THE INTERNATIONAL JOURNAL OF DRUG POLICY, VOL 5, NO 1, 1994
Pirkko Korkia presents data on the prevalence of anabolic steroid (AS) use in Britain, highlights son~e issues arising from the interviews and brings these into the discussion regarding the legal status of ASs and the desirability of controlling them under the Misuse of Drugs Act.
Our understanding of the metabolic effects of testosterone in humans began in the late 1930s when Kenyon (1938) described their effects on skeletal muscle growth and development. These discoveries soon led to the use of testosterone, and its synthetic derivatives, as an aid for improving sports performance (Voy, 1991). Currently national and international doping agencies spend millions of pounds attempting to detect its use which is outlawed in sport. I t is also these organisations and their supporters who have traditionally lobbied for legislating against anabolic-androgenic steroids (ASs) under the Misuse of Drugs Act in the UK. Anabolic steroids, in the UK and most of Europe, are prescription- only medicines, and as such it is legal to buy them and to consume them, but illegal to import, sell or supply them without a licence. In the USA, for example, their pos, session is a criminal offence, and the British Government is considering changing the law to this effect.
In recent years headlines have been made by sportspeople caught using ASs, but increasingly their use among the body,building and body-beautiful fac, tions has gained attention. Doping control in sport aims to prevent artificial and unfair advantage in improving performance. Previous studies in the UK (McKillop, 1987; Williamson, 1991), in Australia (The Black Report, 1989), in the USA (Buckleyetal., 1988) and The Dubin Report (1989) in Canada suggest that the use of ASs is more widespread among weight-training enthusiasts who primarily lift weights in gyms. Most body-building contests are not drug tested and therefore use of ASs tends to be an accept, ed part of training. Competitive sportspeople and body-builders form only a comparatively small group. Most AS drugs originate from the black market and users administer them, often in large dosages. This, together with media reports of death and violent crime associated with their use, has caused concern and fuelled debates on what should be done about AS use.
A study was designed to -explore the extent and uses of ASs in Britain through surveys of syringe exchanges, gymnasia and through interviews with AS users. It was commissioned by the Departments of Health for England, Scotland and Wales and was undertaken at the Centre for Research on Drugs and Health Behaviour between January and December 1992 (Korkia and Stimson, 1993). Views expressed in this paper are those of its author.
Study of syringe exchanges
One hundred and thirty syringe exchanges in England, Scotland and Wales were offered a questionnaire asking if they had supplied AS injectors with clean injecting equipment during 1991.
Study of gymnasia
Weight-training gyms were recruited to the study including privately owned and local authority controlled gymnasia, health, sport and leisure clubs, and centres from five areas: a part of London and Merseyside, England, an area in Swansea, Wales, and areas in Edinburgh and Glasgow, Scotland.
Gyms included in the survey were required to have a good range of weight-training equipment including heavy-duty free weights, benches and racks. Thirtynine gyms and clubs in the five areas were identified as suitable after visits and consultations with local contacts: 22 agreed to participate in a survey and 21 were surveyed.
Each survey was conducted over a 2-day period on days when the maximum number of clients could be expected. Allclients using the gym were offered a onepage questionnaire. The number of clients entering thegym, thosewho refused to take aquestionnaire and the number of questionnaires returned to the collection box were counted.
Interviews with AS users
One hundred and ten face-to,face structured interviews with AS users were conducted, using focused sampling methods and recruiting from nine different geographical areas. Most interviewers had pre-existing contacts with AS users.
Syringe exchange survey
Eighty,eight agencies situated in most counties in England and South Wales replied (68% response rate). Fifty-nine percent had known contacts with AS injectors, whereas 18% said that they had no contacts and 23% were not sure. Agencies which reported AS injecting clients were found in all areas except London.
Of the questionnaires 1677 were returned (59% response rate) and 1669 could be included in the study. Characteristics of the gym survey participants are shown in Table 1.
AS use was reported in all of the areas studied, and in all of the gyms. One hundred and twenty-seven respondents (7.7%) admitted ever taking ASs and 5% of the total sample reported that they were current users (6% of the men and 1,4% of the women).
