Public health impact of AAS

Harrison Pope, Harvard University, USA

In the 21st century, the use of anabolic-androgenic steroids (AAS) has grown into a major worldwide substance use issue affecting tens of millions of individuals. Prior to about 1980, AAS use was largely confined to elite athletes, but in the years thereafter, AAS use started to break out of the athletic world and into the general population. AAS use first became prevalent among ordinary rank-and-file weightlifters in the United States in the 1980s and soon became common in British Commonwealth countries, Nordic countries, and other Western countries by the 1990s. The older members of this group of general-population AAS users – those who started AAS as youths in the 1980s and 1990s – are only now reaching middle age. Thus, the long-term effects of these drugs could not be easily investigated until recent years, when large numbers of aging AAS users began to become available for study.

 Now, data has accumulated showing convincingly that long-term high-dose AAS use causes cardiovascular toxicity, including cardiomyopathy and atherosclerotic disease, leading to an increased risk of heart attacks and strokes. Psychiatric studies have shown that AAS can cause irritability and aggressiveness, sometimes associated with violence, in a small portion of users – but it is still unclear why a minority of users are vulnerable to these effects while a majority is not. Withdrawal from AAS after long-term use may lead to prolonged hypogonadism in men, characterized by loss of libido, erectile dysfunction, and occasionally serious depression. Recent studies have also begun to suggest that long-term high-dose AAS use may cause neurotoxicity, possibly leading to cognitive deficits. However, pending more research, it is still too early to estimate accurately the magnitude of AAS-related public health problems that we may witness over the next decades.

IPEDs injecting and harm

Viv Hope, LJMU, UK

The use of image and performance enhancing drugs (IPEDs) has increased in many countries over recent decades. The injection of these enhancement drugs is associated with a number of health concerns particularly the transmission of blood borne viral infections (HIV, hepatitis B and hepatitis C) and skin and soft tissues problem. While the extent of these and the associated risk have been extensively examined among people who inject psychoactive drugs, much less is known about these among those who inject IPEDs. The intramuscular and subcutaneous injection of IPEDs, combined with the way that these drugs are prepared and used, were historically perceived to result in a much lower infection risk among this group when compared to those injecting psychoactive drugs (which are predominately injected intravenously). Data now indicate that the prevalence of blood borne viral infections among those who inject IPEDs, while not as high as that among those injecting psychoactive drugs, is higher than that in the general population. This presentation will review what is known about the prevalence of both viral and bacterial infections among those who inject IPEDs. It will also examine what is known about risk behaviours for these infections and the uptake of diagnostic testing and other interventions. This review will consider the limitations of our current knowledge and the implications for practice.

Anabolic steroids and the brain

Astrid Bjornebekk, Oslo University Hospital, Norway

Anabolic androgenic steroids (AAS) efficiently provide muscle growth, especially in combination with heavy weight training. However, long-term high dose AAS use has been associated with a range of consequences, where those who develop dependence have the highest risks of serious complications. Of the least studied effects of AAS use is the potential consequences it may have on brain health. We have through many years gathered numerous data on a large sample of AAS-users and non-exposed weightlifters, including various sorts of brain imaging scans, psychological symptoms, and cognitive, cardiovascular and behavioral data. Using machine learning approaches on brain imaging data we have estimated the biological brain age of our participants providing an indication to whether each individuals brain-age is pathological for their chronological age. Our preliminary findings, suggest that AAS use is associated with more evident brain aging on a global full brain measure, and in frontal, occipital and insular regions. On the conference I’ll present brain imaging findings from our studies, and the link between brain findings and behavioral data, including different patterns of use, psychological and medical data.

The ‘dopogenic’ environment and its role in encouraging performance and image enhancing drug use

S.H. Backhouse, Carnegie School of Sport, Leeds Beckett University, UK

The use of image and performance enhancing drugs (IPED) (e.g., anabolic androgenic steroids) is a growing societal problem that poses a threat to public health. This threat relates to the extent of IPED use in recreational sport and exercise contexts and the associated health consequences.  IPED use is a complex behaviour with a myriad of interconnected causes. In this presentation I will explore the ‘dopogenic’ environment and consider how it encourages IPED use. During this presentation, I will consider how modifying the dopogenic environment is an important component of a comprehensive public health approach to preventing the harms associated with IPED use. 

The global prevalence of anabolic-androgenic steroid use

Dominic Sagoe, University of Bergen, Norway

The presentation explores contemporary global evidence on the prevalence of anabolic-androgenic steroid (AAS) use. It is based on two articles on this topic: a meta-analysis, and an associated systematic review. Using evidence from these two works, the presentation will elucidate the prevalence of AAS use across various world regions, user groups, as well as prevalence trends over the last fifty years. The presentation will show that AAS use should be regarded an issue of serious public health concern.

