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"They sent it away for testing and it was all bunk": Exploring perspectives on drug checking among steroid consumers in Queensland, Australia

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Introduction: Research supports the feasibility and acceptance of drug checking among nightlife and festival attendees. Interest in expanding drug checking to other groups of people who use drugs, including those who inject drugs, has grown. However, understanding the acceptability and feasibility of drug checking among specific cohorts, like anabolic-androgenic steroids (AAS) consumers, remains a research gap. This study explores AAS consumers' perspectives on drug checking and service preferences, aiding the preparation for drug checking delivery in Queensland, Australia. Methods: A purposive sampling technique was used to recruit 15 AAS consumers (9 males, 6 females; Mage = 36.80 years, SD = 6.12) from Australia. One-on-one semi-structured qualitative interviews were conducted with questions exploring participants' views on drug checking/testing and their preferences for AAS analysis. Thematic analysis was conducted with final themes established through iterative consensus. Results: Consumers expressed frustration with the prevailing stereotypes, social stigma, and the perception of criminality associated with the use of AAS. There was a strong dependence on personal connections and trusted suppliers, with coaches exerting significant influence. Participants expressed concerns about the widespread availability of counterfeit products and underground operations. The act of using unknown AAS was likened to a game of Russian roulette, underscoring the importance of obtaining accurate information and access to reliable drug checking services. Consumers expressed a preference for a web-based platform that enables individuals to access their own test results while contributing to a comprehensive database of brand-specific testing outcomes. Discussion: AAS consumers recognise the significance of monitoring their AAS use and seek a service that can not only assist them in making informed decisions regarding AAS usage but also potentially contribute to the knowledge of the wider AAS-consuming community. These findings underscore the importance of tailored education, drug checking services, and harm reduction measures to address the diverse needs of AAS consumers.
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International Journal of Drug Policy 119 (2023) 104139
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Research Paper
They sent it away for testing and it was all bunk: Exploring perspectives
on drug checking among steroid consumers in Queensland, Australia
Timothy Piatkowski
a
,
c
,
*
, Cheneal Puljevic
b
,
c
, Cameron Francis
c
, Jason Ferris
c
,
d
,
Matthew Dunn
c
,
e
a
School of Applied Psychology, Grifth University, Gold Coast, QLD, Australia
b
School of Public Health, The University of Queensland, Brisbane, QLD, Australia
c
The Loop Australia, Australia
d
Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia
e
School of Health and Social Development/Institute for Health Transformation, Deakin University, Geelong, Australia
ARTICLE INFO
Keywords:
Anabolic-androgenic steroids
Drug checking
Drug policy
Harm reduction
Risk environments
ABSTRACT
Introduction: Research supports the feasibility and acceptance of drug checking among nightlife and festival
attendees. Interest in expanding drug checking to other groups of people who use drugs, including those who
inject drugs, has grown. However, understanding the acceptability and feasibility of drug checking among
specic cohorts, like anabolic-androgenic steroids (AAS) consumers, remains a research gap. This study explores
AAS consumersperspectives on drug checking and service preferences, aiding the preparation for drug checking
delivery in Queensland, Australia. Methods: A purposive sampling technique was used to recruit 15 AAS con-
sumers (9 males, 6 females; Mage =36.80 years, SD =6.12) from Australia. One-on-one semi-structured
qualitative interviews were conducted with questions exploring participantsviews on drug checking/testing and
their preferences for AAS analysis. Thematic analysis was conducted with nal themes established through
iterative consensus. Results: Consumers expressed frustration with the prevailing stereotypes, social stigma, and
the perception of criminality associated with the use of AAS. There was a strong dependence on personal con-
nections and trusted suppliers, with coaches exerting signicant inuence. Participants expressed concerns about
the widespread availability of counterfeit products and underground operations. The act of using unknown AAS
was likened to a game of Russian roulette, underscoring the importance of obtaining accurate information and
access to reliable drug checking services. Consumers expressed a preference for a web-based platform that en-
ables individuals to access their own test results while contributing to a comprehensive database of brand-
specic testing outcomes. Discussion: AAS consumers recognise the signicance of monitoring their AAS use
and seek a service that can not only assist them in making informed decisions regarding AAS usage but also
potentially contribute to the knowledge of the wider AAS-consuming community. These ndings underscore the
importance of tailored education, drug checking services, and harm reduction measures to address the diverse
needs of AAS consumers.
Introduction
One of the consequences of drug prohibition is the lack of knowledge
regarding the composition and purity of illicit substances (Miron, 2003;
Taylor et al., 2016). This information gap poses signicant risks to in-
dividuals who consume drugs, as they lack knowledge of the contents
which can lead to physical harm (Darke & Farrell, 2014; Unick et al.,
2014). In the context of harm reduction, drug checking has emerged as a
strategy to address this issue. Drug checking programs aim to provide
consumers with accurate and timely information about the content and
potential harms associated with the substances they intend to consume
(Maghsoudi et al., 2022). Drug checking was traditionally designed to
provide harm reduction services and information about illicit substances
in party scenes, however, the remit of drug checking has expanded
signicantly (see Barratt & Measham, 2022). Drug checking programs
can be traced back to the late 1960s in the United States (Barratt et al.,
2018). According to a recent systematic review, these programs have
expanded globally and are now implemented in many countries
* Corresponding author at: School of Applied Psychology, Gold Coast Campus, Grifth University, QLD 4222, Australia.
E-mail address: t.piatkowski@grifth.edu.au (T. Piatkowski).
Contents lists available at ScienceDirect
International Journal of Drug Policy
journal homepage: www.elsevier.com/locate/drugpo
https://doi.org/10.1016/j.drugpo.2023.104139
International Journal of Drug Policy 119 (2023) 104139
2
including the United States, United Kingdom, Netherlands, Switzerland,
Spain, Portugal, Belgium, France, Australia, and Canada (Colledge--
Frisby et al., 2023).
Drug checking initiatives seek to empower individuals to make
informed decisions about their drug use (Weicker et al., 2020). These
programs typically involve analysing drug samples using various
methods, such as spectrometry or reagent testing, to identify the pres-
ence of specic substances and potential adulterants as well as dosage or
strength (Barratt & Measham, 2022). The provision of drug testing re-
sults to consumers provides some information about the potential risks
associated with their drug use (Barratt & Measham, 2022), although it is
important to note that these results may not encompass all possible risks
due to limitations in testing methodologies and the multifaceted nature
of drug-related harms (Masterton et al., 2022). Risks associated with
drug use can be inuenced by various factors, including the environ-
ment and co-substance consumption, which may signicantly impact
the overall risk prole beyond the specic drug content or purity
(Masterton et al., 2022). However, the implementation of drug checking
programs has shown positive outcomes and increased safety among drug
consumers in jurisdictions where it has been applied (Bardwell & Kerr,
2018; Measham, 2019). Feasibility studies indicate acceptance and
willingness among consumer populations to engage with these services
(Kennedy et al., 2018; Krieger et al., 2018; Palamar et al., 2019; Sher-
man et al., 2019). The positive reception among consumer populations
to engage with these services align with the call for widely accessible
harm reduction measures.
The Global Commission on Drug Policy recently advised govern-
ments to make harm reduction measures, including drug checking ser-
vices, widely accessible (Bewley-Taylor & Tinasti, 2020; Buxton et al.,
2020). Although there have been calls for drug checking in Australia for
some time (Ritter, 2020), initially there were only two Australian trials
of drug checking, both performed in a festival context (Byrne et al.,
2018; Olsen et al., 2019). This comprised a xed site trial service
launched in Canberra in 2022, which has been extended and is expected
to become a permanent service (Olsen et al., 2022). In February 2023,
the government of Queensland (the second largest and third most
populous state in Australia) announced support for the introduction of
drug checking services (Australian Broadcasting Corporation, 2023).
