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Harm Reduction 20082008:: IHRA’s 19th International Conference TdAGlblAhTowards A Global Approach

Anabolic and associated drugs: Public health implications and harm reduction Jim McVeigh Reader in Substance Use Epidemiology Liverppyool John Moores University Presentation outline

PlPrevalence o fblitidf anabolic use Reasons for use Adverse effects How and what drugs are used BBiarriers to serv iceengagemen t Models of intervention The extent of use in the general population The extent of anabolic steroid use in the general population

United States studies show 4%to% to 6% (range of 3%to% to 12%) of high school males using anabolic steroids at some time in their life. Estimates as high as 3 million Americans ((19961996)) more than 8383,,000000 young people had used ((19971997)) lifetime prevalence amongst high school males 33..22%% andfd femal es 1.2% Poland ((20062006)) Internet survey 66..22%% among males and 22..99%% among females Denmark ((19981998)) Estimates vary from 1010,,000000 to 5050,,000000++ anabolic steroid users ((20062006//0707)) anabolic steroid lifetime prevalence of 197197,,000000 ((165165,,000000 – 234234,,000000)) 3000

2500

2000 New AS injecting clients New other injecting clients lients

CC AS injecting clients 1500 Other injecting clients umber of NN 1000

500

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year of Presentation/Attendance ‘All’ & ‘new’ clients attending agency based SEPs in Cheshire & Merseyside (1991 to 2005) Pressures on males to initiate anabolic stidteroid use

External – social & Internal cultural Negative body image Media pressure SelfSelf--esteemesteem Sporting influences Pubertal timing EiidtiEconomic considerations Body Dysmorphia Disorder Parental influence (BDD) Peer pressure

“…achieving your full potential is the ultimate battle of mind over body…” “th“...the purest tf form of sport …no ext ernal lifl influences or arbitrary rules, the results are purely down to myself”

“The40 Publicyears ofHealth Action Response” Man

Reasons for use & effects experienced

Reasons for use: Effects experienced: Improve Faster training recovery 88.9% Increase muscle Increased muscle mass 87.6% Improve performance Increased strength 83.9% Train longer Improved performance 78.7% Prevent injury Faster recovery after injury 70. 9% Increase strength Decreased body fat 56.1% SdSpeed up recovery More self confident 52.3% Adverse effects

Use of steroids in high doses has been associated with a diverse number of negative effects on physical and mental health These include: cosmetic effects, reproductive dysfunction, disease, cardiovascular disease, anxiety, aggression, depression and dependence Limitations of evidence

SelfSelf--reportsreports and case reports (many with incomplete clinical history) Naturalistic/crossNaturalistic/cross--sectional/casesectional/case--control/prospectivecontrol/prospective researchtdih studies Limited number of RCTs using “moderate” doses of a single steroid (Do the studies reflect “real“real--life”life” steroid use?) Extrapolating from clinical populations Animal models (can demonstrate that effects are compoundcompound--specific,specific, but can we translate data to humans?) Biological plausibility The easy ones …

Female ••MenstrualMenstrual• irregularities• Male pattern baldness (paradoxically, ••ClitoralClitoralincreased enlargement growth of ) ••SmallerSmaller breasts • Gynaecomastia (also associated with, ••ReReproductiveHCG and ) dysfunction ••DeeDeeppgeninInfectiong of viavoice ••Body/facialBody/facial• Decreased hair production of sperm and shrinking of the testicles • Virilisation in women Common anabolic steroids Most commonly used drugs in conjunction with anabolic steroids Drug % used Drug % used last year last year HCG 22.4 Cocaine 11.8 Growth Hormone 21.2 Ecstasy 3.5 17.6 2.4 Clenbuterol 11.8 Amphetamine 1.2 Ephedrine 949.4 Diuretics 7.1 Insulin 595.9

GHB 3.5 Sample of 85 anabolic steroid users Nalbuphine 121.2 attending Merseyside syringe exchanges IGFIGF--111.21.2 Case study 36 yygear old male using for over 11 years Injected 50 times in the previous year Had informed his GP but not received any drug related services or information Information accessed from trainer,,g internet and magazines In the previous year he had used: decanoate Sustanon 250 Growth hormone Clenbuterol cypionate HCG TttTestosterone propi onat e Tamoxifen undecanoate Ephedrine MthdMethandros teno lone Diuretics Cocaine Why is it difficult to provide harm reduction to anablibolic s tero id users? MISINFORMATION MISTRUST MYTHOLOGY PROPHYLACTIC LIES “There is no conclusive scientific evidence that extremely large doses of an aboli c-an dr ogeni c ster oi ds either aid or hinder athletic performance”

ACSM, 1976

Statement still in effect in the mid 1980s “Although there is still little available evidence regggarding the long term health effects of anabolic steroids, many current or potential anabolic steroid users unfortunately mistake absence of evidence for evidence o f a bsence ”

YliYesalis, 2000 MISINFORMATION, MYTHOLOGY& PROPHYLACTIC LIES …not restricted to the anabolic steroid using communities

Many healthcare professionals base their views regarding the long term health effects of anabolic steroids on a limited number of individual case reports. “Untoward health events in individuals using performance & image enhancing drugs do not necessarily prove causality by those drugs” What can we do?

Sy ringe ex change Nurse led services Medical led service Outreach Specialist targeting Harm reduction messages Look at motivation for use Existing health status Dosage – smallest – do not adoppgt other users regimes Stacking – minimal benefit Cycles – limit the on cycle – ensure off cycle Drugs to combat side effects – if you need them - too high dosage of steroids Injecting Vs Oral Dangers of recreational drug use Injecting techniques Training, Nutrition & Sleep Counterfeit & fakes – check – if in doubt don’t use Warn of sid e e ffect s i ncl udi ng po ten tial f or i rrit abilit y & aggression Contact details Jim M c Ve ig h Reader in Substance Use Epidemiology Centre for Public Health Liverpool John Moores University Castle House, North Street Liverpp,ool, LL33 22AYAY Tel: 0151 231 4512 email: j. mcveigh@ljmu. ac.uk www.cph.org.uk