tag:theconversation.com,2011:/ca/topics/steroids-3587/articlesSteroids – The Conversation2023-07-11T13:47:33Ztag:theconversation.com,2011:article/2093492023-07-11T13:47:33Z2023-07-11T13:47:33ZThe Enhanced Games: letting athletes use drugs could lead to worse problems than cheating<figure><img src="https://images.theconversation.com/files/536308/original/file-20230707-23-64vtgj.jpg?ixlib=rb-1.1.0&rect=39%2C26%2C4342%2C2890&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pro-doping games could lead to athletes being coerced into drug-taking. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-muscular-man-injecting-himself-steroids-402261172">luckyraccoon/Shutterstock</a></span></figcaption></figure><p>What would sport be like if performance-enhancing drugs were allowed? How fast could the fastest athletes run? How high could they jump? How heavy could they lift? The Enhanced Games seeks to answer these questions by removing all restrictions on doping.</p>
<p>In lifting the ban on performance-enhancing drugs, the Enhanced Games challenges a core tenet of modern sports ethics – that sport <a href="https://www.wada-ama.org/en/who-we-are">should be doping-free</a>. </p>
<p>When the first Enhanced Games takes place in December 2024, athletes in its five categories of competition – track and field, swimming, weightlifting, gymnastics, and combat sports – will be allowed to ingest whatever substance they wish to improve their performance. </p>
<p>There will be no tests, no bans, no limits. For some, including the games’ founder Aron D’Souza, the Enhanced Games is the next step in sport’s evolution, but for others, it is a moral stain on the sporting landscape. </p>
<p>Advocates of “enhanced sport” contend that permitting athletes to use whatever drugs they choose will allow sport to <a href="https://www.theguardian.com/sport/2023/jun/24/australian-entrepreneur-plots-enhanced-games-for-drug-taking-athletes">test the limits of human potential</a>, to respect athletes’ bodily autonomy, and to escape the unending cycle of cheating scandals generated by a failing anti-doping system.</p>
<p>However, it is far from clear that enhanced sport will open new horizons of sports performance, support athlete autonomy, or promote fair competition. </p>
<h2>Peak performance?</h2>
<p>Anti-doping rules limit the substances that athletes can use to reach peak performance. <a href="https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1038/bjp.2008.165">Anabolic steroids</a> can help weightlifters to lift heavier and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657498/">erythropoietin</a> can help distance runners to run faster. So the prohibition of these substances appears to place a ceiling on the pursuit of sporting achievement.</p>
<p>Athletic excellence is not, however, reducible to outcomes. </p>
<p>A sprinter who runs with a tailwind, a <a href="https://time.com/3822577/rosie-ruiz-history/">marathon runner who rides the subway</a>, or a high jumper who uses a trampoline are not better placed to explore the limits of human potential in their respective sports. </p>
<p>In each case, an extraneous aid (that is, the tailwind, subway and trampoline) assists the athlete to reach the desired outcome more efficiently but without demonstrating any further athletic skill or ability. These supposed “enhancements” obscure rather than <a href="https://www.taylorfrancis.com/chapters/edit/10.4324/9781003189466-38/doping-sport-john-william-devine">cultivate athletic excellence</a>. </p>
<p>The use of performance-enhancing drugs may, in a range of cases, more closely resemble running with a tailwind than mastering <a href="https://www.dailymail.co.uk/sport/othersports/article-3470075/Justin-Gatlin-breaks-Usain-Bolt-s-100m-record-9-45-second-dash-Japanese-television-wouldn-t-count.html">a new athletic skill</a>. </p>
<p>In evaluating any sports performance, the outcome cannot be detached from the means of its achievement. More work needs to be done by philosophers and sport scientists to determine when, if ever, drug-assisted performance truly extends the limits of human performance, as envisaged by the organisers of the Enhanced Games.</p>
<p>Furthermore, sports are designed to test a specific cluster of skills and capacities, including physical, psychological, tactical and technical abilities. Performance-enhancing drugs elevate the importance of certain physical attributes, such as strength and stamina. </p>
<p>Lifting the ban on drugs would alter the nature of sports by increasing the significance of this sub-set of physical attributes at the expense of other <a href="https://www.tandfonline.com/doi/full/10.1080/00948705.2022.2059489">physical attributes</a>, such as coordination and agility, as well as non-physical attributes such as strategic skill, mental resilience, and technical proficiency.</p>
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<p>A second argument advanced by advocates of the Enhanced Games is that lifting the ban affords athletes more extensive control over their bodies. “<a href="https://www.theguardian.com/sport/2023/jun/30/the-enhanced-games-a-drugs-olympics-where-cheaters-can-prosper">My body, my choice</a>,” as D’Souza, puts it. Allowing athletes to use whatever substances they wish better respects their autonomy – so the argument goes.</p>
<p>However, lifting the doping ban would allow – perhaps even incentivise – athletes to ingest dangerous or untested drugs. Supporters of enhanced sport suggest that this presents no moral concern, provided that athletes <a href="https://www.theguardian.com/sport/2023/jun/30/the-enhanced-games-a-drugs-olympics-where-cheaters-can-prosper">give free and informed consent</a>. </p>
<p>Even charitably assuming that such consent eliminates any moral concern, the removal of the ban will expose unwilling and uninformed athletes to pressure from coaches, parents, sponsors and governments to use dangerous and experimental drugs that could pose a serious risk to their health. Lifting the ban on doping invites the proliferation of coerced doping.</p>
<h2>Time to abandon a failed system?</h2>
<p>The Enhanced Games may find reluctant support from those who oppose the use of performance-enhancing drugs in principle but have become disillusioned by the failure in practice of the World Anti-Doping Agency and national anti-doping agencies to contain the problem. </p>
<p>If sport is replete with cheating by doping and attempts to address this problem impose burdensome <a href="https://www.wada-ama.org/en/athletes-support-personnel/provide-whereabouts#:%7E:text=RTP%20athletes%20may%20submit%20their,simple%2C%20smart%20and%20fast%20manner">bureaucratic</a> and <a href="https://www.wada-ama.org/en/testing-and-investigations">testing</a> obligations on athletes, perhaps the best solution is to lift the ban, both to close off this avenue for cheating and to remove the burdens of anti-doping on athletes.</p>
<p>However, lifting the doping ban would grant further competitive advantage to athletes who represent economic superpowers such as the US and China. These governments could invest huge sums into drug research and development for the benefit of their athletes. They could provide expert medical supervision, not available to athletes from less wealthy states, to ensure that drugs are used in ways that minimise harm and maximise their effect. </p>
<p>In a sporting world in which inequality of opportunity is already rampant, the removal of the doping ban would only deepen an existing moral failing.</p>
<p><a href="https://www.washingtonpost.com/sports/olympics/2022/02/11/russia-olympics-doping-scandal/">Recent doping scandals</a> and persistent rumours that doping remains prevalent among elite athletes provide reason for pessimism about the prospect of doping-free sport, but lifting the ban is not the answer. Doping is a problem that needs to be managed, not side-stepped. Competitions that allow it will increase the risk to athletes’ health, render competition even more unfair and threaten to undermine the fundamental purpose of sport.</p><img src="https://counter.theconversation.com/content/209349/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John William Devine does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Will allowing doping open new horizons of sports performance?John William Devine, Senior Lecturer in Ethics, Department of Sport and Exercise Sciences, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1809472022-08-04T03:51:49Z2022-08-04T03:51:49ZIs it ethical to allow soldiers to take performance enhancing drugs such as steroids?<figure><img src="https://images.theconversation.com/files/472660/original/file-20220705-23-xb41r9.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3537%2C2476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There’s a <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/tsm2.186">long history and growing evidence base</a> that the use of performance enhancing drugs such as anabolic-androgenic steroids to build muscle mass and strength is common in the armed forces, including in Australia. </p>
<p>This isn’t surprising considering the pressures soldiers face to complete missions successfully, achieve elite levels of fitness, and deal with the physical and mental stresses of their profession.</p>
<p>The Australian Defence Force (ADF) is also constantly looking for ways to amplify the performance of soldiers, which includes the <a href="https://researchcentre.army.gov.au/sites/default/files/flwr_web_b5_final.pdf">consideration of technologies</a> both “in” (such as drugs) and “on” (for example exoskeletons) soldiers.</p>
<p>In 2016, the Department of Defence also created the <a href="https://www.dst.defence.gov.au/partner-with-us/university/human-performance-research-network-hprnet">Human Performance Research Network</a>, which is focused on enhancing the physical and cognitive performance of military personnel.</p>
<p>At the same time, the ADF has <a href="https://researchcentre.army.gov.au/library/land-power-forum/anti-doping-sport-and-human-enhancing-technologies-army">adopted</a> parts of the World Anti-Doping Code – a code developed to govern drug use in sport – to manage the governance of human enhancing drugs within the military. Under the code, using steroids isn’t allowed.</p>
<p>But considering the military is constantly looking for means to create “super soldiers”, should we consider allowing the use of steroids and other enhancement drugs?</p>
<p>The answer to this question isn’t clear cut. But there’s no reason to believe the use of enhancement drugs such as steroids by soldiers is, in and of itself, unethical. </p>
<h2>Are the ethics of using steroids on the battlefield the same as those in sport?</h2>
<p>In sport, critics of drug use are concerned with the integrity of the contest. Many consider a level playing field in sport to be an essential element of the fairness of a contest.</p>
<p>But there’s a fundamental difference of purpose between a drug policy designed to protect the integrity of sport and one to protect the integrity of armed forces.</p>
<p>The thought that one side in a battle shouldn’t employ technologies unavailable to their opponents is irrelevant to the conduct of war.</p>
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Read more:
<a href="https://theconversation.com/steroids-in-sport-zero-tolerance-to-testosterone-needs-to-change-48774">Steroids in sport: zero tolerance to testosterone needs to change</a>
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<p>Two things matter for the integrity of a military conflict, according to traditional “just war theory”. Firstly, that the cause is just, or fair. Within just war theory, self-defence is generally regarded as one such just cause.</p>
<p>And second, that the means employed to wage war discriminate between innocents and genuine combatants, and are proportionate.</p>
<p>The use of performance enhancing drugs therefore does not, as such, affect whether a war is fair, at least according to the just war theory.</p>
<h2>Risks and benefits</h2>
<p>The use of steroids is a serious issue when considering the health of soldiers. There’s evidence people who use steroids have a higher risk of various <a href="https://academic.oup.com/edrv/article/35/3/341/2354633">physical and psychological harms</a>, including cardiovascular disease and steroid dependence. </p>
<p>However, there are several issues with using such a simple dichotomy. First of all, life is generally full of risks, and simply avoiding them would mean we would live very sheltered and restricted lives.</p>
<p>Second, it has been well-established that many people use illicit drugs (including steroids) for <a href="https://pubmed.ncbi.nlm.nih.gov/17728122/">pleasurable</a> and <a href="https://www.sciencedirect.com/science/article/abs/pii/S2211266918300707">functional</a> reasons without necessarily experiencing serious harms. For these people, the benefits of using illicit substances outweigh their potential harms.</p>
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<p>The <a href="https://www.ipedinfo.co.uk/resources/downloads/2016%20National%20IPED%20Info%20Survey%20report%20FINAL.pdf">benefits of steroids</a> are obvious. Their use is associated with an increase in muscle strength and mass, reduced risk of injuries, and quicker recovery from injuries.</p>
<p>The use of battlefield medicine and technological developments (such as armour) have long sought to protect the physical and mental health of soldiers. For example, the prescription drug Modafinil, a drug licensed for the treatment of narcolepsy, <a href="https://www.chathamhouse.org/sites/default/files/2020-11/2020-11-11-pharma-enhancement-military-goodley_0.pdf">is approved for use</a> by the Republic of Singapore Air Force, and has been tested for military application in both the US and the UK.</p>