Anabolic steroid use in the Middle East

Mayyada Wazaify, University of Jordan, Jordan

The use of Androgenic Anabolic Steroids (AAS) is an emergent phenomenon in The Middle East; however, research revealed that knowledge, understanding, and awareness of health harms related to AAS appear to be varied. Limited quantitative studies in this region draw a typical profile of AAS users and describe the top sources of obtaining such products as well as the most commonly reported injectable and oral AAS. Building muscle and enhancing physique and training aspects are the primary reported reasons for using AAS in this region.

This presentation will touch base on the main research that has been conducted so far in the Middle East about the use of AAS for performance and image enhancement. The presentation will also discuss the main factors for such growing use (e.g. lack of enforcement of legislation in some countries); the efforts needed for raising awareness of young people and coaches regarding the adverse effects of using such drugs without medical supervision, as well as the need for future research of more qualitative nature into the motivations, attitudes, and experiences of users.

Tracing a typology of anabolic androgenic steroid users

Ask Vest Christiansen, University of Aarhus, Denmark

In this paper, I present a framework, an “ideal typology”, of anabolic steroid use in gym communities. Inspired by sociologist Max Weber’s work, I identify four ideal typical users of AAS: the Expert type, the Well-being type, the YOLO type, and the Athlete type. The presentation describes the most conspicuous and characteristic traits of these four distinct types of users based on their approach to risk and effectiveness respectively. On the one hand, the framework of the ideal types is a theoretical construct that enables us to identify general traits, but on the other hand, it also enables us to position specific users within a framework after assessing their positions on the two dimensions: risks and effectiveness. In this way, the ideal typology can also inform education, prevention, counseling and community-education campaigns to reach certain types of users.

“It’s a man’s world?”

Charlotte McLean, Independent Researcher, UK

Traditionally a male domain, women’s bodybuilding is currently enjoying an increase in popularity due to the rise of the fitness competitor and the gradual shift towards a lean and muscular ideal in mainstream culture. However, there is a paucity of data pertaining to women’s experiences of performance enhancing drugs to increase muscularity within this context. This research draws upon an eighteen-month ethnographic study, which comprised in depth interviews, extensive participant observation, and a significant auto ethnographic element. By illustrating bodybuilding culture, the research situates the decision-making process and justifications surrounding anabolic-androgenic steroids and growth hormone use in women engaging competitively in this sport. It also highlights the rituals and practices embedded in the culture and considers how these influence health and the uptake and engagement with primary and secondary health care settings.

“…but I also like to play on weekends”

Mike Salinas, Manchester Metropolitan University, UK

Users of image and performance enhancing drugs (IPEDs) – and thus, by association, androgenic anabolic steroids (AAS) – are by no means a homogenous group. There exists significant diversity amongst users and their behaviours. As with any other drugs using populations, most users actively seek to mimimise potential harms of AASs by strictly adhering to sets of harm reduction practices. Yet there exist subpopulations of users whose AAS-using practices and lifestyles significantly elevate the risks posed to their health. This includes individuals with extensive polydrug using habits, including concurrent use of multiple IPEDs and recreational drugs. It also includes those disregarding pre-existing medical conditions who still chose to use, or those opting to engage in extended cycles of use. It is not only vital that such users are engaging with professional services, but that such services are appropriately tailored to their needs and – ultimately – help to facilitate less harmful patterns of use.  This presentation draws on data derived from an ethnographic study an independent ‘hardcore’ bodybuilding gym, as well as findings from an IPED user and practitioner survey to highlight the risks associated with these practices.  It concludes by outlining ways that services can better support and engage IPED users beyond needle and syringe provision. 

“…you are pretty much on your own”

Mair Underwood, University of Queensland, Australia

There is a significant difference between the ideal way enhanced bodybuilders would like to use AAS, and how they actually use them in the real world. This paper describes the macro (legal and medical) and micro (local bodybuilding culture) risk environments that place constraints on AAS practice. But most importantly it describes the enabling environments that people who use AAS create in order to reduce the harms of drug use. In response to the constraints on knowledge and health support that result from the legislation and stigmatization of AAS use, enhanced bodybuilders fill the gaps in knowledge, and come up with their own harm reduction strategies and ways around the legal and medical systems. This paper presents the findings from 3 years of online ethnographic research in enhanced bodybuilding communities, and in-depth interviews with 34 enhanced recreational bodybuilders.

