What anabolic-androgenic steroids reveal about the limits of current harm reduction models.

Anabolic androgenic steroids (AAS) and associated drug use is now recognised as a significant concern and an emerging public health issue. Once restricted to the elite sporting arena, recent decades have seen AAS diffuse through bodybuilding and gym culture to an increasingly image conscious general population. This portfolio of research contributes to our understanding of this phenomenon in relation to our understanding of the extent and characteristics of AAS use, emerging harms and the policy response to the issue, as summarised below. While specific prevalence is unknown, data from needle and syringe programmes (NSPs) indicate growing numbers of people who inject AAS and associated drugs. Often portrayed in the media as a homogenous group of young male, working class men, a growing body of research indicates a much more diverse population in relation to demographic characteristics and motivations for use. Further research indicates that this is by no means confined to the United Kingdom (UK) but is a global public health issue although barely recognised in some countries such as the Republic of Ireland. Changes in the specific drugs of use and the regimes employed have been identified, with a growing pharmacopeia of easily accessible and affordable peptide hormones being used as a direct result of the rise of the Internet, coupled with developments in manufacturing and transportation. Opinion, anecdote and targeted marketing on the Internet fill the void of a lack of empirical evidence in the field of AAS, image and performance enhancing drugs (IPEDs) influencing a trend towards higher dosages, multiple drugs and prolonged use. Drug use is not confined to IPEDs, with psychoactive drug use identified in populations in UK and Internationally. Our understanding of the chronic health harms associated with AAS has increased over the last 25 years, in particular cardiovascular damage, psychological harms and the potential for dependence. However, this research has made a significant contribution to the recognition and understanding of the harms associated with the administration of these drugs through injection and the impact of adulterated products as a result of the illicit market. The extent of localised infection and soft tissue injury is a cause for concern, an issue previously neglected. Of further concern is the prevalence of blood borne virus (BBV) infection within the population of AAS users. In the first studies of their kind, HIV amongst AAS injectors has been shown to be at a similar level as that in psychoactive drug injectors in the UK. Hepatitis B and hepatitis C levels were identified as being higher than in the general population, and of key concern is the low levels of awareness of hepatitis C positive status amongst AAS injectors. The UK has operated a comprehensive NSP system since the 1980s, which has seen increasing numbers of AAS injectors however, there remains barriers to engagement with this population of people who inject drugs. Data from interviews and surveys submitted here identify a level of mistrust and lack of confidence among AAS users when it comes to engaging with health professionals. The following thesis, submitted in partial fulfilment of the requirements of Liverpool John Moores University for the degree of Doctor of Philosophy spans over twenty years of academic work within the specific field of AAS use. The research provides the groundwork for the development of meaningful and successful policies and interventions to reduce harm and promote health based on the need of this population. The submission includes a brief critical reflection on the undertaken research and the engagement with the research population, drawing on my experiences, positionality and evolution of knowledge and understanding. This further informs the concluding remarks and suggestions for future research.

Concurrent use of anabolic-androgenic steroids (AAS) and psychoactive substances (illicit drugs and alcohol) is found common in studies among men and involves a higher risk of adverse events than AAS use alone. However, women who use AAS represent an understudied group, and little is known about their pattern of psychoactive substance use and possible links to AAS use. The aim of this mixed methods paper is to a) examine lifetime and problem use of psychoactive substances and AAS, and b) explore experiences of AAS and psychoactive substance use including understandings of how these substances may be related among women with current or previous AAS use.Among sixteen women with current or previous AAS use, lifetime psychoactive substance and AAS use, AAS dependence and problem drug and alcohol use were assessed. In-depth semi-structured interviews were conducted, audio-recorded, transcribed verbatim and analyzed thematically within a biopsychosocial framework applying pharmacological agency; the concept of bodily surveillance of effect and the ability to handle substances instrumentally to feel oneselves/ones bodies better.Twelve participants reported lifetime substance use, where cannabis, cocaine and amphetamines were most commonly used. Substance use problems were found among eight participants; five had lifetime AAS-dependence and clinically significant drug and/or alcohol dependence scores, two had lifetime AAS dependence, and one had clinically significant drug dependence scores. Psychoactive substance use was experienced as unrelated to AAS use or it could be used to counteract side effects of AAS. On the contrary, AAS was used to cope with the bodily and emotional change following withdrawal from psychoactive substances and to counteract bodily effects of long-term substance use. Being in substance use disorder (SUD) treatment after detoxification with affected mental health, a passive lifestyle and experiencing a transition from having an emaciated body, gaining weight and becoming unfit, was experienced to motivate AAS initiation during treatment.The polysubstance nature of AAS use including use of psychoactive substances and risk of developing SUDs poses a significant health risk. Health professionals need to understand motivations for combined use of AAS and psychoactive substances among women to be able to prevent harms and address individual treatment needs.