<p>Individuals who are sleep deprived have decreased psychological and physical capabilities. Soldiers often operate over long hours and are deprived of sleep. So using <a href="https://pubmed.ncbi.nlm.nih.gov/22764609/">stimulants like Modafinil</a> can support maintaining alertness, cognitive function, judgement, and situation awareness in sleep-deprived soldiers.</p>
<p>In a similar manner, steroids could potentially prove useful in protecting the bodies of soldiers.</p>
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Read more:
<a href="https://theconversation.com/doping-soldiers-so-they-fight-better-is-it-ethical-117236">Doping soldiers so they fight better – is it ethical?</a>
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<p>Having said this, special consideration needs to be given to the link between steroid use and aggression.</p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/33745011/">study</a> published in 2021 provides evidence of an increase, although small, in self-reported aggression in healthy males following steroid use. However, the relationship between aggression and steroid use is complex, and there are generally other mediating factors (such as other substance use and personality traits).</p>
<p>Regardless, the fact that steroid use may increase aggression when split-second decisions are required on the battlefield can be morally significant given these are often matters of life and death.</p>
<h2>Consent and coercion</h2>
<p>On the one hand, steroid use is a matter of personal and individual choice.</p>
<p>But on the other, there are tremendous social and cultural pressures to perform and succeed.</p>
<p>Competitive environments particularly, such as the military, have the potential to become highly stressful. As such, soldiers might well feel coerced by their peers and their superiors to undertake bodily or performance enhancement.</p>
<p>If steroids were to be allowed in the military, this would require informed consent.</p>
<p>But considering these pressures, satisfying the requirements of voluntary and informed consent for the use of illicit enhancement drugs within the military might well be challenging.</p>
<p>Such consent will often be undermined due to the pressures on soldiers to perform and succeed within the military.</p>
<h2>Not unethical, but studies needed</h2>
<p>There’s no reason to believe the use of enhancement drugs such as steroids is, in and of itself, unethical.</p>
<p>But there are concerns, such as the long-term health of soldiers, and any possible effects these drugs might have upon the behaviour of soldiers when in combat situations and when they return to society.</p>
<p>What’s required are robust empirical studies to determine the extent of the dangers.</p>
<p>Our list of such concerns isn’t intended to be exhaustive, but rather represents a list of issues that need to be addressed when developing any regulatory frameworks for the use of enhancement drugs in a military context.</p><img src="https://counter.theconversation.com/content/180947/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Just like armour protects soldiers’ bodies, steroids do too. There’s no reason to believe steroid use by the military is unethical, but further studies are needed.Katinka van de Ven, Senior Lecturer, Centre for Rural Criminology, HASSE, University of New England & Visiting Fellow, Drug Policy Modelling Program, SPRC, University of New South Wales, University of New EnglandAdrian Walsh, Professor of Philosophy and Political Theory, University of New EnglandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1768842022-03-08T19:03:02Z2022-03-08T19:03:02ZI’m at home with COVID. When do I need to see a doctor? And what treatments are available?<figure><img src="https://images.theconversation.com/files/448186/original/file-20220224-15-xyr56t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sick-man-cold-lying-bed-blow-496461661">Shutterstock</a></span></figcaption></figure><p>Sorry to hear you tested positive.</p>
<p>Fortunately, for most people – and especially those who are vaccinated – COVID won’t lead to serious illness. Around <a href="https://www.acpjournals.org/doi/full/10.7326/M20-6976">30% of people</a> with COVID won’t have any symptoms.</p>
<p>People with mild and even moderate COVID are likely to be managed at home, rather than going to hospital.</p>
<p>In the past month, new drug treatments have become available for people with mild COVID who are at risk of more severe disease. </p>
<h2>Symptoms to expect</h2>
<p>Common symptoms include sore throat, cough, headache and fatigue. </p>
<p>Some people may also experience muscle pain, nausea, vomiting, diarrhoea, or loss of taste and smell. </p>
<p>You can treat these as you normally would, with paracetamol or ibuprofen, plenty of fluids, rest and patience. </p>
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Read more:
<a href="https://theconversation.com/at-home-with-covid-5-easy-tips-to-help-you-breathe-more-easily-176249">At home with COVID? 5 easy tips to help you breathe more easily</a>
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<h2>Some people are at greater risk of severe disease</h2>
<p>Most people with COVID will only ever have mild symptoms, and will recover in one to two weeks without the need for any treatment. </p>
<p>Some people are at higher risk of developing serious illness from COVID because they are:</p>
<ul>
<li>over 65 years, or over 50 years for Aboriginal and Torres Strait Islander people</li>
<li>unvaccinated or partially vaccinated</li>
<li>pregnant.</li>
</ul>
<p>And/or because they have one or more of the following underlying conditions: </p>
<ul>
<li>lung disease, including chronic obstructive lung disease, asthma or bronchiectasis</li>
<li>heart disease</li>
<li>obesity (body mass index over 30 kg/m2)</li>
<li>diabetes</li>
<li>kidney failure</li>
<li>immunocompromising conditions (weakened immune system).</li>
</ul>
<figure class="align-center ">
<img alt="Woman in bed with COVID, wearing a mask, holding a mug of tea." src="https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/448182/original/file-20220223-21-1sffkcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some people are at risk of developing severe COVID.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sick-elderly-woman-covid19-lies-bed-1687230346">Shutterstock</a></span>
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<p>If you have one or more of these risk factors, talk to your GP, particularly if you’re not up-to-date with your COVID vaccinations. </p>
<p>Your GP might suggest you use a pulse oximeter to keep a track of the oxygen levels in your blood. </p>
<p>Falling oxygen levels (below 92%) can indicate you’re developing more serious illness, and might need to head to hospital for further treatment. </p>
<p>If you have severe trouble breathing or severe chest pain, call 000 for an ambulance to take you to hospital. </p>
<h2>What treatments are available for mild COVID?</h2>
<p>If you’re in a higher-risk group, your GP will also assess whether you might benefit from one of the new medications now <a href="https://covid19evidence.net.au/">available to treat COVID</a>:</p>
<ul>
<li><p>the oral antiviral tablets nirmatrelvir plus ritonavir (Paxlovid) or molnupiravir (Lagevrio)</p></li>
<li><p>the monoclonal antibody sotrovimab (Xevudy), which is given as a single injection at a hospital infusion centre. </p></li>
</ul>
<p>These medications can reduce the risk of serious illness in people who aren’t vaccinated and have risk factors for severe disease. </p>
<p>Ritonavir and molnupiravir affect the way the virus replicates, while sotrovimab enhances the body’s immune response.</p>
<p>They may also benefit people who are vaccinated, but for whom vaccination is less likely to work because their immune systems are less effective. This includes people who have had an organ transplant and those with conditions requiring immune-suppressing treatment, such as rheumatoid arthritis, Crohn’s disease, multiple sclerosis and cancer, for those undergoing chemotherapy.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/taking-covid-pills-at-home-sounds-great-but-we-need-to-use-them-wisely-or-risk-drug-resistance-and-new-variants-176235">Taking COVID pills at home sounds great. But we need to use them wisely or risk drug resistance and new variants</a>
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<p>These medications need to be given within five days of symptoms developing, so it’s important you talk to your GP as soon as possible. </p>
<p>Your GP will carefully consider the benefits of these medications for you, given your health status and other factors, as well as the risks. Each of <a href="https://www.tga.gov.au/sites/default/files/xevudy-cmi.pdf">these drugs</a> have potential <a href="https://www.nps.org.au/assets/NPS/pdf/NPSMW2438_COVID-Antivirals-Factsheet.pdf">side effects</a>.</p>
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<img alt="Carer talks to elderly person in wheelchair." src="https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/448193/original/file-20220224-13-8ayfoz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Medications can benefit people who are vaccinated but have weakened immune systems.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-asian-grandchild-taking-care-her-1818568841">Shutterstock</a></span>
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<h2>Who shouldn’t have them?</h2>
<p>These drugs aren’t suitable for everyone. </p>
<p><a href="https://www.tga.gov.au/sites/default/files/paxlovid-pi.pdf">Paxlovid</a> (nirmatrelvir/ritonavir), for example, has potentially serious interactions with several common medications for high blood pressure, epilepsy, depression and others. </p>
<p>None of the oral antivirals are recommended in pregnancy. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-sotrovimab-the-covid-drug-the-government-has-bought-before-being-approved-for-use-in-australia-165802">What is sotrovimab, the COVID drug the government has bought before being approved for use in Australia?</a>
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</em>
</p>
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<h2>What else might a GP prescribe?</h2>
<p>If you have mild or moderate COVID at home, and are at risk of developing serious illness, your GP might also suggest you take inhaled steroids. </p>
<p>Budesonide and ciclesonide are steroid medications which are also used in asthma. </p>
<p><a href="https://app.magicapp.org/#/guideline/L4Q5An/rec/jmYQkW">Research</a> suggests they may decrease the risk of deterioration from COVID and may accelerate recovery if started within 14 days of your first symptoms.</p>
<figure class="align-center ">
<img alt="Woman consults a doctor via telehealth." src="https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/448192/original/file-20220224-23-83ia0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Talk to your GP as soon as possible, as many COVID medications need to be started within five days of developing symptoms.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/online-telehealth-visit-woman-who-hurt-1703122093">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What happens if you get worse?</h2>
<p>Most people with mild COVID recover without any treatment, but if your symptoms start getting worse, or your blood oxygen levels start to fall, your GP might decide it’s best for you to head to hospital where other treatment options are available. </p>
<p>In hospital, you might be given drugs such as:</p>
<ul>
<li><p>remdesivir (an intravenous antiviral drug) which affects the way the virus replicates</p></li>
<li><p>dexamethasone, baricitinib or tocilizumab. These powerful anti-inflammatory drugs reduce the damaging effects the body’s inflammatory response can have on the lungs. </p></li>
</ul>
<p>You may also need support for your breathing. </p>
<h2>Can I take my normal medications?</h2>
<p>In most cases, you can and should continue to take your existing medications for conditions such as asthma, diabetes or high blood pressure. </p>
<p>Talk to your doctor if you are taking oral menopause hormonal therapies (MHT, also sometimes called hormone replacement therapy or HRT). Your doctor may suggest that you stop these until you have recovered. Both severe COVID and some forms of menopause hormonal therapies can increase the risk of developing blood clots. </p>
<h2>New treatments don’t replace vaccination</h2>
<p>New treatments for COVID are a welcome addition, especially for those who can’t be vaccinated or for whom vaccination is unlikely to be effective. </p>
<p>The COVID research pipeline is <a href="https://www.nature.com/articles/d41586-022-00562-0">expected to deliver</a> more new treatments for COVID in 2022 and the <a href="https://covid19evidence.net.au/">National COVID-19 Clinical Evidence Taskforce</a> will review this new research and update our guidance as the evidence emerges.</p>
<p>However vaccination remains the best form of defence against serious disease and death for COVID.</p><img src="https://counter.theconversation.com/content/176884/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tari Turner receives funding from the Australian Government Department of Health to support the work of the National COVID-19 Clinical Evidence Taskforce.</span></em></p><p class="fine-print"><em><span>Bridget Barber is affiliated with the National COVID-19 Clinical Evidence Taskforce.
