Scand J Med Sci Sports 2011 & 2011 John Wiley & Sons A/S doi: 10.1111/j.1600-0838.2010.01263.x Selling androgenic anabolic steroids by the pound: identification and analysis of popular websites on the Internet F. G. Cordaro, S. Lombardo, M. Cosentino Department of Clinical Medicine, Section of Experimental and Clinical Pharmacology, University of Insubria, Varese, Italy Corresponding author: Marco Cosentino, MD PhD, Department of Clinical Medicine, Section of Experimental and Clinical Pharmacology, University of Insubria, Via Ottorino Rossi n. 9, 21100 Varese VA, Italy. Tel: 139 0332 217410/397410, Fax: 139 0332 217409/397409, E-mail [email protected] Accepted for publication 18 October 2010 Internet websites offering androgenic anabolic steroids medicines (69.6%) or as dietary supplements (30.4%). (AAS) were identified and available products were exam- AAS in medicines were mainly: nandronole (20.4%), ined. Keywords for the website search were: ‘‘anabolic methandrostenolone (18.4%), and testosterone (12.2%). steroids,’’ ‘‘anabolic steroids buy,’’ ‘‘anabolic steroid pur- Dietary supplements contained mainly DHEA and included chase.’’ The first 10 websites offering AAS in the first 10 several fake compounds. Manufacturers were declared for pages of results were considered. At least two AAS-contain- 97.9% of medicines and 66.7% of dietary supplements; ing products per website were selected. Thirty AAS-selling however, several manufacturers were not found on the websites were identified, mainly located in the United States Internet. Described benefits were usually few adverse effects (46.7%) and Europe (30%). Most websites sold other and no estrogenicity. Toxicity was seldom reported and anabolic/ergogenic products (clenbuterol, 76.7%; GH/ presented as mild. Recommended doses were two–fourfold IGF, 60.0%; thyroid hormones, 46.7%; erythropoietin, higher than current medical recommendations. In conclu- 30.0%; insulin, 20.0%) or products for AAS-related ad- sion, misleading information and deceiving practices were verse effects (mainly: estrogen antagonists, 63.3%; products common findings on AAS-selling websites, indicating their for erectile dysfunction, 56.7%; 5a-reductase inhibitors, deleterious potential for public health. 33.3%; anti-acne products, 33.3%). AAS were sold as Androgenic anabolic steroids (AAS) were identified duced adverse effects target several organs and tis- in the early 1930s; however, the use of extracts from sues, including the cardiovascular system, the liver, rodent or dog testes endowed with ‘‘puissance dyna- the reproductive system, the bones, breast and hair, moge´nique,’’ according to Brown-Se´quard’s defini- skin and vocal cords, and even the central nervous tion, was already popular at the end of 18th century, system. In particular, the central effects of AAS in the context of ‘‘organotherapy’’ (Sneader, 2005). include: increased libido in men and women, which AAS mimic the effects of the male gonadal steroids may be difficult to control, hypomania, heightened testosterone and dihydrotestosterone, resulting in irritability, increased aggression and hostility, de- increased muscle growth and strength. As a conse- structive and self-destructive impulses (Kicman, quence, athletes have been using and abusing AAS 2008). Recently, AAS dependence has been proposed for decades, a fraudulent practice banned since 1975 as a valid diagnostic entity, and probably a growing by the International Olympic Committee and subse- public health problem (Brower, 2009; Kanayama et quently by all major athletic organizations and al., 2009). Indeed, awareness of the risks associated sporting bodies (Verroken & Mottram, 2005). with AAS abuse led several countries to introduce Several therapeutic drugs containing AAS are controls on their use and prescription: in the United available for the treatment of cachexia associated Kingdom, AAS are controlled by the Misuse of with chronic disease as well as for loss of muscle mass Drugs Act (Royal Pharmaceutical Society of Great in the elderly; however, their effects on physical Britain, 2010), in Canada they are included in the function and quality of life are still debated (Kicman, Controlled Drugs and Substances Act (Minister of 2008). On the other side, in sport AAS are well- Justice of Canada, 2010), while the Congress of the known performance enhancers, and their use occurs United States passed the Anabolic Steroid Control at supratherapeutic doses, often taking illicit pre- Act in 1990 (updated in 2004) and AAS were soon parations from the black market, thus leading to an classified as Schedule III substances under the Con- increased risk of serious adverse effects. AAS-in- trolled Substances Act (U.S. Department of Justice, 1 Cordaro et al. 2005). In Italy, as in many