreach and services

Little involvement from general practitionersLittle involvement from general practitioners

Lack of credible information due to scarcity of evidenceLack of credible information due to scarcity of evidence

Lack of evidence base for harm reduction or drug Lack of evidence base for harm reduction or drug preventionprevention

Ideal service provision

•Multi-disciplinary approach within a harm Multi-disciplinary approach within a harm reduction philosophyreduction philosophy

•Appropriately experienced physicianAppropriately experienced physician•Specialist informationSpecialist information•Sports scientist/physiologistSports scientist/physiologist•Sports nutritionistSports nutritionist

Does this model exist?Does this model exist?

Harm reduction messagesHarm reduction messages•Look at motivation for useLook at motivation for use•Existing health statusExisting health status•Dosage – smallest – do not adopt other users Dosage – smallest – do not adopt other users regimesregimes•Stacking – minimal benefitStacking – minimal benefit•Cycles – limit the on cycle – ensure off cycleCycles – limit the on cycle – ensure off cycle•Drugs to combat side effects – if you need them - Drugs to combat side effects – if you need them - Too high dosage of steroidsToo high dosage of steroids•Injecting Vs OralInjecting Vs Oral•Dangers of recreational drug useDangers of recreational drug use•Injecting techniquesInjecting techniques•Training, Nutrition & SleepTraining, Nutrition & Sleep•Counterfeit & fakes – check – if in doubt don’t useCounterfeit & fakes – check – if in doubt don’t use•Warn of side effects including potential for irritability Warn of side effects including potential for irritability & aggression& aggression

What anabolic steroid users should What anabolic steroid users should monitor monitor

NutritionNutritionMeals including: Meals including:

ProteinProteinFatFatCarbohydratesCarbohydratesCaloriesCalories

Body weightBody weightWeekly – same timeWeekly – same time

SleepSleepHours slept each nightHours slept each night

MoodMoodIrritability, triggers, energy levelsIrritability, triggers, energy levels

What anabolic steroid users should What anabolic steroid users should monitor monitor

TrainingTraining

Daily record of Daily record of SetsSetsWeightsWeightsRepsRepsBodyparts exercisedBodyparts exercisedPerceived intensity (scale)Perceived intensity (scale)Perceived difficulty Perceived difficulty (scale)(scale)Injuries/pain – specifyInjuries/pain – specifyInput/advice receivedInput/advice receivedProgress towards targetsProgress towards targets

Medical examination should includeMedical examination should include

Medical history (Including steroid related)Medical history (Including steroid related)AgeAgeHeightHeightWeightWeightPulsePulseBlood pressureBlood pressureSocial and lifestyle assessmentSocial and lifestyle assessmentFull drug use history (Including non performance Full drug use history (Including non performance enhancing drugs)enhancing drugs)Age first usedAge first usedAge first injectedAge first injectedReasons for useReasons for useSide effects experiencedSide effects experienced

Investigations may includeInvestigations may include

RoutinelyFull Blood countSerum urea and electrolytesLiver function testsLipid and cholesterol profilesThyroid functionTestosteroneGlucose Offered/indicated/requestedProstate specific antigenAntibody tests for: HIVHepatitis CHepatitis B

Resources available/in progress from LJMUResources available/in progress from LJMU

• Steroid user triage/assessment formSteroid user triage/assessment form• Steroid research forum (forthcoming)Steroid research forum (forthcoming)• Anabolic Steroid Research NetworkAnabolic Steroid Research Network• In-house training (other people also provide In-house training (other people also provide training)training)• Ad hoc brief consultation/advice for NeX Ad hoc brief consultation/advice for NeX workers (with caveats!)workers (with caveats!)

Contact details:Contact details:

Martin ChandlerMartin ChandlerInter Agency Drug Misuse Database ManagerInter Agency Drug Misuse Database Manager

Jim McVeighJim McVeighReader in Substance Use EpidemiologyReader in Substance Use Epidemiology

Centre for Public HealthCentre for Public HealthLiverpool John Moores UniversityLiverpool John Moores University

Castle House, North StreetCastle House, North StreetLiverpool, L3 2AY Liverpool, L3 2AY

Tel: 0151 231 4531/4512Tel: 0151 231 4531/4512Email: Email: m.chandler@ljmu.ac.ukEmail: Email: j.mcveigh@ljmu.ac.uk