AS use varied a great deal between gyms, ranging from no reports to 46% of all clients. In four of the gyms AS use was between 24% and 46%,
TABLE 1: Characteristics of gym survey participants
|Men||1310 (79)||29 (9.1)||119 (9.1)||78 (6)|
|Women||349 (21)||27 (7.4)||8 (2.3)||5 (1.4)|
* Sex was not identified for 10 subjects. AS ever = those who had ever used AS. AS current = current users of AS.
Interviews with 110 AS users
Ninety-seven interviewees were men and 13 were women with an average age of 27±7 (17-56) and25±5 (18-35) years, respectively. Twelve interviewees were aged 19 years or under. They were from a wide range of backgrounds including unemployed, unskilled workers, top professionals, and the unemployed; 81 % were in employment or were students. Table 2 describes their'career' in AS use. Fifty per cent of interviewees reported that most of their friends also used ASs, and the majority had introduced someone else to ASs. ASs were used mainly to increase muscle mass and size, and to enable them to train harder and longer. Perceived benefits in terms of gains in size, faster recovery, strength, improved performance and confidence were felt to be substantial by most users.
The AS most commonly used by men were Deca-Durabolin (nandrolone decanoate), Dianabol (me thandrosteno lone) and variations of testosterone. The women tended to use Anavar (oxandrolone), Dianabol (methandrostenolone) and Win, strol (stanozolol). Use of veterinary drugs such as Equipoise (boldenone) and Finajet (trenbolone) were also reported. Twenty-three per cent reported having taken oestrogen antagonists (mainly taken by men to prevent gynaccomastia which is caused by the aromatisation of androgens to oestrogens), 11 % human chorionic gonadotrophin (hCG) (to restore spermatogenesis), four took diuretics and four took clenbuterol during their last'on cycle'. The mean time 'on cycle' was 11 weeks (s.d. ± 7) and 'cycles' varied from 1 to 29 weeks.
TABLE 2: Anabolic steroid use: a career chart*
|Sex||Weight training initiated (years)||AS first tried (years)||Regular AS use began (years)||Current age (years)|
*Ages are approximate.
Description of use
The mean number of drugs (including ASs and others taken concomitantly) during the present or last cycle was 3.2 (s.d. ± 2. 1) (maximum 16) by men and 2.2 (s.d. ± 1. 2) (maximum 4) by women. Eighty-three per cent took two or more different drugs.
The mean doses of Dianabol and Deca-Durabolin reported by men exceeded medical recommendations (Wadler and Hainline, 1989) by 4 and 14 times, whereas the maximum reported doses of the same drugs were 34 and 24 times greater. Individual drug doses reported by women were close to medical recommendations, though most took two or more drugs simultaneously.
ASs were taken by injection only by 9%, tablets only by 19% and 63% took a combination of both. Most reported injecting themselves and 25% were injected by a friend.
Interviewees were asked to respond to a symptom checklist of health effects experienced while taking ASs. Seventeen did not report any while 7 7% report, ed two or more. Most health effects involved cosmetic complaints, but 56% of the men reported testicular atrophy, 36% elevated blood pressure, 22% nosebleeds, 6% kidney problems and 5% reported liverproblems. Women tended to sufferfrom cosmetic effects and 8% also reported menstrual irregularities.
Fifteen per cent indicated that they had suffered permanent side effects from AS use.
Thirty-five per cent of interviewees had received regular medical cheeks and 33% had told their GP about their AS use. Three reported that they had been refused a service by their GR Forty-eight percent were concerned about the long,term effects of AS and 44% indicated that they would stop using them if it was proven that they cause serious side effects, such as cancer.
In the past 6 months, 81 % had used alcohol, 25% cannabis, 18% amphetamines, 4% cocaine and 5% had taken other substances including LSD and Ecstacy.
Over 80% agreed that it is easy for them to obtain ASs, and they reported spending up to £500 for an average 'on cycle' of 11 weeks. Eightyseven per cent said that they would still continue using ASs even if their possession became illegal.
Our study was the first attempt to investigate the extent of AS use in Britain. Although our data do not allow us to estimate the number of AS users in this country, partly due to lack of data regarding ( 1 ) the number of gyms in the UK and (2) the percentage of the population who train with weights outside their home, the data nevertheless suggest that AS use is relatively common among regular gym attenders in British towns. It is well known that a small proportion of Britons are prepared to take regular and vigorous exercise like weight-training, which must accompany AS use, and therefore it is unlikely that AS use would reach epidemic proportions.