The recent recommendation to make drug checking services widely
accessible aligns with the harm reduction approach, which recognises
the social context and inuences surrounding substance use (Bewley--
Taylor & Tinasti, 2020; Buxton et al., 2020). The support for introducing
drug checking services by the government of Queensland reects a step
towards implementing population-level interventions aimed at reducing
drug-related harms and addressing health inequalities. While previous
studies surrounding these services have focused on populations such as
the nightlife/festival attendees, particularly ecstasy consumers, there is
still a gap in research regarding the perspectives and experiences of
those involved in the consumption of performance and image enhancing
drugs (PIEDs) such as anabolic-androgenic steroids (AAS). Therefore, in
the context of the Queensland governments commitment to supporting
such services, this study specically aimed to explore AAS consumers
attitudes, perceptions, and needs regarding drug checking. Doing so
aligns service provision with broader goal of enhancing health outcomes
for this population given the high representation of AAS consumption in
Queensland, accounted for by the overrepresentation of AAS-related
arrests compared to other states and territories (Australian Criminal
Intelligence Commission, 2021).
The present study
There has been a consistently growing global trade in PIEDs (Mag-
nolini et al., 2022; Paoli & Donati, 2014) with AAS being a prominently
used group of these substances (Dunn et al., 2021; Dunn & Piatkowski,
2021; Hope et al., 2021). Despite a growing AAS market, these sub-
stances have been often reported to be variable in their quality
(Magnolini et al., 2022). Research suggests that illicit AAS generally lack
the specied active ingredient entirely or contain a different amount or
type of active ingredient than indicated on the labelling, highlighting
issues of misrepresentation and inconsistency in product composition
(Coimbra et al., 2021; da Justa Neves and Caldas, 2017). For example, a
global study of 5,413 samples suggested that the average estimated
prevalence of counterfeit AAS within the illicit market was 36%, while
an additional 37% were classied as substandard in terms of quality
(Magnolini et al., 2022). Coomber et al. (2015) found that the percep-
tion of risk for AAS consumers regarding substance analysis cannot be
solely determined based on forensic ndings. This is because users
genuinely believe that they are buying legitimate and effective AAS, and
they employ various subjective methods to ensure the authenticity of the
products (Coomber et al., 2015). Therefore, for AAS consumers, drug
checking can offer crucial information on the presence and purity of a
substance. This is particularly signicant given the high prevalence of
counterfeit AAS products in circulation (Coomber et al., 2015; Turnock
& Gibbs, 2023; van de Ven et al., 2020), where unintended use of
harsher varieties of AAS, such as Trenbolone (19-Nor AAS), can have
severe psychosocial consequences compared to testosterone or
DHT-derivatives of testosterone (Piatkowski et al., 2023b). Further-
more, the unpredictable combination of unknown substances or
dangerously high or low doses in counterfeit AAS products (Magnolini
et al., 2022) adds another layer of risk, increasing the potential for un-
foreseen and unpredictable health consequences among consumers.
Creating a bridge between public health and drug policy in the
context of AAS would be a signicant step towards providing adequate
healthcare to this, often overlooked, group of substance consumers
(Dunn et al., 2023; Piatkowski et al., 2022, 2023a). The risk environ-
ments framework provides a theoretical foundation for doing so (Rho-
des, 2002), emphasising the importance of enabling contexts and
resources in advancing harm reduction (Duff, 2009, 2011). Substance
use, including AAS, is inuenced by various interacting factors within a
social context. Hanley Santos and Coomber (2017) indicate that patterns
of AAS use among consumers varied based on their motivations, prior
knowledge, and experiences. Many users had limited knowledge about
AAS before starting their use, relying on information from peers or
suppliers, which was sometimes inaccurate or incomplete (Hanley
Santos & Coomber, 2017). As Hanley Santos and Coomber (2017) sug-
gest, when developing interventions targeting AAS use, it is crucial to
consider the broader context (e.g., motivations and experiences).
Therefore, we extend this study by investigating how individualssocial
contexts and cultural interpretations of risk practices shape their
engagement with and perceptions of drug checking services, aiming to
enhance our understanding of the complexities surrounding risk be-
haviours and informing drug policy and practice in the context of drug
checking. While there is some integration of AAS consumers in harm
reduction, predominantly through needle service provision (Kimergard
& McVeigh, 2014; Piatkowski, Hides et al., 2022), ensuring the delivery
of sterile injecting equipment should be regarded as a minimal
requirement (Bates et al., 2021), Scholars have suggested harm reduc-
tion frameworks should expand to encompass a comprehensive range of
harm reduction interventions that address the needs of individuals using
AAS throughout their entire usage cycle, including those who opt for
temporary or permanent cessation of use (Bates et al., 2021; Bates &
Vinther, 2021). Therefore, further establishing the position of AAS
within harm reduction frameworks can facilitate an alliance between
public health policy and AAS consumers. This research is the rst study
internationally which attempts to investigate AAS consumersperspec-
tives on drug checking services, lling a research gap in the existing
literature. Drawing on a small group of consumers, this study explored
AAS consumersperspectives on drug checking services and investigated
strategies to meet their needs, aiding the preparation for drug checking
delivery in Queensland, Australia.
T. Piatkowski et al.
International Journal of Drug Policy 119 (2023) 104139
3
Methods
Sampling and recruitment
A sample of 15 AAS consumers (>18 years of age) were recruited
through purposive sampling techniques, leveraging the personal and
professional networks of the research team. These networks include The
Loop Australia and Queensland Injectors Voice for Advocacy and Action
(QuIVAA). Those interested and eligible completed informed consent
procedures. Participants were reimbursed for their time with a gift card.
Ethical approval was granted from the Grifth University Human
Research Ethics Committee (Approval: 2023/257).
Materials and data collection
Participants were invited to take part in one-on-one semi-structured
qualitative interviews. Questions included: Why do you believe testing
AAS is important/not important? What do you think about testing/
checking AAS? If there was a drug checking/testing service which could
analyse AAS, what information would you like to receive? Participants
were also asked for demographic information, such as age and their
gender. These interviews took place on the MS Teams platform, where
audio recordings were transcribed automatically. These transcripts were
checked for errors and imported into NVivo (QSR) for further analysis.
The mean length of interviews was 39 minutes and 32 seconds (Range =
14-118 minutes).
Data analysis
Data collection and preliminary analysis were conducted concur-
rently by the rst author, allowing for reexivity and adaptation of the
semi-structured interview guide questions with emerging insights
(Braun & Clarke, 2023). For instance, participants were specically
prompted to share their previous experiences related to AAS testing, as
several individuals in the sample had undergone such testing. Moreover,
additional prompts were introduced to encourage participants to pro-
vide more detailed responses to specic inquiries, such as "What po-
tential health effects can arise from the use of untested steroids?" The
data was analysed through a lens of social constructivism (Adams,
2006). This ontological position was recognised as suitable given that
knowledge is co-constructed through the interaction between the
researcher and participants, as the research aims and theoretical
framework shape the analysis of data and the resulting ndings
(Poucher et al., 2020). Further, given that the research aimed to explore
the perspective of this unique group of substance consumers and facil-
itate a collaborative research process, this was deemed a suitable
framework (Noorbergen et al., 2021). Once all interviews were
completed and transcribed, data were imported into NVivo for thematic
analysis. Thematic analysis followed Braun and Clarkes six-step guide
(Braun & Clarke, 2019) involving data familiarisation, initial code
generation, identication of potential themes, review of themes, de-
ning/naming themes, and writing up ndings. Inductive analysis was
used to identify codes which were synthesised into themes to summarise
the key ndings from the interviews (Azungah, 2018). The coding
process continued until achieving inductive thematic saturation, a point
where the collected data ceased to yield signicant novel insights that
were pertinent to the research aims (Guest et al., 2020; Saunders et al.,
2018). This state of saturation was marked by the absence of newly
identied codes, themes, or sub-themes in the incoming data, which
could not be accounted for by the existing knowledge and literature in
the eld (Guest et al., 2020; Lam et al., 2022; Saunders et al., 2018).
Specically, no additional meaningful information or patterns emerged
from the data, indicating that the data analysis reached a point of
saturation, where the research aims were sufciently addressed, and
further data collection was unlikely to contribute substantially to the
research outcomes. The research team then met to discuss and review
this categorisation to arrive at nal themes and subthemes and names
thereof by an iterative consensus decision-making process (Braun &
Clarke, 2021). Participants were assigned with pseudonyms to preserve
their anonymity.
