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Background: A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a diverse population with varying motivations. Evidence has increased greatly in recent years to support understanding of this form of substance use and the associated health harms, but there remains little evidence regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health problems. Methods: A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible. Results: In total, 109 eligible studies were identified, which included case reports representing a diverse range of disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings were limited throughout by the case report study designs and limited information was provided. Conclusion: This scoping review indicates that while a range of case reports describe treatments provided to AAS users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.
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R E V I E W Open Access
Treatments for people who use anabolic
androgenic steroids: a scoping review
Geoff Bates
1*
, Marie-Claire Van Hout
1
, Joseph Tay Wee Teck
2
and Jim McVeigh
3
Abstract
Background: A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a
diverse population with varying motivations. Evidence has increased greatly in recent years to support
understanding of this form of substance use and the associated health harms, but there remains little evidence
regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify
and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and
prevent associated health problems.
Methods: A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative
citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions
delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible.
Results: In total, 109 eligible studies were identified, which included case reports representing a diverse range of
disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant
evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions
requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and
infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of
treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings
were limited throughout by the case report study designs and limited information was provided.
Conclusion: This scoping review indicates that while a range of case reports describe treatments provided to AAS
users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users
in any settings. Evidence is urgently required to support the development of effective services for users and of
evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent
reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within
broader health- or drug-related journals, will support development of the evidence base.
Keywords: Anabolic androgenic steroids, Drug treatment, Health care, Dependence, Behaviour change
Introduction
Human enhancement drug use differs from other forms of
drug use by virtue of the motivation or purpose of their
use. Typically, they are not consumed either for a treatment
of an illness or injury nor for instant gratification through
their psychoactive properties. Instead, their function is an
attempt to change an individuals appearance or improve a
skill, ability or activity [1,2]. Characterised by mansen-
deavour to gain an advantage over his competitor, their
usage is by no means a new phenomenon, featured in
social, ritual and sporting contexts throughout recorded
history. Attempts to classify enhancement drugs have re-
sulted in the six broad categories of drugs to increase lean
muscle mass, to suppress appetite or reduce weight, to
change the appearance of the hair or skin, to increase sex-
ual desire or enhance performance, to improve cognitive
function and to enhance mood or social interaction. Over
the past 30 years, there has been growing media, policy and
academic interest in this form of drug use, in particular the
classification of drugs used to enhance musculature size
and strength. Most notable within this category are the
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: g.bates@ljmu.ac.uk
1
Public Health Institute, Liverpool John Moores University, Liverpool, England
Full list of author information is available at the end of the article
Bates et al. Harm Reduction Journal (2019) 16:75
https://doi.org/10.1186/s12954-019-0343-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
anabolic androgenic steroids (AAS) and their associated
drugs [36]. Also included in this classification are a range
of other hormones [711] including human growth hor-
mone [12,13] and insulin [7,14].
While AAS doping remains a concern for sport, both
at elite and recreational levels [1517], the wider soci-
etal impact is now apparent [4,18,19]. Although preva-
lence estimates of clandestine behaviours such as AAS
are notoriously difficult, a growing body of evidence
has indicated that while well established in North
America, northern Europe and Australia, there are con-
cerns across the globe [6,19].
In recent years, research has provided a more nuanced
understanding of AAS use in relation to the diverse
characteristics and motivations of users [2027], to-
gether with knowledge of the variety and patterns of
drug use from both academic studies [2834] and other
sources [35]. Extensive research and comprehensive re-
views have provided details of the identified adverse
health conditions experienced by users of these durgs
[36], while new research has identified new and concern-
ing health risks [37,38] and the potential for transmis-
sion of blood-borne viruses [20,29,3943].
A body of research has discussed the risk of develop-
ing AAS dependence and it is estimated that up to 30%
of AAS users may develop dependence, characterised by
the simultaneous use of multiple AAS in large doses
over long periods of time [36,44]. While AAS are not
explicitly recognised in the Diagnostic and statistical
manual of mental disorders (DSM 5) as one of nine clas-
ses of drugs [45], they may be considered under the
tenth other (or unknown) substanceclass. The DSM 5
determines the severity of a substance use disorder from
mild to severe according to the presence of up to 11 cri-
teria. It is argued that while there are differences be-
tween AAS and psychoactive drugs dependence, such as
that AAS are typically used over a period of weeks and
months to increase muscularity rather than to achieve a
highin the short-term, these criteria are still highly
applicable to AAS dependence [46]. Criteria such as
tolerance, withdrawal, use of the substance in larger
amounts, unsuccessful attempts to reduce or stop using
the substance, and time spent on activity related to the
substance use have all been identified as features of AAS
dependence [44,46]. A number of hypotheses to explain
AAS dependence have been put forward [47,48] and
recommendations for treating what has been described
as steroid abuseor dependence have long been pro-
posed [4951].
Recent recommendations to treat steroid dependence
include a staged discontinuation, managing withdrawal
symptoms, maintaining abstinence and attenuating com-
plications of chronic use [5153]. Long-term use of AAS
at high doses may lead to the development of a range of
withdrawal symptoms following cessation, including de-
pression, insomnia, suicidal ideation and fatigue, which
may persist for many months [47,51,54]. Withdrawal is
characterised by psychiatric and neuroendocrine symp-
toms, with the user ultimately re-initiating AAS to allevi-
ate or avoid their onset. Supporting discontinuation may
require a multidisciplinary approach with input from
health professionals such as a GP, addiction specialist,
psychiatrist and endocrinologist [53]. Swedish guidelines
for diagnosing and treating AAS abuse[55] include ad-
vice around psychosocial treatments, such as cognitive
behavioural therapy, counselling group therapy and mo-
tivational interviewing. These therapies address the
users preoccupation with enhancing their muscularity,
their experiences of past bullying or violence, and result-
ing self-esteem and confidence issues. Brower (2009) be-
lieves that these entrenched psychological issues should
be addressed once acute withdrawal is resolved as part
of successful treatment [51]. Muscle dysmorphia and
associated drive for muscularity [5658] may be risk fac-
tors for both initiating and continuing AAS use, and po-
tentially dependence [52]. It may be necessary to identify
and address such disorders through counselling or psy-
chotherapies as part of AAS treatment to reduce likeli-
hood of re-initiation [53].
There has been a fourfold increase in the number of
English language academic papers published between
1995 and 2015 [59]. However, there remains scant evi-
dence in relation to effective policy and practice within
the topic. While we have a greater understanding of the
environmental influences and risk factors for use [17,
6062], there are few robust findings to support the
effective prevention of AAS use. Little progress has
been made in answering the fundamental questions of
how do we make AAS less attractive and how do we
make these drugs less accessible to those at risk of initi-
ating use [6366].
Tensions between some AAS users and the medical
community are well documented [26,6769]andlong
established [70], predating anti-doping or legislative
control in most countries. Although psychological harm
andthepotentialdemandforinterventionstoaddress
dependence are also well recognised [7175]anddiag-
nostic tools available [52,76], available services are few
and far between. Harm reduction programmes, in the
form of needle and syringe programmes (NSP), have
clearly been successful in engaging AAS users in
Australia [42,43,77,78] and, in particular, the United
Kingdom [5,30,79,80]. However, even where uptake
of service is high, substantial numbers of AAS users do
not access these services [26,68,80,81]. Policy guid-
ance regarding the delivery of harm reduction services
for AAS users, centred around NSP provision, is in
place in the United Kingdom [82,83], with its
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importance recognised in National Drug Strategy and
Treatment guidelines [84,85]. While these guidelines
are based on well-established principles of treatment
engagement and harm reduction, there is an urgent
needtoidentifywherewehaveevidencetosupport
specific interventions and where the evidence gaps
remain.
Aims
The overall aim of this review was to identify and describe
what is known about psychosocial and medical interven-
tions that aim to support and achieve cessation of AAS,
and treat and prevent associated health consequences.
Specifically, the review aimed to identify:
1. What studies have examined the implementation
and impact of interventions to support ASS
cessation, and manage the health consequences
related to cessation?
2. What studies have examined the implementation
and impact of interventions to treat the harms or
side effects associated with AAS use?
3. What are the implications of these findings, and
what are the gaps in the evidence base that research
in this area needs to address?
Methodology
The review was undertaken following Arksey and
OMalleys guidance for scoping reviews, which informed
the development of review methods and write-up of
methods and findings [86].
Inclusion and exclusion criteria
Studies were eligible that included males or females with
current or discontinued use of AAS alone, or AAS use
alongside other substances. Use for any reason (for ex-
ample, strength or sporting enhancement, aesthetic rea-
sons) was acceptable with the exception of where AAS
were prescribed or taken as part of a treatment regimen
or in a controlled medical setting. Studies of any psycho-
social or medical treatment interventions were eligible,
including those that aimed to support individuals to dis-
continue AAS use or to treat the health consequences of
current or past use. This included, but was not restricted
to, treating AAS withdrawal, physical or psychological de-
pendence, injuries, acute conditions, chronic conditions,
side effects and blood-borne viruses. Studies that did not
provide a description of the treatment given or those that
did not describe any outcome following treatment at any
follow-up time were excluded. Interventions that took
place in any setting were eligible, including, but not re-
stricted to, primary and secondary care, community set-
tings such as drugs misuse services, NSPs and AAS
clinics, sport and fitness environments, and prisons.
All types of study designs were considered due to the
anticipated lack of high-quality controlled trials. Arti-
cles published in English were eligible with no date
restrictions.
Search strategy
Initially, a comprehensive search was carried out in four
bibliographic databases (Medline, PsycINFO, Sports Discus
and the Social Sciences Citation Index) in January 2018. A
search strategy was developed initially in Medline and
adapted for the other databases. The full Medline search is
provided in Additional file 2.
The reference lists of all identified papers were screened
to identify potentially eligible studies. Forward citation
searches for included articles were executed in PubMed
and the identified studies were assessed against the review
inclusion criteria. This iterative process continued for all
articles identified through these steps. Due to the nature
of the evidence base, with studies likely to cover a broad
range of topics and to be published in a wide variety of
sources, these additional searches were expected to be im-
portant to identify relevant literature. Initially, titles and
abstracts for all articles identified were reviewed against
the inclusion criteria by one reviewer. A sample of 10%
was independently reviewed by a second reviewer. The full
texts for all articles included at this stage were retrieved
and subjected to further screening against inclusion
criteria.
Data extraction and synthesis
The relevant characteristics of identified studies were ex-
tracted into structured tables. This included population
characteristics and details of their AAS use, the symp-
toms requiring treatment or reasons for seeking help,
diagnosis, details of the treatment given and the out-
comes of this treatment. Studies were grouped by the
types of harms identified in Pope and colleaguesreview
of the harms associated with AAS use [36]. A formal as-
sessment of study quality was not undertaken, as this
step is not recommended for scoping reviews [86]. How-
ever, comments on the overall nature, strengths and lim-
itations of the evidence base are provided alongside
discussion of review findings.
Results
Identification of studies
Database searching identified 3,684 articles. Following
screening of article title and abstracts against review in-
clusion criteria, full-text articles were accessed for 76
articles and these were again reviewed against the inclu-
sion criteria. An additional 64 studies were identified
through checking the reference lists and citations of the
included articles. These were screened in the same
manner. Following full-text screening, 46 articles were
Bates et al. Harm Reduction Journal (2019) 16:75 Page 3 of 15
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excluded, predominantly because no treatments were
reported. The reasons for exclusion at this stage are
reported in Fig. 1.
Summary of findings
In total, 109 studies met the review inclusion criteria.
Summaries of the included studies are provided in
Table 1, grouped by the type of condition that required
treatment. The studies were carried out in 28 countries,
most prominently the USA (n=33)andtheUK(n=
21). One study followed a retrospective chart review de-
sign with the others case report (n= 94) or case series
(n= 14) designs. With the lack of any controlled stud-
ies, it was difficult to draw conclusions relating to the
effectiveness of any treatments provided. Additionally,
there were substantial variations across studies in the
depth of reporting about participants, settings, condi-
tion requiring treatment, the treatments provided and
outcomes. The identified studies were published in
sources representing a diverse range of disciplines.
Across the included studies, all participants were male.
They included a wide range of ages, with the majority in
their 20s and 30s, and represented a broad range of ex-
perience using AAS from recent initiators to long-term
use. Participantsmotivations and history were not re-
ported in a consistent manner to understand factors
driving AAS use, but they were frequently described as
participating in bodybuilding or weight-lifting activities.
The types of conditions requiring treatment included
psychiatric (n= 12), neuroendocrine (n= 11), hepatic (n
= 25), kidney (n= 6), cardiovascular (n= 26), musculo-
skeletal (n= 13) and infectious (n= 7). A further eight
studies were categorised as otherdisorders. In a small
number of studies, participants were diagnosed with
multiple conditions, but they have been grouped by the
primary diagnosis.