</span></em></p><p class="fine-print"><em><span>Josh Davis receives salary funding (career development fellowship) and project funding (SNAP trial grant) from the NHMRC. He is affiliated with the National COVID-19 Clinical Evidence Taskforce.
</span></em></p><p class="fine-print"><em><span>Executive Director of the National COVID-19 Clinical Evidence Taskforce</span></em></p>Most people with COVID will recover at home without any treatment. But some people who are at risk of severe disease could benefit from new medicines to reduce the chance of the disease progressing.Tari Turner, Director, Evidence and Methods, National COVID-19 Clinical Evidence Taskforce; Associate Professor (Research), Cochrane Australia, School of Population Health and Preventive Medicine, Monash University, Monash UniversityBridget Barber, Associate Professor, infectious diseases, QIMR Berghofer Medical Research InstituteJosh Davis, Professor - School of Medicine and Public Health, University of NewcastleSteven McGloughlin, Director Intensive Care Unit Alfred Health and Adjunct Associate Professor Epidemiology and Preventative Medicine Monash University, The National Trauma Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657302021-11-23T01:54:57Z2021-11-23T01:54:57ZWe expected people with asthma to fare worse during COVID. Turns out they’ve had a break<figure><img src="https://images.theconversation.com/files/431230/original/file-20211110-19-1bg65ie.jpg?ixlib=rb-1.1.0&rect=499%2C0%2C6229%2C2417&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There were fears at the beginning of the COVID pandemic that people with asthma would fare much worse than those without it. Intuitively, a disease that attacks the lungs should put asthma sufferers at much greater risk.</p>
<p>But this hasn’t been borne out.</p>
<p>Firstly, it’s turned out people with asthma are at <a href="https://doi.org/10.1111/resp.14003">slightly lower</a> <a href="https://asthma.org.au/wp-content/uploads/2020/10/COVID-rapid-review_Summarised-report-for-technical-audience-VF-clean_v2.pdf">risk of acquiring COVID</a>, being <a href="https://www1.racgp.org.au/newsgp/clinical/why-are-patients-with-asthma-not-at-increased-susc">hospitalised with it</a> or indeed dying from it compared to people without asthma. Though, someone with asthma who is hospitalised with COVID is <a href="https://asthma.org.au/wp-content/uploads/2020/10/COVID-rapid-review_Summarised-report-for-technical-audience-VF-clean_v2.pdf">slightly more likely to require ICU admission</a>.</p>
<p>In addition, asthma attack rates have <a href="https://www.bmj.com/company/newsroom/fewer-people-sought-medical-help-for-severe-asthma-attacks-during-the-covid-19-pandemic/">substantially</a> <a href="https://doi.org/10.1016/j.jaip.2021.04.038">reduced</a> in many parts of the world.</p>
<p>What explains this?</p>
<h2>Asthma sufferers aren’t getting sicker from COVID</h2>
<p>Asthma is an umbrella term for a range of diseases of the airways, which have similar outcomes – constriction of the airways causing difficulty breathing. In some forms of asthma the constriction is a result of inflammation, or rash, within the lung.</p>
<p>Many people with asthma take asthma preventers, which are a type of steroid drug we lung experts call “inhaled corticosteroids”. These drugs reduce the amount of inflammation in the lungs.</p>
<p>Interestingly, another steroid, <a href="https://theconversation.com/dexamethasone-the-cheap-old-and-boring-drug-thats-a-potential-coronavirus-treatment-140932">dexamethasone</a>, is being used as a treatment for COVID for this same reason.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dexamethasone-the-cheap-old-and-boring-drug-thats-a-potential-coronavirus-treatment-140932">Dexamethasone: the cheap, old and boring drug that's a potential coronavirus treatment</a>
</strong>
</em>
</p>
<hr>
<p>Asthmatics might be <a href="https://www1.racgp.org.au/newsgp/clinical/why-are-patients-with-asthma-not-at-increased-susc">inadvertently reducing the risk of severe COVID</a> if they contract it by regularly using their preventers, because they are “pre-treated” if you like.</p>
<p>Indeed some preventers are thought to be “anti SARS-CoV-2”, that is, they have <a href="https://www.thelancet.com/article/S2213-2600(21)00160-0/fulltext">some ability to kill the virus</a> that causes COVID. </p>
<p>What’s more, <a href="https://doi.org/10.1111/resp.14003">some good evidence from Australia</a> demonstrates that patients with asthma have decreased “ACE2 gene expression”. ACE2 is the point of entry for the SARS-CoV-2 virus to get into our cells.</p>
<p>If you have less ACE2 then there are fewer gateways for the virus to enter our cells, and there’s less opportunity for the infection to take hold.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928">What is the ACE2 receptor, how is it connected to coronavirus and why might it be key to treating COVID-19? The experts explain</a>
</strong>
</em>
</p>
<hr>
<h2>Why have asthma attacks declined?</h2>
<p>There a number of possible reasons why asthma attacks have declined.</p>
<p>Asthma is a chronic condition which can flare up when sufferers are exposed to their “triggers”. Common ones are pollens, chemicals, dust mites, pets, mould, smoke, or viruses.</p>
<p>Social distancing and locking down millions of people around the world has been a real time case study in what staying at home would do to asthma rates.</p>
<p>Because people in lockdown go outside a lot less, it could reduce their exposure to pollen and other allergens and irritants outdoors such as smoke, thereby reducing asthma attacks.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1413669341334224896"}"></div></p>
<p>What’s more, social distancing and lockdowns also significantly reduce the number of interactions between people, thereby reducing the spread of infectious diseases. We’ve been able to reduce COVID cases this way, and flu cases too. </p>
<p>In 2019, there were <a href="https://www.guild.org.au/__data/assets/pdf_file/0025/84229/Influenza-Report-30-October-2019.pdf">302,084 flu cases</a> notified to health departments in Australia. And that was with a significant proportion of the population vaccinated.</p>
<p>In 2021, up to November 7, there have been just <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-ozflu-flucurr.htm">598 flu cases</a>.</p>
<p>Along with this, we can presume there have been far fewer common colds and other types of infectious diseases.</p>
<p>Viruses can cause asthma flare ups, which is known by lung experts as “viral exacerbation of asthma”. So fewer people with colds and the flu could also <a href="https://doi.org/10.1136/bmj.m2806">contribute to lower asthma attack rates</a>.</p>
<p>There have also been reports of <a href="https://www.bmj.com/company/newsroom/fewer-people-sought-medical-help-for-severe-asthma-attacks-during-the-covid-19-pandemic/">fewer people seeking medical care</a> for fear of contracting COVID in health-care settings, which may be another reason for fewer people seeking care for asthma. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1438252369435709447"}"></div></p>
<h2>What will happen to asthma post-COVID?</h2>
<p>We’re used to tolerating a certain level of many infectious diseases in the community, particularly things like common colds, strep throat, even glandular fever and the flu.</p>
<p>For many of us, this is no big deal and the only effects are feeling not great for a few days or weeks of the year.</p>
<p>But for many others, these sorts of common infectious illnesses can be deadly. Think about someone with cystic fibrosis, which severely damages the lungs and digestive system. If they get a cold or the flu, it can seriously knock them around, or even kill them. Same with someone who takes medications to depress their immune system, for example people with rheumatoid arthritis.</p>
<p>These infections result in many hospitalisations, which puts pressure on the whole hospital system.</p>
<p>From COVID, we know there are simple measures we can take to substantially reduce the transmission of these seemingly “benign” diseases, including wearing masks, not going to work or socialising when you’re sick, and washing/sanitising your hands regularly.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1457578153107415043"}"></div></p>
<p>We’ve reached the milestone of having <a href="https://www.reuters.com/world/asia-pacific/australia-hits-magnificent-milestone-with-80-rate-vaccinations-2021-11-06/">more than 80% of Australians over 16 fully vaccinated</a> against COVID, and <a href="https://www.reuters.com/world/asia-pacific/australia-eases-international-border-ban-first-time-since-march-2020-2021-10-31/">international travel is resuming</a>. Returning travellers are likely to bring with them new flu strains that we’re totally unprepared for.</p>
<p>Usually flu vaccines for Australia are designed to tackle strains from the Northern Hemisphere winter so we’re prepared for when the new strain arrives in our winter.</p>
<p>But there has been such little flu overseas, and with the understandable focus on COVID, our vaccines for flu and other existing conditions may need to be revisited.</p>
<p>Not revisiting existing vaccines for flu and other previously common conditions may lead to a <a href="https://www.abc.net.au/news/2021-09-16/queensland-what-happened-to-the-flu-in-2021/100456616">wave of flu</a> and many other diseases, given we’ll have limited <a href="https://www.economist.com/britain/2021/08/19/out-of-lockdown-britons-are-discovering-other-viruses-still-exist">immunity to them</a>.</p>
<p>So we may soon see asthma attacks take off again, exacerbated by viruses.</p><img src="https://counter.theconversation.com/content/165730/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Thompson receives research funding from the NHMRC, is immediate past president of the Thoracic Society of Australia and New Zealand and has received speaker fees from GSK, Mundipharma, Chiesi and Astra Zeneca.</span></em></p>Not only have asthma attack rates decreased during the pandemic, evidence suggests people with asthma are not at increased risk of severe outcomes from COVID.Bruce Thompson, Professor and Dean of the School of Health Sciences, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1556342021-03-01T13:17:35Z2021-03-01T13:17:35Z6 COVID-19 treatments helping patients survive<figure><img src="https://images.theconversation.com/files/386857/original/file-20210228-144318-1vaegg6.jpg?ixlib=rb-1.1.0&rect=729%2C6%2C3360%2C2146&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New treatments target different stages of COVID-19, including before patients become sick enough to need a hospital.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-doctor-checking-on-covid-19-infected-patient-royalty-free-image/1217660650">Juan Monino via Getty Images</a></span></figcaption></figure><p>A year ago, when U.S. health authorities issued their first warning that COVID-19 would cause <a href="https://www.cdc.gov/media/releases/2020/t0225-cdc-telebriefing-covid-19.html">severe “disruption to everyday life,”</a> doctors had no effective treatments to offer beyond supportive care.</p>
<p>There is still no quick cure, but thanks to an unprecedented global research effort, several treatments are helping patients survive COVID-19 and stay out of the hospital altogether. </p>
<p>COVID-19 treatments target <a href="https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/">two broad problems</a>: the coronavirus’s ability to spread through the body, and the damage caused by the body’s <a href="https://doi.org/10.1038/s41586-020-03148-w">immune system response</a>. When the virus enters the body, it takes over cells and uses them to replicate itself. In response, the body sends inflammatory signals and <a href="https://www.sciencedirect.com/science/article/pii/S0012369220351576">immune cells</a> to fight the virus. In some patients, that inflammatory response can continue even after the virus is under control, leading to damage in the lungs and other organs. </p>
<p>The best tool is prevention, including using <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html">face masks</a> and vaccines. Vaccines train the immune system to fight off attackers. With less risk of an uncontrolled infection, they can cut the risk of death from COVID-19 to <a href="https://www.gov.il/en/departments/news/20022021-01">near zero</a>. But vaccine supplies are limited, even with a <a href="https://theconversation.com/how-does-the-johnson-and-johnson-vaccine-compare-to-other-coronavirus-vaccines-4-questions-answered-155944">third vaccine now authorized for U.S. use</a>, so treatments for infected patients remain crucial.</p>
