Precincts and prospects of polypharmacy in anabolic-androgenic steroid users

Dominic Sagoe, PhD, Department of Psychosocial Science, University of Bergen, Norway

An important dimension of illicit anabolic-androgenic steroid [steroid(s)] use is polydrug use or polypharmacy: the simultaneous use of steroids and other licit and illicit drugs or substances. “Stacking”, the combined use of different types of steroids, is connected to polypharmacy. It is important to note the illicit market availability of ‘pre-stacked’ steroids: concoctions of various types of steroids.

A large proportion of steroid users practice polypharmacy in order to enhance the positive effects of steroids, deal with the negative effects of steroids, and for relaxation or recreation among others [1]. Although sometimes beneficial, long-term steroid use and polypharmacy has been associated with various adverse effects and is considered an issue of serious public health concern [2].

Dangers of steroid-based polypharmacy

First, the use of ancillary and supplementary substances can generally exacerbate the risks of experiencing debilitating consequences associated with steroid use.

Additionally, the ‘war on doping in sports’ and ‘anti-roid rage in society’ has resulted in the largely ‘underground’ production, marketing and use of steroids and most performance and image enhancing drugs (PIEDs). This underground phenomenon can lead to accidental and intentional production with poor quality, adulterated and noxious ingredients as well as contamination.

In this regard, polypharmacy may exacerbate the risks of poisoning as well as viral infection. Similarly, polypharmacy can result in unintended chemical interactions thereby producing toxic substances that can have enervating biological effects.

Related to this, it is widely acknowledged that steroid users do not disclose their behaviour to healthcare providers [3]. As explained above, this is understandable in the ‘war on doping in sports’ and ‘anti-roid rage in society’ milieus. It is also explainable by the belief in the steroid-using community that many medical professionals have pedestrian knowledge of steroids and other PIEDs [4].

Such mistrust, sometimes genuine [5], and consequential non-disclosure of steroid use history may lead health providers to unintentionally administer or prescribe medication to current steroid-using patients thereby exacerbating the risks of experiencing side effects from steroid use. A related potentially-harmful consequence is the confounding of the intended health benefits of prescribed drugs through undisclosed current steroid use.

Another important consideration is psychoforensic evidence delineating polypharmacy as a major explanation for aggressive, violent and criminal behaviour among some steroid users. In this regard, there is evidence that polypharmacy accounts for the relationship between steroid use and involvement in antagonistic and unlawful, typically violent, behaviour [6].

Furthermore, a characteristic of persons satisfying criteria for steroid dependence is polypharmacy [7]. While the role of polypharmacy in the trajectory of steroid dependence is not yet clear, it is reasonable that steroid-dependent individuals may resort to the use of other ancillary and supplementary drugs and substances in the quest for larger or better effects.

Implications of steroid-based polypharmacy for practice and research

The serious implications of steroid-based polypharmacy described above demands that the phenomenon attract the attention of clinicians, policymakers and researchers. It is imperative that stakeholders collaborate in an effort to elucidate the main and interactive psychophysical effects of the use of these substances.

It is also important that adequate substance use screening is conducted prior to the prescription of medication and medical treatment of steroid users. Consolidating trust between health providers and the steroid or PIED-using community may facilitate the attainment of more adequate substance use histories of steroid and PIED users. This is important for dealing with unintended chemical interactions and steroid-confounding of the potential benefits from prescribed drugs.

Additionally, most PIEDs and pre-stacked steroids are relatively new and their production and use is to a large extent an ‘underground’ phenomenon. As a result, there is a dearth of knowledge of these substances. Pharmacopoeial and epidemiological tracing of these substances is important. Relatedly, the systematic gathering and content as well as quality analysis of these substances may provide useful evidence for preventive and therapeutic interventions and related social policies.

It is also clear that legal nutritional supplements are sometimes adulterated with steroids and other PIEDs or doping substances [8]. It has been indicated that the use of such adulterated supplements may be a gateway to mainstream steroid use and its associated polypharmacy [9]. Preventive efforts must highlight the potential dangers of careless supplement use.

It is also clear that harm reduction interventions can be useful in dealing with many of the dangers of illicit steroid use and polypharmacy outlined previously. Well-guided discussions on the decriminalization of steroid and PIED use outside the context of the professional sports arena may also generate useful accord.

Finally, there is the need for further investigations to elucidate better the aetiology and pathway to illicit steroid use and polypharmacy.

References

1.       Sagoe, D., McVeigh, J., Bjørnebekk, A., Essilfie, M. S., Andreassen, C. S., & Pallesen, S. (2015). Polypharmacy among anabolic-androgenic steroid users: A descriptive metasynthesis. Substance Abuse Treatment, Prevention, and Policy, 10, 12. doi: 10.1186/s13011-015-0006-5

2.       Sagoe, D., Molde, H., Andreassen, C. S., 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.

3.       Kanayama, G., Brower, K. J., Wood, R. I., Hudson, J. I., & Pope, H. G. (2010). Treatment of anabolic–androgenic steroid dependence: Emerging evidence and its implications. Drug and Alcohol Dependence, 109, 6–13.

4.       Pope, H. G., Kanayama, G., Ionescu‐Pioggia, M., & Hudson, J. I. (2004). Anabolic steroid users’ attitudes towards physicians. Addiction, 99, 1189–1194.

5.       Yu, J., Hildebrandt, T., & Lanzieri, N. (2015). Healthcare professionals’ stigmatization of men with anabolic androgenic steroid use and eating disorders. Body Image, 15, 49–53.

6.       Lundholm, L., Frisell, T., Lichtenstein, P., & Langstrom, N. (2015). Anabolic androgenic steroids and violent offending: Confounding by polysubstance abuse among 10365 general population men. Addiction, 110, 100–108.

7.       Kanayama, G., Hudson, J. I., & Pope, H. G. (2009). Demographic and psychiatric features of men with anabolic-androgenic steroid dependence: A comparative study. Drug and Alcohol Dependence, 102, 130–137.

8.       Rahnema, C. D., Crosnoe, L. E., & Kim, E. D. (2015). Designer steroids–over‐the‐counter supplements and their androgenic component: Review of an increasing problem. Andrology, 3, 150–155.

9.       Hildebrandt, T., Harty, S., & Langenbucher, J. W. (2012). Fitness supplements as a gateway substance for anabolic-androgenic steroid use. Psychology of Addictive Behaviors, 26, 955–962.