BackgroundThe use of anabolic androgenic steroids (AAS) and associated image and performance enhancing drugs (IPEDs) is now a global phenomenon. There is a need to develop evidence to support the development of interventions to prevent the commencement of use, to minimise the potential harms or to support those in their cessation of use. While the United Kingdom (UK) is no exception to this issue, its public health and legislative response to the phenomenon differs to other countries and requires the examination of research specific to the UK. Therefore, a scoping review has been conducted to examine the recent relevant literature to help inform the development and evaluation of effective interventions to reduce the harmful use of IPEDs.MethodsA comprehensive search strategy was developed for multiple bibliographic databases, supported by and iterative citation searching process and complimented by expert input from the Anabolic Steroid UK Network. Research conducted by or UK academics or within the UK were eligible, if published in the previous five years.ResultsIn total 87 eligible outputs were identified, including 26 review articles, 25 qualitative papers and 24 quantitative papers. together with small numbers of clinical studies/case reports (6) and commentaries/correspondence (6). The most common topics of research were public health, treatment and harm reduction (41), followed by studies focusing on epidemiology, sub-groups of people using IPEDs and motivations for use (34). The studies illustrated the diverse populations of people who use a range of enhancement drugs including concomitant psychoactive drug use. A number of papers focused on blood borne viruses and associated issues, while others reported on the uptake of needle and syringe programmes. No effectiveness evaluations related to any aspect of treatment, harm reduction or other intervention were published during study period.ConclusionThere is a need for the development of effectiveness evaluations of current interventions and any future service provision for people using image and performance enhancing drugs. While there have been no studies of this nature to date, this review illustrates the rich data that has been gathered through diverse methodologies, that will assist in the development of future effectiveness evaluations.

Understanding of the choices and motivations of people who use anabolic androgenic steroids (AAS) for muscular enhancement has increased greatly in the past thirty years, along with understanding of a wide range of health harms associated with this form of drug use in the community. During this period the predominant public health intervention for this population in the UK has consistently remained the provision of injecting equipment to prevent blood borne virus (BBV) transmission. The study explored the health professionals’ and other stakeholders’ perceptions on: whether the current UK public health response is sufficient to address the needs of people who use AAS, and if not, what other needs they might have. This included an exploration of whether there were gaps in harm reduction strategies or other behavioral outcomes and interventions that were needed. Interviews with 27 stakeholders who provide support to people who use AAS in a variety of roles established consensus on the need for a range of interventions to reduce harm and risk in those that choose to use AAS, to prevent initiation, to motivate and support cessation, and to prevent relapse. Study findings indicate that while providing sterile injecting equipment remains essential, it should be considered a bare minimum. The challenge is to develop and deliver a range of harm reduction interventions that look beyond BBV prevention to provide appropriate support to who choose to use AAS at all points in their cycles of use and ultimately for those choosing the temporary or permanent cessation of use.

To the Editor. In their article “Anabolic Steroid Use by Male and Female Middle School Students,” Faigenbaum et al1 indicate that 2.7% of middle school students (grades 5 through 7) report anabolic steroid use. Anabolic-androgenic steroids (AS) can be administered orally or intramuscularly; the latter is the route of administration for 50% of AS users.2 It has been indicated previously that 25% of students who report AS use share needles for injection.3 Therefore, this young and relatively uneducated AS user group is potentially at risk for infections related to injection. We conducted a MEDLINE (1966–1998) and AIDSLINE (1980–1998) world literature review to examine references that attributed infections to AS injection.We found infections attributable to the multi-person use of needles and syringes and improper injection techniques in 11 individuals. None of these cases were among children or younger adolescents. The mean age of these individuals was 25 years (mean, 18–37 years). Three separate cases of human immunodeficiency virus (HIV) infection occurred in male, heterosexual bodybuilders who shared needles that were used for AS injection on multiple occasions.4–6 One of the individuals who was diagnosed with HIV infection also acquired hepatitis B through shared AS needles.4 Two cases of thigh abscesses were discovered in male and female professional weight lifters who injected a veterinary preparation of stanozolol contaminated with Mycobacterium smegmatis.7 Two case reports of staphylococcal gluteal abscesses developed in young bodybuilders 18 and 21 years of age.8 The steroids were injected by other weight lifters who were not trained in sterile injection technique. A staphylococcal abscess occurred in a 24-year-old bodybuilder who reported, for financial reasons, reusing needles on multiple occasions.9 Pectoral and deltoid abscesses were reported in a 20-year-old AS injector who had injected his AS preparation and then returned the needle to the vial to inject into another muscle group.10 The patient was thought to have contaminated his multi-dosage vial with skin flora and subsequently spread the infection.10 A counterfeit AS preparation contaminated with Pseudomonas spp was responsible for a deep gluteal abscess in one AS injector.11 Immune suppression secondary to long-term AS use may have contributed to Candida albicans endophthalmitis in a 24-year-old athlete who reported a 2-year history of injecting AS.12Serious infections attributable to AS injection have been reported in young adult professional and recreational athletes. Many of these young adult athletes appeared to have limited education about sterile injection technique and limited access to sterile needles and syringes. It is doubtful that adolescent middle school students have better education or easier access to needles and syringes. Although a harm reduction model may be appropriate for older athletes with a longer history of use, it is of paramount importance to encourage adolescents to abstain from AS use and injection. Intervention strategies to lower the intent to use AS among adolescents should include education regarding the potential infectious complications related to injection. Further studies that examine the prevalence and incidence of blood-borne pathogens and behavioral studies of the injection practices among AS users are needed.This work was supported in part by the National Institutes of Health, National Institute on Drug Abuse K20 Grant DA00268 to Dr Josiah D. Rich.