The researchers involved in this study brought together diverse
expertise from the elds of behavioural science, public health, and social
work. The rst author acknowledges his lived experience in the strength
sport and tness community. This rsthand involvement provided a
comprehensive understanding of the subcultures that emerge among
AAS users, and the authors lived experience served as an asset during
interviews, facilitating in-depth exploration and enriching the depth of
inquiry (Zampini et al., 2021). The other authors contributed different
perspectives and interpretations to the ndings, generating novel
themes that contributed to the construction of the ndings in accordance
with established best practice (Braun & Clarke, 2023).
Findings
The participant pool consisted of male (n =9) and female (n =6)
participants whose mean age was 36.80 (SD =6.12); see Table 1 for full
participant characteristics. All participants in the study were either
originally from Queensland or had lived in Queensland for a portion of
their lives. However, two participants resided outside of Queensland at
the time of data collection. Seven participants had previously or were
currently testing their AAS through a private operator. We identied
four overarching themes that developed from the data.
Theme 1: Russian roulette: perceptions of unknown substances and
interactions with the criminal system
The metaphor of playing ‘Russian roulette emerged repeatedly in
participant narratives when describing the process of using untested
AAS, underscoring the uncertainty and potential harm associated with
using unknown substances. Stories of individuals injecting substances
that were revealed to be cooking oil or other unintended compounds
highlight the risks that consumers face when using product purchased in
a marketplace where there is no formal quality control due to its illegal
nature. One participant conveyed the potential consequences of unin-
formed decisions in the context of AAS use:
Albert [37, Male]: Its like playing Russian roulette isnt it. Youre
putting something into body thinking that its somethinginjecting
and having it smell like either like rosemary oil or sesame seed oil
and ending up with massive sort of welts and acne. Its infected sort
of injection sites because like – “I think its, I think its testosterone.
Ill use it.
Many participants considered AAS to be overlooked and receive little
attention within the harm reduction space. Participants expressed frus-
tration with the prevailing stereotype that associates AAS use
Table 1
Participant details.
P Pseudonym Gender Age Interview Length (M:S)
1 Bryce M 33 31:04
2 Paul M 41 34:55
3 Albert M 37 33:32
4 Phoebe F 21 30:20
5 Henry M 35 31:15
6 Cuthbert M 35 13:31
7 Jayden M 38 117:47
8 Paris F 43 34:16
9 Alexis F 32 25:21
10 Willy M 41 52:12
11 Victor M 39 25:33
12 Samantha F 42 44:23
13 Danielle F 30 16:06
14 Winslow M 40 38:57
15 Rose F 45 48:10
T. Piatkowski et al.
International Journal of Drug Policy 119 (2023) 104139
4
exclusively with ‘massive bodybuilders.
Jayden [38, Male]: Steroids is something which is sort of often
overlooked in terms of, you know, seeing it as a drug because, you
know, people just think oh, you know, its these massive body-
builders that are taking it.
In turn, this frustration appeared to drive consumers into increas-
ingly insular communities. Given the legalities surrounding illicit sub-
stance consumption in Australia, there were also criminality factors
which heightened participants penchant for close-knit groups.
Henry [35, Male]: Yeah, like I said, man, like a lot of people, theyre
really shady, but they dont talk about it [AAS]. And for obvious
reasons, they might not want people to know that theyre doing what
theyre doing.
For instance, several participants shared experiences that under-
scored the criminal nature of AAS use. These occurrences ranged from
interactions with police, as well as instances of being caught with un-
derground AAS and subsequent legal consequences. These experiences
were not uncommon among participants.
Jayden [38, Male]: Theres been a couple times, you know, outside of
our gym where? You know, a few of us have sort of been randomly
pulled over by police ofcers, you know, after walking out with bags
from the gym.
Cuthbert [35, Male]: Ive been caught a couple of times. I got raided and
the cops found my stuff and Ive been in court a few times.
Interestingly, in occasions when police seized and tested these
compounds, they were reported to be counterfeit.
Albert [37, Male]: Im all for it [drug checking] because there was
there was an incident where I got caught with underground steroids.
And they sent it away for testing [forensic analysis] and it was all
bunk [fake].
Ultimately, participants believed that the ability to test AAS in a safe
manner and receive feedback would reduce the likelihood of encoun-
tering counterfeit or harmful substances.
Samantha [42, Female]: I think people being able to test stuff and
realise how crap it is, and how much theyre just throwing their
money away on shit is more likely to prevent steroid use than harsh
laws.
Theme 2: social networks and personal relationships: its all word of
mouth
Social relationships held signicant importance in the acquisition of,
by the consumers standard, reliable AAS. Participants described their
preferred strategies for nding reliable sources of AAS. They stressed the
importance of personal connections and social validation, relying on
suppliers who have established relationships with high-level athletes.
Trust was placed in individuals who demonstrated passion and expertise
in manufacturing AAS. This social validation helped legitimise the
sources and provided consumers with a sense of condence in the sub-
stances they obtained.
Rose [45, Female]: I physically like, I know the person that Im
buying gear [AAS] off, as in have a social relationship with them.
This sounds really odd but also to know how passionate they are
about what they do in regards to manufacturing performance
enhancing drugs. I also know that they supply to a lot of really high-
level athletes.
Several participants noted that coaches played a pivotal role in
shaping the market by endorsing specic suppliers and vouching for the
quality and legitimacy of the products. Participants mentioned instances
where coaches themselves used the same substances and assured their
athletes about their safety and effectiveness. This dynamic creates a
bidirectional effect, as athletes place trust in their coaches judgment
and follow their recommendations. Coaches, as inuential gures
within the AAS community, contribute to the establishment of reliable
sources and inuence the choices made by consumers.
Phoebe [21, Female]: Theyre oftentimes buying it off their coach
who like their coach is endorsing this particular supplier and prob-
ably getting a cut as well and like. The coach is assuring them that the
quality is amazing, all the qualitys legit. Like, I take this stuff, blah
blah, blah, like, and these are like young girls that theyre doing this
to.
The participant narratives underscored that trust is built through
ongoing interactions and a sense of familiarity. They express satisfaction
in knowing the person they are buying from, believing that this
connection ensures greater accountability and decreases the likelihood
of being deceived or sold counterfeit substances. This interpersonal
dimension of the market fosters a sense of reliability and reduces the
perceived risk associated with purchasing and using AAS.
Victor [39, Male]: I have, you know, a good relationship with the person
who supplies me.
Danielle [30, Female]: So, the person that I get it off is also in the
powerlifting world. So he has used all of those things. I trust him in
terms of providing legit stuff.
Social networks were important in obtaining reliable AAS and
shaping the market. Participants expressed trust in their personal re-
lationships with suppliers, who were considered to be well-connected
within the AAS manufacturing community. They relied on word-of-
mouth information and anecdotal evidence, verging on myth, from
other consumers to assess the quality and safety of the substances they
purchase.
Cuthbert [35, Male]: Its hard because batches do change so often.
The truth is, yeah, you can go on the bodybuilding forums, and you
can do as much as you possibly can to research and stuff like that, but
its all word of mouth.
Theme 3: navigating product legitimacy and quality: theres no receipt
Despite the importance of social networks, reliability and trustwor-
thiness of AAS sources were frequently questioned, given the prevalence
of counterfeit and substandard products. Notwithstanding the methods
outlined previously that participants used to try and ensure they were
using good quality product, they still expressed concerns over the lack of
transparency and the potential for unscrupulous actors to manipulate
the contents of the purchased products.
Rose [45, Female]: Ive known suppliers to tell me that they have
supplied gear to people they didnt like, and they just lled the
containers up with oilpeople they see in the gym every day.
Counterfeit and substandard substances were prevalent, leading to
scepticism about the transparency and integrity of suppliers. The illegal
nature of the market limited consumers recourse in addressing these
issues, as there was no ofcial avenue to report or address counterfeit
products. Participants expressed frustration over the lack of account-
ability, recognising the inherent challenges of illicit trade. As one
participant noted, attempts to manipulate labelling systems and
distribute inferior products not only undermined the branding efforts of
legitimate suppliers but also left consumers powerless to seek recourse.
The absence of regulatory oversight and the illegal nature of the trade
contributed to a sense of helplessness and the inability to voice concerns
or seek redress.