Medical knowledge of AS-related health effects has been mainly derived from ill patients who were given these drugs as treatment (Friedl, 1993). It would probably be wrong to assume that the way such patients metabolise and react to AS therapy is similar to that of young, healthy and active sportsmen and -women. It is possible though that long-term ill effects of ASs have gone unnoticed because most do not con, sult a medical professional for their AS use. It is also important to bear in mind that AS use has increased substantially in the last 5 years and their effects will probably be realised only in future years. Unfortunately data about long,term effects of ASs and other drugs used concomitantly have not been collected and we are left guessing whether the short-term changes, which are well documented, actually translate into significant longer-term problems. There are case reports of medical conditions which have been linked to AS use, however; other confounding factors were also often identified (Friedl, 1993).
Users of AS are widely perceived as compromising their health, and there have been some reports suggesting that AS use may have psychological consequences, such as unsocial behaviour, irritability and violent tendencies (Choi et al, 1990; Bahrke, 1993; Su et al., 1993). Some research has found that AS use may lead to dependence (Brower et al., 199 1). These are serious considerations but at present we do not have any conclusive evidence supporting or denying substantial adverse effects (Yesalis et al., 1989; Friedt, 1993).
The orally active 17-alkylated androgens (for example Dianabol and Anavar) have been more frequently associated with adverse health effects than other AS compounds (Paradinasetal., 1977,Thompson et al., 1989; Malarkey et al., 199 1 ). Data from long-term studies of the effectiveness of testosterone enanthate as a male contraceptive indicated that subjects developed few side effects (WHO, 1990). These examples serve to highlight that AS drugs sho~ld perhaps not be viewed as one type of a drug, but as different compounds with differing potential for harm.
The use of excessively high doses of androgens, including the 'safer' parenteral preparations, may cause harmful side effects (Kruskemper, 1968). Our interview data with AS users show that a mixture of ASs including oral and parenteral compounds are commonly used. Each drug is often taken in larger doses than the medical recommendations. An average of over three different drugs (maximum of 16 by one subject) were consumed during the same cycle, thus causing circulating androgen levels to be high. The common practice of'cycling'AS may, however, provide along enough drug,free period to reduce some of their adverse effects.
In recent years the media have reported on the deaths of strongmen and body-builders who were assumed or known to have used ASs. Our data show that AS users often take other preparations in conjunction with ASs, mainly to prevent their unwanted effects, such as fluid retention, testicular atrophy and gynaecomastia. They also consume other drugs like amphetamines, cocaine and cannabis. The combined effects of 'cocktails' taken by AS users have not been studied in any detail and information about their long-term effects is completely lacking.
It is possible that polydrug use may be responsible for some of the side effects reported. The combination of, for example, diuretics and clenbuterol may lead to severe abnormalities in heart conductivity, because both cause potassium excretion. The relatively cornmon use of oestrogen blockers may further reduce the plasma levels of high,density lipoprotein cholesterol (the protective cholesterol), which is adversely affectedby 17-alkylated androgens. Mostusersobtain their drugs from black market sources. The quality and contents of these products are often questionable thus complicating the evaluation of the effects of ASs on individuals.
The desirability of legislating ASs under the Misuse of Drugs Act is not obvious. Currently we have no data about the long-term health problems encountered by AS users. Case-report data have not often been able to confirm that AS are responsible for ill health. Data regarding their short-term effects show that these are often reversible when AS use ceases. It was interesting that 87% of our interviewees said that they would continue to use ASs even if their possession became illegal. Comments provided by AS users at the end of their interview often pointed out that, should possession of AS be made illegal, 'hard core' dealers would get involved in AS distribution as users might resort to crime to obtain money for increasingly expensive drugs. One of the concerns was that the market would become flooded by AS and related drugs which are of extremely dubious content and quality, potentially causing a great deal of harm to users. Perhaps the most severe result of such policy would be the ethical dilemma of the medical profession who might feel unable to provide help for AS users. The use of syringe exchanges may become less popular with the fear of being caught, thus possibly putting more people at risk of contracting the hepatitis and HIV viruses through ill-informed injecting practices.
Banning the use of'hard'drugs has not prevented their use and may have created more problems than it has solved. It is hoped that a more constructive attitude will be adopted towards AS use.
Ms Pirkko Korkia, The Centre for Research on Drugs and Health Behaviour, 200 Seagrave Road, London SW6 IRQ, UK
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