In 1991, Robert Voy, MD, former Chief Medical Officer of the United States Olympic Committee, commented: If we will have reached a point of no return with this win at all costs attitude, the gold medals won't shine as brightly, the flags won't wave as boldly, the torch will flicker dimly, and we will have lost one of the greatest treasures ever known.1 It appears that Dr. Voy's predictions have already come to pass. In 1998 and 1999 alone, the public was bombarded with a constant stream of drug scandals that included, among others: • Chinese swimmers being ejected from the World Championships in Australia after having tested positive for banned substances; • former East German coaches and physicians tried and fined for their roles in the systematic doping of East German athletes over three decades; • a Canadian snowboarder, Ross Rebagliati, testing positive for marijuana after having won a gold medal at the Winter Olympics in Nagano, Japan; • Olympic gold medalist swimmer Michelle Smith deBruin being accused and found guilty of manipulating her urine sample in an out-of-competition drug test; • cyclists, coaches, physicians, and trainers participating in the Tour de France implicated in a widespread, systematic doping scheme; • Olympic champion shot putter Randy Barnes testing positive for androstenedione; • baseball home run king Mark McGwire admitting using androstenedione; • Olympic sprint champion Florence Griffith-Joyner dying at age 38, and rumors of prior performance-enhancing drug use that surrounded her victories at the Seoul Olympic Games being resurrected; • Uta Pippig, three-time winner of the Boston Marathon, testing positive for a high level of testosterone; and • Australian Open tennis champion Petr Korda testing positive for an anabolic steroid. When discussing the problem of performance-enhancing drug use, it is important to remember that sport is a microcosm of our society, and that the problems surrounding sport are by no means limited to drug use. During the 1980s, 57 of 106 universities in National Collegiate Athletic Association (NCAA) Division I-A were punished by the NCAA via sanctions, censure, or probation for rule violations. 2 These offenses did not involve illicit drug use by athletes, but rather unethical behavior of coaches, athletic administrators, staff, and faculty, the very men and women who should be setting the example for those athletes. More recently, United States collegiate athletes have been convicted of criminal offenses related to sports gambling. In addition, an NCAA survey of 2,000 Division I male football and basketball players found that 72% had gambled in some form and that 25% reported gambling on collegiate sports; 4% had even bet on games in which they played. 3 Among members of the International Olympic Committee (IOC), bribery, graft, and other corruption appear to be entrenched in the culture of the organization (Swift E, “Breaking point,”Sports Illustrated, February 1, 1999, pp. 34–35). 4 A common factor among all of these scandals is money. In the 1990s, there is no doubt that sport has become a multinational industry of huge proportions. The IOC, NCAA, National Football League (NFL), National Basketball Association (NBA), and Major League Baseball (MLB), among others, are all billion-dollar businesses (“A survey of sport: not just a game,”Economist, June 6, 1998, pp. 2–23; Hiestand M, “The B word—billion—no longer out of bounds,”USA Today, January 12, 1999, pp. 1A–2A). A free society often relies on the news media to inform the populace regarding the incidence and magnitude of problems, such as doping in sport. Even though the epidemic of drug use in sport has been common knowledge among insiders, the news media, especially in the United States, does not appear to have engaged in a widespread, concerted effort to chronicle this issue. Unfortunately, the media, particularly television news programs, are often influenced by conflicts of interest within their parent companies between those reporting the news and those responsible for the broadcast of major sporting events. Few would argue that an in-depth exposé of drug use, for example in the NFL or the Olympics, would enhance the marketing of these highly lucrative sporting events. Before any effort can be made to address the issue of doping in sport, it is critical that all of the stakeholders acknowledge that a problem exists. In this regard, we need to fully appreciate the high entertainment value placed on sport by society. Some go so far as to argue that sport is the “opiate of the masses,” a contention made by Karl Marx regarding religion. If sport has become the opiate of the masses, then we must be prepared for indifference on the part of the public regarding drug use in sport, at least at the elite level. Moreover, it could be argued that if substantial inroads are made regarding the epidemic of doping, fans may express anger rather than appreciation toward those fighting drug use. Many people view competitive sport as an escape from the problems of daily life, and do not wish to be confronted with the moral and ethical aspects of doping. Further, if antidoping efforts are successful, once bigger-than-life idols could begin to appear all too human in stature, and breaking of records at national, Olympic, and world levels could become so rare that the fervor of fans will wane and the sport business will suffer. In the United States, even high school sport appears to be expanding as a source of entertainment for adults, as shown by the increasing level of television coverage of high school football and basketball games. Consequently, it can be argued that the growth of the high school sport entertainment business is contributing to the increase in anabolic steroid use among adolescents that has been observed during the 1990s. Sport has also been used by governments as a tool to control the masses or as justification for their social, political, and economic systems. “Bread and circuses” (panem et circenses) were used in this fashion by the emperors of Rome. 5 Nazi Germany, the Soviet Union, East Germany, and Communist China all have used sport for political advantage. 6 Consequently, such governments arguably would be less than enthusiastic participants in the fight against doping, or for that matter, even publicly acknowledging the existence of widespread doping. On the contrary, there is a reasonable amount of evidence that the governments of the Soviet Union, East Germany, and Communist China all played significant roles in the systematic doping of their athletes. With many societal problems, identifying potential solutions is easy, but agreeing on a proper course of action and successfully completing it are difficult. The following are our alternative suggestions for dealing with the use of anabolic steroids and other performance-enhancing drugs: legalization, interdiction, education, and alteration of societal values and attitudes related to physical appearance and winning in sport. Legalization: An End to Hypocrisy? The legalization of illicit drugs has for some time been the subject of heated debate: comments range from “morally reprehensible” to “accepting reality.” Legalization would reduce the law enforcement costs associated with illicit anabolic steroid use and the substantial cost of drug testing. Even some opponents of legalization must concede that such an action would lessen the level of hypocrisy in sport. It can be argued that society and sport federations have turned a blind eye or have subtly encouraged drug use in sport as long as the athletes have not been caught or spoken publicly about their use of anabolic steroids. 