Further details on participantsAAS use, conditions re-
quiring treatment, the treatments provided and outcomes
are provided in Additional file 1.
Treatment to support AAS cessation
Four studies reported abstinence-focussed interventions
following a diagnosis of AAS dependence. In two cases,
patients participated briefly in a drug treatment
programme [88,97]beforewithdrawing.Inone,thepa-
tient received medication and psychosocial interven-
tions to manage AAS and opioid withdrawal [93]and
withdrawal symptoms abated over time. Detail on the
nature of these treatments was not provided. In the
remaining study, the patient received medication for a
short period before deciding to resume their AAS use
due to withdrawal symptoms [98]. There was no evi-
dence identified here, however, regarding psychosocial
interventions that have sought to address any associ-
ated psychological disorders amongst users seeking
treatment for their AAS use or any other condition.
Additionally, no evidence was identified on approaches
to reduce risk of relapse by developing social support
systems, improving self-confidence or managing stress,
Fig. 1 Flow of studies through the review
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Table 1 Summary of included studies
Reference
no.
Country Study
design
Diagnosis Treatment approach
Psychiatric (n= 12)
[87] USA CS Depression Medical therapy
[88] USA CR Substance dependence Drug treatment programme participation
[89] Canada CR Depressed mood with anxiety, paranoia, derealisation Medical therapy, electroconvulsive treatment
[90] Greece CR Mood disorder with manic features Medical therapy
[91] Germany CR Mania Medical therapy
[92] USA CR Borderline personality disorder with antisocial traits Medical therapy, education about AAS, psychotherapy
[93] India CR Substance dependence including opioids and AAS Medical therapy for AAS and opioid withdrawal,
psycho-education and relapse prevention
[94] Ireland CR Mixed psychotic disorder Medical therapy
[95] USA CR Acute mania Medical therapy
[96] UK CR Psychosis with low mood Medical therapy
[97] USA CR AAS dependence Drug treatment programme participation
[98] USA CR AAS dependence Medical therapy
Neuroendocrine (n= 11)
[99] Netherlands CR Hypogonadotropic hypogonadism Medical therapy
[100] USA CR Hypogonadism Medical therapy
[101] Malaysia CR Complete azoospermia Medical therapy
[102] UK CR Severe hypogonadotropic hypogonadism Medical therapy
[103] UK CS Azoospermia Advice to discontinue AAS
[104] USA CR Impotencereduced testicular volume on both sides and
gynaecomastia on both sides
Medical therapy
[105] USA CR Azoospermia Discontinuation of all medications; medical therapy
[106] USA RCR Azoospermia AAS cessation and medical therapy
[107] Italy CR Hypogonadotropic hypogonadism Medical therapy following AAS discontinuation
[108] USA CS Hypogonadism Medical therapy
[109] USA CR Azoospermia Medical therapy
Hepatic (n= 25)
[110] USA CR Tumour haemorrhage in liver. On second presentation:
tender hepatomegaly and haemorrhage, tachycardia
Surgery; instruction to discontinue AAS
[111] Mexico CR Liver toxicity, cholestasis Medical therapy; AAS discontinued
[112] USA CS Hepatotoxicity Medical therapy
[113] USA CR Liver toxicity Medical therapy
[114] USA CS Hepatotoxicity. In one case, patient suffered from renal
failure.
Medical therapy
[115] Spain CS 1) Hyperechogenic lesions in the liver; 2) Acute renal
failure, muscular damage, metabolic alkalosis and
hypernatraemia
1) Instruction to discontinue AAS; inclusion in liver
transplantation program; 2) Patient received
haemodialysis; instruction to discontinue AAS.
[116] UK CR Hepatic rupture with cardiovascular collapse, sepsis
and acute renal failure
Resuscitation, surgery
[117] Germany CR Hepatocellular carcinoma. Liver was enormously
enlarged
Chemoembolization was declined by patient who was
recommended for transplantation
[118] Australia CR Hepatocellular carcinoma Surgery
[119] Lebanon CR Liver injury resulting in prolonged cholestasis and acute
kidney injury
Advice to discontinue AAS, medical therapy, plasma
exchange. Patient refused renal biopsy.
[120] China CR Dilated cardiomyopathy and acute hepatic injury Medical therapy
[121] Poland CR Severe intrahepatic cholestasis that developed to severe Medical therapy
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Table 1 Summary of included studies (Continued)
Reference
no.
Country Study
design
Diagnosis Treatment approach
liver failure
[122] UK CS Cholestasis Medical therapy
[123] Spain CR Severe cholestatic jaundice Unclear
[124] USA CS Severe hepatotoxicity, cholestasis Medical therapy
[125] Netherlands CR Mild jaundice; cholestatic hepatitis identified through
liver biopsy
Medical therapy
[126] UK CR Three grade II oesophageal varices Blood transfusion and sclerotherapy
[127] Australia CR Intrahepatic cholestasis Medical therapy
[128] USA CR Severe cholestasis and renal failure. Re-admitted
with pruritus
Medical therapy
[129] Spain CR Hepatic rupture, liver failure. Hematoma of the liver Surgery
[130] USA CR Acute, nonobstructive, intrahepatic cholestatic hepatitis Medical therapy; advice to avoid other medications
[131] USA CR Severe jaundice, bile acid nephropathy Medical therapy, blood transfusion, AAS discontinued
[132] Spain CS Severe cholestasis, hepatotoxicity Medical therapy followed by MARS therapy
[133] Brazil CR Giant hepatic adenoma Surgery
[134] Germany CR Hepatocellular carcinoma Surgery
Kidney (n=6)
[135] USA CR Initial diagnosis of hepatic adenomatosis (2004). On third
admission, diagnosed with chronic kidney disease and
coronary artery disease (2013)
Advice given to discontinue AAS initially. Surgery
at later presentation.
[136] Spain CR Severe acute kidney failure with high blood pressure,
anaemia and thrombocytopenia
Medical therapy
[137] Iran CR Acute renal failure; muscle injury and rhabdomyolysis Medical therapy
[138] Brazil CS Acute kidney injury in both cases Medical therapy.
[139] USA CR Recurrent renal infarction Medical therapy, AAS counselling
[140] Lebanon CR Acute pancreatitis, acute renal failure and hypercalcemia. Medical therapy
Cardiovascular (n= 26)
[141] Japan CR Cardioembolic stroke Medical therapy, AAS use discontinued
[142] Sweden CR Intraparenchymal haemorrhage in right parietal lobe;
right cortical venous thrombosis
Anticoagulation therapy
[143] UK CR Acute myocardial infarction Surgery
[144] Egypt CR Severe toxic cardiomyopathy. Medical therapy
[145] Canada CR Cardiomyopathy Incubation, medical therapy, resuscitation, dialysis and
device implantation, addiction counselling referral
[146] Argentina CR Posterior territory ischemic stroke. Intubation and ventilation; rehabilitation
[147] Sweden CR Severe hypertension Aggressive treatment with intravenous drugs;
AAS cessation
[148] Turkey CR Acute coronary syndrome Medical therapy
[149] Sweden CS i) Occlusion of all major arteries of the leg.
ii) Arterial thrombosis:
i) Surgery
ii) Thrombolysis attempted with no improvement.
Surgery performed.
[150] Canada CR Stroke. Upon readmission 3 years later, diffused
distal arterial thrombosis
Medical therapy
[151] Kuwait CR Cardiomyopathy, stroke and peripheral vascular disease Medical therapy
[152] Portugal CR Severe toxic cardiomyopathy. Medical therapy
[153] USA CR Myocardial infarction Medical therapy
[154] Turkey CR Myocardial infarction Medical therapy
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Table 1 Summary of included studies (Continued)
Reference
no.
Country Study
design
Diagnosis Treatment approach
[155] Greece CR Myocardial infarction Medical therapy
[156] USA CR Acute myocardial infarction and polycythaemia Surgery, medical therapy, phlebotomy.
[157] Portugal CR Myocardial infarction Medical therapy.
[158] Turkey CR Acute inferior myocardial infarction, renal infarction Medical therapy, surgery
[159] USA CR Acute myocardial infarction Medical therapy, rehabilitation
[160] USA CR Myocardial infarction Medical therapy
[161] Australia CR Persistent atrial fibrillation Electrical cardioversion, medical therapy.
[162] Germany CR Severe coronary heart disease Surgery, medical therapy
[163] UK CR Coronary thrombus Medical therapy
[164] USA CR Cardiomyopathy, severe systolic dysfunction and Class IV
heart failure.
Medical therapy and device implementation
until discharge.
[165] USA CR Cardiomyopathy, acute systolic heart failure. Medical therapy, instruction not to use AAS.
[166] Finland CS Cardiac hypertrophy Surgery, medical therapy. In one case, no treatment
was reported
Musculoskeletal (n= 13)
[167] USA CR Tear in the midsubstance of the triceps tendon. Surgery, immobilisation
[168] Israel CR Massive rhabdomyolysis Medical therapy
[169] Ireland CR Quadriceps tendon rupture, patella tendon rupture,
distal femur fracture, patella dislocation in both legs
Surgery, immobilisation, physiotherapy
[170] Iran CR Quadriceps tendon rupture in both knees and
partial rupture of triceps tendon.
Surgery, immobilisation, physiotherapy
[171] UK CR Bilateral rupture of the quadriceps tendon Surgery, immobilisation
[172] Denmark CR Complete rupture of the extensor pollicis longus tendon. Surgery, immobilisation
[173] Finland CR Complete bilateral quadriceps tendon rupture in both legs Surgery, immobilisation
[174] UK CR Rupture of both quadriceps tendons Surgery, immobilisation, physiotherapy
[175] Finland CR Bilateral distal biceps tendon avulsions Surgery, immobilisation, physiotherapy
[176] UK CR Complete rupture of the anterior cruciate ligament Physiotherapy
[177] UK CR Rhabdomyolysis. Initially diagnosed with musculoskeletal
pain.
Medical therapy
[178] UK CR Bilateral simultaneous traumatic upper arm compartment
syndromes
Surgery
[179] Italy CR Complete tear of quadriceps tendon Surgery, immobilisation, rehabilitation
Infectious (n=7)
[180] USA CR Abscess. Medical therapy; AAS counselling
[181] Israel CR Full thickness skin and subcutaneous tissue necrosis Surgery
[182] USA CR Pyomyositis Medical therapy, surgery
[183] UK CS Injection injury Surgery, medical therapy
[184] Turkey CR Spontaneous corpus cavernosum abscess Surgery
[185] UK CR Necrotizing myositis Surgery, medical therapy
[186] UK CR Abscess Surgery, medical therapy
Other (n=8)
[187] UK CR Chronic laryngitis Medical therapy followed by laser treatments
[188] UK CR Hypokalaemia and metabolic alkalosis. Fluid provision
[189] UK CR Abnormal lipid profile Advice to stop using AAS
[190] UK CR Acute respiratory distress syndrome Intubation and ventilation; rehabilitation.
[191] USA CR Multiple organ dysfunction syndrome, acute kidney injury Resuscitation, medical therapy, ventilation,
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all identified as potentially important factors to be ad-
dressed during AAS treatment [51,52,55].
Two studies were identified in this review where individ-
uals who discontinued AAS use needed treatment for sub-
sequent psychiatric symptoms including depression and
suicidal ideation [87,89]. A further 11 studies reported
treatments for neuroendocrine disorders, primarily with
men who had discontinued their AAS use prior to the
onset of symptoms. Administering AAS suppresses the
hypothalamicpituitary testicular axis, particularly when
used in large amounts and for long periods, and inhibits
production of testosterone [195]. Men who discontinue
long-term AAS use are at risk of hypogonadism and while
this may frequently be temporary and resolve spontan-
eously, it may in some cases persist for long periods after
cessation, requiring medical treatment [51,196198].
Symptoms of hypogonadism may be behind the with-
drawal experiences of people with a dependence on AAS
[51]. These difficult experiences have been identified as an
influencing factor in usersdecisions to continue or re-
instate AAS use [52]. The limited evidence here shows
that positive outcomes are consistently reported in the
treatment of men suffering with neuroendocrine disorders
following AAS cessation.
Treatment for harms associated with AAS use
The bulk of the evidence identified related to current
or former users receiving treatment for an acute or
chronic condition or injury associated with their AAS
use. This included psychiatric disorders (n= 12), hep-
atic and kidney disorders (n= 31), cardiovascular disor-
ders (n= 26), musculoskeletal disorders (n= 13) and a
range of other disorders (n= 8). The management of
such conditions in the AAS-using group is similar to
that of the general population [53]anddetailsarede-
scribed in the tables in the additional material provided.