Albert [37, Male]: Someone tried to knock off their [brand name]
labelling system and there was a heap around of it [product]stuff
that was sort of bunk shit which sort of wrecked their branding and
T. Piatkowski et al.
International Journal of Drug Policy 119 (2023) 104139
5
theres nothing that you can do about it because its illegal. Who are
we going to fucking tell?
Winslow [40, Male]: Theres no receipt. So, youd legitimise the trade
process if people were able to test it.
The comparison between pharmaceutical-grade AAS and those pro-
duced in underground operations also emerged as a noteworthy
distinction. Participants recognised that obtaining AAS directly from
testosterone-replacement therapy clinics offered a higher level of con-
dence in terms of product quality and legitimacy. Pharmaceutical-
grade AAS were often considered more potent and reliable, leading to
a perception of increased control and effectiveness. However, the illicit
nature of the AAS market and the associated risks of legal repercussions
made accessing pharmaceutical-grade products difcult for many
consumers.
Victor [39, Male]: I know a lot of guys who have gone from under-
ground to pharma [pharmaceutical testosterone] and then go wow.
They feel the difference in a smaller dose of pharma because its
stronger and its more legit and controlled. To know what youre
getting, its a roll of the dice, because who knows how those guys are
making it, right.
To mitigate the risks associated with product legitimacy, participants
had various strategies for checking the quality and authenticity of the
AAS they obtained. These strategies ranged from visual inspections to
more advanced techniques, such as testing. Participants emphasised the
importance of testing the substances they purchase to verify their po-
tency and purity.
Paris [43, Female]: So there has been two different brands that Ive
used and stuck with. I tested and they both came back as great
quality. So I was like okay, done. Im onto a good thing, not gonna
change it.
Forums also played a signicant role in disseminating information
and experiences related to product legitimacy and brand reputation.
These sites were used so that consumers could share their testing results
and discuss trusted and untrusted brands. These forums provided con-
sumers an opportunity to navigate the complex landscape of the AAS
market and make informed decisions about their purchases.
Alexis [32, Female]: I know theres a private group there where you
can pay per month and then you get access to those results. But
getting access to those results, youd at least know which branch you
should denitely stick away from.
Despite the awareness of the prevalence of counterfeit and sub-
standard AAS and the inherent risks associated with them, consumers
continued to rely on these products to discern authenticity. These pro-
cesses underscore an urgency for enhanced measures, such as drug
checking services, to address the persistent issues precluding consumers
from ensuring reliable AAS for informed decision-making among
consumers.
Theme 4: emphasis on testing, transparency, and support: theres a level of
trust that needs to be built
There was strong inclination to possess comprehensive knowledge
about the composition, potency, and absence of contaminants in AAS.
The signicance of ensuring accurate labelling of AAS was emphasised,
indicating the commitment of consumers to procure and use AAS that
are not only effective but also considered ‘safe. This nding underscores
the importance placed by consumers on obtaining reliable and trust-
worthy AAS products.
Bryce [33, Male]: Were gonna want to know the labels right. The
compound. The purity. If theres anything that shouldnt be in there.
The idea of drug checking was met with acceptance by participants.
They saw no issues with sending their samples to a testing facility and
receiving results through an email or an online portal. The convenience
and anonymity offered by this approach aligned with the participants
desire for harm reduction in a public space. They emphasised that AAS
use is a niche community with unique complexities, and the availability
of reliable drug checking services would contribute to harm reduction
efforts.
Victor [39, Male]: It is a little bit more serious for us [AAS con-
sumers]. Youre making sure something that youre putting intra-
muscularly into your system is what it is. You see some horror stories
where guys put in random stuff and get an infection and have to get it
cut out.
Consumers discussed the potential benets of real-time monitoring
and anonymous dissemination of testing results. They envisioned that
their individual test results could contribute to a larger database of
brand-specic testing outcomes. This approach would allow consumers
to track the quality and consistency of different brands over time,
leading to informed decisions about their purchases.
Alexis [32, Female]: Then you can database it. If youve got an account
you can log into, you can see what things were and what they are.
The participants recognised the potential benets of a service that
provided information and support for harm reduction in the context of
AAS use. They believed that if such a service existed, individuals would
be less likely to use variable dosed or contaminated substances.
Phoebe [21, Female]: I think with regards to harm reduction, say
they had that service accessible where they could test their gear. I
think if they found out what they were taking currently or had plans
to take was fake or underdosed, overdosed, or contaminated etc. they
may be less inclined to take that. They may just do something else
like I think it would be so helpful just if it was accessible.
Trust and rapport emerged as signicant factors in the participants
discussions about accessing support services. These views were closely
linked to participants experiences of persistent stigma associated with
AAS use, describing it as a "hush, hush" and taboo subject. Engaging in
discussions about AAS use was perceived as socially unacceptable,
leading to secrecy and silence among consumers. The prevailing stigma
created an environment of fear and apprehension, contributing to a
culture of secrecy surrounding AAS consumption.
Bryce [33, Male]: Yeah, its still like very, you know, hush, hush. I
know a lot of people that use or have used, but its still a very taboo
subject.
As a result, participants stressed the importance of building trust
with the service providers which already had strong rapport in the
community needle service providers (NSPs). The close and trusted
association with NSPs and AAS consumers has been demonstrated to
facilitate access to essential resources, support, and information related
to safe injection practices, harm reduction, and other health-related
services.
Henry [35, Male]: I walk in the front door [of the NSP] and walk out.
You take those brown bags out; everyone knows what it is and I dont
care. I think that it [the NSP] helps in a big way. Down on the [place
name] in [place name] theres one needle exchange and thats the
one I used to go to. Theyre good.
Phoebe [21, Female]: So, I guess if the service was attached to like a
needle exchange that would be helpful.
Building on this, participants recognised that trust is vital to estab-
lishing a safe and supportive environment where individuals can seek
advice and share their experiences openly. The presence of qualied
experts or individuals with rsthand experience was highly valued, as
they could offer reliable and informed guidance.
T. Piatkowski et al.
International Journal of Drug Policy 119 (2023) 104139
6
Henry [35, Male]: If theres a physical location, keeping it like the needle
exchanges is good. Theyre always kind of tucked around the back, not
visible inside.
Alexis [32, Female]: You know, theres I think theres a level of trust
that needs to be built for the service and the site [drug checking xed
site] and those people who work within it.
The participants further highlighted the role of peers in the AAS
community. They discussed the need for peer-led support, where in-
dividuals with extensive knowledge and experience could provide
mentorship and guidance to those seeking information. Participants
acknowledged that not all sources of advice are reliable, and the inu-
ence of peers could be signicant in shaping individualsdecisions and
practices. They expressed the desire for expert opinions and in-
terventions to ensure the safe and effective use of AAS.
Samantha [42, Female]: You know, even something like some
mentorship or like maybe someone with far more lived experience.
For example, having a look at someones cycle because people do run
stuff which makes no sense, could be harmful for them.
There is a strong linkage between Theme 2 and Theme 4 which
highlights the interplay between social relationships and the emphasis
on trust in the context of AAS consumption. Social relationships and
trust are integral factors inuencing AAS consumer behaviour and mo-
tivations. There was signicance placed on personal connections in
obtaining reliable AAS, relying on individuals with established re-
lationships with high-level athletes and coaches who vouched for the
quality and legitimacy of the products. This social network played a
pivotal role in shaping the market and inuencing consumers choices.
Building trust with service providers was also emphasised, as they
served as trusted sources of support, information, and harm reduction
resources within the community. The participants discussions under-
lined the importance of trust, rapport, and ongoing interactions in
establishing a safe and supportive environment, where individuals could
seek advice and share experiences openly. Peer-led support, mentorship,
and guidance were also recognised as valuable resources. These ndings
underscore the intricate relationship between social relationships and
trust, as well as their collective impact on the experiences and behav-
iours of AAS consumers.
Discussion
Enhancing awareness and facilitating access to reliable drug check-
ing services emerged as critical needs within a sample of people from the
AAS community in Queensland, Australia. The signicance of recog-
nising potential risks of underground AAS and educating consumers
about physical harms through public health initiatives as well as the
provision of drug checking services, were underscored by consumers.
