Anabolic steroid use – what’s the harm in it?

Jim McVeigh, Acting Director, Centre for Public Health, Liverpool John Moores University and Andreas Kimergård, Principal Research Fellow, Addictions Department, Institute of Psychiatry, King’s College London

The use of performance enhancing drugs is by no means a new phenomenon, with the historical practice of doping in sport being well established. However, in recent decades, across many countries, there has been increasing concern, as the use of drugs such as anabolic steroids and growth hormones has diffused from elite sport and competitive bodybuilding to the wider society. Many countries have responded with changes to legislation and enforcement policy, while in some, a more pragmatic approach of harm reduction has also been adopted. 

Despite concerted efforts to prevent the onset and continuation of use and reduce the incidence rate, evidence from a recent meta-analysis of studies by Sagoe and colleagues indicates an increase in global prevalence from 2.9% in studies between 1990 & 1999 compared to 3.2% in studies between 2000 & 2013. While it is notoriously difficult to estimate the prevalence of illicit behaviours and the size of hidden populations, these findings are credible and consistent across many of the 187 studies examined. Therefore the numbers involved are a genuine concern. However, what is the harm in people using anabolic steroids and associated drugs?

With the vast majority of anabolic steroid users not engaged in competitive sport, the moral and ethical debates surrounding doping are clearly redundant in this respect and attention must be restricted to the potential physical, psychological and social harm and how these might be reduced. In a statement by the Endocrine Society, Pope and colleagues outline a range of adverse events associated with the use of anabolic steroids, raising concerns regarding the emerging evidence related to cardiovascular effects, hematologic effects, psychiatric and neuropsychologic effects, and hormonal and metabolic effects. As identified by the authors there are significant gaps and limitations in the evidence relating to these adverse consequences — many of which were previously identified by the UK Advisory Council on the Misuse of Drugs. Much of the data are derived from case reports/series and cross-sectional studies, as it is neither ethical nor practical to replicate the high-dose polydrug regimes used by anabolic steroid users. The application of gold standard methodologies such as randomized controlled trials will not happen, hindering the certainty of causal link and preventing the quantification of risk.

The lack of a robust and definitive evidence base regarding the adverse effects of specific drugs and drug use practices is a considerable barrier to effective health related engagement between health professionals and anabolic steroid users (and potential users). For many within the anabolic steroid community there is a level of mistrust and a lack of confidence in the medical profession leading to an over reliance on anecdote, personal experience and peer consensus. This lack of engagement and trust towards the health sector (and for many, the scientific community in general) is understandable. Until relatively recently there has been continued denial of the efficacy of anabolic steroids and a range of other anabolic agents. This has often been accompanied by exaggerated claims regarding the risk and severity of adverse effects and unsubstantiated claims of fatalities. Campaigns (often well-meaning but ill-conceived), have sought to deter the onset or continued use of these drugs by shock tactics, worst case scenarios and prophylactic lies. This approach is clearly counterproductive, taking no account of the mindset of the target population and the availability of opposing information on the Internet.

Regardless of the barriers to the development of robust evidence relating to the adverse consequences of anabolic steroid use, there are major concerns for public health including:

1)       The consequences of an uncontrolled illicit market

2)       Anabolic steroids and associated drugs are usually injected

Research has consistently shown that the vast majority of anabolic steroids and associated drugs are illicitly manufactured (as are many other lifestyle/performance enhancing drugs). This means that products are reaching the end user with no quality assurance or oversight. The result is a product that may bear no relationship to the drug stated on the label, with variation in dosage of active pharmaceuticals, substitution of alternative drugs (either deliberate or accidental), inclusion of additional active substances, contamination with fungus, bacteria, heavy metals or a range of other toxins. Many of these products are injected and have resulted in localised infections, abscess formation, surgery, prolonged treatment and disfigurement. In some cases poor injecting technique has contributed to the infection and delayed engagement with health services has exacerbated the problem.

Of even greater concern are the findings of a recent study of injecting anabolic steroid users in the United Kingdom in which the presence of blood borne viruses has been identified. In fact, at 1.5% the prevalence of HIV amongst injectors of anabolic steroids and associated drugs is the same as that of heroin injectors in the United Kingdom. Until now it has been generally believed that the sharing of injecting equipment and prevalence of blood borne viruses in this population was negligible. As this study was one of the largest of its kind, collecting biological samples from approximately 400 anabolic steroid injectors, we have no reason to believe that the situation with regards to blood borne virus prevalence in the United Kingdom is any different to other parts of the world.

This information needs to be effectively communicated and meaningful interventions established. Few have managed to combine acceptability within the steroid using community and the required scientific rigour. Public health cannot wait for the development of a robust evidence base relating to the quantification of health risks for this group. Nor can the population be targeted with half-truths with the expectation of positive behavioural change. There is now clear evidence of the presence of HIV within the community of anabolic steroid injectors in the United Kingdom. There is also irrefutable evidence of widespread adulterated and substandard products being used in countries across the world with the potential to poison and infect. In the United Kingdom we see the consequences of these illicitly manufactured products in the levels of localised inflammation, infections and tissue damage. As we continue to do further studies, these dangers are clear and must be addressed now. This also provides health practitioners the perfect opportunity to engage in a meaningful way with an often hard-to-reach community.

Suggested further reading

Evans-Brown M, Kimergård A, McVeigh J. (2009) Elephant in the room? The methodological implications for public health research of performance-enhancing drugs derived from the illicit market. Drug Testing and Analysis 1: 323-326.

McVeigh J, Evans-Brown M, Bellis MA. (2012) Human enhancement drugs and the pursuit of perfection. Adicciones 24: 185-190.

Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergård A, Croxford S, Beynon CM, Parry JV, Bellis MA, Ncube F. (2013) Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open 3: e003207.

Kimergård A, McVeigh J, Knutsson S, Breindahl T, Stensballe A. (2014) Online marketing of synthetic peptide hormones: poor manufacturing, user safety, and challenges to public health. Drug Testing and Analysis 6: 396-398.

Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergård A, Parry JV, Ncube F. (2014) Injection site infections and injuries among men who inject image and performance enhancing drugs: prevalence, risks factors, and healthcare seeking. Epidemiology and Infection, Online ahead of print.

Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. (2014) The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Annals of Epidemiology 24: 383-398.

Kimergård A. (2014) A qualitative study of anabolic steroid use amongst gym users in the United Kingdom: Motives, beliefs and experiences. Journal of Substance Use, Online ahead of print.

Pope HG, Wood RI, Rogol A, Nyberg F, Bowers L, Bhasin S. (2014) Adverse Health Consequences of Performance-Enhancing Drugs: An Endocrine Society Scientific Statement. Endocrine Reviews 35: 341-375.

Kimergård A, Breindahl T, Hindersson P, McVeigh J. (2014) The composition of anabolic steroids from the illicit market is largely unknown: implications for clinical case reports. QJM: An International Journal of Medicine, Online ahead of print.