There was, however, limited evidence of engagement
with users regarding their AAS use as part of their
more general treatment. There were examples where
participants were stated to have discontinued AAS fol-
lowing treatment and remained abstinent at follow-up
[133,157,159], but patientsAAS status at this time
was not routinely reported.
Treatment as an opportunity for engagement
In a small proportion of studies (n= 10), it was reported
that some form of intervention to bring about, or maintain
change in AAS use was included as part of the treatment
provided. This was most commonly instruction or advice
to discontinue AAS use, with a more substantial element
such as counselling only reported in three studies [139,
145,180]. Where reported, such efforts were based on
suppling risk information associated with AAS but not
support with discontinuation, such as managing with-
drawal symptoms. No form of harm reduction interven-
tions were initiated alongside or following any treatments
provided. Only one study [145] reported signposting or
referral to another service for further support.
In comparison to people who use other psychoactive
drugs, AAS users are less likely to suffer acute adverse
effects from their substance use, or to have their occupa-
tional performance or relationships impaired and are,
therefore, less reliant upon health professionals [44].
Research has consistently indicated this group to be reluc-
tant to seek medical help or engage with health profes-
sionals [67,199201]. Where health professionals identify
AAS use in a patient and are providing treatment for an
associated harm, this may, therefore, provide a rare oppor-
tunity to motivate changes in behaviour. There were ex-
amples in this review of studies that included recent
initiators. For example, in 12/25 studies included here
reporting hepatic disorders, patients had initiated AAS use
fewer than 6 months prior to treatment. Contact with a
health professional at this stage could provide a valuable
opportunity to engage with the individual about their mo-
tivations and substance use before habitual use develops
or becomes entrenched, or identify and treat any under-
lying factors. In a further 5/25 studies, long-term AAS use
of over 5 years was reported, and up to 15 years. For such
individuals, this contact could provide opportunity to test
for disorders associated with long-term use, promote
behaviour change and discuss long-term plans for discon-
tinuation of use.
Encouraging discontinuation and delivering harm reduction
with patients treated for a disorder associated with AAS
Where a patient is receiving treatment, there will be a range
of factors that affect the appropriateness of delivering any
Table 1 Summary of included studies (Continued)
Reference
no.
Country Study
design
Diagnosis Treatment approach
and refractory supraventricular tachycardia haemodialysis and electrical cardioversion for different
symptoms.
[192] USA CR New onset of diabetes Medical therapy, AAS advice
[193] Lebanon CS Spontaneous subdural haematoma Surgery
[194] UK CR Bilateral internal laryngocoeles Medical therapy
CR case report, CS case series, RCR retrospective chart review
Bates et al. Harm Reduction Journal (2019) 16:75 Page 8 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
form of AAS intervention or investigating any other poten-
tial harms. For example, in many of the studies identified,
the individuals treated had discontinued their AAS use a
substantial time prior to seeking treatment. Additionally,
many were diagnosed with acute conditions, for which im-
mediate, and in some cases substantial, treatment was re-
quired. In such cases, it is not surprising that the acute
harm will be the focus of the treatment. However, where
AAS use is suspected or confirmed, a number of diagnostic
tests may be appropriate to identify potential physiological
or psychiatric harms [53]. Recommendations for general
practitioners who identify AAS use in a patient include
strongly encouraging cessation and management of with-
drawal symptoms in those that do discontinue, as well as
information on injecting practices, promoting alternatives
to AAS and informing about long-term health harms for
those who continue to use [202]. Continued encourage-
ment and monitoring of psychiatric and physiological com-
plications is recommended for those who are not prepared
to consider discontinuation [53].
An instruction not to use AAS may be effective in
some cases, but for individuals who are highly motivated
to use AAS in response to a desire to change their ap-
pearance or performance, it may have little impact. Ex-
periencing harm or increasing knowledge of potential
risks may not only reduce motivation to use amongst
users who may accept risks as a potential consequence
of use, but also one that they can manage through their
practices [60]. Where it is identified that users intend to
continue administering AAS following treatment, it is
important that they receive appropriate harm reduction
advice, such as on safe injecting, blood-borne viruses
(BBVs) and AAS cycles. For example, in seven studies,
treatments for infectious complications associating with
injecting AAS were reported. There was no indication of
relevant harm reduction work included alongside treat-
ment, such as advice or demonstration relating to inject-
ing or injecting techniques in any of these studies, with
the exception of Rich and colleagues who reported
provision of counselling on the risks of BBVs [180].
Discussion
Research over the past 30 years has provided a far richer
understanding of the populations of AAS users, their
characteristics, behaviours and motivations. While the
specific risks attached to each AAS and the probability
or magnitude of harm associated with highly individua-
lised and complex drug regimens cannot be known, we
now have a far greater understanding of the potential
harms caused by these drugs. However, the evidence
base for interventions has not kept pace. The examples
of treatment identified in this review were set within pri-
mary and secondary care facilities. No studies were iden-
tified that explored the effectiveness of any approaches
to encourage cessation or treat dependence within other
settings where health professionals are likely to encoun-
ter users, such as steroid clinics, drugs services or NSPs.
Consequently, there is a lack of any evidence on the ef-
fectiveness of such services for bringing about behaviour
change in users. Within any setting there is scarce evi-
dence on treating AAS dependence, including initiating
and maintain cessation and managing withdrawal symp-
toms outside of case reports of former users seeking
support for neuroendocrine disorders.
The findings of this scoping review are characterised by
missed opportunities. While the failure to report good
practice or supplementary activity is not proof that it does
not occur, without confirmation we cannot make assump-
tions. The extensive literature outlining the symptomatic
treatment of AAS-related harms within numerous medical
and surgical specialisms fails to provide evidence of inter-
vention or referral to address the major causative factor,
the patientsAAS use. This scoping review has reported
only a sample of the myriad of case reports involving the
treatment of AAS-related harms. These case reports not
only demonstrate the lack of evidence of intervention ef-
fectiveness to support the cessation of AAS use or reduce
the associated harms, they also fail to show that actual ac-
tivity occurred. As a minimum, future case reports should
report if any assessment for AAS dependence were con-
ducted. Details of advice or interventions provided to AAS
users or any referral or signposting are also essential infor-
mation. Referrals to primary care, endocrinologists, addic-
tion specialists or harm reduction providers are essential
building blocks in identifying care pathways and potential
effective interventions. Case reports are published pre-
dominantly in clinical journals, often relating to medical
or surgical specialisms. The publication of reports in
broader health or public health journals or journals related
to drug use, addiction or harm reduction would facilitate
the inclusion of clinical experiences within a wider ap-
proach to addressing the harms associated with AAS use.
Despite the comprehensive research and literature re-
lating to AAS dependence, there remains little evidence
regarding effective interventions to support cessation of
use or management of withdrawal. It is hoped that the
development diagnostic tools [46], guidelines for clinical
management [85] and harm reduction [82] or the
commissioning of health services [83] will be accompan-
ied by robust research and evaluation. Evaluations to
date have been small scale and lack generalizability.
In addition to the need to ensure accurate and consist-
ent reporting of activity and an upscaling of research
and evaluation, there is a need to ensure that interven-
tions are culturally appropriate to the target groups.
Much of the work to date has focused on the bodybuild-
ing communities of North America, Northern Europe
and Australia. It is clear that AAS use is a global issue,
Bates et al. Harm Reduction Journal (2019) 16:75 Page 9 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
with research emerging from lowmiddle income coun-
tries around the world in addition to industrialised high-
income states. Of added significance is the diversity of
individual AAS users. Interventions will need to be tai-
lored to meet the varied characteristics and motivations
of users, going beyond those looking to achieve a stylised
bodybuilding appearanceor excel at sport or even the
young males attempting to bulk up. Evidence from the
United Kingdom indicates that there are as many AAS
users over 40 years of age as there are those under the
age of 25 years [31]. It is well established that AAS use is
not restricted to men and while rates amongst women
are much lower [203], the complexities of treatment and
care are undoubtedly much higher [23,204,205]. Preva-
lence of AAS use is higher amongst groups with specific
characteristics such as professions where size or strength
is an asset [206209], amongst gay and bisexual men
[20,22,29,210,211] and those using or who have previ-
ously used other drugs [212][30,33,67,212214].
These sub groupsmay or may not require specific in-
terventions and may merely illustrate the complexities of
human nature. The majority of AAS users will not initi-
ate or continue AAS by virtue of membership of one of
these groups but will have a range of susceptibilities and
motivations for use.
Beyond these challenges, to develop effective services
for users of AAS is the ongoing lack of confidence that
some communities of AAS users feel towards health care
professionals and primary care in particular [30,67,199]
and a feeling that reliable and relevant health information
can be gained elsewhere [215]. Built on the long-standing
dismissive approach towards the effectiveness of anabolic
steroids by elements of the health profession [216,217]
and an ongoing just say nostance amongst some practi-
tioners, it is evident that establishing trust through listen-
ing to the AAS-using communities will be an essential
element of intervention and service development [26].
Conclusions
This scoping review of the literature has identified treat-
ments given to AAS users for a wide range of physio-
logical and psychological harms. Despite the large number
of articles identified, the evidence base consists of case re-
ports of predominantly treatment of physiological harms
and there is scarce evidence on treating dependence, man-
aging withdrawal, or initiating behaviour change in users
in any settings. Evidence is urgently required to support
the development of effective services for users and of
evidence-based guidance and interventions to respond to
users in a range of healthcare settings. More consistent
reporting in articles of whether engagement or assessment
relating to AAS was initiated, and publication within
broader health- or drug-related journals, will support de-
velopment of the evidence base.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12954-019-0343-1.
Additional file 1. Data extraction tables. The data extraction tables
contain the full data extracted from the 109 articles included in the
review. This includes participant information, condition requiring
treatment, the treatment provided and the outcomes of treatment.
Additional file 2. Search strategy. The full search strategy used in
Medline is provided.
Abbreviations
AAS: Anabolic androgenic steroids; BBV : Blood-borne virus; DSM: Diagnostic
and statistical manual of mental disorders; NSP: Needle and syringe
programme
Acknowledgements
Not applicable.
Authors' contributions
GB managed the review and lead protocol development, evidence search,
article screening, data extraction and data synthesis. GB drafted the article
methodology and result sections. MCVH provided methodological and topic
expertise and helped to shape the review through supporting the
development of the protocol and search strategy. MCVH screened a
proportion of articles and commented on findings and written drafts. JT
provided medical expertise supporting the development of the review and
presentation of data, checked data extraction, and commented on written
drafts. JMV provided topic expertise and helped to shape the review through
supporting the development of the protocol, data extraction, data synthesis
and presentation of findings. JMV drafted the article introduction and
discussion sections. All authors read and approved the final manuscript.
Funding
No funding was received to support this review.
Availability of data and materials
All data generated or analysed during this study are included in this
published article and its supplementary information files.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Public Health Institute, Liverpool John Moores University, Liverpool, England.
2
MRC/CSO SPHSU, University of Glasgow, Glasgow, Scotland.
3
Department of
Sociology, Manchester Metropolitan University, Manchester, England.
Received: 2 May 2019 Accepted: 21 November 2019
References
1. Evans-Brown M, McVeigh J, Perkins C, Bellis M. Human enhancement drugs:
the emerging challenges to public health. Liverpool: North West Public
Health Observatory; 2012.
2. McVeigh J, Evans-Brown M, Bellis MA. Human enhancement drugs and the
pursuit of perfection. Adicciones. 2012;24(3):18590.
3. Kanayama G, Pope HG. History and epidemiology of anabolic androgens in
athletes and non-athletes. Mol Cell Endocrinol. 2018;464(C):413.
4. Kanayama G, Kaufman MJ, Pope HG. Public health impact of androgens.
Curr Opin Endocrinol. 2018;25(3):21823.
5. McVeigh J, Begley E. Anabolic steroids in the UK: an increasing issue for
public health. Drugs. 2017;24(3):27885.
Bates et al. Harm Reduction Journal (2019) 16:75 Page 10 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
6. Sagoe D, Pallesen S. Androgen abuse epidemiology. Curr Opin Endocrinol
Diabetes Obes. 2018;25(3):18594.
7. Anderson LJ, Tamayose JM, Garcia JM. Use of growth hormone, IGF-I, and
insulin for anabolic purpose: Pharmacological basis, methods of detection,
and adverse effects. Mol Cell Endocrinol. 2017.
8. Van Hout MC, Hearne E. Netnography of female use of the synthetic
growth hormone CJC-1295: pulses and potions. Subst Use Misuse. 2016;
51(1):7384.
9. Brennan R, Van Hout MC, Wells J. Heuristics of human enhancement risk: a
little chemical help? Int J Health Prom Educ. 2013;51(4):21227.