other countries, it is illegal (Parkinson & Evans, 2006). Circumstantial evidence to obtain or sell them without a prescription, and indeed suggests that Internet is possibly the primary recently nandrolone has been included in the list of means for buying and selling illicit AAS (Govern- controlled substances in view of its addictive poten- ment Accountability Office, 2005) and a primary tial (Minister of Health of Italy, 2010). source of non-medical AAS information (Perry A major reason for concern is that most AAS users et al., 2005). are not competitive athletes at all, but simply indivi- The present study was therefore devised to identify duals troubled with their ‘‘body image’’ (Buckley et a representative sample of websites offering AAS on al., 1988; Kanayama et al., 2001). Such kind of the Internet and to evaluate their characteristics with ‘‘ordinary’’ AAS users rarely seek treatment and particular regard to the types of products available often distrust and escape physicians, while com- and the kind of information provided. A sample of monly abusing of two or more AAS and often taking products was also selected and the related claims huge doses for prolonged periods (reviewed by Ka- were carefully scrutinized. nayama et al., 2008). The medical and psychiatric consequences of AAS abuse however usually occur after long-term use at supraphysiologic doses, there- Methods fore, because widespread use of AAS began to Internet search emerge only in about 1980, it is likely that the social The search was conducted by one of us (F. G. C.), who acted consequences will become increasingly evident in the as a consumer and attempted to purchase AAS on the next few years, when hundreds of thousands of AAS Internet. The search was performed by use of a personal users begin to pass the age of 45 (Kanayama et al., computer connected to Internet via ADSL, from August 9 to September 29, 2009, using Mozilla Firefox ver. 3.0.15 as 2008). Prevention of AAS misuse is therefore of key Internet browser. Google was selected as the search engine importance and should include, besides random because it accounts for about 65% of Internet searches in the doping analyses, longer disqualifications of AAS- world (Search Engine Watch Staff, 2009) and for up to 88% in using athletes, and tougher legislation against posses- Italy (Bonfils, 2010). The keywords used were ‘‘anabolic sion of AAS, also medical and pedagogic interven- steroids,’’ ‘‘anabolic steroids buy,’’ ‘‘anabolic steroid pur- chase,’’ and the search was performed in English and in tions, particularly targeted to adolescents and other Italian. more vulnerable subjects (Sjo¨qvist et al., 2008; Grey- danus & Patel, 2010). To this end, however, physi- cians and educators must be aware of the attitudes Websites and beliefs of AAS users, which preferentially derive For each combination of keywords, we identified the first 10 from consultation of friends, of people who sold websites that offered AAS (or products presented as such) in them AAS, or even in particular in recent times, the first 10 pages of results. We then recorded for each website specialized Internet sites (Pope et al., 2004). the universal resource locator and the position in the list of Indeed, despite the increasing regulation, available Google results. Additional information about the websites (IP locations and addresses, names of domains, registration/crea- evidence indicates that the world traffic of doping tion/expiration/last update date of domains, registrants/ad- substances and in particular of AAS is sharply ministrators of websites) was subsequently obtained by the use increasing, in particular through the Internet (Do- of WhoIs Source (whois.domaintools.com). Website analysis nati, 2007). Among the various pathways sought by included: website language(s), sold products, drug prescription drug traffic, the Internet is probably the main world- requirements, need for creation of a personal account and subsequent login, indication of a minimum/maximum amount wide channel for easy access to drugs and other of products that could be bought, payment options, and substances. According to a report focused on pain shipment methods. Finally, an image of the website homepage relievers, anxyiolitics, and stimulants, 85% of web- was obtained and the date and hour of the last access to the sites selling controlled drugs did not require buyers website were registered. to have a prescription (The National Center on Addiction and Substance Abuse at Columbia Uni- versity, 2008). Although recently it has been sug- Medicines and other products gested that the Internet is still a relatively minor At least two AAS-containing products were identified for each source for illicit purchases of prescription medica- website. Selection was made