Treatment for anabolic steroid users

Geoff Bates, University of Bath, UK

Title: Treatments for people who use AAS: lots of studies, but very little evidence to support health professionals encourage cessation and treat dependence and withdrawal

An ever-increasing body of evidence supports our understanding of the health harms associated with AAS use. Evidence-informed Interventions to modify behaviour amongst users, and to treat dependence and manage withdrawal symptoms amongst those who chose to stop, are therefore required. This presentation discusses the findings from a systematic scoping review that aimed to identify studies of psychological or medical treatment interventions delivered in any setting in response to AAS or an associated harm.
The review highlighted that there remains very little evidence on treating AAS dependence, managing withdrawal or initiating behaviour change in users in any setting. While over 100 examples were identified, predominantly case studies, where treatment was provided for associated health harms, engagement about AAS between users and health professionals providing such treatment appears very limited.

This presentation will summarise these findings, identify gaps in the evidence-base and discuss the implications for practice and research.

“Mind the gap”

Ingrid Havnes, Oslo University hospital, Norway
National Advisory Unit on SUD treatment

Use and possession of AAS became illegal in 2013 in Norway and AAS users received patient rights to decentralized outpatient substance use disorder (SUD) treatment. National guidelines states that clinicians should assess mental health symptoms following cessation as well as providing psychosocial interventions and ensure treatment of other health issues. Still, few AAS users seek outpatient SUD treatment.

A study exploring barrier to seeking SUD treatment among men found that users experienced the SUD treatment system to be alienating; They saw their struggle to cease AAS use to be different from being dependent on psychoactive substances, and they had a healthy identity as opposed to how they viewed patients with severe SUDs. They also lacked trust in treatment providers to have the knowledge and the means (e.g. access to endocrine therapy), to provide treatment of their AAS-related health problems. To facilitate treatment seeking, a national information service was initiated to inform AAS users and their next of kin about AAS-related side effects, treatment options and expected outcomes. Mental health problems was the most common given motivation to cease use and three out of four desired treatment after the information session.

AAS use is associated with psychoactive substance use. In a national SUD treatment survey; 35.6% of the men and 8.0% of the women reported lifetime AAS use and AAS users had more severe substance use than non-AAS users. During treatment, more than half (58%) of all patients had not been asked about AAS use. Lifetime AAS use is common and comprise an underrecognized problem in SUD treatment.

The Norwegian SUD treatment model focus on psychosocial and psychopharmacological treatment.  Every SUD department must cooperate with and refer patients to their local endocrinologists who have little experience with the patient group who are often met with rejection or a restrictive approach. Therefore, health professionals in SUD treatment and somatic health services need more knowledge to address the biopsychosocial needs of patients with SUDs and current or previous AAS use; and patients with AAS dependence. 

Experiences of an endocrinologist in an outpatient clinic

Willem de Ronde, Amsterdam University, Holland

The ‘Anabolenpoli’ or AAS clinic was established in 2010 by the department of internal medicine of the Spaarne Gasthuis in Haarlem with the goal to gain more insight into the characteristics of AAS users, the methods of AAS use and the health risks associated with AAS abuse in the Netherlands. Patients need a referral to the clinic from their general practitioner or a medical specialist and the health care provided is fully covered by Dutch health care insurance. To date more almost 400 patients from all over the Netherlands have visited the clinic. The focus of care is targeted primarily at the somatic sequelae of current or past androgen abuse.

 Since 2015 the clinic conducts the HAARLEM study (Health risks of Anabolic Androgenic steRoid use by maLe aMateur athletes). This is a prospective observational cohort study in 100 users of anabolic steroids aimed at monitoring the somatic and psychological side effects of androgen abuse. Research is conducted in close collaboration with the Dutch anti Doping Authority and several Dutch academic centers. In this presentation, we will describe 10 years of experience with the management of steroid abusers and we will discuss the results of the first year follow up of the HAARLEM cohort.

The Glasgow experience

John Campbell, GCC, NHS Scotland, UK

John has managed and worked in the Glasgow IPED Clinic since its inception in 2010. During this time his approach and the range interventions provided have developed. In particular, the analysis of bloods has become central to how the clinic functions. With 10 years of blood analysis it’s not difficult to link abnormalities with patterns of use or specific IPEDs used.  A new IPED database has been created in partnership with our 3 specialist clinics in Scotland.  The database acts a ‘light assessment tool’ which links IPEDs used with identified harms and any issues identified in blood analysis. It is hoped this will provide a standardised approach to blood testing and interventions.

Afternoon tea with Bill and Joe

William Llewellyn, “Anabolics”, USA and Joe Kean, CGL, UK