10. Thevis M, Thomas A, Kohler M, Beuck S, Schanzer W. Emerging drugs:
mechanism of action, mass spectrometry and doping control analysis. J
Mass Spectrom. 2009;44(4):44260.
11. Thevis M, Beuck S, Thomas A, Kortner B, Kohler M, Rodchenkov G, et al.
Doping control analysis of emerging drugs in human plasma - identification
of GW501516, S-107, JTV-519, and S-40503. Rapid Commun Mass Spectrom.
2009;23(8):113946.
12. Holt RI, Sonksen PH. Growth hormone, IGF-I and insulin and their abuse in
sport. Br J Pharmacol. 2008;154(3):54256.
13. Evans-Brown M, McVeigh J. Injecting human growth hormone as a
performance-enhancing drug-perspectives from the United Kingdom. J
Substance Use. 2009;14(5):26788.
14. Underwood M. "Slin is the safest and most anabolic hormone": exploring
bodybuilders' use of insulin as a performance and image enhancing drug.
Drug Alcohol Rev. 2018;37:S70S.
15. Ulrich R, Pope HG, Cleret L, Petroczi A, Nepusz T, Schaffer J, et al. Doping in
two elite athletics competitions assessed by randomized-response surveys.
Sports Med. 2018;48(1):2119.
16. Mottram DR, Chester N. Drugs in Sport. 7 ed: Routledge; 2018.
17. Backhouse SH, Griffiths C, McKenna J. Tackling doping in sport: a call to take
action on the dopogenic environment. Br J Sports Med. 2017.
18. Auchus RJ, Brower KJ. The public health consequences of performance-
enhancing substances: who bears responsibility? JAMA. 2017;318(20):19834.
19. Sagoe D, Molde H, Andreassen CS, Torsheim T, Pallesen S. The global
epidemiology of anabolic-androgenic steroid use: a meta-analysis and
meta-regression analysis. Ann Epidemiol. 2014;24(5):38398.
20. Ip EJ, Doroudgar S, Shah-Manek B, Barnett MJ, Tenerowicz MJ, Ortanez M,
et al. The CASTRO study: unsafe sexual behaviors and illicit drug use among
gay and bisexual men who use anabolic steroids. Am J Addict. 2019;28:101.
21. Blashill AJ, Calzo JP, Griffiths S, Murray SB. Anabolic steroid misuse among
US adolescent boys: disparities by sexual orientation and race/ethnicity. Am
J Public Health 2017(0):e1-e3.
22. Griffiths S, Murray SB, Dunn M, Blashill AJ. Anabolic steroid use among gay
and bisexual men living in Australia and New Zealand: Associations with
demographics, body dissatisfaction, eating disorder psychopathology, and
quality of life. Drug Alcohol Dependence. 2017;181:1706.
23. Börjesson A, Gårevik N, Dahl M-L, Rane A, Ekström L. Recruitment to doping
and help-seeking behavior of eight female AAS users. Subst Abuse Treat
Prev Policy. 11(2016, 1):11.
24. Zahnow R, McVeigh J, Bates G, Hope V, Kean J, Campbell J, et al. Identifying
a typology of men who use anabolic androgenic steroids (AAS). Int J Drug
Policy. 2018;55:10512.
25. Christiansen AV, Vinther AS, Liokaftos D. Outline of a typology of mens use
of anabolic androgenic steroids in fitness and strength training
environments. Drugs. 2016;24(3):295305.
26. Underwood M. The unintended consequences of the current approach to
blood borne virus prevention amongst people who inject image and
performance enhancing drugs: a commentary based on enhanced
bodybuilder perspectives. Int J Drug Policy. 2019;67:1923.
27. Ip EJ, Trinh K, Tenerowicz MJ, Pal J, Lindfelt TA, Perry PJ. Characteristics
and behaviors of older male anabolic steroid users. J Pharm Pract.
2015;28(5):4506.
28. Teck JTW, McCann M. Tracking internet interest in anabolic-androgenic
steroids using Google Trends. Int J Drug Policy. 2018;51:525.
29. Ip EJ, Yadao MA, Shah BM, Doroudgar S, Perry PJ, Tenerowicz MJ, et al.
Polypharmacy, infectious diseases, sexual behavior, and psychophysical
health among anabolic steroid-using homosexual and heterosexual gym
patrons in San Francisco's Castro District. Subst Use Misuse. 2017;52(7):
95968.
30. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergard A,
et al. 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. 2013;3(9):e003207e.
31. Begley E, McVeigh J, Hope V, Bates G, Glass R, Campbell J, et al. Image and
Performance Enhancing Drugs: 2016 National Survey Results. Liverpool:
Liverpool John Moores University; 2017.
32. Dodge T, Hoagland MF. The use of anabolic androgenic steroids and
polypharmacy: A review of the literature. Drug Alcohol Depend. 2011.
33. Sagoe D, McVeigh J, Bjornebekk A, Essilfie MS, Andreassen CS, Pallesen S.
Polypharmacy among anabolic-androgenic steroid users: a descriptive
metasynthesis. Subst Abuse Treat Pr. 2015;10(ARTN 12).
34. Jennings CJ, Patten E, Kennedy MC, Kelly C. Examining the profile and
perspectives of individuals attending harm reduction services who are users
of performance and image enhancing drugs. Merchants Quay Ireland:
Dublin; 2014.
35. Llewellyn W. Anabolics. 11 ed. Jupiter, FL: Molecular Nutrition; 2017.
36. Pope HG, Wood RI, Rogol A, Nyberg F, Bowers L, Bhasin S. Adverse health
consequences of performance-enhancing drugs: an Endocrine Society
scientific statement. Endocr Rev. 2014;35(3):34175.
37. Westlye LT, Kaufmann T, Alnaes D, Hullstein IR, Bjornebekk A. Brain
connectivity aberrations in anabolic-androgenic steroid users. Neuroimage
Clin. 2017;13:629.
38. Bjornebekk A, Walhovd KB, Jorstad ML, Due-Tonnessen P, Hullstein IR, Fjell
AM. Structural brain imaging of long-term anabolic-androgenic steroid users
and nonusing weightlifters. Biol Psychiatry. 2017;82(4):294302.
39. Hope VD, McVeigh J, Smith J, Glass R, Njoroge J, Tanner C, et al. Low levels
of hepatitis C diagnosis and testing uptake among people who inject
image and performance enhancing drugs in England and Wales, 2012-15.
Drug Alcohol Depend. 2017;179:836.
40. Hope VD, Harris R, McVeigh J, Cullen KJ, Smith J, Parry JV, et al. Risk of
HIV and hepatitis B and C over time among men who inject image
and performance enhancing drugs in England and Wales: Results from
cross-sectional prevalence surveys, 1992-2013. Jaids-J Acq Imm Def.
2016;71(3):3317.
41. Ip EJ, Yadao MA, Shah BM, Lau B. Infectious disease, injection practices,
and risky sexual behavior among anabolic steroid users. Aids Care.
2016;28(3):2949.
42. Rowe R, Berger I, Yaseen B, Copeland J. Risk and blood-borne virus testing
among men who inject image and performance enhancing drugs, Sydney,
Australia. Drug Alcohol Rev. 2017;36(5):65866.
43. Iversen J, Hope VD, McVeigh J. Access to needle and syringe programs by
people who inject image and performance enhancing drugs. Int J Drug
Policy. 2016;31:199200.
44. Kanayama G, Brower K, Wood R, Hudson J, Pope H. Anabolic-androgenic
steroid dependence: an emerging disorder. Addiction. 2009;104(12):196678.
45. Association AP. Diagnostic and statistical manual of mental disorders (DSM-
5®): American Psychiatric Pub; 2013.
46. Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG. Issues for DSM-V:
clarifying the diagnostic criteria for anabolic-androgenic steroid
dependence. Am J Psychiatr. 2009;166(6):6424.
47. Kashkin KB, Kleber HD. Hooked on hormones?: An anabolic steroid
addiction hypothesis. JAMA. 1989;262(22):316670.
48. Brower KJ. Rehabilitation for anabolic-androgenic steroid dependence. Clin
Sport Med. 1989;1:17181.
49. Giannini AJ, Miller N, Kocjan DK. Treating steroid abuse: a psychiatric
perspective. Clin Pediatr. 1991;30(9):53842.
50. Corcoran JP, Longo ED. Psychological treatment of anabolic-androgenic
steroid-dependent individuals. J Subst Abuse Treat. 1992;9(3):22935.
51. Brower KJ. Anabolic steroid abuse and dependence in clinical practice. Phys
Sportsmed. 2009;37(4):13140.
52. Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG Jr. Treatment of
anabolic-androgenic steroid dependence: Emerging evidence and its
implications. Drug Alcohol Depend. 2010;109(1-3):613.
53. Casavant M, Griffith J. Anabolic steroid use disorder New Jersey: BMJ
Americas Office; 2017 [Available from: https://bestpractice.bmj.com/topics/
en-gb/987]. Accessed Aug 2018.
54. Malone DA, Dimeff RJ, Lombardo JA, Sample RH. Psychiatric effects and
psychoactive substance use in anabolic-androgenic steroid users. Clin J
Sport Med. 1995;5(1):2531.
55. Arver S, Borjesson A, Bottiger Y, Edin A, Garevic N, Lundmark J, et al.
Swedish clinical guidelines on: The abuse of anabolic androgenic steroids
and other hormonal drugs. Stockholm: Karolinska University Hospital; 2013.
Bates et al. Harm Reduction Journal (2019) 16:75 Page 11 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
56. Rohman L. The relationship between anabolic androgenic steroids and
muscle dysmorhpia: a review. Eating Disord. 2009;17(3):18799.
57. Kanayama G, Barry S, Hudson J, Pope H. Body image and attitudes toward
male roles in anabolic-androgenic steroid users. Am J Psychiatr. 2006;163(4):
697703.
58. Pope H, Gruber AJ, Choi P, Olivardia R, Phillips KA. Muscle dysmorphia: an
underrecognized form of body dysmorphic disorder. Psychosomatics. 1997;
38(6):54857.
59. McVeigh J. The public health implications of anabolic steroid use in the
United Kingdom. A shot in the Dark: Steroids, IPEDs - the Hidden Harm
Conference; 26th April 2018; Colchester2018.
60. Hanley Santos G, Coomber R. The risk environment of anabolic-androgenic
steroid users in the UK: examining motivations, practices and accounts of
use. Int J Drug Policy. 2017;40:3543.
61. Bates G, Tod D, Leavey C, McVeigh J. An evidence-based socioecological
framework to understand mens use of anabolic androgenic steroids and
inform interventions in this area. Drugs. 2018:19.
62. Pope HG, Kanayama G, Hudson JI. Risk factors for illicit anabolic-androgenic
steroid use in male weightlifters: a cross-sectional cohort study. Biol
Psychiatr. 2012;71(3):25461.
63. de Ronde W. Preventing anabolic steroid abuse: a long way to go. J Intern
Med. 2018.
64. Bates G, Begley E, Tod D, Jones L, Leavey C, McVeigh J. A systematic review
investigating the behaviour change strategies in interventions to prevent
misuse of anabolic steroids. J Health Psychol. 2017. https://doi.org/10.1177/
1359105317737607.
65. Backhouse S, Collins C, Defoort Y, McNamee M, Parkinson A, Sauer M. Study
on doping prevention: a map of legal, regulatory and prevention practice
provisions in EU 28. Luxembourg: Publications Office of the European
Union; 2014. Report No.: 9279435426.
66. NICE. Drug misuse prevention: targeted interventions (NG64). London: NICE;
2017.
67. Zahnow R, McVeigh J, Ferris J, Winstock A. Adverse effects, health service
engagement, and service satisfaction among anabolic androgenic steroid
users. Contemp Drug Prob. 2017;44(1):6983.
68. Kimergard A, McVeigh J. Variability and dilemmas in harm reduction for
anabolic steroid users in the UK: a multi-area interview study. Harm Reduct
J. 2014;11(ARTN 19).
69. Dunn M, Henshaw R, McKay F. Understanding health service use and needs
of performance and image enhancing drug users in regional Queensland.
Drug Alcohol Rev. 2014;33:24.
70. Wade CH. Anabolic steroids: doctors denounce them, but athletes aren't
listening. Science. 1972;176:14013.
71. Brower KJ, Blow FC, Beresford TP, Fuelling C. Anabolic-androgenic steroid
dependence. J Clin Psychiatry. 1989;50(1):313.
72. Copeland J, Peters R, Dillon P. A study of 100 anabolic-androgenic steroid
users. Med J Aust. 1998;168(6):3112.
73. Midgley SJ, Heather N, Davies JB. Dependence-producing potential of
anabolic-androgenic steroids. Addict Res. 1999;7(6):53950.
