An increasing number of men – and boys – are using anabolic steroids to change their physique. But how can you spot the signs and help users kick the habit?

More men are becoming dissatisfied with their appearance thanks, in part, to shifting cultural norms and expectations about what is considered to be ‘the body beautiful’. 

Worryingly, as men hit the gym in the hope of transforming their bodies, some are turning to anabolic steroids to achieve the muscle mass and physique they desire. While some believe that taking anabolic steroids will help them become fit and healthy, this isn’t true: taking anabolic steroids is a dangerous drug habit.

Anabolic steroids are manufactured drugs that mimic the effects of the male hormone testosterone. They are usually injected into muscle, but some are available in tablet form, or as creams or gels that are applied to the skin. They have limited medical uses and are not to be confused with corticosteroids, a different type of steroid drug that’s commonly prescribed for a variety of conditions. 

Scale of use

The vast majority of anabolic steroid users inject the drugs, with many doing so at gyms. The Crime Survey for England and Wales estimates that 60,000 people are using steroids to gain muscle, become leaner and fitter or to get stronger, but experts believe the figure to be much higher than this. 

“It is a big underestimate,” says Professor Julien Baker, an expert in steroid use from the University of the West of Scotland. “There are needle exchanges in Cardiff and Glasgow which say they’ve seen a 600 per cent increase for steroid users over 10 years. The real figure is definitely in the hundreds of thousands.”

Public Health England (PHE) says local monitoring shows that steroid users are widespread in some areas – for instance, recent figures from the north of England showed that in 12 out of 14 areas, the use of image and performance enhancing drugs (IPEDs) such as anabolic steroids was reported by more than half of people using needle and syringe programmes (NSPs).

In four of those areas, over 70 per cent of people accessing NSPs were using IPEDs, and in Essex, drugs charity Open Road says that 25 per cent of all first time users are teenagers, with boys as young as 14 taking steroids.

Sarah Wright, chief executive of Open Road, says 47 per cent of those accessing the charity’s needle exchange services are injecting performance enhancing drugs. “We have been seeing an overall increase in year-on-year visits by these service users, with roughly 32 per cent being new to either the service and/or use of steroids,” she says. “However, the total number of people using these drugs will be significantly higher, due to the fact that we as an organisation do not have the data for people only using pharmacies and/or sourcing all their equipment online.”

What the charity has seen, following analysis of a small steroid treatment pilot service within its needle and syringe programme, is a significant increase in steroid users accessing its needle exchange services, equating to one new user each day over the last year.

Accessing steroids

Anabolic steroids are prescription-only, class C drugs that can only be dispensed by pharmacists. It’s not illegal to possess, import or export anabolic steroids for personal use, as long as they’re not posted or delivered by courier or freight service. However, it’s illegal to possess, import or export anabolic steroids if it’s believed people are supplying or selling them. The penalty is an unlimited fine, or even a prison sentence.

Users often obtain their drugs from illicit and poorly-controlled sources and evidence from PHE shows widespread adulteration of anabolic steroids, with many products containing substances and dose strengths different to what is specified on the label, as well as potential bacterial and fungal contamination. 

Sarah says the vast majority of clients accessing Open Road’s needle exchange services disclose sourcing their performance enhancing drugs online and/or through social networks, with users being “rarely concerned” about the origin or quality of the product being purchased.

Sharing needles

As anabolic steroids are often injected, there are risks associated with sharing needles. As with recreational drug use, these include vein damage that can lead to ulcers or gangrene, hepatitis B and C infection and HIV transmission.

Prevalence rates for HIV are now higher among steroid users than heroin users, according to the Centre for Public Health at Liverpool John Moores University, and the Open Road needle exchange has seen an increase in steroid users exhibiting poor injecting practices and disclosing the sharing of equipment. Studies have reported that 1.5 per cent of steroid injectors across England and Wales are HIV positive – equivalent to the level among opiate injectors. A further eight per cent have been infected with hepatitis B and five per cent with hepatitis C.

Health consequences

As prescription-only medicines, if taken without medical advice to increase muscle mass and improve athletic performance, anabolic steroids can cause addiction, as well as serious side effects and potentially dangerous medical conditions, such as high blood pressure or heart attacks.

The physical effects of anabolic steroids in men can include:

  • Reduced sperm count
  • Infertility
  • Shrunken testicles
  • Erectile dysfunction
  • Baldness
  • Breast development
  • Increased risk of developing prostate cancer
  • Severe acne
  • Stomach pain.

In addition, users can develop:

  • Heart attack or stroke
  • Liver or kidney tumours
  • High blood pressure
  • Blood clots 
  • Fluid retention
  • High cholesterol. 

The use of anabolic steroids also has implications for people with diabetes, according to Dan Howarth, head of care at Diabetes UK. “Anabolic steroids cause hunger and can raise metabolism,” he says, “all of which will impact on diabetes management. In addition, they are usually used alongside testosterone, which will increase the risk of sexual dysfunction in people with diabetes.”

There are also psychological effects, such as aggressive or manic behaviour, mood swings, hallucinations and delusions, and if they’re misused by adolescents who haven’t yet had the growth spurt associated with puberty, steroids can cause premature ageing of the bones and restricted growth.