Notably, the initiatives emphasised by consumers echo extant work in
this area, including specic types of information to effectively manage
risks associated with AAS use, medical and emotional assistance, and the
need for addressing societal biases and promoting understanding (Har-
vey et al., 2020; Underwood et al., 2021). Consumers drew parallels
between the uncertainty and potential harm associated with consuming
unknown substances and the risky nature of ‘playing Russian roulette.
They expressed a specic desire for detailed knowledge regarding the
composition, purity, and absence of contaminants in the AAS they use.
Their vision encompassed a web-based platform that enables individuals
to anonymously access their own test results while contributing to a
comprehensive database of publicly available brand-specic testing
outcomes. Transparency and real-time monitoring via web platform
were identied as potential mechanisms to incentivise suppliers to
improve product quality. Accessible harm reduction support was desired
by this group, both at a point-of-care xed site and via digital platforms.
There was importance placed on condentiality and trust as key ele-
ments in facilitating effective interventions. While these ndings align
with the existing literature on the broader group of illicit substance
consumers who welcome drug checking services (Kennedy et al., 2018;
Krieger et al., 2018; Palamar et al., 2019; Sherman et al., 2019, Valente
et al., 2019), it is important to acknowledge that this study contributes
to the establishment of specic support and needs within the AAS
community. This aspect positions these ndings as a potential reference
point for policy makers, demonstrating the unique requirements and
advocating for the implementation of targeted interventions and support
services for AAS consumers.
Shaping the steroid market: enabling contexts to reduce harm
Drug harms are shaped by social situations and environments,
expanding the responsibility for harm reduction beyond individuals to
include social and political institutions (Rhodes, 2009). Contemporary
discourse in the eld of public health, drawing upon diverse research
traditions, underscores the signicance of social determinants in
shaping health disparities and asserts that effective mitigation of these
disparities necessitates the implementation of population-level in-
terventions (Gehring et al., 2022). However, scholars have asserted that
relying solely on ‘persuasionand ‘command and controlstrategies for
intervention is insufcient (Bacon & Seddon, 2020; Ritter, 2010).
Notably, market-driven regulation has been suggested to have the po-
tential to mitigate the harms associated with drug use for some time
(Ritter, 2010), further evidenced by proactive support from consumer
groups (Measham & Turnbull, 2021). Implementation of market stra-
tegies such as drug checking can effectively alter consumer preferences
and incentivise changes in the behaviour of sellers operating within the
drug market (Ritter, 2010; Seddon, 2020). For AAS, the surging unreg-
ulated supply from online sources is accompanied by misleading infor-
mation regarding the benets and risks associated with their use (Gibbs,
2023; Turnock & Gibbs, 2023), posing signicant concerns. The present
study builds on previous work, outlining AAS consumers overreliance on
information from suppliers (Hanley Santos & Coomber, 2017). There-
fore, public drug checking services, with provision for AAS, could have
potential to shape the market for AAS consumers, representing an
enabling place and resource (Duff, 2010, 2011). Due to the reported
structure of AAS markets (Coomber et al., 2015) this ‘shapingmay have
large-scale impact.
Social environments signicantly inuence AAS consumers de-
cisions and experiences (Hanley Santos & Coomber, 2017; Kimergard &
McVeigh, 2014). AAS consumers trusted their long-term drug dealers
due to established relationships, consistent supply, and effective
communication, which shares parallels with other illicit substance
consuming cohorts (Bardwell et al., 2019). Participants in this study
relied on word-of-mouth information and trusted suppliers who had
established relationships. Further, tting with previous work, coaches
(Gibbs et al., 2022; Gibbs & Piatkowski, 2023; Piatkowski et al., 2023b,
2023c) and peers (Piatkowski, Hides et al., 2022) inuenced consumers
choices by endorsing specic suppliers, reecting their important
structural position within AAS communities. Trust in personal connec-
tions may create a perception of reliability and reduce perceived risks
associated with AAS procurement and use. However, it is important to
recognise that this trust may be misplaced, as the trusted individuals
may not have direct control over the quality of the substances they sell,
and their own suppliers may play a signicant role in determining
product quality. Perhaps, as a result, participants did discuss concerns
about counterfeit and substandard products in the AAS market, indica-
tive of current trends (Frude et al., 2020; van de Ven et al., 2020). Un-
derground operations were recognised as variable in product quality,
while pharmaceutical-grade AAS were seen as more potent and reliable,
albeit difcult to access, reective of existing work (Dunn et al., 2021;
Underwood et al., 2021). Online forums have been proposed to provide
a platform for sharing harm reduction information (Tighe et al., 2017),
which the current ndings build on, demonstrating a component of
reducing harm is employed through consumer-driven measures to
T. Piatkowski et al.
International Journal of Drug Policy 119 (2023) 104139
7
increase brand transparency. Strategies for checking quality and
authenticity ranged from visual inspections to advanced techniques like
QR codes and private testing services. Although consumers indicated
some utility of private testing services, they specied public drug
checking services would be welcomed and preferrable. Ultimately, the
discussion on drug checking services which catered to AAS consumers
underscored the signicance of providing this group with feedback on
testing results, enabling them to modify their usage practices, thus,
empowering them to make informed decisions and incentivise suppliers
to improve the quality and legitimacy of their products. The practice of
making informed choices on substance consumption has demonstrated
its benecial impact on consumershealth, particularly in the context of
engaging with other illicit substances (Bardwell et al., 2019; Barratt
et al., 2018).
Conclusions
The present study investigated the specic needs of a sample of AAS
consumers from Queensland, Australia regarding drug checking services
and their perceptions of the most effective strategies for meeting those
needs. Although the study sample was modest, this work represents the
worlds rst research to explore AAS consumers drug checking needs.
These ndings contribute to establishing specic support and needs
within the AAS community, serving as a potential reference point for
policy makers to advocate for targeted interventions for AAS consumers.
The study underscores the importance of tailored education and drug
checking services to address the diverse needs of AAS consumers.
Further research may assess the utility of building strategies for pro-
ducing and disseminating education to AAS consumers alongside drug
checking services. These measures could further mitigate the risks
associated with AAS use and enhance harm reduction efforts.
CRediT authorship contribution statement
Timothy Piatkowski: Writing review & editing, Writing original
draft, Resources, Project administration, Methodology, Investigation,
Formal analysis, Data curation, Conceptualization. Cheneal Puljevic:
Writing review & editing, Formal analysis. Cameron Francis: Writing
review & editing, Formal analysis, Conceptualization. Jason Ferris:
Writing review & editing, Formal analysis. Matthew Dunn: .
Declaration of Competing Interest
Drs Piatkowski, Dunn, Puljevic, and Prof Ferris, are volunteer
members of The Loop Australia, which is a national organisation for
drug checking and drug checking research. Cameron Francis is the CEO
of The Loop Australia.
Funding
Dr Cheneal Puljevi´
c is supported by Discovery Early Career
Researcher Award from the Australian Research Council
(DE230101131).
Ethics
The Authors declare all procedures were performed in compliance
with relevant institutional guidelines and that the appropriate institu-
tional committee(s) have approved them. We also include a statement in
the manuscript regarding appropriate ethical safeguards and ethical
approvals which were obtained.
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T. Piatkowski et al.
... These changes have led to prescribers exercising caution when initiating testosterone treatment in men without reproductive pathology [6,10], with reports of prescribers being monitored [26] alongside claims of misconduct [27]. Subsequently, people who use androgens have reported difficulty in acquiring these medications [28,29]. These trends map onto extant work which has documented the utilisation of androgens and other AAS for self-administered TRT [20,30]. ...
... While harm reduction approaches have become foundational in the management of other substances, such as opioids [34][35][36][37], they remain underdeveloped and contentious in the context of androgens and AAS [7,38]. This is an area in urgent need of attention given that illicitly sourced AAS often contain unknown or harmful substances [29,39,40], with research indicating that more than two-thirds of these products are of questionable quality [41], exposing people to heightened health risks such as increased instance of bacterial infection [29,42]. One aspect of harm reduction for people who use AAS involves improving access to legitimate, prescription-based androgens. ...