74. Pope HG Jr, Kanayama G, Athey A, Ryan E, Hudson JI, Baggish A. The
lifetime prevalence of anabolic-androgenic steroid use and dependence in
Americans: current best estimates. Am J Addict. 2014;23(4):3717.
75. Ip EJ, Lu DH, Barnett MJ, Tenerowicz MJ, Vo JC, Perry PJ. Psychological and
physical impact of anabolic-androgenic steroid dependence.
Pharmacotherapy. 2012;32(10):9109.
76. Pope HG Jr, Kean J, Nash A, Kanayama G, Samuel DB, Bickel WK, et al. A
diagnostic interview module for anabolic-androgenic steroid dependence:
preliminary evidence of reliability and validity. Exp Clin Psychopharmacol.
2010;18(3):2032013.
77. Van de Ven K, Maher L, Wand H, Memedovic S, Jackson E, Iversen J. Health
risk and health seeking behaviours among people who inject performance
and image enhancing drugs who access needle syringe programs in
Australia. Drug Alcohol Rev. 2018:doi: https://doi.org/10.1111/dar.12831.
78. Jacka B, Peacock A, Degenhardt L, Bruno R, Clare P, Kemp R, et al. Trends in
PIEDs use among male clients of needle-syringe programs in Queensland,
Australia; 2007-2015. Int J Drug Policy. 2017;46:748.
79. Kimergard A, McVeigh J. Environments, risk and health harms: a qualitative
investigation into the illicit use of anabolic steroids among people using
harm reduction services in the UK. BMJ OPEN. 2014;4(6).
80. McVeigh J, Beynon C, Bellis MA. New challenges for agency based
syringe exchange schemes: analysis of 11 years of data (19912001) in
Merseyside and Cheshire, United Kingdom. Int J Drug Policy.
2003;14(5-6):399405.
81. Glass R, Hope VD, Njoroge J, Edmundson C, Smith J, McVeigh J, et al.
Secondary distribution of injecting equipment obtained from needle
and syringe programmes by people injecting image and performance
enhancing drugs: England and Wales, 2012-15. Drug Alcohol Depend.
2018;195:404.
82. NICE. Needle and syringe programmes NICE public health guidance. NICE:
National Institute for Health and Care Excellence; 2014.
83. Public Health England. Providing effective services for people who use
image and performance enhancing drugs. London: PHE Publications; 2015.
84. HM Government. 2017 Drug Strategy. London 2017.
85. Department of Health. Drug misuse and dependence: UK guidelines on
clinical management. London: Department of Health; 2017.
86. Arksey H, O'Malley L. Scoping studies: towards a methodological framework.
Int J Soc Res Methodol. 2005;8(1):1932.
87. Malone DA, Dimeff RJ. The use of fluoxetine in depression associated with
anabolic steroid withdrawal: a case series. J Clin Psychiatry. 1992;53(4):1302.
88. Hays LR, Littleton S, Stillner V. Anabolic steroid dependence. Am J Psychiatr.
1990;147(1):122.
89. Allnutt S, Chaimowitz G. Anabolic steroid withdrawal depression: a case
report. The Canadian Journal of Psychiatry / La Revue canadienne de
psychiatrie. 1994;39(5):3178.
90. Papazisis G, Kouvelas D, Mastrogianni A, Karastergiou A. Anabolic
androgenic steroid abuse and mood disorder: a case report. Int J
Neuropsychopharmacol. 2007;10(2):2913.
91. Gahr M, Kolle MA, Baumgarten E, Freudenmann RW. Mania related to
mesterolone in a previously mentally healthy person. J Clinical
Psychopharmacol. 2012;32(5):7345.
92. Rashid W. Testosterone abuse and affective disorders. J Subst Abuse
Treatment. 2000;18(2):17984.
93. Ranjan R, Parmar A, Pattanayak RD, Dhawan A. Dependence on
anabolic-androgenic steroids: a case report and brief review. Delhi
Psychiatry J. 2014;17(2):4814.
94. Duffy RM, Kelly BD. Steroids, psychosis and poly-substance abuse. Irish J
Psychol Med. 2015;32(2):22730.
95. Franey DG, Espiridion ED. Anabolic steroid-induced mania. Cureus. 2018;
10(8):e3163e.
96. Stanley A, Ward M. Anabolic steroids--the drugs that give and take away
manhood. A case with an unusual physical sign. Med Sci Law. 1994;34(1):823.
97. Brower KJ, Blow FC, Beresford TP, Fuelling C. Anabolic-androgenic steroid
dependence. J Clin Psychiatry. 1989;50:31.
98. Tennant F, Black DL, Voy RO. Anabolic steroid dependence with opioid-type
features. N Engl J Med. 1988;319(9):578.
99. van Breda E, Keizer HA, Kuipers H, Wolffenbuttel BHR. Androgenic anabolic
steroid use and severe hypothalamic-pituitary dysfunction: a case study. Int
J Sports Med. 2003;24(3):1956.
100. Tan RS, Vasudevan D. Use of clomiphene citrate to reverse premature
andropause secondary to steroid abuse. Fertility Sterility. 2003;79(1):2035.
101. Menon DK. Successful treatment of anabolic steroid-induced azoospermia
with human chorionic gonadotropin and human menopausal
gonadotropin. Fertil Steril. 2003;79(Suppl 3):165961.
102. Gill GV. Anabolic steroid induced hypogonadism treated with human
chorionic gonadotropin. Postgrad Med J. 1998;74(867):456.
103. Gazvani MR, Buckett W, Luckas MJ, Aird IA, Hipkin LJ, Lewis-Jones DI.
Conservative management of azoospermia following steroid abuse. Hum
Reprod. 1997;12(8):17068.
104. Bickelman C, Ferries L, Eaton RP. Impotence related to anabolic steroid use
in a body builder. Response to clomiphene citrate. Western J Med. 1995;
162(2):15860.
105. Turek PJ, Williams RH, Gilbaugh JH III, Lipshultz LI. The reversibility of
anabolic steroid-induced azoospermia. J Urol. 1995;153(5):162830.
106. Cohen JJ, Honig S. Anabolic steroid-associated infertility: a potentially
treatable and reversible cause of male infertility. Fertility Sterility. 2005;84:
S223.
107. Pirola I, Cappelli C, Delbarba A, Scalvini T, Agosti B, Assanelli D, et al.
Anabolic steroids purchased on the Internet as a cause of prolonged
hypogonadotropic hypogonadism. Fertility Sterility. 2010;94(6):2331.e13.
108. Street C, Scally MC. Pharmaceutical intervention of anabolic steroid induced
hypogonadism - our success at restoration of the HPG axis. Med Sci Sports
Exercise. 2000;32(5S).
Bates et al. Harm Reduction Journal (2019) 16:75 Page 12 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
109. Jarow JP, Lipshultz LI. Anabolic steroid-induced hypogonadotropic
hypogonadism. Am J Sports Med. 1990;18(4):42931.
110. Martin NM, Abu Dayyeh BK, Chung RT. Anabolic steroid abuse causing
recurrent hepatic adenomas and hemorrhage. World J Gastroenterol. 2008;
14(28):45735.
111. Sánchez-Osorio M, Duarte-Rojo A, Martínez-Benítez B, Torre A, Uribe M.
Anabolic-androgenic steroids and liver injury. Liver Int. 2008;28(2):27882.
112. Chahla E, Hammami MB, Befeler AS. Hepatotoxicity associated with anabolic
androgenic steroids present in over-the-counter supplements: a case series.
International Journal of Applied. 2014;4(3).
113. Awai HI, Yu EL, Ellis LS, Schwimmer JB. Liver toxicity of anabolic androgenic
steroid use in an adolescent with nonalcoholic fatty liver disease. J Pediatr
Gastroenterol Nutr. 2014;59(3):e32e3.
114. Krishnan PV, Feng Z-Z, Gordon SC. Prolonged intrahepatic cholestasis and
renal failure secondary to anabolic androgenic steroid-enriched dietary
supplements. J Clin Gastroenterol. 2009;43(7):6725.
115. Socas L, Zumbado M, Perez-Luzardo O, Ramos A, Perez C, Hernandez JR,
et al. Hepatocellular adenomas associated with anabolic androgenic steroid
abuse in bodybuilders: a report of two cases and a review of the literature.
Br J Sports Med. 2005;39(5):e27.
116. Patil JJ, O'Donohoe B, Loyden CF, Shanahan D. Near-fatal spontaneous
hepatic rupture associated with anabolic androgenic steroid use: a case
report. Br J Sports Med. 2007;41(7):4623.
117. Solbach P, Potthoff A, Raatschen HJ, Soudah B, Lehmann U, Schneider A,
et al. Testosterone-receptor positive hepatocellular carcinoma in a 29-year
old bodybuilder with a history of anabolic androgenic steroid abuse: a case
report. BMC Gastroenterol. 2015;15:60.
118. Gorayski P, Thompson CH, Subhash HS, Thomas AC. Hepatocellular
carcinoma associated with recreational anabolic steroid use. Br J Sports
Med. 2008;42(1):745 discussion 5.
119. El Khoury C, Sabbouh T, Farhat H, Ferzli A. Severe cholestasis and bile cast
nephropathy induced by anabolic steroids successfully treated with plasma
exchange. Case Reports Med. 2017;2017.
120. Li C, Adhikari BK, Gao L, Zhang S, Liu Q, Wang Y, et al. Performance-
enhancing drugs abuse caused cardiomyopathy and acute hepatic injury in
a young bodybuilder. Am J Mens Health. 2018;12(5):17004.
121. Stepien PM, Reczko K, Wieczorek A, Zarebska-Michaluk D, Pabjan P, Krol
T, et al. Severe intrahepatic cholestasis and liver failure after stanozolol
usage - case report and review of the literature. Clin Exper Hepatol.
2015;1(1):303.
122. Elsharkawy AM, McPherson S, Masson S, Burt AD, Dawson RT, Hudson
M. Cholestasis secondary to anabolic steroid use in young men. BMJ.
2012;344:e468.
123. Ampuero J, Garcia ES, Lorenzo MM, Calle R, Ferrero P, Gomez MR.
Stanozolol-induced bland cholestasis. Gastroenterol Hepatol.
2014;37(2):712.
124. Singh V, Rudraraju M, Carey EJ, Byrne TJ, Vargas HE, Williams JE, et al. Severe
hepatotoxicity caused by a methasteron-containing performance-enhancing
supplement. J Clin Gastroenterol. 2008;43(3):287.
125. Boks M, Tiebosch AT, van der Waaij LA. A jaundiced bodybuilder Cholestatic
hepatitis as side effect of injectable anabolicandrogenic steroids AU - Boks.
Marije N J Sport Sci. 2017;35(22):22624.
126. Winwood PJ, Robertson DA, Wright R. Bleeding oesophageal varices
associated with anabolic steroid use in an athlete. Postgrad Med J. 1990;
66(780):8645.
127. Ding NS, De Cruz P, Lim L, Thompson A, Desmond P. Androgenic-anabolic
steroid drug-induced liver injury. Intern Med J. 2013;43(2):2156.
128. Nasr J, Ahmad J. Severe cholestasis and renal failure associated with the use
of the designer steroid Superdrol (methasteron): a case report and literature
review. Dig Dis Sci. 2009;54(5):11446.
129. Marcacuzco Quinto AA, Manrique Municio A, Loinaz Segurola C, Jimenez
Romero LC. Spontaneous hepatic rupture associated with the use of
anabolic steroids. Cirugia Espanola. 2014;92(8):5702.
130. Hymel BM, Victor DW, Alvarez L, Shores NJ, Balart LA. Mastabol induced
acute cholestasis: a case report. World J Hepatol. 2013;5(3):1336.
131. Flores A, Nustas R, Nguyen HL, Rahimi RS. Severe cholestasis and bile acid
nephropathy from anabolic steroids successfully treated with
plasmapheresis. ACG Case Rep J. 2016;3(2):1335.
132. Diaz FC, Saez-Gonzalez E, Benlloch S, Alvarez-Sotomayor D, Conde I, Polo B,
et al. Albumin dialysis with MARS for the treatment of anabolic steroid-
induced cholestasis. Ann Hepatol. 2016;15(6):93943.
133. Pais-Costa SR, Lima OA, Soares AF. Giant hepatic adenoma associated with
anabolic-androgenic steroid abuse: case report. Arquivos brasileiros de
cirurgia digestiva : ABCD = Brazilian archives of digestive surgery. 2012;25(3):
180-2.
134. Hardt A, Stippel D, Odenthal M, Hölscher AH, Dienes H-P, Drebber U.
Development of hepatocellular carcinoma associated with anabolic
androgenic steroid abuse in a young bodybuilder: a case report. Case
Reports in Pathology. 2012;2012:195607.
135. Kesler T, Sandhu RS, Krishnamoorthy S. Hepatology: hepatocellular
carcinoma in a young man secondary to androgenic anabolic steroid abuse.