<p>As <a href="https://profiles.dom.pitt.edu/PACCM/faculty_info.aspx/Bain7069">doctors who</a> <a href="https://profiles.dom.pitt.edu/PACCM/faculty_info.aspx/Suber7040">work with</a> <a href="https://profiles.dom.pitt.edu/PACCM/faculty_info.aspx/Kitsios6908">COVID-19 patients</a>, we have been following the drug trials and success stories. Here are six treatments commonly used today for COVID-19. As you’ll see, timing matters.</p>
<h2>Treatments that can keep you out of the hospital</h2>
<p>Two promising types of treatments involve injecting antiviral antibodies into high-risk COVID-19 patients before the person becomes severely ill.</p>
<p>Our bodies naturally create antibodies to <a href="https://www.nih.gov/news-events/nih-research-matters/decoding-variety-human-antibodies">recognize foreign invaders</a> and help fight them off. But natural antibody production takes several days, and SARS-CoV-2 – the coronavirus that causes COVID-19 – replicates fast. Studies show that injecting patients with antibodies soon after symptoms begin can help protect patients against serious infection.</p>
<figure class="align-center ">
<img alt="Chart of treatments" src="https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=356&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=356&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=356&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=447&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=447&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386252/original/file-20210224-19-hu120q.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=447&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Treatments for COVID-19 and their timing.</span>
<span class="attribution"><span class="source">Georgios D. Kitsios</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p><strong>Monoclonal antibodies:</strong> These lab-engineered antibodies can bind to SARS-CoV-2 and prevent the virus from entering cells and infecting them. They include <a href="https://www.fda.gov/media/143605/download">Bamlanivimab</a> and the combined therapy <a href="https://www.fda.gov/media/143894/download">casirivimab/imdevimab</a> developed by Regeneron. The U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibodies-treatment-covid-19-0">granted emergency use authorization</a> for these therapies because they have been found to protect high-risk patients from hospitalization and death. Once patients are sick enough to need hospitalization, however, studies <a href="http://doi.org/10.1056/NEJMoa2033130">haven’t found a proven benefit</a> from them. </p>
<p><strong>Convalescent plasma:</strong> Another way to deliver antibodies involves blood drawn from patients who have recovered from COVID-19. Convalescent plasma is primarily given in research settings because the clinical evidence so far is mixed. Some trials show <a href="http://doi.org/10.1056/NEJMoa2033700">benefits early in the disease</a>. Other studies have <a href="https://www.recoverytrial.net/files/recovery_statement_cp_2021-01-15_final.pdf">not shown any benefit in hospitalized patients</a>. </p>
<p>There may be a role for convalescent plasma as a supplemental therapy for some patients because of the <a href="https://science.sciencemag.org/content/early/2021/02/02/science.abf6950">growing threat of mutated SARS-CoV-2 variants</a>, which may evade monoclonal antibody therapy. However, careful research is necessary.</p>
<h2>Treatments for hospitalized patients</h2>
<p>Once patients become so sick that they have to be hospitalized, treatments change. </p>
<p>Most hospitalized patients have difficulty breathing and low oxygen levels. Low oxygen occurs when the virus and corresponding immune response injure the lungs, resulting in swelling in lung air sacs that restricts the amount of oxygen getting into the blood. Patients hospitalized with COVID-19 usually need supplemental medical oxygen to help them breathe. Doctors frequently treat patients on oxygen with the antiviral agent remdesivir and anti-inflammatory corticosteroids. </p>
<figure class="align-center ">
<img alt="A physical therapist talks with a COVID-19 patient in Cranston, Rhode Island." src="https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386861/original/file-20210228-13-s0warc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most hospitalized COVID-19 patients have trouble breathing and getting enough oxygen.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakFieldHospitalPhotoEssay/cec76efd357b4a138db53f2a87683178/photo">AP Images/David Goldman</a></span>
</figcaption>
</figure>
<p><strong>Remdesivir</strong>: Remdesivir, originally designed to treat hepatitis C, stops the coronavirus from replicating itself by <a href="http://doi.org/10.1074/jbc.RA120.013679">interfering with its genetic building blocks</a>. It has been shown to <a href="http://doi.org/10.1056/NEJMoa2007764">shorten the length of hospital stays</a>, and doctors may prescribe it to patients on oxygen shortly after arrival in the hospital. </p>
<p><strong>Corticosteroids</strong>: <a href="https://theconversation.com/steroids-cut-covid-19-death-rates-but-not-for-everyone-heres-who-benefits-and-who-doesnt-145605">Steroids</a> calm the body’s immune response and have been used for decades to treat inflammatory disorders. They are also widely available, cheap and well-studied medications, so they were among the first therapies to enter clinical trials for COVID-19. Several studies have shown that low-dose steroids reduce deaths in hospitalized patients who are on oxygen, including the sickest patients in the intensive care unit, or ICU. Following the findings of the landmark <a href="http://doi.org/10.1056/NEJMoa2021436">RECOVERY</a> and <a href="http://doi.org/10.1001/jama.2020.17022">REMAP-CAP</a> COVID-19 studies, steroids are now the standard of care for patients hospitalized with COVID-19 who are treated with oxygen. </p>
<p><strong>Blood thinners</strong>: Inflammation during COVID-19 and other viral infections can also increase the risk of blood clots, which can cause <a href="http://doi.org/10.1056/NEJMoa1702090">heart attacks</a>, <a href="http://doi.org/10.1056/NEJMc2009787">strokes</a> and dangerous <a href="http://doi.org/10.1001/jama.2020.13372">clots in the lungs</a>. Many patients with COVID-19 are given the blood thinners heparin or enoxaparin to prevent clots before they occur. Early data from a <a href="https://www.nih.gov/research-training/medical-research-initiatives/activ">large trial of COVID-19 patients</a> suggests that hospitalized patients <a href="https://www.nih.gov/news-events/news-releases/full-dose-blood-thinners-decreased-need-life-support-improved-outcome-hospitalized-covid-19-patients">benefit from higher doses</a> of blood thinners. </p>
<p>Some patients with COVID-19 become so sick that they need an ICU for high levels of oxygen support or a ventilator to help them breathe. There are several therapies available for ICU patients, but <a href="https://www.nih.gov/news-events/news-releases/nih-activ-trial-blood-thinners-pauses-enrollment-critically-ill-covid-19-patients">ICU patients have not been found to benefit</a> from high doses of blood thinners. </p>
<h2>Treating the sickest patients</h2>
<p>ICU patients with COVID-19 are <a href="http://doi.org/10.1001/jama.2020.17023">more likely to survive</a> if they receive steroids, studies have found. However, low-dose steroids alone may not be enough to curb excessive inflammation.</p>
<p><strong>Tocilizumab:</strong> Tocilizumab is a lab-generated antibody that blocks the interleukin-6 pathway, which can cause inflammation during COVID-19 and other diseases. <a href="https://doi.org/10.1101/2021.01.07.21249390">New results</a> from the REMAP-CAP trial that have not yet been peer-reviewed suggest that a single dose of tocilizumab given within one to two days after being placed on respiratory support reduced the risk of death in patients already receiving low-dose steroids. Tocilizumab has also been shown to benefit patients with high levels of inflammation in early results from <a href="https://doi.org/10.1101/2021.02.11.21249258">another trial</a>.</p>
<p>These innovative therapies can help, but careful supportive care in the ICU is also crucial. <a href="https://www.atsjournals.org/page/ajrccm/collections/fifty-years-of-research-in-ards">Decades of extensive research</a> have defined core management principles for helping patients with severe lung infections who need ventilators. These include <a href="http://doi.org/10.1056/NEJM200005043421801">avoiding underinflation and overinflation</a> of the lung by the ventilator, treating pain and anxiety with low levels of sedative medications, and periodically placing certain patients with low oxygen levels <a href="http://doi.org/10.1056/NEJMoa1214103">on their belly</a>, among many other interventions. The same key principles likely apply to <a href="https://doi.org/10.1513/AnnalsATS.202008-1026OC">patients with COVID-19</a> to help them survive and recover from a critical illness that can last weeks or months. </p>
<p>Medical progress since the start of the pandemic has been awe-inspiring. Doctors now have vaccines, antiviral antibodies for high-risk outpatients and several treatments for hospitalized patients. Continued research will be crucial to improve our ability to fight a disease that has already claimed <a href="https://coronavirus.jhu.edu/map.html">more than 2.5 million lives</a> worldwide.</p><img src="https://counter.theconversation.com/content/155634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William G. Bain receives research funding from the United States Department of Veterans Affairs; the National Institutes of Health; the University of Pittsburgh Vascular Medicine Institute, the Hemophilia Center of Western Pennsylvania; and the Institute for
Transfusion Medicine. </span></em></p><p class="fine-print"><em><span>Georgios D. Kitsios has received research funding from the National Institutes of Health, the Clinical and Translational Science Institute at the University of Pittsburgh, and Karius, Inc.</span></em></p><p class="fine-print"><em><span>Tomeka L. Suber receives research funding from the National Institutes of Health, Burroughs Wellcome Fund, and the Samuel and Emma Winters Foundation.</span></em></p>A year after it became clear that COVID-19 was becoming a pandemic, there is still no cure, but doctors have several innovative treatments. Some are keeping patients out of the hospital entirely.William G. Bain, Assistant Professor of Medicine, University of PittsburghGeorgios D. Kitsios, Assistant Professor of Medicine, University of PittsburghTomeka L. Suber, Assistant Professor of Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1531782021-02-19T13:19:19Z2021-02-19T13:19:19ZWomen of color spend more than $8 billion on bleaching creams worldwide every year<figure><img src="https://images.theconversation.com/files/382789/original/file-20210205-13-1d5k6lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Skin-lightening creams for sale in a shop in New Delhi, India, in 2020. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/this-photo-taken-on-july-8-2020-shows-packages-of-unilever-news-photo/1226007169?adppopup=true">Sajjad Hussain / Getty Images</a></span></figcaption></figure><figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=255&fit=crop&dpr=1 600w, https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=255&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=255&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=321&fit=crop&dpr=1 754w, https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=321&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/384056/original/file-20210212-17-19nbl8g.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=321&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>The idealization of light skin as the pinnacle of beauty <a href="https://www.nytimes.com/2016/11/26/fashion/skin-bleaching-south-africa-women.html">affects self-esteem</a> for women of color around the world. In many cultures, skin color is a <a href="https://doi.org/10.3389/fpsyg.2019.01516">social benchmark</a> that is often used by people of color and whites alike in lieu of race. Attractiveness, marriageability, career opportunities and socioeconomic status are directly <a href="https://www.nytimes.com/2010/01/16/health/16skin.html">correlated</a> with skin color. </p>
<p>As a result, many women of color seek chemical remedies to lighten their complexion. They have created a booming global business in bleach creams and <a href="https://www.un.org/africarenewal/magazine/april-2019-july-2019/paying-high-price-skin-bleaching">injectables</a> valued at <a href="https://www.strategyr.com/market-report-skin-lighteners-forecasts-global-industry-analysts-inc.asp">US$8.6 billion</a> in 2020; $2.3 billion was spent in the U.S. alone. The market is projected to reach $12.3 billion by 2027. </p>