Sarah also points out the psychosocial implications for those using performance enhancing drugs, which have an impact on the users and their families. “Quickly escalating use and potential relationship difficulties as a consequence of mood swings and/or ‘roid rage’ (e.g. domestic violence) serve as reminders of the ripple effect which can be experienced when somebody decides they want to begin using performance enhancing drugs,” she says. “And there is also the financial cost of participating in successive courses – anywhere up to £400 per month. This can impact on a family unit significantly.”

Because anabolic steroids are addictive, users can crave them, require more to get the same effect, and have withdrawal symptoms if they suddenly stop taking them.

As with many medications, the best way to come off anabolic steroids is by gradually reducing the dose. Stopping them suddenly can result in withdrawal symptoms such as depression and apathy, anxiety, lack of concentration, insomnia, anorexia, decreased sex drive, fatigue, headaches, and muscle and joint pain.

Engaging with users

The National Institute for Health and Care Excellence (NICE) has highlighted the importance of engaging with and providing appropriate services for people abusing IPEDs such as anabolic steroids.

Needle and syringe programmes (NSPs) are available, but in its 2015 report Providing effective services for people who use image and performance enhancing drugs, PHE highlighted substantial variability in NSP provision across different areas and services. It found that some IPED users do not engage with local services because of the potential stigma of being seen as a drug injector. Others do not want to mix with people who inject opiates or stimulants. They may also find it difficult to access services because of their own working hours. 

PHE suggests that providing specialist IPED clinics, especially out of hours, may lead to better engagement. Other services integrated or aligned with NSPs could also support improved health outcomes for IPED users. PHE says that offering a range of services and interventions beyond basic needle and syringe provision, such as health checks and dietary advice, may also increase uptake. 

Pharmacy’s role

With the right knowledge, there is support and advice that community pharmacy teams can provide to customers who are using or trying to come off anabolic steroids. This will mainly centre on advising customers to talk to a GP if they think they are addicted to these drugs, and treatment could include referral to a drugs counsellor. 

As many IPED users are known to access the drugs in their local gyms, pharmacy teams could encourage staff at these facilities to be on the lookout for people who need support, or simply encourage staff to place posters or information leaflets in changing rooms to signpost people to local drug treatment and other services. 

PHE says it is also important that pharmacy teams are suitably trained to feel confident engaging with IPED users and to help the users feel confident in receiving their support. For example, if you provide a needle and syringe programme, have you had training on IPED use? 

As essential members of your community’s wider healthcare team, knowing as much as you can about these issues, and being able to address them with IPED users, will enable you to gain their confidence more effectively. This way, you will be better equipped to provide them with vital advice on the significant harm they could be doing to their health with these drugs.

It's a man's world

It’s a well known fact that men visit pharmacies far less frequently than women. But when they do take the time to come in, staff need to be on hand with appropriate support and advice

  • Weight

In England, 14 million men are overweight or obese but are not being adequately helped by weight management programmes, according to the Men’s Health Forum. 

Community pharmacy has a huge opportunity to help since talking to a GP, or just managing to get an appointment, is not always easy. 

Men who come in to talk about weight need to know about diabetes, cardiovascular problems and fertility problems, which can all be caused by being overweight. Positive information about the benefits of weight loss should be available to them without scaring them off.

  • Fertility

Male fertility is a huge taboo in the UK, with many men unwilling to discuss or address their concerns with their partner or GP, according to research from Nuffield Health, in partnership with Infertility Network UK. 

The research shows that a vast number of men are unaware of the significant impact that their lifestyle choices could have on their fertility. Infertility Network UK says that any advice that pharmacy can give around improving lifestyle – stopping smoking, for example – can have a positive effect, although if men have specific concerns, they should visit their GP.

  • Testicular cancer

Each year, testicular cancer affects over 2,200 men and around 60 young men will die of the disease. It most commonly affects men aged 15-45 years, but if it’s caught at an early stage, there is a high cure rate, with 98 per cent surviving the disease. Regular self checks are therefore recommended and men should be encouraged to get any abnormalities checked out at the earliest opportunity.

  • Alcohol

Men and women are now advised not to drink more than 14 units of alcohol a week. The charity Drinkaware says that this is equivalent to six pints of four per cent beer, six glasses of 13 per cent wine, or 14 glasses of 40 per cent spirits.

Men who are dependent on alcohol increase their risk of developing high blood pressure, stroke, coronary heart disease and liver disease. They may also develop mental health and psychological problems such as anxiety, depression and suicidal feelings because regular heavy drinking interferes with neurotransmitters in the brain that are needed for good mental health. 

  • Mental health

Three-quarters of people who take their own lives are men, and male mental health has become a big concern in recent years for healthcare professionals and policy makers. As a frontline service, pharmacy has a real opportunity to spot the signs in customers early, and offer advice and signposting that can make a difference.

Mental Health First Aid training can help you recognise and work effectively with people who are experiencing mental health issues and includes some of the less obvious signs men may exhibit rather than being open about mental health issues. Find out more at: mhfaengland.org.

The Men’s Health Forum also has information and guides on how to engage with men about mental health issues.

25 per cent of all first time users are teenagers, with boys as young as 14 taking steroids

Originally Published by Training Matters

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