J Gastroenterol Hepatol. 2014;29(11):1852.
136. Merino Garcia E, Borrego Utiel FJ, Martinez Arcos MA, Borrego Hinojosa J, Perez
Del Barrio MP. Kidney damage due to the use of anabolic androgenic
steroides and practice of bodybuilding. Nefrologia. 2018;38(1):1013.
137. Tarashande Foumani A, Elyasi F. Oxymetholone-induced acute renal failure:
a case report. Caspian J Intern Med. 2018;9(4):4102.
138. Daher EF, Silva Junior GB, Queiroz AL, Ramos LM, Santos SQ, Barreto DM, et al.
Acute kidney injury due to anabolic steroid and vitamin supplement abuse:
report of two cases and a literature review. Int Urol Nephrol. 2009;41(3):71723.
139. Colburn S, Childers WK, Chacon A, Swailes A, Ahmed FM, Sahi R. The cost of
seeking an edge: recurrent renal infarction in setting of recreational use of
anabolic steroids. Anna Med Surgery (2012). 2017;14:258.
140. Samaha AA, Nasser-Eddine W, Shatila E, Haddad JJ, Wazne J, Eid AH. Multi-
organ damage induced by anabolic steroid supplements: a case report and
literature review. J Med Case Rep. 2008;2:340.
141. Shimada Y, Yoritaka A, Tanaka Y, Miyamoto N, Ueno Y, Hattori N, et al.
Cerebral infarction in a young man using high-dose anabolic steroids. J
Stroke Cerebrovasc Dis. 2012;21(8):906.e911.
142. Sveinsson O, Herrman L. Cortical venous thrombosis following exogenous
androgen use for bodybuilding. BMJ Case Rep. 2013;2013.
143. Garg P, Davis G, Wilson JI, Sivananthan M. Intravascular ultrasound and
angiographic demonstration of left main stem thrombus-high-risk
presentation in a young adult with anabolic steroid abuse. Am Heart Hosp
J. 2010;8(2):E125E7.
144. Shamloul RM, Aborayah AF, Hashad A, Abd-Allah F. Anabolic steroids abuse-
induced cardiomyopathy and ischaemic stroke in a young male patient.
BMJ Case Rep. 2014;2014.
145. Luc JGY, Buchholz H, Kim DH, MacArthur RGG. Left ventricular assist device
for ventricular recovery of anabolic steroid-induced cardiomyopathy. J Surg
Case Rep. 2018;2018(8):rjy221rjy.
146. Santamarina RD, Besocke AG, Romano LM, Ioli PL, Gonorazky SE. Ischemic
stroke related to anabolic abuse. Clin Neuropharmacol. 2008;31(2):805.
147. Edvardsson B. Hypertensive encephalopathy associated with anabolic
androgenic steroids used for bodybuilding. Acta Neurologica Belgica. 2015;
115(3):4578.
148. Sonmez E, Turkdogan KA, Yilmaz C, Kucukbuzcu S, Ozkan A, Sogutt O.
Chronic anabolic androgenic steroid usage associated with acute coronary
syndrome in bodybuilder. Turkish J Emerg Med. 2016;16(1):357.
149. Falkenberg M, Karlsson J, Ortenwall P. Peripheral arterial thrombosis in two
young men using anabolic steroids. Eur J Vasc Endovasc. 1997;13(2):2236.
150. Laroche GP. Steroid anabolic drugs and arterial complications in an athlete--
a case history. Angiology. 1990;41(11):9649.
151. Youssef MYZ, Alqallaf A, Abdella N. Anabolic androgenic steroid-induced
cardiomyopathy, stroke and peripheral vascular disease. BMJ Case Reports.
2011;2011. https://doi.org/10.1136/bcr.12.2010.3650.
152. Bispo M, Valente A, Maldonado R, Palma R, Glória H, Nóbrega J, et al.
Anabolic steroid-induced cardiomyopathy underlying acute liver failure in a
young bodybuilder. World J Gastroenterol. 2009;15(23):2920.
153. Goldstein DR, Dobbs T, Krull B, Plumb VJ. Clenbuterol and anabolic steroids:
a previously unreported cause of myocardial infarction with normal
coronary arteriograms. South Med J. 1998;91(8):7804.
154. Güneþ Y, Erbaþ C, Okuyan E, Babalýk E, Gürmen T. Myocardial infarction
with intracoronary thrombus induced by anabolic steroids. Anatol J Cardiol.
2004;4(4):3578.
155. Christou GA, Christou KA, Nikas DN, Goudevenos JA. Acute myocardial
infarction in a young bodybuilder taking anabolic androgenic steroids: a
case report and critical review of the literature. Eur J Prev Cardiol. 2016;
23(16):178596.
156. Stergiopoulos K, Brennan JJ, Mathews R, Setaro JF, Kort S. Anabolic steroids,
acute myocardial infarction and polycythemia: a case report and review of
the literature. Vasc Health Risk Manag. 2008;4(6):147580.
Bates et al. Harm Reduction Journal (2019) 16:75 Page 13 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
157. Santos RP, Pereira A, Guedes H, Lourenço C, Azevedo J, Pinto P. Anabolic
drugs and myocardial infarction - a clinical case report. Arquivos brasileiros
de cardiologia. 2015;105(3):3169.
158. Ýlhan E, Demirci D, Güvenç TS, Çalýk AN. Acute myocardial infarction and
renal infarction in a bodybuilder using anabolic steroids. Turk Kardiyol Dern
Ars. 2010;38(4):2758.
159. Huie MJ. An acute myocardial infarction occurring in an anabolic steroid
user. Med Sci Sports Exerc. 1994;26(4):40813.
160. Ferenchick GS, Adelman S. Myocardial infarction associated with anabolic
steroid use in a previously healthy 37-year-old weight lifter. Am Heart J.
1992;124(2):5078.
161. Lau DH, Stiles MK, John B, Shashidhar, Young GD, Sanders P. Atrial
fibrillation and anabolic steroid abuse. Int J Cardiol. 2007;117(2):e867.
162. Mewis C, Spyridopoulos I, Kuhlkamp V, Seipel L. Manifestation of severe
coronary heart disease after anabolic drug abuse. Clin Cardiol. 1996;
19(2):1535.
163. Ment J, Ludman PF. Coronary thrombus in a 23 year old anabolic steroid
user. Heart. 2002;88(4):342.
164. Ahlgrim C, Guglin M. Anabolics and Cardiomyopathy in a bodybuilder: case
report and literature review. J Card Fail. 2009;15(6):496500.
165. Joseph J, Naqvi S, Sturm E. Reversible anabolic androgenic steroid-induced
cardiomyopathy. Cardiovasc Disord Med. 2017;2(3):13.
166. Nieminen MS, Ramo MP, Viitasalo M, Heikkila P, Karjalainen J, Mantysaari M,
et al. Serious cardiovascular side effects of large doses of anabolic steroids
in weight lifters. Eur Heart J. 1996;17(10):157683.
167. Stannard JP, Bucknell AL. Rupture of the triceps tendon associated with
steroid injections. Am J Sports Med. 1993;21(3):4825.
168. Farkash U, Shabshin N, Pritsch M. Rhabdomyolysis of the deltoid muscle in a
bodybuilder using anabolic-androgenic steroids: a case report. J Athletic
Train (National Athletic Trainers' Association). 2009;44(1):98100.
169. Fenelon C, Dalton DM, Galbraith JG, Masterson EL. Synchronous quadriceps
tendon rupture and unilateral ACL tear in a weightlifter, associated with
anabolic steroid use. BMJ Case Rep. 2016;2016.
170. Bagherifard A, Jabalameli M, Rezazadeh J, Ghaffari S, Tabrizian P.
Simultaneous bilateral quadriceps tendon rupture following a low - energy
trauma in a male body builder with the history of anabolic - androgenic
steroids consumption. Shafa Orthopedic J. 2018;5(2).
171. Liow RY, Tavares S. Bilateral rupture of the quadriceps tendon associated
with anabolic steroids. British J Sports Med. 1995;29(2):779.
172. KramhØFt M, Solgaard S. Spontaneous rupture of the extensor pollicis
longus tendon after anabolic steroids. J Hand Surg. 1986;11(1):87.
173. Tapaninen T, P V. Simultaneous bilateral rupture of the quadriceps tendon
associated with anabolic steroids - a case report. Annals of Clinical Case
Reports. 2016;1(1220).
174. David HG, Green JT, Grant AJ, Wilson CA. Simultaneous bilateral quadriceps
rupture: a complication of anabolic steroid abuse. J Bone Joint Surgery
British Volume. 1995;77(1):15960.
175. Visuri T, Lindholm H. Bilateral distal biceps tendon avulsions with use of
anabolic steroids. Med Sci Sports Exerc. 1994;26(8):9414.
176. Freeman BJ, Rooker GD. Spontaneous rupture of the anterior cruciate
ligament after anabolic steroids. Br J Sports Med. 1995;29(4):2745.
177. Adamson R, Rambaran C, D'Cruz DP. Anabolic steroid-induced
rhabdomyolysis. Hospital Med (London, England: 1998). 2005;66(6):362.
178. Erturan G, Davies N, Williams H, Deo S. Bilateral simultaneous traumatic
upper arm compartment syndromes associated with anabolic steroids. J
Emerg Med. 2013;44(1):8991.
179. Leopardi P, Vico G, Rosa D, Cigala F, Maffulli N. Reconstruction of a chronic
quadriceps tendon tear in a body builder. Knee Surg Sports Traumatol
Arthrosc. 2006;14(10):100711.
180. Rich JD, Dickinson BP, Flanigan TP, Valone SE. Abscess related to anabolic-
androgenic steroid injection. Med Sci Sports Exerc. 1999;31(2):2079.
181. Friedman O, Arad E, Ben AO. Body builder's nightmare: black market steroid
injection gone wrong: a case report. Plastic Reconstructive Surgery Global
Open. 2016;4(9):e1040.
182. Shiber JR. Pyomyositis due to anabolic steroid injection. J Emerg Med. 2013;
44(1):e6970.
183. Evans NA. Local complications of self administered anabolic steroid
injections. Br J Sports Med. 1997;31(4):34950.
184. Tüzel E. Spontaneous corpus cavernosum abscess in a healthy man
using long-term androgenic anabolic steroids. World J Mens Health.
2015;33(1):368.
185. Grant S, Dearing J, Ghosh S, Collier A, Bal AM. Necrotizing myositis of the
deltoid following intramuscular injection of anabolic steroid. Int J Infect Dis.
2010;14(9):e8234.
186. Marquis C, Maffulli N. Anabolic steroid related abscess - a risk worth taking?
Injury Extra. 2006;37:4514.
187. Ray S, Masood A, Pickles J, Moumoulidis I. Severe laryngitis following
chronic anabolic steroid abuse. J Laryngol Otol. 2008;122(3):2302.
188. Maini AAN, Maxwell-Scott H, Marks DJB. Severe alkalosis and hypokalemia
with stanozolol misuse. Am J Emerg Med. 2014;32(2):196.e34.
189. Labib M, Haddon A. The Adverse effects of anabolic steroids on serum
lipids. Ann Clin Biochem. 1996;33(3):2634.
190. Cooper I, Reeve N, Doherty W. Delayed diagnosis of a cerebrovascular
accident associated with anabolic steroid use. BMJ Case Rep. 2011;2011.
191. Unai S, Miessau J, Karbowski P, Baram M, Cavarocchi NC, Hirose H. Caution
for anabolic androgenic steroid use: a case report of multiple organ
dysfunction syndrome. Respiratory Care. 2013;58(12):e15963.
192. Geraci MJ, Cole M, Davis P. New onset diabetes associated with bovine
growth hormone and testosterone abuse in a young body builder. Hum
Exp Toxicol. 2011;30(12):200712.
193. Alaraj AM, Chamoun RB, Dahdaleh NS, Haddad GF, Comair YG.
Spontaneous subdural haematoma in anabolic steroids dependent
weight lifters: reports of two cases and review of literature. Acta
Neurochir (Wien). 2005;147(1):857 discussion 7-8.
194. Moor JW, Khan MI. Growth hormone abuse and bodybuilding as
aetiological factors in the development of bilateral internal laryngocoeles. a
case report. Eur Arch Otorhinolaryngol. 2005;262(7):5702.
195. Tan RS, Scally MC. Anabolic steroid-induced hypogonadism towards a unified
hypothesis of anabolic steroid action. Med Hypotheses. 2009;72(6):7238.
196. Kanayama G, Hudson JI, Pope HG. Long-term psychiatric and medical
consequences of anabolicandrogenic steroid abuse: a looming public
health concern? Drug Alcohol Depend. 2008;98(1):112.