... While harm reduction approaches have become foundational in the management of other substances, such as opioids [34][35][36][37], they remain underdeveloped and contentious in the context of androgens and AAS [7,38]. This is an area in urgent need of attention given that illicitly sourced AAS often contain unknown or harmful substances [29,39,40], with research indicating that more than two-thirds of these products are of questionable quality [41], exposing people to heightened health risks such as increased instance of bacterial infection [29,42]. One aspect of harm reduction for people who use AAS involves improving access to legitimate, prescription-based androgens. ...
Article
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Background Legitimate androgen use, such as testosterone replacement therapy, requires a legal prescription. Off-label use for reasons like wellness and aesthetics continues to grow. Recent regulatory changes in Australia aim to curb non-prescribed androgen use, potentially intensifying stigma, however seeking prescriptions through legal channels persists. This study aimed to explore community pharmacists’ knowledge, attitudes, and practices regarding individuals who use androgens. Methods We conducted semi-structured interviews with 15 community pharmacists, to explore knowledge and experiences related to the dispensing of androgens. The data analysis followed an iterative process, developing a codebook for thematic analysis and aligning findings with relevant literature. Results Pharmacists face challenges when meeting the needs of individuals using androgens. They often made judgments based on appearance, leading to stigmatisation and potential refusal of prescription supply. However, this is tempered by the complex environment that pharmacists work in with respect to professional and legal requirements. Limited knowledge about androgens and varying exposure to people who use androgens were evident, prompting a unanimous desire for tailored training, especially in communication skills and interaction strategies. Conclusions Facilitating androgen use within regulated healthcare settings, under professional medical supervision, is crucial to mitigating health risks. Varied pharmacist knowledge underscores the urgent need for targeted training, emphasising education initiatives to address structural stigma and inform healthcare policies globally.
... Importantly, the clandestine nature of AAS production [18] means that a substantial proportion-over 66%reportedly contain harmful or unidentified substances [19], which exacerbate the risks associated with their use. The risks of using AAS in combination with harmful adulterants [20,21] underscores the urgent need for harm reduction interventions. ...
Article
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Background and Aims The clandestine production and distribution of anabolic-androgenic steroids (AAS) poses health risks due to the uncertainty of their contents. This study aimed to test the chemical content of AAS samples and provide aggregate results back to the community, exploring how these results influenced usage decisions and risk management. Design A mixed-methods approach was used, combining chemical analysis of AAS samples with qualitative interviews. Participants submitted samples for testing, and the results were later shared with them. Semi-structured interviews explored participants' perceptions of AAS risks and the impact of testing results on their behaviour. Setting The study was conducted at CheQpoint drug checking service in Brisbane, Australia. Participants Thirty-two samples were submitted for testing between 19 April and 7 June 2024, with 23 samples analysed. A total of 25 active AAS users participated in interviews. Measurements Chemical analyses identified substances present and assessed active ingredient concentrations. Qualitative interviews gathered participants' perceptions, and these data were analysed through iterative categorisation, guided by the Health Belief Model. Findings Chemical analysis identified that 13% of samples contained substances different from what was expected. Concentrations of active ingredients were close to expected levels [e.g. testosterone propionate at 96.2 mg/mL (range = 91.39–101.01 mg/mL)]. Interviews identified four key theme categories. Participants sought testing primarily for substance verification, expressing concerns about contamination and dosage. Barriers to testing included limited access and fear of disclosure. While testing was seen as a valuable harm reduction tool, gaps in health guidance and follow-up support were identified as areas for improvement. Conclusions Thirteen percent of 23 anabolic-androgenic steroid (AAS) samples analysed contained substances different from what was expected. Interviews with active AAS users highlighted the need for reliable information, accessible testing services and tailored health approaches for AAS use.
... The analysis focused on reviewing codes related to specific topics (e.g., 'psychedelic attitudes' and 'knowledge gaps') to discern emergent analytic themes (e.g., attitudes, knowledge, risk, design). Theme categories were documented through memos, fostering regular discussions within the other members of the research team [23]. ...
Article
Introduction This study explores the attitudes of psychologists towards psychedelics and psychedelic‐assisted therapy (PAT) following the world‐first regulatory changes in 2023 in Australia which permitted psilocybin and 3,4‐methylenedioxy‐methamphetamine (MDMA) to be used in clinical services. Methods A purposive sample of 20 Australian psychologists was recruited using snowball sampling. Semi‐structured interviews were conducted which explored participants' attitudes, knowledge and concerns about PAT. Data were coded and analysed to identify and develop theme categories. Results Most psychologists exhibited positive attitudes towards psychedelics and their therapeutic potential, viewing them as promising for addressing chronic mental health conditions like depression. However, there was a notable concern regarding the limited evidence on efficacy and potential adverse experiences, as well as the complexity of the individualised treatment protocol. Despite enthusiasm, many psychologists had limited detailed knowledge about the interventions themselves. The need for comprehensive education and training programs, including exposure to psychedelic experiences and credible higher education institutions, was emphasised to ensure competence in administering PAT. Discussion and Conclusions Psychologists displayed notably positive attitudes towards PAT, likely reflecting both shifting perceptions of psychedelics and self‐selection bias within the sample. Despite this optimism, concerns were raised about psychiatric risks and the necessity for comprehensive and reputable training and supervision. The cohort showed openness to both novel treatments and innovative training methods, underscoring the importance of enhancing educational frameworks to ensure effective implementation of PAT.
... Additionally, the study's reliance on selfreported data introduces the potential for response bias, as participants may underreport or misreport their trenbolone use and associated psychological symptoms. The accuracy of self-reported AAS compounds and dosages is another concern, particularly given evidence indicating that AAS purchased on the black market are often mislabelled or contain different compounds than stated on the packaging (Coomber et al., 2014;Magnolini et al., 2022;Piatkowski et al., 2023c). This misreporting could affect the study's findings. ...
Article
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Introduction: The link between anabolic-androgenic steroid (AAS) use and psychosocial effects such as aggression and violence is contentious. Few studies differentiate between types of AAS. This study focuses on trenbolone to assess its psychological risks and effects on aggression compared to other AAS. We hypothesised that there would be a positive relationship between trenbolone dosage and both psychological distress and aggression among people who use AAS. Methods: Using purposive and snowball sampling of people using AAS, we conducted an online survey to investigate the relationship between trenbolone use and other AAS use. Participants completed sections on demographics, trenbolone and other illicit drug use, the Kessler Psychological Distress Scale, and the Buss and Perry Aggression Questionnaire. Data were analysed using multinominal and multivariable regression. Results: The study included 282 males using AAS. Over 33% (n=93) reported currently using trenbolone, with 55.3% (n=156) of participants reporting having used trenbolone in the past, and 11.7% (n=33) reporting having never used trenbolone. Those who had never used trenbolone were not significantly different on age, height, weight, and BMI compared to those who had. After controlling for age and BMI, dose of trenbolone was significantly (p=0.045) associated with higher levels of verbal aggression. Conclusion: The study highlights trenbolone’s association with increased verbal aggression among males using AAS, particularly at higher doses. Further research should continue to differentiate between AAS types and the accompanying health harms.
... Such an approach would reduce the tremendous costs and other contextual problems associated with on-going drug monitoring in field-based research (Gibson & Manley, 1991;Harper et al., 2017). With the increase in media attention and policy debate (Piatkowski et al., 2023b;Ritter, 2020) directed toward both off-site and on-site "pill testing" 5 (see Barratt & Mesham, 2022 for a review) surrounding music events (e.g., festivals and nightclubs) both in Australia (Barratt et al., 2018;Olsen et al., 2022) and internationally (Butterfield et al., 2016;Colledge-Frisby et al., 2023;Groves, 2018), another key benefit to analyzing samples on-site and in real time could be that it inadvertently operates as a low-cost public health intervention. Considering the expanding nature of drug checking services in Australia, investigating attitudes toward similar services and consumer preferences regarding off-site versus mobile testing facilities can enrich the on-going policy discourse surrounding harm reduction strategies in Queensland. ...