1,7,8 In the United States, legalization of anabolic steroid use in sport would involve two levels of authority. At one level, federal and state laws related to the possession, distribution, and prescription of anabolic steroids would have to be changed. If in the future anabolic steroids become an accepted means of contraception or as treatment for “andropause,” it is difficult to understand how anabolic steroids could remain a Schedule III controlled substance in the United States. At the second level, bans on anabolic steroids now in place in virtually every sport would have to be rescinded. Legalization would bring cries that the traditional ideals of sport and competition were being further eroded. However, given the continued litany of drug and other sport scandals that have taken place in full public view, in this jaundiced age it is hard to imagine that many people believe the so-called traditional ideals even exist in elite sports. It has long been asserted that legalization of anabolic steroids would force athletes to further expose themselves to the potential for physical harm or to compete at a disadvantage. Some have even questioned the basic premise that banning drugs in sport benefits the health of athletes and have argued that “the ban has in fact increased health risks by denying users access to medical advice and caused users to turn to high-risk black market sources.” 9 Legalization would allow athletes to use pharmaceutical-grade steroids while being monitored by a physician. It can also be argued that the dangers of steroid use are not, in itself, a realistic deterrent, given the existing levels of use of tobacco, alcohol, and other illicit drugs that pose similar risks. In 1999, it seems that legalization of anabolic steroid use in sport is not acceptable. However, if the impotence of drug testing, which is now in full public view, persists for much longer, it is easy to imagine the IOC or other sport federations throwing up their hands in frustration and allowing the athlete with the best chemist to prevail. Interdiction: A Question of Cost-Effectiveness The United States federal government and all state governments currently have laws regarding distribution, possession, or prescription of anabolic steroids. 10 The Federal Food, Drug, and Cosmetic Act (FFDCA) was amended as part of the Anti-Drug Abuse Act of 1988, such that distribution of steroids or possession of steroids with intent to distribute without a valid prescription became a felony. This legislation not only increased the penalties for illicit distribution of steroids but also facilitated prosecution of these crimes under the FFDCA. In 1990, the Anabolic Steroids Control Act was signed into law by President Bush and added anabolic steroids to Schedule III of the Controlled Substances Act. This law institutes a regulatory and criminal enforcement system whereby the United States Drug Enforcement Administration (DEA) controls the manufacture, importation, exportation, distribution, and dispensing of anabolic steroids. However, the act did not provide extra resources to the DEA for shouldering the added responsibility. As the use of anabolic steroids is increasingly criminalized, drug use will likely be driven further underground, and the source of the drugs will increasingly be clandestine laboratories, the products of which are of questionable quality. It also appears that in some areas criminalization has already altered the distribution network for anabolic steroids; athletes used to sell to other athletes, but sellers of street drugs are now becoming a major source of anabolic steroids. 11 Even though the legal apparatus to control steroid trafficking exists, enforcement agents already are struggling to handle the problems of importation, distribution, sales, and use of other illicit drugs such as cocaine and heroin. 11 Based on what we know about the physical, psychological, and social effects of steroids, it is neither realistic nor prudent that enforcement efforts for steroids should take precedent over those for more harmful drugs. This line of reasoning should not be used as a rationale for a lack of effective action against steroids; nevertheless, the outlook that limited resources can be stretched to cover yet another class of drugs is not optimistic, 11 especially given recent increases in recreational drug use among adolescents. 12 The availability of anabolic steroids in this country suggests that there is reason to believe that the United States simply may not have the law enforcement manpower to deal with apprehending and punishing sellers of anabolic steroids and other performance-enhancing drugs. Nonetheless, between February 1991 and February 1995, 355 anabolic steroid investigations were initiated by the United States DEA. 13 There have been more than 400 arrests, and more than 200 defendants have been convicted. However, because of the way criminal penalties were developed for steroid infractions, an individual brought to court on charges of distribution or selling must be a national-level dealer to receive more than a “slap on the wrist” and/or a short visit to a “country club” prison. For this reason, United States law enforcement agents often do not bother pursuing small cases because the costs of prosecution vastly outweigh any penalties that will be assessed. Drug testing by sport federations is yet another form of interdiction. Such testing has been partially successful when directed at performance-enhancing drugs that, to be effective, must be in the body at the time of competition, such as stimulants and narcotics. Drug testing has been even less effective against anabolic steroids, which are used during training or used to enhance an athlete's capacity to train. Testing can be circumvented by the steroid user in several ways. Generally, to avoid a positive test result, athletes can determine when to discontinue use before a scheduled test or, in the case of an unannounced test, titrate their dose using transdermal patches or skin creams containing testosterone so as to remain below the maximum allowable level. Further confounding the issue are other drugs used by athletes, such as human growth hormone and erythropoietin, for which no effective tests currently exist. Moreover, testing for anabolic steroids is expensive (∼$120.00/test), and although organizations like the IOC, NFL, or NCAA may be able to institute such procedures, the cost is prohibitive for the vast majority of secondary schools. Consequently, only a handful of secondary school systems in the United States test for anabolic steroid use. Although interdiction through law enforcement and drug testing has intuitive appeal, its impact on the nonmedical use of anabolic steroids and other performance-enhancing drugs is open to debate. Since the flurry of legislative activity at the state and national levels regarding control of the manufacture, distribution, prescription, and possession of steroids in the late 1980s and the early 1990s, use among adolescents in the United States has increased significantly. As to the future of testing, it is difficult to be optimistic: over the past 30 years, drug users have consistently outplayed the drug testers. In addition, one can only speculate as to the future challenges posed by impending advances in genetic engineering. Will we be able to genetically enhance muscle mass, aerobic capacity, vision, and neurologic response? 14 Education: Is Anybody Listening? Since the 1980s, the United States Public Health Service, the United States Department of Education, and many state education departments, state and local medical societies, private foundations, and sports federations have been involved in prevention efforts related to steroid abuse. For the most part, these have centered on development and distribution of educational materials and programs such as posters, videos, pamphlets, and workshops. For example, the Iowa High School Athletic Association has developed an educational booklet that provides information on the effects of steroid use but also includes strength-enhancing alternatives to steroids and prevention ideas. 