197. Kanayama G, Hudson JI, DeLuca J, Isaacs S, Baggish A, Weiner R, et al.
Prolonged hypogonadism in males following withdrawal from anabolic-
androgenic steroids: an under-recognized problem. Addiction (Abingdon,
England). 2015;110(5):82331.
198. de Souza GL, Hallak J. Anabolic steroids and male infertility: a
comprehensive review. BJU Int. 2011;108(11):18605.
199. Pope HG, Kanayama G, Ionescu-Pioggia M, Hudson JI. Anabolic steroid
users' attitudes towards physicians. Addiction. 2004;99(9):118994.
200. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergard A,
et al. Injection site infections and injuries in men who inject image- and
performance-enhancing drugs: prevalence, risks factors, and healthcare
seeking. Epidemiol Infection. 2015;143(1):13240.
201. Bates G, McVeigh J. Image and performance enhancing drugs - 2015 survey
results. Liverpool: Centre for Public Health; 2016.
202. Brooks JHM, Ahmad I, Easton G. 10-minute consultation anabolic steroid
use. Bmj-Brit Med J. 2016;355.
203. Kanayama G, Boynes M, Hudson JI, Field AE, Pope HG. Anabolic steroid
abuse among teenage girls: an illusory problem? Drug Alcohol Depend.
2007;88(2-3):15662.
204. Korkia P, Lenehan P, McVeigh J. Non-medical use of androgens among
women. J Perform Enhanc Drugs. 1996;1(2):71.
205. Ip EJ, Barnett MJ, Tenerowicz MJ, Kim JA, Wei H, Perry PJ. Women and anabolic
steroids: an analysis of a dozen users. Clin J Sport Med. 2010;20(6):47581.
206. Hoberman J. Dopers in uniform: Police officers' use of anabolic steroids in
the United States. In: Møller V, Waddington I, Hoberman JM, Møller V,
Waddington I, Hoberman JM, editors. Routledge handbook of drugs and
sport. New York, NY, US: Routledge/Taylor & Francis Group; 2015. p. 43952.
207. Turvey BE, Crowder S. Anabolic steroid abuse in public safety personnel: a
forensic manual. San Diego: Academic Press; 2015.
208. Humphrey KR, Decker KP, Goldberg L, G. PH, Green GA. Anabolic
steroid use and abuse by police officers: policy & prevention. The
Police Chief. 2008;LXXV.
209. Waterhouse J. Rise in soldiers testing positive for steroid use. Newsbeat
[Internet]. 2014 25/3/2019.
210. Bolding G, Sherr L, Maguire M, Elford J. HIV risk behaviours among gay men
who use anabolic steroids. Addiction (Abingdon, England). 1999;94(12):
182935.
211. Bolding G, Sherr L, Elford J. Use of anabolic steroids and associated
health risks among gay men attending London gyms. Addiction. 2002;
97(2):195203.
Bates et al. Harm Reduction Journal (2019) 16:75 Page 14 of 15
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
212. Cornford CS, Kean J, Nash A. Anabolic-androgenic steroids and heroin use: a
qualitative study exploring the connection. Int J Drug Policy. 2014;25(5):
92830.
213. Kanayama G, Pope HG, Hudson JI. Associations of anabolic-androgenic
steroid use with other behavioral disorders: an analysis using directed
acyclic graphs. Psychol Med. 2018:18.
214. Salinas M, Floodgate W, Ralphs R. Polydrug use and polydrug markets
amongst image and performance enhancing drug users: Implications
for harm reduction interventions and drug policy. Int J Drug Policy.
2019;67:4351.
215. Kimergard A. A qualitative study of anabolic steroid use amongst gym users
in the United Kingdom: motives, beliefs and experiences. J Subst Use. 2015;
20(4):28894.
216. Taylor WN. Anabolic steroids and the athlete. 2 ed. Jefferson, NC:
MacFarland and Company Inc. Publishers; 2001.
217. Pampel FC. Drugs and Sport. New York: Facts on File; 2007.
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... This will require new policy frameworks and priorities, however preventing and reducing the harms associated with IPED use is not straightforward. Firstly, there is very little existing evidence on effective responses to guide the implementation of interventions, policies and services, including provision of harm reduction services or approaches to manage cessation ( Bates et al., 2019 ). This is the case even for well-established approaches such as the provision of injecting equipment in NSPs. ...
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Background Effective harm reduction work is needed to prevent and respond to the harms associated with image and performance enhancing drug (IPED) use and the diverse needs of IPED communities. Methods based around understanding and mapping complex systems have previously been applied to advance thinking on a range of complex health issues. We applied a systems perspective to explore factors that contribute to IPED-related harms in the UK and to identify harm reduction priorities. Methods An illustrative systems map was developed based on methods for mapping complex systems with expert stakeholders. Participants in two online workshops debated the important factors contributing to harm amongst people who use IPEDs and helped to refine and clarify the map. Discussions using the map reflected on where in the system intervention is needed and the policy implications. Results Stakeholders (n=18) identified 51 distinct factors as being important determinants of IPEDs-related harms, and the connections between them. These were grouped under nine domains that formed this system: identity, cognitive processes, beliefs about risk and harm, health and wellbeing, social environment, beliefs about healthcare, healthcare providers, interventions, and IPED markets. Four harm reduction priorities identified through reflexive discussion included providing a wider range of interventions, improving engagement between the IPED communities and healthcare professionals, new approaches to disseminating information in the community, and early intervention. Conclusion Systems mapping methods are a useful approach to engage stakeholders to discuss drug use issues. A comprehensive policy response is required to this complex issue that recognises diversity in IPEDs communities, their decision-making, and their intervention and service needs, as current approaches are failing to adequately address important areas of harm. Engaging with a wide range of stakeholders is critical to generate new insights that can help respond effectively to reduce the risk of health harms.
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In the past, research, policy and media have reported the use of anabolic androgenic steroids (AAS) primarily among younger males. However, recent studies have indicated the presence of an older cohort of men who use AAS in comparison to previous years. We carried out a scoping review of the extant literature to map and describe what is known about the use of AAS by older men (>40 years). A systematic search collected and analysed empirical research and grey literature relevant to the research question. Following application of inclusion and exclusion criteria, 44 studies were included which were subsequently charted and thematically analysed. The records included originated from the UK, USA, Canada, Australia, Slovenia, Norway, Spain, Turkey, Switzerland, Japan, and five global studies and were published between 1996 and 2021. Age ranged overall from 14 to 78 years old, however our review only discussed findings pertaining to those older than 40. Three main themes with subthemes were generated as follows: 1) Characteristics of AAS Use; Self-reported Adverse Effects from AAS Use; and Harms Diagnosed by Medical Professional. The review highlights the significant risks to hypothalamic-pituitary testicular function, cardiovascular health, and other organ systems as a result of the ageing man who is motivated to sustain masculine characteristics such as muscularity, youthfulness, sexual function, and perceived desirability and attractiveness. Future research is required to further understand the motivations of older men who use AAS. Furthermore, there is a need for age-specific research and recommendations to inform future policy and practice pertaining so that age-appropriate healthcare and policy decisions can be made in the future.
Article
Behavioral aspects of organized sports activity for pediatric athletes are considered in a world consumed with winning at all costs. In the first part of this treatise, we deal with a number of themes faced by our children in their sports play. These concepts include the lure of sports, sports attrition, the mental health of pediatric athletes (i.e., effects of stress, anxiety, depression, suicide in athletes, ADHD and stimulants, coping with injuries, drug use, and eating disorders), violence in sports (i.e., concepts of the abused athlete including sexual abuse), dealing with supervisors (i.e., coaches, parents), peers, the talented athlete, early sports specialization and sports clubs. In the second part of this discussion, we cover ergolytic agents consumed by young athletes in attempts to win at all costs. Sports doping agents covered include anabolic steroids (anabolic-androgenic steroids or AAS), androstenedione, dehydroepiandrostenedione (DHEA), human growth hormone (hGH; also its human recombinant homologue: rhGH), clenbuterol, creatine, gamma hydroxybutyrate (GHB), amphetamines, caffeine and ephedrine. Also considered are blood doping that includes erythropoietin (EPO) and concepts of gene doping. In the last section of this discussion, we look at disabled pediatric athletes that include such concepts as athletes with spinal cord injuries (SCIs), myelomeningocele, cerebral palsy, wheelchair athletes, and amputee athletes; also covered are pediatric athletes with visual impairment, deafness, and those with intellectual disability including Down syndrome. In addition, concepts of autonomic dysreflexia, boosting and atlantoaxial instability are emphasized. We conclude that clinicians and society should protect our precious pediatric athletes who face many challenges in their involvement with organized sports in a world obsessed with winning. There is much we can do to help our young athletes find benefit from sports play while avoiding or blunting negative consequences of organized sport activities.
Article
Anabolic-androgenic steroid (AAS) have widespread and growing illicit use as image and performance enhancing drugs (IPED), predominantly in young men. Users trying to stop AAS are prone to distressing withdrawal symptoms which may trigger relapse in use. It is important to develop therapies to support AAS withdrawal. The illicit nature of AAS use has impeded the robust characterisation of its clinical withdrawal syndrome within any single study. Therefore, we conducted a systematic review summarising the available clinical studies describing symptoms associated with non-medically indicated AAS use, and AAS withdrawal. Reported clinical features of AAS withdrawal include headache, fatigue, myalgia, restlessness, insomnia, low mood and libido, anorexia, suicidal ideation, body image dissatisfaction, and steroid cravings; novel therapies for AAS withdrawal would need evaluation against these symptoms.
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Objective Supraphysiologic doses of anabolic androgenic steroids (AAS) are widely used to improve body image and sport performance goals. These substances can easily be acquired over the internet, leading to a substantial black market. We reviewed literature that assessed the quality and quantity of AAS found on the black market. Methods We searched PubMed/Medline, Embase and Google Scholar for articles published before March 2022. Additional hand searches were conducted to obtain studies not found in the primary literature search. Studies were included if they report on qualitative and/or quantitative analytical findings of AAS from the black market. Primary outcomes were proportions of counterfeit or substandard AAS. Eligible articles were extracted; quality appraisal was done using the ToxRTool for in-vitro studies. We used random-effects models to calculate the overall mean estimates for outcomes. The review protocol has been published and registered in INPLASY. Results Overall, 19 studies, which in total comprised 5,413 anabolic samples, met the inclusion criteria, and passed the quality appraisal from two WHO world regions that reported findings, the Americas and Europe. Most studies were nonclinical laboratory studies (95%) and provided samples seized by authorities (74%). In 18 articles, proportions of counterfeit substances and in eight articles, proportions of substandard substances were presented. The overall mean estimate for counterfeit anabolic steroids found on the black market was 36% (95% CI = 29, 43). An additional 37% (95% CI = 17, 63) were of substandard quality. We also demonstrate that these drugs could contain no active ingredient, or in another amount than that labeled, a wrong active ingredient, as well as not all or more active ingredients than were labeled. High heterogeneity among all analyses and significant differences between geographical subgroups were found. Conclusion With this systematic review and meta-analysis, we demonstrate that substantial mean proportions of black-market AAS are counterfeit and of substandard quality. These products pose a considerable individual and public health threat, and the very wide range in proportions of fake black-market AAS puts the user in a situation of unpredictable uncertainty. There is a great need for future prevention and harm-reduction programs to protect users from these substances.
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The use of anabolic androgenic steroids (AAS) has diffused from elite sport and competitive bodybuilding and is now commonplace in the gyms of the UK. People who use AAS are by no means an homogenous group but comprised of multiple sub-groups with varied motivations, characteristics, risk behaviours and engagement with services. While personal possession of AAS is legal in the UK, many people who use these drugs remain secretive, sometimes in response to the stigma fuelled by the mainstream media. Drawing on our own research and other published literature, we explore the stigma experienced by people who use AAS, together with the discriminatory and sometimes stigmatising behaviours exhibited by some members of this community.
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Objectives To estimate the overall prevalence of androgenic-anabolic steroids (AAS) users seeking support from physicians. Secondary objectives are to compare this prevalence in different locations and among subpopulations of AAS users, and to discuss some of the factors that could have influenced the engagement of AAS users with physicians. Design Systematic review and meta-analysis. Data sources MEDLINE, PsycINFO, Web of Science and SciELO were searched in January 2022. Eligibility criteria Quantitative and qualitative studies reporting the number of AAS users who sought support from physicians, with no restrictions of language or time of publication. Data extraction and synthesis Two independent reviewers extracted data and assessed the quality of studies, including publication bias. A random-effects meta-analysis was performed to estimate the overall prevalence of AAS users seeking support from physicians, followed by pooled prevalence rates by studies’ location and the subpopulation of AAS users. Results We identified 36 studies published between 1988 and 2021, involving 10 101 AAS users. The estimated overall prevalence of AAS users seeking support from physicians is 37.12% (95% CI 29.71% to 44.52%). Higher prevalence rates were observed in studies from Australia (67.27%; 95% CI 42.29% to 87.25%) and among clients of the needle and syringe exchange programme (54.13%; 95% CI 36.41% to 71.84%). The lowest prevalence was observed among adolescent AAS users (17.27%; 95% CI 4.80% to 29.74%). Conclusion Our findings suggest that about one-third of AAS users seek support from physicians, with remarkable differences between locations and subpopulations of AAS users. Further studies should investigate the factors influencing the engagement of AAS users with physicians. PROSPERO registration number CRD42020177919.