Article
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Background We sought to determine whether various ion scanner devices could provide a practical alternative in field-based research, where affordable and accessible drug screening is needed for comprehensive and ongoing investigation. Methods In Study 1, off-site sample analysis proved inconclusive, rendering Protocols A and B impractical for ongoing drug screening. Conversely, Study 2’s on-site, real-time analysis (Protocol C) emerged as a more effective method. The Itemizer3, particularly in Protocol C, excelled in discerning drug users. Comparing admitted drug use rates in both studies, the mere presence of an objective measure, confirmational or not, likely facilitated more truthful participant responses, highlighting the efficacy of real-time, on-site drug screening using IMS/ITMS technologies. Findings All samples analyzed off-site in Study 1 were found to be inconclusive. As such, Protocols A and B were not feasible for on-going drug screening and monitoring. Conversely, the results of Study 2 Protocol C demonstrated that harvesting samples directly off participants on-site and analyzing these in-real time to be a more efficacious method. Our findings in Protocol C also show that the Itemizer3 was better at identifying those who did not use drugs from those who did. Looking at the incidence rates of admitted drug use in Studies 1 and 2, we find that simply having an objective measure present (irrespective of whether it is confirmational or not) likely resulted in us obtaining more truthful responses from participants about their use of drugs. Conclusions Our results underscore IMS/ITMS practicality for on-site NED drug screening.
... Future campaigns could utilise participant perspectives to inform collaboratively driven harm reduction strategies both including and beyond informational videos. This type of collaborative work with consumers has demonstrated increased community receptivity for public health initiatives (Piatkowski et al., 2023b(Piatkowski et al., , 2024 and approaches in this licit sector (Harden et al., 2001) may adopt similar frameworks for curbing vaping initiation among non-smokers (Stalgaitis et al., 2023). ...
Article
Objective Vaping, initially a smoking cessation aid, is now a widespread recreational activity sometimes associated with perceived health concerns. This study explored attitudes, harm perceptions and cessation barriers in the context of participants’ vaping behaviours, guided by the theoretical lens of fundamental social causes. Design and Setting The study focused on a subset of 571 current adult vapers from a larger survey investigating vaping attitudes. It analysed open-text survey responses relating to vaping behaviours. To analyse the responses, we employed layered analyses, using deductive conceptual mapping to inform an inductive thematic content analysis. Results Participants mentioned nuanced vaping risks, citing cancer and respiratory concerns, often comparing them to tobacco’s well-known harmful effects. Despite acknowledging vaping’s potential harms, participants perceived the practice to be less harmful than smoking, emphasising relative safety. Some viewed vaping positively for former smokers, contingent on regulated products. This complex attitude balance reflected the intricate interplay between health concerns and social dynamics. Recurrent vaping symbolised consistent engagement, with cravings and widespread availability associated with quitting challenges. Conclusions Participants’ nuanced perceptions of health risks reflect a harm duopoly, resembling illicit drug harm tiering. There is a complex interplay between health knowledge and social influences in the context of vaping behaviours. Study findings underscore the need for messaging interventions discouraging vaping among those who do not smoke tobacco to consider these health and social dynamics, leveraging collaborative design.
... The final point is greater supervision, which is where both the original article and Cox and Piatkowski agree heavily upon. If TEG were to take place, they could benefit from a service that tests IPEDs and anabolic steroids (Piatkowski et al., 2023) to reduce risk and harm to their athletes to remove harmful and counterfeit products (Magnolini et al., 2022). Alongside ensuring a "safer" and possibly verified supply chain of IPEDs to the athletes, Piatkowski et al. (2024b) have also discussed the idea of a testosterone prescription service when referring to discussions about testosterone replacement therapies. ...
Article
I want to thank all the authors for responding to the commentary on the enhanced games (TEG) published in July 2024. All the corresponding replies support the work outlined in the original manuscript (Richardson, 2024a) and have further expanded upon the points raised with exciting discussions. Each of the responses covers the following topics: (a) Cox and Piatkowski – Harm Reduction and Drug Testing, (b) Heffernan – Sociology and Marketing Deception, (c) Henning – Anti-Doping = Harm Reduction and finally, (d) Turnock – Prohibition, Fairness and the Future of Sport. I will explore these positions and provide my own viewpoint to each response followed by a summary of the work with future directions for TEG.
... ' The discussion extends to the illicit enhancement drug market, community testing practices (e.g. Piatkowski et al., 2023), and the role online community forums play in this landscape, offering insights for those seeking to understand how iPeD forums play a role in harm reduction more broadly. ...
... Following this, the first author applied the finalised codes to all interview transcripts. Analysis focused on reviewing codes related to specific topics and peer workforce challenges, identifying the emergent analytic themes which had been documented [26]. ...
Article
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Introduction: Peers in the alcohol and other drug sectors possess lived–living experience (LLE) crucial for shaping community care. However, genuine consumer collaboration is often confounded by stigma. This study examined peers’ perceptions, exploring their experiences regarding workforce dynamics, policy implications, and impacts on health equity. In presenting the research, we sought to synthesise the research methods and illustrate the methodological innovation and knowledge production in substance use research through authentic collaboration. Methods: We purposively sampled peer networks and community organisations, involving peer-researchers in planning, design, and analysis. We conducted semi-structured digital interviews with 18 peers and applied iterative coding to analyse the data. Results: This collaborative process provided nuanced insights into sectoral challenges. Peers expressed emotional strain revisiting personal substance use experiences, blurring personal and professional boundaries. Tokenistic peer involvement critiques underscored the need for genuine leadership and organisational support. Conclusion: We advocate for a shift towards equitable and inclusive policy development through both organisational and systemic restructuring. However, these changes are hamstrung by broader policy frameworks, which require a shift to peer-led principles, ensuring the expertise of peers is genuinely valued. Policymakers should invest in expanding peer frameworks, acknowledging the diversity within communities of people who use drugs to improve health equity and public health outcomes. This innovative approach to substance use research emphasises the transformative impact of integrating LLE into research.
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Martial arts and combat sports (MA&CS) have emerged as a promising avenue for enhancing health and wellbeing amidst growing concerns about noncommunicable diseases and mental health issues. This study explored the lived experiences of practitioners engaged in modern MA&CS, such as mixed martial arts (MMA), to understand how the practice of modern MA&CS impacts individuals biologically, psychologically and socially. Guided by the Biopsychosocial Model of Health and adopting a social constructivism lens, 16 participants aged 28-55 years underwent semi-structured interviews, exploring the physiological, psychological and social dimensions of their engagement in modern MA&CS. Through thematic analysis, three overarching themes were developed. The first theme highlighted the role of rigorous training in fostering resilience, discipline and personal growth. The second theme demonstrated how MA&CS builds self-confidence, reduces aggression and encourages prosocial behaviour. Lastly, the third theme underscored the importance of gym environments in fostering inclusivity, mutual respect and belonging. Modern MA&CS training transcends the gym offering a unique framework that promotes biopsychosocial wellbeing through resilience, confidence and community connection. Modern MA&CS holds potential for educational, therapeutic and community interventions aimed at fostering holistic wellbeing across diverse contexts.
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Background The masculinizing effects from anabolic–androgenic steroid (AAS) appear to be different between men and women, leading to calls for more gender-specific information regarding women and AAS use. This study sought to gather perspectives from both men and women on the unique challenges surrounding women’s use of AAS, irrespective of their personal use. Secondly, the study interrogated how women’s AAS practices differ from those of men specifically. Methods The data presented in this paper come from a subsample of participants who participated in a larger study investigating women and performance and image enhancing drug (PIED) use in Australia. Participants were included in the current analysis if they were: (i) males or females who competed with or coached female strength athletes using AAS and (ii) female and male strength athletes who used AAS. The final sample comprised 21 participants of which there was a proportion of males (n = 7) and females (n = 7) using AAS. Results Women’s choices in AAS selection were predominantly around oral compounds (e.g. Oxandrolone) as well as other PIEDs (e.g. Clenbuterol). Some women report the use of injectable AAS represents a change in the profile of the typical female user as it reportedly comes alongside drastic physical and psychological changes. Conclusions The unique challenges facing women who use AAS are largely isolation and stigma, with little evidence-based practice or education being available to them online or through peer-groups. Future work may consider piloting harm reduction strategies that may be co-designed with this group.