15 The United States Department of Education and other sources have developed a variety of informational posters targeted at high school students to provide facts about steroids, their adverse effects, alternatives to their use, and their illegal status. 16,17 Video distributors now have a wide range of videotape programs available on steroid use prevention and body building techniques. 18 Educational consulting firms provide antisteroid training, program, and curriculum development to junior and senior high schools across the United States. 19,20 Major television networks have presented special programming targeted at adolescent audiences to relay the possible consequences of steroid use (“Testing Dirty,” American Broadcasting Company Afterschool Special; “The Fourth Man,” Columbia Broadcasting System Schoolbreak Special; “Benny and the Roids,” Walt Disney Educational Productions). United States health educators have made some inroads in changing several high-risk behaviors, such as high-fat diets, sedentary lifestyles, and smoking. However, educators are well armed with vast quantities of scientific data regarding the deleterious nature of these activities. Further, these are behaviors on which society has increasingly frowned. In sports, however, athletes who use anabolic steroids have enjoyed significant improvements in physical performance and appearance, and society is much less likely to shun these behaviors. Adulation of fans, the media, and peers is a strong secondary reinforcement, as are financial, material, and sexual rewards. Another fly in the education ointment is the possibility that anabolic steroids taken intermittently in low to moderate doses may have only a negligible impact on health, at least in the short term. In 1989, several experts at the National Steroid Consensus Meeting concluded that according to the existing evidence, these drugs represent more of an ethical dilemma than a public health problem. 21 Although there is still little available evidence regarding the long-term health effects of anabolic steroids, many current or potential anabolic steroid users unfortunately mistake absence of evidence for evidence of absence. Even more frustrating is the fact that in two national studies, a large percent of the anabolic steroid users surveyed expressed no intention to stop using anabolic steroids if deleterious health effects were unequivocally established. 22,23 Clearly, the paucity of scientific information has impeded the formulation of effective health education more than that, the of health effects made by some in sports and by the news media have further between athletes and However, even if long-term deleterious effects were well for use of anabolic steroids, with and suggests that substantial would of these problems and in and effective prevention and could in part the significant increase in anabolic steroid use among adolescents a behavior that has in major benefits to the such as appearance and athletic a and education to tobacco, alcohol, and drug prevention have not been In there is evidence that a prevention that to adolescents from becoming involved with anabolic steroids may to increased because information their This to a prevention and to Steroids in part on positive educational related to and The also on increasing of the of social they are likely to to use anabolic steroids and to against these are for and media to use anabolic steroids. and reporting of anabolic steroid use among adolescents was in an effort to the widespread use of anabolic steroids among peers as is an This has been successful in attitudes and behaviors related to steroid use and effective over several Unfortunately, the of the is open to The on male high school football players and was not to address anabolic steroid use among among of steroid use have In addition, the long-term of this is still and the has yet to be in other Moreover, there are two important and as yet regarding the are school in an age of to time and to this it would be far and to to only to this problem and efforts to an by the and the use of available educational and The second is even more to school In an when some believe that the at all is the will some schools to will some schools to institute a that could reduce steroid use at the cost of an to an who to a no on the use of performance-enhancing This is given some by of high school coaches the use and in some so-called such as and to their athletes. Although athletes about the health risks and ethical associated with anabolic steroid use to some this be as a with legalization, interdiction, and education, our social appears to receive far less in many the social a more on drug use in sport than do the more A of performance-enhancing anabolic steroids, are not or after the for these drugs was by our societal on winning and physical An does not believe that a is our society games for but society the of at and is a culture that on competition, in business and in sport. However, we long that competition of all must exist within some A of competition is to win or be the very best in any many in our society appear to have taken a attitude, and winning to be the only of If we this then it easy to or be to the that one should win at any At that doping a very with the the means of anabolic steroids and other This at any take is not The in the Olympics were and of athletes to these are well Smith argued that the level of in at the turn of the what we Even the American football was as a and and a American football a further with that the only of drug use, have been at the and Olympic levels during the Moreover, because of in the news media and and by athletes, adolescents are of the part that anabolic steroids and other performance-enhancing drugs in the of many so-called athletes. on appearance, especially the of is also long An of men to the of by yet another who at the of who played in several in the with at the of and other and roles for a athletic In addition, a of such as and and some elite athletes, such as baseball Mark are in part for their bigger-than-life Anabolic steroid use among was given national during a steroid trafficking in The by President Bush of an individual who as a and at least in part as a of steroid use, as of the on and was yet another we our Such of and as a of and winning efforts of posters on and that students to no to Some argue that our attitudes and values related to sports and appearance are too entrenched to may be particularly when it to elite levels of there is simply too much However, if we control our competitive and we then must to anabolic steroid use, even among our current for dealing with the use of anabolic steroids in sport is and interdiction and However, 10 after our society was made that our were using steroids, our efforts to deal with this problem have not been very Since a of national on anabolic steroid use have been by the United States federal government or by sports and educational The of these was to and/or information or to a for At this all of these appear to have been a effort to deal with the but this of the while the social of drug use in sport has been If we our current course in the of increased high levels of anabolic steroid use use of other performance-enhancing then we as sports and coaches are guilty of for the of and distribute educational for the of and the of law of these our in the of our deal with our to sport and our on winning and