Article
Background : Patient-physician interactions involve complex interplays between patient and physician autonomy. This is intensified in stigmatised populations, such as anabolic-androgenic steroid (AAS) users. The current study investigated what factors influence clinical interactions between physicians and AAS users, thus providing a holistic understanding of the underlying dynamics. Methods : For this exploratory two-cohort qualitative study, UK-based physicians (n = 6) and AAS-users (n = 6) were recruited via purposive and snowball sampling. Data were collected using semi-structured interviews. These interviews were audio-recorded, transcribed verbatim, and inductively analysed using reflexive thematic analysis. Results : Six themes were identified for AAS-using patients (perceived bias and lack of clinical knowledge; perceived power imbalance; riskiness of disclosure; feeling misidentified; experiencing hostility and prejudice; and collaborative clinical interactions) and four for physicians (professional barriers: lack of knowledge, guidelines and resources; preconceptions and prior understandings; direct exposure influences clinical confidence; and professional role quandary). The overall picture suggests primary impactive factors involve stigma management techniques among AAS-using patients and coping with clinical uncertainty for physicians. Conclusions : Blurred lines between enabling versus management impact both the AAS-using patient and the physician. Greater clarity is required regarding what constitutes as appropriate management and further discussion is warranted about the role of physician and patient autonomy. Improving access to healthcare services and expertly guided AAS cessation, if necessary, are vital for effective harm-reduction.
Article
Cardiovascular complications from drugs of abuse are becoming more apparent due to increased usage worldwide. Substance abuse can cause both acute and chronic cardiovascular complications and is increasing in prevalence especially in young adults. These substances contribute to the development of acute coronary syndrome, type II myocardial injury, arrhythmias, cardiomyopathies and have numerous other cardiovascular complications. Although no screening guidelines exist, clinical awareness of these potential complications and their prevention, clinical presentation, diagnosis, and treatment are critically important. Management of cardiovascular disease should be coupled with appropriate social and mental health interventions to provide sustained clinical benefit. The higher the number of substances used recreationally, the greater the risk of premature heart disease. Epidemiological studies showed that 1 in 5 young adults misuse several substances and often start using at younger ages with a greater risk for adverse health outcomes over the long-term. The aim of this review is to highlight the basic epidemiology, cardiac complications, and disease-specific treatment options of commonly abused substances including methamphetamine, cocaine, alcohol, anabolic-androgenic steroids, cannabis, and tobacco.
Purpose of review: Androgen abuse is more prevalent among gay and bisexual (i.e. sexual minority) men than heterosexual men. We review recent research about androgen abuse in sexual minority men and provide relevant social, cultural, and historical contexts. Recent findings: Androgen abuse among sexual minority men is shaped by the intersections of sexuality, desirability, masculinity, and race. Muscular male bodies are desired and - in erotic settings especially - prized as literal embodiments of masculinity. Racist stereotypes unjustly diminish the desirability and masculinity of sexual minority men who belong to racial minorities, especially those who are Asian or Black, and the higher rates of androgen abuse among these racial minorities may reflect a compensatory motivation for these diminishments. The historical context for sexual minority men - decades of subjugation alongside stereotypes of masculinity-compromising effeminacy - further complicate the intersections of sexuality with androgen abuse. Harm minimization efforts led by empathetic endocrinologists stand the best chance of achieving positive outcomes for sexual minority men who use androgens. Summary: More dedicated research on androgen abuse among sexual minority men is needed as this population requires thoughtfully designed research that is incorporative - at a minimum - of the complexities of sexuality, desirability, masculinity, and race.
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Background: Over the past two decades, the use of image and performance enhancing drugs (IPEDs) has increased significantly. Once largely confined to professional athletes, IPED use has transcended the elite sporting arena and is now predominantly found among non-elite, recreational gym users. This paper presents research findings from a qualitative study of IPED use and supply in a 'hardcore' bodybuilding gym in the north of England. This article makes an original contribution to the field by providing an in-depth account of the use and supply of IPEDs among this population, demonstrating the intersectionality that exists across IPEDs, diverted medication and both licit and illicit substance use and supply. Methods: The findings are based on the research team's privileged access to an independent, 'hardcore' body building gym in the north of England. Four fieldworkers undertook overt systematic observations, supplemented by 20 semi-structured interviews. Results: Amongst this sample of bodybuilders, substance use transcended IPEDs to encompass a much broader cocktail of substances all who used IPEDs concomitantly used diverted medication as a means of negating anticipated side-effects, and over half used illegal psychoactive drugs. Furthermore, virtually all of these substances were available to buy via the gym, through fellow gym members and, at times, staff. Conclusion: This article draws three main conclusions. (1) We are witnessing a convergence of IPED use and supply with diverted medication and 'traditional' recreational substances. (2) The extensive poly-substance use reported by interviewees in this sample necessitates a review of existing harm reduction advice for IPED users that takes into consideration the full range of substances currently being used. (3) Punitive drug policy reform that aims to reduce IPED markets needs to consider the potential to displace social supply towards more commercially-driven dealing. Harsher drug laws may also risk criminalising and stigmatising IPED users.
Article
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Background and Objectives The majority of anabolic androgenic steroid (AAS) studies have focused on the general male population. Approximately 15% of gay or bisexual men are seropositive for HIV and many AASs are administered via injection. Thus, AAS use among gay and bisexual men likely poses a greater risk of spreading infectious disease. Gay and bisexual men who use AAS were compared with non‐users regarding self‐reported seropositivity for HIV and hepatitis B and C, sexual behaviors and injection practices, illicit drug and alcohol use, and psychiatric disorders. Methods The CASTRO (Castro Anabolic Steroid Research Observation) study was a 108‐item cross‐sectional survey of 153 gay and bisexual men who exercise. Data collection occurred outside four gyms in the San Francisco Castro District. Results The lifetime prevalence of AAS use among gay and bisexual men in the study was 21.6%. AAS users and non‐users did not differ in self‐reported seropositivity for HIV or hepatitis B and C, but AAS users reported higher rates of male‐male condomless anal sex in the past year (84.8 vs 60.8%, p < .01) than non‐users. More AAS users used ecstasy and methamphetamines (39.4 vs 16.7%, p < .01 and 18.2 vs 5.0%, p = .01, respectively) than non‐users. Discussion and Conclusions Gay and bisexual men who used AAS were more likely to engage in unsafe sexual behaviors and use illicit drugs relative to non‐users. Multiple factors place AAS users at higher risks for spreading infectious diseases. Scientific Significant Our study suggests increased infectious disease risk among gay and bisexual men who use AAS. (Am J Addict 2019;XX:1–10)
Article
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Background The prevalence of using anabolic steroids such as oxymetholone is increasing. This highlights the need for closely monitoring side effects of this drug. Acute renal failure (ARF) has been reported as a complication of rhabdomyolysis in anabolic steroids users. Case presentation We present one 33-year-old man complaining of decreased urine volume, urine color change, and lower abdominal pain. He is engaged with a rare side effect of oxymetholone abuse. During assessments of potential medical issues associated with the intake of anabolic steroids, known side effects are known to be transient, but the need for appropriate interventions remains essential. Conclusions Rhabdomyolysis due to drug use and the consequent acute kidney injury are among the lethal risks associated with anabolic steroid abuse. In most cases, the symptoms are extensive and often misleading. Therefore, detailed history taking, physical scrutiny, paraclinical testing, and early diagnosis are crucial for rhabdomyolysis patients.
Article
Blood-borne viruses (BBVs) are an established focus of drug research and harm reduction. While a focus on BBVs has been applied to people who inject image and performance enhancing drugs (IPEDs), research has demonstrated that there are significant differences between this group and people who inject other drugs. Furthermore, the literature on BBVs and IPED use has been misrepresented by the media and harm reduction programs, with significant consequences for how some people who inject IPEDs view academic research and health services. It seems time to ask, is our current approach to the issue of BBV among people who inject IPEDs the most appropriate, and are there ways that it could be improved to ensure that there are no unintended consequences? In this commentary I suggest ways research and harm reduction efforts could tackle the issue of BBV without exacerbating existing divides between people who inject IPEDs and the health and academic communities. These suggestions are based on the views of the enhanced bodybuilders with whom I am privileged to work.
Chapter
Athletes are liable for both targeted and randomised, no-notice drug testing, both in-competition and out-of-competition. Those athletes who use prohibited substances and methods are, unsurprisingly, keen to avoid detection. Procedures that are used for this subterfuge are classified by the World Anti-Doping Agency (WADA) as chemical and physical manipulation and are themselves subject to anti-doping rule violation regulations. The chapter describes some of the techniques that have been used by individual athletes in an attempt to avoid detection and the methods by which such abuse is monitored and controlled. Attention is also drawn to institutionalised manipulation of the doping control process. The chapter provides illustrative case studies in which various manipulative methods have been used by both individual athletes and by institutions. The most common method of manipulation used by athletes, as determined from WADA laboratory results, has involved sharing of urine samples between fellow athletes or using that from other individuals. © 2018 selection and editorial matter, David R. Mottram and Neil Chester.
Article
Background: People who inject image and performance enhancing drugs (IPEDs) are often the largest group using needle and syringe programmes (NSPs) in the UK. NSP providers report these clients repeatedly collecting large amounts of equipment for others. The extent of secondary distribution of injecting equipment is unknown. Methods: Data from national surveillance of people injecting IPEDs were used. Participants completed a questionnaire and provided a dried-blood spot sample. Data from two biennial surveys was combined; repeat participants were excluded. Self-reported data was used to explore the extent of secondary distribution. Results: Of the participants, 87% (467) reported NSP use; median age was 31 years; 98% were male. A third (34%, 157) reported collecting equipment for others. Of those collecting for others, 154 reported how many people they had collected for: 55% had collected for one person, 27% for 2–9 people, 5% for 10–19 and 13% for 20 or more (no difference by psychoactive drug use). Those vaccinated for hepatitis B were more likely (22% [15/68] vs 6% [5/86], p = 0.003), and those reporting redness/swelling at an injection site were less likely to collect equipment for at least 20 others (8% [8/106] vs 25% [12/48], p = 0.003). Overall, 154 people collected equipment for 639-1569 people injecting IPEDs. Conclusions: Secondary distribution of injecting equipment is common among those injecting IPEDs and using NSPs. Whilst not allowing for rotational collection within groups, our analysis suggests that many of those injecting IPEDs are not in direct contact with NSPs. Innovation approaches for harm reduction interventions are needed.
Article
In 2017 Rich Piana, an American body builder and internet celebrity, suddenly died at the age of 46. Piana was not particularly successful as a competitive body builder, however, he became an internet sensation due to his massive body size and controversial videos about his long term anabolic steroid‐ and growth hormone abuse. Shortly after his death many speculated that his demise must have been related to his steroid addiction. The autopsy, however, was inconclusive about the cause of death [1]. This article is protected by copyright. All rights reserved.
Article
Herein we report a case of a 26-year-old gentleman with severe cardiomyopathy likely secondary to anabolic-androgenic steroid (AAS) abuse who received a HeartMate II (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) for rapidly deteriorating heart failure with hemodynamic compromise. Following 18 months on LVAD support, excellent recovery of ventricular function was achieved to allow for LVAD discontinuation. Given that active substance abuse is a contraindication to heart transplantation, few options remain for patients with AAS induced heart failure. Our case demonstrates that LVAD therapy can be an important intervention for bridging to candidacy, recovery or destination therapy.
Article
There are numerous reports of the psychiatric effects of anabolic-androgenic steroid (AAS) use. However, these effects have not been clearly elicited in controlled clinical trials. This discrepancy is largely due to the presence of a variety of synergistic factors seen in the real-life setting of AAS abuse. In this case, we report a patient in acute mania admitted to Frederick Memorial Hospital in Frederick, Maryland. He had no prior history or family history of manic episodes. His symptoms were refractory to initial pharmacologic intervention. The onset of his symptoms was likely related to the initiation of AAS use. However, his symptoms were likely potentiated by heavy daily cannabis use. The patient showed a gradual improvement over the second week of his hospitalization. He was discharged on antipsychotics and scheduled to follow up with a therapist and psychiatrist.