<p>In my <a href="https://scholar.google.com/citations?user=lfBeq78AAAAJ&hl=en">work</a> in behavioral science and colorism, I studied the phenomenon of skin bleaching during a decade of travel around the world during which I visited every major racial group – and tracked the <a href="https://theconversation.com/bleached-girls-india-and-its-love-for-light-skin-80655">growth of this industry</a>. The practice has both significant racial implications and health concerns. </p>
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<figcaption><span class="caption">A new Netflix documentary called ‘Skin’ explores the practice of skin bleaching in African culture.</span></figcaption>
</figure>
<h2>A common practice</h2>
<p>As I stated during my interview on Oprah’s 2015 “Light Girls” documentary, while bleaching the skin is common, it’s both <a href="https://tubitv.com/movies/514763/light-girls">dangerous and potentially life-threatening</a> because products contain steroids, hydroquinone bleach and mercury. The World Health Organization <a href="https://www.washingtonpost.com/politics/2019/06/15/dangerous-skin-bleaching-has-become-public-health-crisis-corporate-marketing-lies-behind-it/">warns</a> that skin bleaching can cause liver and kidney damage, neurological problems, cancer and, for pregnant women, stillbirth.</p>
<p>The practice is not new. It became <a href="https://www.un.org/africarenewal/magazine/april-2019-july-2019/paying-high-price-skin-bleaching">popular in many African countries</a> in the 1950s; today, about 77% of Nigerians, 27% of Senegalese and 35% of South African women bleach their skin. Indian caste-based discrimination was outlawed in 1950, but dark-skinned women (and men) are still <a href="https://www.pri.org/stories/2019-03-05/even-harvard-pedigree-caste-follows-shadow">persecuted</a> – and fair skin remains a distinguishing social factor, associated with purity and elite status. </p>
<p>In the Middle East, the practice of bleaching is most common in <a href="https://doi.org/10.1111/j.1365-4632.2010.04463.x">Jordan</a>, with 60.7% of women bleaching. The Brazilian government seems to sanction white skin over dark by encouraging <a href="https://openscholarship.wustl.edu/cgi/viewcontent.cgi?article=1551&context=law_globalstudies">immigration from Europe and discouraging persons of African descent</a>. </p>
<p>Light skin is idealized in North America, but the phenomenon is contentious because bleaching is perceived as a desire to be white. So bleaching creams are <a href="https://www.latimes.com/archives/la-xpm-2006-aug-30-na-skincream30-story.html">marketed in the U.S.</a> not to lighten skin, but to “erase blemishes” and “age spots.”</p>
<p>Their <a href="https://theconversation.com/black-americas-bleaching-syndrome-82200">use in the U.S. spiked</a> after the 1967 U.S. Supreme Court <a href="https://scholar.google.com/scholar_case?case=5103666188878568597&q=Loving+v.+Virginia&hl=en&as_sdt=6,33&as_vis=1">ruling</a> that legalized interracial marriage. </p>
<p>In the aftermath of the civil rights movement, dark-complected immigrants from developing countries flocked to the U.S., carrying with them an ideal of light-skinned beauty – and they <a href="https://www.law.uci.edu/lawreview/vol3/no4/Jones.pdf">bleached their skin to attain it</a>. </p>
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<figcaption><span class="caption">Ideals of light-skinned beauty stemming from European colonization contributed to a lucrative bleach cream industry.</span></figcaption>
</figure>
<h2>Perpetuating ‘colorism’</h2>
<p>Bleach cream manufacturers now face growing pressure to address racism, with activists arguing that their products perpetuate a preference for lighter skin. In 2020, Johnson & Johnson announced that it will <a href="https://www.nytimes.com/2020/06/19/business/johnson-and-johnson-skin-whitening-cream.html">no longer sell</a> two products marketed to reduce dark spots that were widely used as skin lighteners. </p>
<p>L’Oreal, the world’s largest producer of bleach creams, pledged to <a href="https://www.forbes.com/sites/jemimamcevoy/2020/06/26/loreal-unilever-reassess-skin-lightening-products-but-wont-quit-the-multi-billion-dollar-market/?sh=5481ae19223a">remove</a> the words “white,” “fair,” and “light” from labels – but it will still manufacture these products. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Some among African countries have moved to <a href="https://www.voanews.com/archive/east-african-countries-move-ban-skin-bleaching-products">ban</a> bleaching creams. The success of the blockbuster film “Black Panther” has likewise sparked a movement celebrating dark skin, with hashtags including #melaninpoppin and #blackgirlmagic. </p>
<p>As I see it, public education and activism on this issue must prevail to protect the health and self-esteem of women of color. The failure of either will only prolong the problem – while sustaining an $8.6 billion bleach cream beauty industry.</p><img src="https://counter.theconversation.com/content/153178/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald E. Hall does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fair skin as a beauty ideal underpins the global bleach cream industry – valued at $8.6 billion. There is a nascent backlash against the practice, which endangers health and can perpetuate racism.Ronald E. Hall, Professor of Social Work, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1493562020-11-16T13:24:14Z2020-11-16T13:24:14ZWhat monoclonal antibodies are – and why we need them as well as a vaccine<figure><img src="https://images.theconversation.com/files/369350/original/file-20201113-13-73ma5p.jpg?ixlib=rb-1.1.0&rect=26%2C35%2C5964%2C3943&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Y-shaped proteins called antibodies are vital for attacking and destroying the virus.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/molecular-model-of-immunoglobulin-royalty-free-image/1133973940?adppopup=true">Dr_Microbe/Getty Images</a></span></figcaption></figure><p>When <a href="https://www.npr.org/sections/latest-updates-trump-covid-19-results/2020/10/03/919898777/timeline-what-we-know-of-president-trumps-covid-19-diagnosis">President Trump was diagnosed with COVID-19</a>, <a href="https://theconversation.com/trump-is-taking-the-latest-in-covid-19-treatments-heres-what-doctors-know-works-against-the-virus-147398">one of the cutting-edge experimental therapies</a> he received was a mixture of monoclonal antibodies. But now a vaccine <a href="https://theconversation.com/why-we-didnt-get-a-vaccine-by-election-day-but-why-we-may-get-one-soon-149690">may soon be available.</a> So are other therapies necessary or valuable? And what exactly is a monoclonal antibody? </p>
<p>Over the past few months, the public has learned about <a href="https://theconversation.com/trump-is-taking-the-latest-in-covid-19-treatments-heres-what-doctors-know-works-against-the-virus-147398">many treatments</a> being used to combat COVID-19. An antiviral like <a href="https://www.covid19treatmentguidelines.nih.gov/antiviral-therapy/remdesivir/">remdesivir</a> <a href="https://theconversation.com/remdesivir-explained-what-makes-this-drug-work-against-viruses-137751">inhibits the virus from replicating</a> in human cells. <a href="https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/blood-derived-products/convalescent-plasma/">Convalescent plasma</a> from the blood of donors who have recovered from COVID-19 may contain antibodies that suppress the virus and inflammation. Steroids like <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2021436">dexamethasone</a> may modify and reduce the dangerous inflammatory damage to the lungs, thereby slowing respiratory failure. </p>
<p>The FDA issued emergency use authorization for <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibody-treatment-covid-19">Eli Lilly’s monoclonal antibody, called bamlanivimab</a>, and <a href="https://www.fiercepharma.com/manufacturing/regeneron-predicts-300-000-covid-19-cocktail-doses-ready-by-january-and-substantially">Regeneron is waiting for FDA’s green light</a> for its antibody treatment. Monoclonal antibodies are particularly promising in therapy because they can neutralize the SARS-CoV-2 virus, which causes COVID-19, and block its ability to infect a cell. This might be a lifesaving intervention in people who are unable to mount a strong natural immune response to the virus – those over 65 or with existing conditions that make them more vulnerable.</p>
<p>I’ve worked in <a href="https://rodneyerohde.wp.txstate.edu/">public health and medical laboratories</a> for decades, specializing in the study of viruses and other microbes. Even when a vaccine for COVID-19 becomes available, I see a role for monoclonal antibody therapy in getting the pandemic under control.</p>
<h2>Why should we care?</h2>
<p>Until a <a href="https://theconversation.com/achieving-covid-19-herd-immunity-through-infection-is-dangerous-deadly-and-might-not-even-work-148769">large percentage of a population has immunity</a> to an infectious disease – either through a vaccine or the unchecked spread through a community – the world must rely on other weapons in our war against the COVID-19 pandemic.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=677&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=677&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=677&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=850&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=850&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369352/original/file-20201113-13-1x5penz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=850&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Herd immunity results when the majority of the population gains immunity to the virus either through vaccination or infection. When this happens, vulnerable people who cannot get vaccinated are protected by the ‘herd.’</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/herd-immunity-royalty-free-illustration/1223117661?adppopup=true">smodj/iStock/Getty Images Plus</a></span>
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<p>Along with the previously mentioned therapies, monoclonal antibodies can offer us another tool to neutralize the virus once it causes an infection. </p>
<p>These man-made antibodies offer the world the possibility of immunotherapy similar to the use of <a href="https://www.covid19treatmentguidelines.nih.gov/immune-based-therapy/blood-derived-products/convalescent-plasma/">convalescent plasma</a> but with a more targeted and accurate action. While a vaccine will ultimately help protect the public, vaccination will not be an instantaneous event, delivering vaccine to 100% of the population. Nor do we know how effective it will be.</p>
<p>The impact of a vaccine also isn’t instantaneous. It takes several weeks to generate a powerful antibody response. In the interim, monoclonal antibodies could help mop up virus that is multiplying in the body.</p>
<h2>Antibody 101</h2>
<p>An antibody is a Y-shaped protein naturally produced by our body’s immune system to target something that is foreign, or not part of you. These foreign bodies are called antigens and can be found on allergens, bacteria and viruses as well as other things like toxins or a transplanted organ.</p>
<p>A monoclonal antibody treatment mimics the body’s natural immune response and targets foreign agents, like a virus, that infect or harm people. There are also monoclonal antibodies that pharmaceutical companies have <a href="https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/monoclonal-antibodies">designed that target cancer cells</a>. Monoclonal antibodies are one of most powerful types of medicine. In 2019 <a href="https://www.nature.com/articles/d41573-020-00047-7">seven of the top 10 best-selling drugs</a> were monoclonal antibodies.</p>
<p>For President Trump, the experimental treatment made by the pharmaceutical company <a href="https://investor.regeneron.com/news-releases/news-release-details/regenerons-regn-cov2-antibody-cocktail-reduced-viral-levels-and">Regeneron</a> included two antibodies.</p>
<p>Typically the spike protein on the coronavirus fits perfectly into the ACE2 receptor on human cells, a protein common in lung cells and other organs. When this connection happens, the virus is able to infect cells and multiply inside them. But monoclonal antibodies can slow or halt the infection by <a href="https://www.nature.com/articles/s41467-020-18319-6">attaching to the viral spike protein before it reaches the ACE2 receptor</a>. If this happens, the virus becomes harmless because it can no longer enter our cells and reproduce.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369351/original/file-20201113-23-1tevnts.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When antibodies (white) bind to the spike proteins covering the surface of the virus, SARS-CoV-2 can no longer infect human cells.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/antibodies-responding-to-coronavirus-royalty-free-illustration/1220609745?adppopup=true">JUAN GAERTNER/SCIENCE PHOTO LIBRARY/Getty Images</a></span>