Anabolic androgenic steroid (AAS) and performance-enhancing drug (PED) use is a prevalent medical issue, especially among men, with an estimated 2.9-4 million Americans using AAS in their lifetime. Prior studies of AAS use reveal an association with polycythemia, dyslipidemia, infertility, hypertension, left ventricular hypertrophy, and multiple behavioral disorders. AAS withdrawal syndrome, a state of depression, anhedonia, and sexual dysfunction after discontinuing AAS use, is a common barrier to successful cessation. Clinical resources for these patients and training of physicians on management of the patient using AAS are limited. Many men are hesitant to seek traditional medical care due to fear of judgment and lack of confidence in physician knowledge base regarding AAS. While proposed approaches to weaning patients off AAS are published, guidance on harm reduction for actively using patients remains sparse. Medical education regarding the management of AAS use disorder is paramount to improving care of this currently underserved patient population. Management of these patients must be non-judgmental and focus on patient education, harm reduction, and support for cessation. The approach to harm reduction should be guided by the specific AAS/PEDs used.

Chapter 12 - Notes on harm reduction and the opioid epidemic in the United States

Individuals who use anabolic-androgenic steroids (AAS) may engage in concurrent psychoactive drug use recreationally and/or as an additional training aid. Aside from cannabis, individuals who use AAS most commonly report concurrent use of stimulants such as amphetamines and cocaine. In this study, we examine demographic characteristics, frequency of heavy drinking, and nightclubbing in a sample of 993 men from the Global Drug Survey 2015 who reported both AAS and psychoactive drug use before exploring the relationship between motivation for AAS use and the propensity to concurrently engage with stimulant-type substances. Results of a logistic regression analysis suggest that the propensity for concurrent use of AAS and stimulants is greater when AAS use is motivated by weight loss goals, while performance goals are associated with reduced odds of concurrent stimulant use. Identifying individuals who are at risk of polydrug use and associated harms can inform targeted harm reduction strategies.