Article
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Introduction: There are a variety of harms associated with anabolic-androgenic steroids (AAS), with some AAS associated with an increased risk profile for users. Despite potentially different risk profiles, these harms are seldom discussed with respect to specific compounds although recent ethnographic research has identified a need to do so. Specifically, myth has developed among users with trenbolone reportedly having more dramatic effects on individuals, with reports of aggression, violent behaviour and extreme mood disturbances, and this is reflected in extant literature. This paper aims to report on the narrative surrounding the use of trenbolone among AAS users. Method: As part of a larger qualitative study, a number of AAS users were interviewed regarding their usage practices. A narrative emerged regarding the physical and psychological harms which accompanied their AAS use of which trenbolone played a central role (N = 16). Results: Of all the AAS, trenbolone was viewed as having the most deleterious consequences for those who used it. Users reported an extreme shift in risk profile for psychosocial harms, particularly increased aggression and violent behaviour, as well as impulsivity regulation issues. AAS-using peers and family members of users reported the readily observable effect of trenbolone. Discussion and conclusions: Users should be cognisant of the potential for significant harms and health-care providers working with this group may consider more focused screening strategies. Future policy decisions regarding AAS may wish to consider the pivotal role trenbolone plays in adverse outcomes for this unique group of substance users.
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This article sets out to investigate the marketing of image and performance enhancing drugs (IPEDs) on the social media platforms Facebook and Instagram. Drawing upon a ‘connective’ ethnographic exploration of IPED use and supply, the paper first outlines a supplier typology on these platforms, before shedding light on the marketing strategies employed by sellers in order to overcome the inherent distrust of online sales and build a trustworthy brand. Techniques identified include athlete sponsorship, the sharing of bodybuilding fitspiration content, self-objectification, posting images showcasing transformation photos and customer feedback, and seasonal sales and promotions. Analysis encompasses the centrality of product branding, the overlaps between licit and illicit market advertising strategies, and the affordances of the platforms under study. Finally, conclusions relating to the implications of these findings to scholarship, policy, and regulation are offered.
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In recent years there has been an increasing focus on the potential public health risks attached to human enhancement drugs (HEDs). While much work has explored the use and supply of HEDs, the market for these compounds is constantly evolving, with new substances being created and sold, and access becoming increasingly simplified through digital platforms. However, one area that has yet to receive scholarly attention is the availability of 'grey market' novel synthetic peptide hormones (SPH) through sellers on the mainstream e-commerce platforms Amazon, eBay, and Alibaba. This commentary piece therefore sets out to uncover this burgeoning corner of the broader HEDs trade in the UK market. Findings indicate that SPH are readily accessible over these e-commerce sites, with sellers evading restrictions by claiming that the substances are 'not for human consumption' or 'for research only', while simultaneously advertising their products as wellbeing supplements. Labelling practices are further identified as a point of concern, since packaging is not necessarily reflective of product quality or true location of origin. Finally, discussion centres on the enhanced legitimacy offered by selling through mainstream sites like Amazon, the capacity for counterfeiting and misrepresentation, and the public health implications of this substantial grey market.
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It is well-established that performance and image enhancing drugs (PIEDs) are effective in increasing muscle mass and strength. PIEDs are unique in that, while harm may result from use, there is little evidence of widespread individual or social harm comparable with other illicit substances. However, given the rapid growth of the online health and fitness industry, the digital consumption of hardcore fitness content represents a space ripe for indirect harms. A poignant example of this trend among the digital health and fitness community is the contestation around 'fake natty' users, who falsely claim to not use PIEDs. The non-disclosure of use has the potential to give individuals who are not enhanced the false impression that they too can achieve a bodily ideal which is similar, potentially resulting in psychological distress and risky behaviours. In this commentary, we discuss this harmful phenomenon using the case study of the fitness influencer Brian Johnson, more commonly known as Liver King. Employing a psycho-criminological lens, we use Social Identity Theories to understand the 'Primal' identity, before unpacking Johnson's disavowal of his PIED consumption through Sykes and Matza's (1957) techniques of neutralization. We conclude with an overview of the harms surrounding fake natural influencers and cognitive dissonance, before attempting to map a path towards emic harm reduction in collaboration with the digital fitness community.
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With rising numbers of drug-related deaths in the UK and globally, exploration of interventions that seek to reduce drug-related harm is essential. Drug checking services (DCS) allow people to submit drug samples for chemical analysis and receive feedback about the sample, as well as harm reduction advice. The use of DCS is often linked to festival and/or nightlife settings and to so-called ‘recreational’ drug use, but research has also shown the potential of community-based DCS as an intervention serving more varied demographics of people who use drugs, including more marginalised individuals and those experiencing drug dependence. Whilst there is a growing evidence base on the effectiveness of drug checking as a harm reduction intervention, there is still limited evidence of the underlying mechanisms and processes within DCS which may aid implementation and subsequent engagement of people who use drugs. This presents a challenge to understanding why engagement differs across types of DCS, and how best to develop and deliver services across different contexts and for different populations. To explore the contexts and mechanisms which impact engagement in community-based DCS, a realist review was undertaken to synthesise the international evidence for the delivery and implementation of DCS. There were 133 sources included in the review. From these sources the underlying contexts, mechanisms, and outcomes relating to DCS implementation and engagement were developed and refined into seven programme theories. The findings of this review are theoretically novel and hold practical relevance for the design of DCS, with implications for optimisation, tailoring, and implementing services to reach individuals in different settings.
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Background: Harm reduction and treatment programmes are essential for reducing harms for people who inject drugs (PWID). We aimed to update estimates from a 2017 review of global coverage of needle and syringe exchange programmes (NSPs), opioid agonist treatment (OAT), and other harm reduction services that target PWID (eg, take-home naloxone [THN] programmes, supervised consumption facilities, and drug checking services). Methods: We did a systematic review of available evidence from peer-reviewed and grey literature databases for studies published between Jan 1, 2017, and May 31, 2022. Programmatic data were collected on the availability of services, the number of sites, people accessing services, and equipment distributed in countries where there is evidence of injecting drug use. National estimates of coverage of OAT (ie, number of people accessing OAT per 100 PWID) and NSPs (ie, number of needles and syringes distributed per PWID per year) were generated where available using the most recent data. Regional and global estimates were derived and compared with WHO indicators. The study was registered with PROSPERO (CRD42020173974). Findings: We included 195 studies and found there were 90 countries implementing OAT (75% of the PWID population) and 94 countries implementing NSPs (88% of the global PWID population). Only five countries (2% of the global PWID population) are providing high coverage of both services. Far fewer countries were implementing THN programmes (n=43), supervised consumption facilities (n=17), and drug checking services (n=26), with nine countries implementing all five services. Globally, we estimated there were 18 (95% uncertainty interval [UI] 12-27) people accessing OAT per 100 PWID, and 35 (95% UI 24-52) needles and syringes being distributed per person who injects drugs per year. More countries reported high (OAT 24; NSPs 10), moderate (OAT 8; NSPs 15), and low (OAT 38; NSPs 47) coverage of services compared with the previous review. Interpretation: Global coverage of OAT and NSPs has increased modestly in the past 5 years but remains low for most countries. Programmatic data on other key harm reduction interventions are scarce. Funding: Australian National Health and Medical Research Council.
Article
Background: Research with men who use anabolic-androgenic steroids (AAS) shows typologies exist where some younger and less risk-averse users engage in polysubstance use. Little research has investigated polysubstance use among women who use AAS. Method: This study explored patterns of AAS and other illicit substance use among a sample of female AAS users involved in strength sports (e.g., bodybuilding) from Australia (n=7). The research also engaged in interviews with male AAS users who came into frequent contact with women using AAS either by coaching them or as peers (n=7). Data were analysed within a constructivist framework using thematic analysis. Results: The data suggests belonging to a female strength athlete identity may have pseudo-protective elements which results in reducing licit substance use, however, illicit substance use does not run counter to the culture and may be supported by it. Discussion: Women who use AAS identified underlying factors, related to significant previous events in their lives, contributing to their polysubstance use. The male participants expressed similar views regarding underlying factors which contributed to women's use of other substances for recreational purposes. Further investigations are warranted to explore, more fully, the psychosocial factors which contribute to use of multiple illicit substances among women who use AAS and whether typologies exist.