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<h2>How are monoclonal antibodies created?</h2>
<p>Monoclonal antibodies that neutralize the coronavirus are <a href="https://www.iavi.org/news-resources/features/what-are-monoclonal-antibodies-and-can-they-treat-covid-19">complicated to manufacture and produce</a>. They must be made inside cells taken from a hamster’s ovary and grown in gigantic steel vats. The antibodies that these cells manufacture must then be extracted and purified. Unfortunately these monoclonal antibodies, which have been used for other illnesses for years, are often <a href="https://www.bmj.com/bmj/section-pdf/187706?path=/bmj/345/7887/Feature.full.pdf">quite expensive.</a> </p>
<p><a href="http://doi.org/10.1126/science.abf0591">Regeneron’s two antibodies</a> are targeted to the spike protein of SARS-CoV-2 – the protrusions on the surface of virus that give it a crown-like look and are critical for infecting human cells. </p>
<p>One of Regeneron’s two antibodies is a replica, or clone, of an antibody harvested from a person who recovered from COVID-19. The second antibody was identified in a mouse that was biologically engineered to have a human immune system. When this mouse was injected with the spike protein, its human immune system generated antibodies against it. One of the most effective mouse antibodies was then harvested and used to form part of this therapy. </p>
<p><a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibody-treatment-covid-19">Eli Lilly’s monoclonal antibody therapy, bamlanivimab</a>, was identified from a blood sample taken from one of the first U.S. patients who recovered from COVID-19. </p>
<p>Both companies have in place large-scale manufacturing with robust, global supply chains in place to produce the monoclonal antibodies, with many global manufacturing sites to ramp up supply. Eli Lilly has <a href="https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-november-9-2020">received FDA approval</a>, and <a href="https://www.fiercepharma.com/pharma/amid-covid-19-effort-regeneron-wins-first-fda-approval-for-ebola-treatment">Regeneron is still awaiting approval</a>. Unfortunately, there will likely be a shortage of the antibodies in the early going of approvals. </p>
<h2>Monoclonal antibodies plus a vaccine</h2>
<p>Monoclonal antibodies will be able to complement vaccines by offering rapid protection against infection. When they are given to an individual, monoclonal antibodies provide instantaneous protection for weeks to months. Vaccines take longer to provide protection since they must challenge the immune system. But the advantage of a vaccine is that they usually provide long-term protection.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Regeneron’s and Eli Lilly’s products are both delivered by intravenous injection, after which the patient must be monitored by health care professionals. <a href="https://www.iavi.org/news-resources/features/what-are-monoclonal-antibodies-and-can-they-treat-covid-19">Since they offer immediate protection</a>, the implications to treat or provide protection to high-risk populations is immense. </p>
<p>These medicines have the potential to treat infected patients or prevent infection of essential health care and public health professionals on the front line of this pandemic. Monoclonal antibodies could also be useful for older people, young children and immunocompromised people for whom vaccines either don’t work or can be dangerous.</p><img src="https://counter.theconversation.com/content/149356/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rodney E. Rohde does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Monoclonal antibodies are synthetic molecules manufactured in the lab. But do we need them if a vaccine is on its way?Rodney E. Rohde, Professor Clinical Laboratory Science, Texas State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1455852020-09-07T15:59:54Z2020-09-07T15:59:54ZWhat are corticosteroids and why are they effective at fighting severe COVID-19?<figure><img src="https://images.theconversation.com/files/356740/original/file-20200907-20-9civiq.jpg?ixlib=rb-1.1.0&rect=268%2C0%2C4575%2C2766&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hospital-senior-patient-lying-bed-talking-1186739332">Gorodenkoff/Shutterstock</a></span></figcaption></figure><p>Following reports in June that the cheap <a href="https://theconversation.com/dexamethasone-what-is-the-breakthrough-treatment-for-covid-19-140966">steroid drug dexamethasone</a> could help treat patients severely ill with COVID-19, scientists and clinicians urged caution. They were careful to highlight the <a href="https://www.thebottomline.org.uk/blog/ebm/recovery-covid-19-dexamethasone/">need for</a> further study to confirm the drug’s place – as well as that of similar steroids – in the treatment of the disease.</p>
<p>The World Health Organization has now offered this confirmation. It has published <a href="https://jamanetwork.com/journals/jama/fullarticle/2770279">an analysis</a> showing that severely ill COVID-19 patients’ survival rates improved when they were treated with dexamethasone and other corticosteroids.</p>
<p>The WHO study pooled data from seven different trials that evaluated the effectiveness of these drugs, looking at the outcomes of 1,703 patients with severe COVID-19. Those treated with one of three corticosteroids – hydrocortisone, dexamethasone or methylprednisolone – had a risk of death after 28 days of 32%. For those receiving usual care or a placebo, the risk was 40%.</p>
<h2>What are corticosteroids?</h2>
<p>The word “steroid” can be misleading. Corticosteroids don’t have the same actions as the testosterone derivatives – androgens, or “anabolic” steroids – used by bodybuilders and dodgy sports competitors.</p>
<p>Corticosteroids are used largely to treat illnesses that result from inflammation, in which the body’s immune system mounts an exaggerated response to something or attacks its own cells. This family of drugs have been around for decades – dexamethasone was <a href="https://www.pharmaceutical-technology.com/features/dexamethasone-covid-19-uk/">approved for medical use</a> in 1961.</p>
<figure class="align-center ">
<img alt="A tube of hydrocortisone cream." src="https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=363&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=363&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=363&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356739/original/file-20200907-16-slwy4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Although available as creams, for COVID these drugs are delivered orally or intravenously.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Tube_of_hydrocortisone_cream.jpg">Father Goose/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>The study found the strongest association with improved survival was with hydrocortisone – whose name might sound familiar. It has been used for many decades, in a variety of forms, for treating inflammatory conditions, ranging from mild eczema to severe inflammatory bowel disease. It’s also used to treat endocrine disorders such as <a href="https://www.nhs.uk/conditions/addisons-disease/">Addison’s disease</a>.</p>
<p>Hydrocortisone is the name given to the <a href="https://www.yourhormones.info/hormones/cortisol/">stress hormone cortisol</a> when it is used as a drug. Along with other members of the corticosteroid family, when administered it mimics the actions of cortisol in the body.</p>
<p>Primarily, this involves acting on receptor proteins inside of cells. When these receptors are activated, they move to <a href="http://tmedweb.tulane.edu/pharmwiki/doku.php/glucocorticoid_pharmacology">the cell’s nucleus</a> and bind to specific regions of DNA, switching on particular genes or preventing others from being switched on. </p>
<p>Many of the genes targeted are responsible for producing cytokines: small proteins that signal between immune cells to promote or regulate the immune response. The steroids also target genes that produce receptors that the cytokines themselves act on. So they can both reduce the quantity of cytokines the body makes and render them less effective.</p>
<h2>Why they are useful</h2>
<p>Severe respiratory disease in COVID-19 patients is associated with a phenomenon known as a <a href="https://www.frontiersin.org/articles/10.3389/fimmu.2020.01446/full">“cytokine storm”</a>. This occurs when the immune system goes into overdrive and produces very large quantities of these proteins, leading to an exaggerated inflammatory reaction.</p>
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<p>The results include swelling and an accumulation of fluid and white blood cells, which have the potential to damage tissues. When this happens in the respiratory system, it leads to respiratory distress as a result of the airway-wall swelling and fluid accumulating in the lungs. A cytokine storm can also produce responses affecting the whole body that may lead to <a href="https://www.labnews.co.uk/article/2030776/why-covid-19-kills-some-and-not-others-a-tale-of-two-conditions">multiple organs failing</a>.</p>
<p>So in diseases where cytokine storms can make people severely ill, the genes producing cytokines and their receptors are one possible target for successful therapies. This is why steroids were included in the <a href="https://www.recoverytrial.net/">RECOVERY trial</a> – the major project that is looking for already-existing drugs that can be used to treat COVID-19 – and in the separate trials reported on by the WHO. </p>
<h2>Is it all good news?</h2>
<p>Interestingly, the benefits seen with hydrocortisone and dexamethasone occurred at fairly low doses. No additional benefit was seen when higher amounts were used. And a more potent steroid, methylprednisolone, showed lower effectiveness than hydrocortisone, albeit in a smaller study.</p>
<p>This raises the question of steroids’ immunosuppressive action: while inflammation is a major factor in many diseases, it is also a key component of the body’s protection against infection. Suppressing the immune system might help to dampen down life-threatening cytokine storms, but it also presents the risk <a href="https://www.endocrinologyadvisor.com/home/topics/general-endocrinology/glucocorticoid-use-increases-susceptibility-risk-for-covid19/">of reducing</a> the body’s ability to fight the viral infection that underlies the disease. </p>
<p>Balance is crucial in the maintenance of life, and balancing suppression of inflammation against suppression of immunity is a vital consideration in use of drugs like hydrocortisone. One study has found that steroids’ effects on the immune system can leave COVID-19 patients <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195158/">vulnerable to bacterial infections</a>, for instance, and may lengthen how long patients have to stay in hospital. </p>
<p>It therefore shouldn’t be assumed that steroids are a risk-free option for severely ill patients.</p><img src="https://counter.theconversation.com/content/145585/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gordon Dent does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hydrocortisone – a common remedy for eczema – joins dexamethasone as a proven treatment for the worst cases of coronavirus.Gordon Dent, Senior Lecturer in Pharmacology, Keele UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1456052020-09-04T12:22:01Z2020-09-04T12:22:01ZSteroids cut COVID-19 death rates, but not for everyone – here’s who benefits and who doesn’t<figure><img src="https://images.theconversation.com/files/356451/original/file-20200903-14-1pq21eh.jpg?ixlib=rb-1.1.0&rect=643%2C333%2C1841%2C1066&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Steroids could do more harm than good in patients with milder cases of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/patient-lies-in-bed-connected-to-medical-equipment-in-the-news-photo/1223660331">Go Nakamura/Getty Images</a></span></figcaption></figure><p>New studies show that treating critically ill COVID-19 patients with inexpensive steroids can cut their risk of dying from the illness by a third. The results are so clear that the World Health Organization changed its advice on Sept. 2 and now strongly recommends corticosteroids as a first-line treatment for the sickest patients.</p>
<p>Steroids aren’t risk-free, however. They can have side effects, and they could do more harm than good in patients with milder cases of COVID-19.</p>
<p>I am <a href="https://scholar.google.com/citations?user=z6NOSbcAAAAJ&hl=en">a pulmonologist and critical care physician</a> and co-author of <a href="http://doi.org/10.1001/jama.2020.17022">one of</a> <a href="https://jamanetwork.com/journals/jama/fullarticle/2770279">three new studies</a> that analyzed data from clinical trials involving the effect of steroids on thousands of critically and severely ill COVID-19 patients. Here’s what people need to understand about steroids as a treatment for COVID-19.</p>