The spread of HIV infection among injection drug users (IDUs) one of the most challenging and tenacious aspects of the drug problem plaguing the United States. Injection drug use represents a major public health challenge because of the multiple health, psychological, and social problems that must be overcome to address this addictive behavior and disease transmission (Office of National Drug Control Policy [ONDCP], 2000). National statistics indicate that injection drug use continues unabated with an estimated 1.1 to 1.5 million IDUs in the United States (Holmberg, 1996). The twin epidemic of injection drug use and AIDS has exacted a tremendous strain on the U.S. health care system, with the estimated treatment costs for IDUs infected with HIV and in the later stages, AIDS, totaling $3.7 billion (Harwood, Fountain, & Livermore, 1998). According to the Centers for Disease Control and Prevention (2000), 753,907 cumulative cases of AIDS were reported in the United States as of June 2000. Approximately 36 percent (n = 270,721) of the reported AIDS cases occurred among IDUs, their sexual partners, and their children. Because HIV can be transmitted both sexually and perinatally, drug injectors are also placing their potential children at increased risk. This evidenced by 8,804 cumulative pediatric AIDS cases reported by midyear 2000, with more than half of these cases caused by injection drug use by the mother, or by the mother having sex with an IDU. A disproportionate number of members of racial and ethnic minority groups being ravaged by the disastrous consequences of AIDS, with African Americans and Latinos accounting for 76 percent of the injection-related AIDS cases in the United States. Until a cure for AIDS found, or a vaccine for HIV developed, there a critical need to reduce the spread of HIV transmission among individuals who choose to inject illicit substances. Harm-reduction interventions and policies have emerged as viable strategies to ameliorate the adverse health, social, or economic consequences associated with injection-related behaviors (Brettle, 1991; Des Jarlais, 1995; Des Jarlais & Friedman, 1993; Inciardi & Harrison, 2000; Marlatt, 1998; Nadelmann, 1998). PRAGMATIC LESSONS FROM A PUBLIC HEALTH MODEL Harm reduction, also called damage limitation, risk reduction, and harm minimization, a goal of public health policies and interventions aimed at decreasing the deleterious consequences spurred by illicit drug use (Marlatt, Somers, & Tapert, 1993; Newcombe, 1992; Single, 1995). Present drug control measures and treatment philosophies in the United States deem abstinence as the most effective means of reducing the individual and public health risks associated with injection drug use (ONDCP, 2000). Harm reduction a point of departure from these traditional beliefs. Proponents of the harm reduction model do not view abstinence as the only desirable objective for drug users. By acknowledging the prevalence of illicit drug use in our communities and that drugs may not always be used in a safe manner, harm reduction seeks to remedy these problems through pragmatic, incremental, and nonjudgmental interventions and policies (Des Jarlais, 1995; Des Jarlais, Friedman, & Ward, 1993; Schilling & El-Bassel, 1998). Harm reduction measures do not ascribe to a specific formula, but should reflect specific individual and community needs. Therefore, practitioners should always be conscious of starting where the client is during the course of the therapeutic process. The common principles that are central to harm-reduction practice are as follows: * The harm-reduction approach does not attempt to minimize or ignore the pervasive public health consequences associated with injection drug use, but rather accepts that the nonmedical use of psychoactive drugs an inevitable occurrence in a society that has access to such drugs (Des Jarlais, 1995). …

Chapter 8 - Opioid use disorder and endocarditis

Socio-economic changes that occured in the wake of dismemberment of former Yugoslavia resulted in the appearance of social pathology, one of which was the increase in the use of psychoactive substances. The overwhole epidemiological research in the use of psychoactive substances has not been conducted so far. The aim of this study was to establish the type and form of the use of psychoactive substances considering sex and age, as well as risk factors for the use of psychoactive substances among the children and adolescents. The research was carried out among 1011 elementary school children (seventh and eighth grades) and secondary school children (all four grades) in the area of Belgrade from October 2003 to January 2004. Out of the total number 457 (45.2%) were elementary school pupils and 554 (54.8%) secondary school pupils. There were 524 (51.8%) boys and 487 (48.2%) girls, aged from 12 to 18 years (the average age being 15.3 years). The method used was the European School Survey Project on Alcohol and Other Drugs Questionaire. Chi-square test, Mann-Whitney, Student's t test and Logistic Regression test were used in statistical processing of the data. Totally 14.2% examinees tried psychoactive substances. The most frequent drug used at the first contact was marijuana (10.8%) at the age of 15 tried by 12.7% examinees, inhalants (4.4%), amphetamines (4.1%), sedatives (3.7%), alcohol combined with marijuana (3.9%), then cocaine (2.8%), heroine (2.3%), alcohol combined with sedatives (2.2%), and ecstasy (1.6%), followed by anabolic steroids, heroin, diethilamid lisergic acid (LSD) and magic mushrooms. It was determined that going out in the evening, smoking and binge form drinking were directly connected with the use of psychoactive substances. Totally 14.2% of the exameneers used psychoactive substances, mostly marijuana, followed by amphetamines and others. New tendencies of use characterized by the increase in the use are of synthetic substances, simultaneous use of more psychoactive substances and younger age. The risk factors are going out in the evening, smoking, binge drinking and use of synthetic substances among peers. Our research indicates the neccessity of primary prevention.

The clinical content of preconception care: preconception care for men

Editorial: showing due DILI-gence--the lessons from anabolic steroids.

BackgroundAlthough harm reduction is highlighted as an effective intervention for alcohol and drug use, a funding gap for harm reduction interventions has been identified, mainly in low- and middle-income countries. In these countries, tensions between abstinence and harm reduction models have impaired the shift from punitive practices to evidence-based interventions committed to guaranteeing the human rights of people who use drugs. Since 2015, the Brazilian government has adopted a more punitive and abstinence-focused drug policy that jeopardizes the care of people who use alcohol and other drugs and the comprehension of the harm reduction workers' perspective in relation to their practice. Therefore, this study aimed to comprehend the meanings constructed by Brazilian harm reduction workers regarding their practices with vulnerable populations amidst a context of political tension.MethodsWe conducted 15 in-depth semi-structured qualitative interviews with harm reduction workers employed in public health services for at least 6 months. Data were analyzed using thematic analysis.ResultsThe thematic axis "The joy and pain of being a harm reduction worker in Brazil" was constructed and divided into four major themes: (1) Invisibility of harm reduction work; (2) Black, poor, and people who use drugs: identification with the service users; (3) Between advocacy and profession: harm reduction as a political act; (4) Small achievements matter. Despite the perceived invisibility of harm reduction workers in the public health and alcohol and drug fields, valuing small achievements and advocacy were important resources to deal with political tension and punitive strategies in Brazil. The findings also highlight the important role of harm reduction workers due to their personal characteristics and understanding of drug use behavior, which bring the target audience closer to actions within the public health system.ConclusionThere is an urgent need to acknowledge harm reduction based on peer support as a professional category that deserves adequate financial support and workplace benefits. Additionally, expanding evidence-based harm reduction interventions and community-based voluntary drug use treatment centers should be prioritized by public policies to address the human rights violations experienced by people who use drugs.