<h2>Who benefits from taking steroids?</h2>
<p>It’s important to understand that steroids can benefit the sickest patients hospitalized with COVID-19, but they’re <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1">not a treatment for relatively mild cases</a>. </p>
<p>With COVID-19 and other infectious diseases, there are two key components: the infection itself and the body’s response to that infection. </p>
<p>In the sickest patients, the body’s immune system response is <a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690">so robust it can injure organs</a>. So, calming the immune response may be important. But someone who is less severely ill may need the body’s immune response to prevent the infection from getting worse. You wouldn’t want to interfere with the immune response unless it was harming the patient.</p>
<h2>How do corticosteroids help critically ill patients?</h2>
<p>When an infection triggers an <a href="https://www.merckmanuals.com/home/immune-disorders/biology-of-the-immune-system/overview-of-the-immune-system">inflammatory response</a>, specialized white blood cells are activated to go find the virus or bacteria and destroy it. It’s more of a bomb effect than a targeted missile strike – the immune cells attack broadly, and the inflammation created can damage other cells in the vicinity.</p>
<p>That response can get <a href="https://theconversation.com/coronavirus-cytokine-storm-this-over-active-immune-response-could-be-behind-some-fatal-cases-of-covid-19-136878">out of control</a> and continue even after the infectious agent is gone. In a really exuberant immune response, the patient can have respiratory failure and end up on a ventilator, or have circulatory failure and end up in shock, or they could develop kidney failure from the shock.</p>
<p>In patients with severe COVID-19, corticosteroids are likely able to calm that inflammatory response and prevent the progression of organ damage, potentially in the lungs. </p>
<p>Scientist aren’t yet certain that that is how steroids are working. What we do know from the new studies is that people with severe COVID-19, particularly those with respiratory complications, benefit from relatively low-dose courses of corticosteroids. A combined analysis of the recent studies found the death rate four weeks after infection was <a href="http://doi.org/10.1001/jama.2020.17023">significantly lower</a> in patients with severe COVID-19 who received steroids than those who did not.</p>
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<h2>Why does the World Health Organization recommend not using steroids for cases that aren’t severe?</h2>
<p>No treatment comes without risk.</p>
<p>Steroids are well-known immune-suppressing medications that have been used for decades. They’re commonly used for treating chronic diseases that are inflammation-related, like asthma, or autoimmune disorders such as lupus or rheumatoid arthritis. But there may be consequences.</p>
<p>The potential harms from using steroids in a hospital include an increased risk of bacterial or fungal infections, hyperglycemia, acquired muscle weakness and gastrointestinal bleeding.</p>
<p>For people with milder cases of COVID-19, taking steroids could mean increasing their risks with little potential benefit.</p>
<p>Taking steroids long-term also carries other risks, including predisposition to infection and developing osteoporosis, cataracts and glaucoma. So, to take steroids as a potential preventive measure against COVID-19 could come with significant potential risk to otherwise healthy people.</p>
<h2>Do steroids carry risks for critically ill patients?</h2>
<p>It’s common for ICU patients, particularly those on ventilators, to develop hospital-acquired infections such as pneumonia or bloodstream infections related to intravenous catheters. Being on corticosteroids can increase a patient’s risk of developing secondary infections, or it can contribute to muscle weakness which may impact the patient’s ability to come off of a ventilator when the disease resolves.</p>
<p>Still, the benefits of steroids for treating critically ill COVID-19 patients appear to outweigh the harms.</p>
<h2>How large should the dose be?</h2>
<p>Part of the challenge in treating critically ill patients with steroids is determining the dose and timing of the medication.</p>
<p>In the context of this study, the dose of steroids is relatively low and it’s also a short duration. The trials haven’t shown a significant increase in adverse events in the context of using the short-course, relatively low dose of steroids. So, in that patient population, the benefit outweighs the risk, but the risk is not zero.</p>
<p>The risk profile increases with higher doses. So, the recommendation would be to start with the relatively low doses that have been studied. <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1">The WHO recommends</a> low doses for 7-10 days.</p>
<h2>Which steroids are most effective?</h2>
<p>I don’t think it matters which corticosteroid is used as long as the steroid has some glucocorticoid activity.</p>
<p>The REMAP-CAP study <a href="http://doi.org/10.1001/jama.2020.17022">looked at hydrocortisone</a>. Another trial <a href="http://doi.org/10.1001/jama.2020.17021">involved dexamethasone</a>, the steroid the president was given. Others <a href="http://doi.org/10.1001/jama.2020.17023">studied methylprednisolone</a>, though they were smaller and provided less data. The trials all point in a similar direction, suggesting the anti-inflammatory <a href="http://tmedweb.tulane.edu/pharmwiki/doku.php/glucocorticoids">glucocorticoid</a> activity is the important feature and not the specific steroid. </p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p>
<h2>How will this new advice change treatment?</h2>
<p>Based on the studies to date, hospitalized patients with COVID-19 pneumonia and requiring oxygen should be started on a low-dose course of steroids. That should certainly be the case if they’re in the intensive care unit and require more intensive organ support, such as being on a ventilator, receiving non-invasive ventilation, or receiving high-flow oxygen.</p>
<p>Importantly, however, steroids have not been shown to benefit asymptomatic patients with COVID-19 or patients with mild disease without pulmonary problems based on the data we’ve seen so far. </p>
<p>Physicians should think of steroids at low doses as the standard of care for critically ill patients with COVID-19 pneumonia.</p><img src="https://counter.theconversation.com/content/145605/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bryan McVerry receives funding from the National Heart Lung and Blood Institute and from Bayer Pharmaceuticals. Inc. </span></em></p>Three new studies show corticosteroids can reduce deaths in critically ill COVID-19 patients. But what about other patients?Bryan McVerry, Associate Professor of Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1453672020-09-03T15:26:44Z2020-09-03T15:26:44ZCRISPR can help combat the troubling immune response against gene therapy<figure><img src="https://images.theconversation.com/files/356159/original/file-20200902-24-lmdp9z.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5176%2C5176&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Introducing healthy genes to replace defective ones is the essence of gene therapy.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/gene-therapy-royalty-free-image/574880295?adppopup=true">KTSFotos/Getty Images</a></span></figcaption></figure><p>One of the <a href="https://doi.org/10.1016/j.ymthe.2020.01.001">major challenges facing gene therapy</a> - a way to treat disease by replacing a patient’s defective genes with healthy ones - is that it is difficult to safely deliver therapeutic genes to patients without the immune system destroying the gene, and the vehicle carrying it, which can trigger life-threatening widespread inflammation.</p>
<p>Three decades ago researchers thought that gene therapy would be the ultimate treatment for genetically inherited diseases like <a href="https://ghr.nlm.nih.gov/condition/hemophilia">hemophilia</a>, <a href="https://www.nhlbi.nih.gov/health-topics/sickle-cell-disease">sickle cell anemia</a> and genetic diseases of metabolism. But the technology couldn’t dodge the immune response.</p>
<p>Since then, researchers have been looking for ways to perfect the technology and control immune responses to the gene or the vehicle. However, many of the strategies tested so far have <a href="https://www.sciencemag.org/news/2020/06/two-deaths-gene-therapy-trial-rare-muscle-disease">not been completely successful</a> <a href="https://www.sciencehistory.org/distillations/the-death-of-jesse-gelsinger-20-years-later">in overcoming this hurdle</a>. </p>
<p>Drugs that suppress the whole immune system, such as steroids, have been used to dampen the immune response when administering gene therapy. But it’s difficult to control when and where steroids work in the body, and they create unwanted side effects. My colleague <a href="http://www.ebrahimkhanilab.com">Mo Ebrahimkhani</a> and I wanted to tackle gene therapy with immune-suppressing tools that were easier to control.</p>
<p><a href="https://www.kianilab.com">I am a medical doctor and synthetic biologist</a> interested in gene therapy because six years ago my father was diagnosed with <a href="https://www.cancer.gov/types/pancreatic">pancreatic cancer</a>. Pancreatic cancer is one of the deadliest forms of cancer, and the current available therapeutics usually fail to save patients. As a result, novel treatments such as gene therapy might be the only hope.</p>
<p>Yet, many gene therapies fail because patients either already have pre-existing immunity to the vehicle used to introduce the gene or develop one in the course of therapy. This problem has plagued the field for decades, preventing the widespread application of the technology.</p>
<h2>Gene therapy: past and present</h2>
<p>Traditionally scientists use viruses - from which dangerous disease-causing genes have been removed - as vehicles to transport new genes to specific organs. These genes then produce a product that can compensate for the faulty genes that are inherited genetically. This is how gene therapy works. </p>
<p>Though there <a href="https://www.asgct.org/research/news/april-2020/world-hemophilia-day">have been examples</a> showing that <a href="https://www.labiotech.eu/medical/bluebird-bio-gene-therapy-thalassemia/">gene therapy was helpful</a> in some genetic diseases, they are still not perfect. Sometimes, a faulty gene is so big that you can’t simply fit the healthy replacement in the viruses commonly used in gene therapy.</p>
<p>Another problem is that when the immune system sees a virus, it assumes that it is a disease-causing pathogen and launches an attack to fight it off by producing antibodies and immune response – just as happens when people catch any other infectious viruses, like SARS-CoV-2 or the common cold. </p>
<p>Recently, though, with the rise of a <a href="https://www.sciencenewsforstudents.org/article/explainer-how-crispr-works">gene editing technology called CRISPR</a>, scientists can do gene therapy differently.</p>
<p>CRISPR can be used in many ways. In its primary role, it acts like a genetic surgeon with a sharp scalpel, enabling scientists to find a genetic defect and correct it within the native genome in desired cells of the organism. It can also repair more than one gene at a time. </p>
<p>Scientists can also use CRISPR to turn off a gene for a short period of time and then turn it back on, or vice versa, without permanently changing the letters of DNA that makes up or genome. This means that researchers like me can leverage CRISPR technology to revolutionize gene therapies in the coming decades.</p>
<p>But to use CRISPR for either of these functions, it still needs to be packaged into a virus to get it into the body. So some challenges, such as preventing the immune response to the gene therapy viruses, still need to be solved for CRISPR-based gene therapies. </p>
<p>Being trained as <a href="http://www.kianilab.com">a synthetic biologist</a>, I teamed up with Ebrahimkhani to use CRISPR to test whether we could shut down a gene that is responsible for immune response that destroys the gene therapy viruses. Then we investigated whether lowering the activity of the gene, and dulling the immune response, would allow the gene therapy viruses to be more effective.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<h2>Preventing the immune response that destroys gene therapy viruses</h2>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=688&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=688&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=688&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=864&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=864&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356160/original/file-20200902-14-5r5jt3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=864&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">CRISPR can precisely remove even single units of DNA.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/gene-editing-conceptual-illustration-royalty-free-illustration/1015902954?adppopup=true">KEITH CHAMBERS/SCIENCE PHOTO LIBRARY/Getty Images</a></span>
</figcaption>
</figure>
<p><a href="https://www.genecards.org/cgi-bin/carddisp.pl?gene=MYD88">A gene called Myd88</a> is a key gene in the immune system and controls the response to bacteria and viruses, including the common gene therapy viruses. We decided to temporarily turn off this gene in the whole body of lab animals. </p>
<p>We injected animals with a collection of the CRISPR molecules that targeted the Myd88 gene and looked to see whether this reduced the quantity of antibodies that were produced to specifically fight our gene therapy viruses. We were excited to see that the animals that received our treatment using CRISPR produced less antibody against the virus.</p>
<p>This prompted us to ask what happens if we give the animal a second dose of the gene therapy virus. Usually the immune response against a gene therapy virus prevents the therapy from being administered multiple times. That’s because after the first dose, the immune system has seen the virus, and on the second dose, antibodies swiftly attack and destroy the virus before it can deliver its cargo.</p>
<p>We saw that animals receiving more than one dose did not show an increase in antibodies against the virus. And, in some cases, the effect of gene therapy improved compared with the animals in which we had not paused the Myd88 gene. </p>
<p>We also did a number of other experiments that proved that tweaking the Myd88 gene can be useful in fighting off other sources of inflammation. That could be useful in diseases like sepsis and even COVID-19. </p>
<p>While we are now beginning to improve this strategy in terms of controlling the activity of the Myd88 gene. Our results, now published in <a href="https://www.nature.com/articles/s41556-020-0563-3">Nature Cell Biology</a>,
provide a path forward to program our immune system during gene therapies and other inflammatory responses using the CRISPR technology.</p><img src="https://counter.theconversation.com/content/145367/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samira Kiani is a co-founder and founding CSO of Safegen Therapeutics. She receives funding from National Institute of Health for her research program.</span></em></p>The immune system is trained to destroy viruses, even when they carry therapeutic cargo as is the case in gene therapy. Now researchers have figured out how to dial down the immune response.Samira Kiani, Associate Professor of Pathology, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1442492020-09-02T13:51:10Z2020-09-02T13:51:10ZMen are buying potentially risky steroid substitutes online to get the ‘ideal body’<figure><img src="https://images.theconversation.com/files/354966/original/file-20200826-7087-dhrj2z.jpg?ixlib=rb-1.1.0&rect=22%2C0%2C6809%2C4891&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Selective androgen receptor modulators (SARMs) may be perceived as a safer muscle-building alternative to steroids.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Unapproved muscle-building drugs are being <a href="https://doi.org/10.1210/jc.2018-01706">sold over the internet</a>. These chemicals, called SARMS or selective androgen receptor modulators, are popular in part due to their <a href="https://www.uspharmacist.com/article/recreational-use-of-selective-androgen-receptor-modulators">perceived safety compared to anabolic steroids</a>, but the health risks of these drugs are still widely unknown and potentially serious.</p>
<h2>Images in society influence our body image</h2>
<p>Images of bodies surround us in our daily life, in advertising, media, the Twitterverse and dating apps, informing <a href="http://hdl.handle.net/10523/7863">the way we feel and think about our bodies</a>. We come to understand ourselves through the images circulating in our culture and society that define what it means to belong to a particular gender. </p>
<p>For many men, social images create an understanding of what their bodies should look like to be <a href="https://doi.org/10.1177/1557988316669042">considered masculine</a>. Often the dominant ideal, both celebrated and desired, is fat-free, with bulging muscles and well-defined pecs: a celebration of <a href="https://doi.org/10.1080/14680777.2017.1367701">strength and power</a>.</p>
<figure class="align-center ">
<img alt="A young man in a hoodie looks pensive with his arms folded across his chest. Behind him, on a blackboard, a drawing of caricatured muscular arms lines up with his shoulders." src="https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354704/original/file-20200825-15-5cxmst.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">For many men, social images create an understanding of what their bodies should look like to be considered masculine.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Many men strive to embody this idealized image of masculinity, but it’s not one everyone can achieve. The difference between men’s actual bodies and the cultural ideas about masculinity that may <a href="https://doi.org/10.1176/appi.ajp.157.8.1297">explain the rise of muscle dysmorphia and anabolic steroid abuse</a>. </p>
<p>We suggest that more discussion is needed surrounding both masculine body image ideals and the potential dangers of SARMs in our society.</p>
<h2>Body image standards affect men differently</h2>
<p>For many <a href="https://www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf">sexually diverse men</a> (gay, bi, pansexual, queer, men who have sex with men, etc.), the consequences of not living up to idealized standards for masculine bodies <a href="https://doi.org/10.1176/appi.ajp.157.8.1297">can be toxic</a>, including negative body image and <a href="https://doi.org/10.1016/j.bodyim.2019.08.007">body dissatisfaction</a>. </p>
<p>This can influence the way people live, such as eating and exercising. For example, one study noted a small association with social media use and <a href="https://doi.org/10.1089/cyber.2017.0375">body dissatisfaction, eating disorder symptoms and thoughts about using anabolic steroids</a>. Sexually diverse men have also reported engaging in <a href="https://doi.org/10.1136/bmjopen-2014-005205">intensive anaerobic training, the use of protein powders and the use of anabolic steroids</a> to achieve their desire to become muscular. </p>
<p>Ethnicity can also intersect with body image for sexually diverse men. <a href="https://doi.org/10.1016/j.bodyim.2013.03.006">In one study</a>, Black, East/Southeast Asian, South Asian, Latino/Brazilian gay and bisexual men report skipping meals, vomiting and taking steroids to achieve bodies that cultural messages and images define as the most masculine. </p>
<h2>Potential danger</h2>
<p>Anabolic steroids can be viewed by men with body dissatisfaction as <a href="https://doi.org/10.1001/jama.2016.17441">a way to achieve this idolized masculine body</a>. Now SARMs, which are not steroids per se but <a href="https://www.uspharmacist.com/article/recreational-use-of-selective-androgen-receptor-modulators#:%7E:text=Discovered%20in%20the%20late%201990s,and%20facilitate%20recovery%20from%20exercise.&text=SARMs%20are%20not%20anabolic%20steroids,to%20androgen%20receptors%20">act in a similar way</a> by increasing muscle mass and strength, are perceived as a safer alternative to steroids and are easily purchased online: A potential danger for those desperate to achieve these hyper-muscular bodies.</p>
<figure class="align-right ">
<img alt="A black dumbbell with drug capsules in the foreground" src="https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354706/original/file-20200825-18-1edejsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anabolic steroids can be viewed by men with body dissatisfaction as a way to achieve the idolized masculine body. Now SARMS may be viewed as an alternative to steroids.</span>
<span class="attribution"><span class="source">(Pexels)</span></span>
</figcaption>
</figure>
<p>SARMS have been researched for more than 20 years as treatments for medical conditions including cancer, osteoporosis, Alzheimer’s disease and muscle-wasting, but no SARMs are approved by the FDA for any medical condition yet and they are not authorized for use in Canada. In fact, Health Canada released a <a href="https://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2020/72293a-eng.php">public health advisory</a> in March 2020 advocating against the use of SARMs, and reported a seizure of various SARMs from stores in Alberta.</p>
<p>We know little about the safety and toxicity of these drugs, which is what makes them risky. A 32-year old male recently suffered <a href="https://doi.org/10.14309/crj.0000000000000370">severe liver injury</a> after taking a SARM for two weeks, suggesting there are indeed health risks.</p>
<p>A factor that may have contributed to this case is that recreational steroid users often take <a href="https://doi.org/10.1210/jc.2018-01706">much higher doses than what is prescribed for medical patients</a>. SARMs, like other drugs, can have <a href="https://doi.org/10.1111/bcp.13316">dose-dependent effects</a>. If men are taking high doses to achieve the dominant image of a masculine body, it is likely that their health risks are higher as well. </p>
<p>Although SARMs may end up being safe drugs when properly used for medical conditions, there are still major <a href="https://doi.org/10.1080/13543784.2020.1777275">health concerns</a> involved with taking SARMs currently, including liver damage, cardiovascular issues and testosterone suppression. Furthermore, the purity of SARMs bought online is currently <a href="https://doi.org/10.1002/dta.2908">highly questionable</a>.</p>
<h2>What can we do?</h2>
<p>In light of these safety concerns, the <a href="https://www.congress.gov/bill/116th-congress/senate-bill/2895/text">SARMs Control Act of 2019</a> was introduced to the United States Congress, which seeks to tighten regulatory control over these drugs. This act effectively equates SARMs with anabolic steroids on a regulatory level. This type of regulation is necessary to help contain a drug with health risks and potential for abuse.</p>
<p>Thus, we have a storm brewing. On one hand we have unrealistic masculine body image standards for gay men, which promote and even demand the use of anabolic drugs to reach that goal. On the other hand, SARMs promise the idolized body and are easily available over the internet.</p>
<p>We need to honestly discuss the dangers of promoting unattainable masculine body image standards for men of all sexual orientations and warn about easily accessible SARMs that may not be safe to use and almost certainly not safe to abuse.</p><img src="https://counter.theconversation.com/content/144249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Idealized standards for muscular, fat-free male bodies may be fuelling the use of SARMs, or selective androgen receptor modulators, unapproved muscle-building drugs that are easily available online.Stefan Heinze, Graduate student in Pharmacology, Dalhousie UniversityPhillip Joy, Assistant Professor, Mount Saint Vincent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1415132020-07-01T12:30:14Z2020-07-01T12:30:14ZWhich drugs and therapies are proven to work, and which ones don’t, for COVID-19?<figure><img src="https://images.theconversation.com/files/344835/original/file-20200630-103673-pcawdc.jpg?ixlib=rb-1.1.0&rect=0%2C10%2C6679%2C4426&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We are slowly figuring out which drugs and therapies are effective against the new coronavirus.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/china-wuhan-smartphone-with-aliepress-logo-with-royalty-free-image/1203497795?adppopup=true&uiloc=thumbnail_similar_images_adp">Anton Petrus / Getty Images</a></span></figcaption></figure><p><em>Leer <a href="https://theconversation.com/que-medicamentos-y-tratamientos-se-ha-demostrado-que-funcionan-y-cuales-no-para-la-covid-19-143395">en español</a></em></p>
<p><a href="https://uvahealth.com/findadoctor/profile/william-petri">I am a physician and a scientist</a> at the University of Virginia. I care for patients and conduct research to find better ways to diagnose and treat infectious diseases, including COVID-19. Here I’m sharing what is known about which treatments work, and which don’t, for the new coronavirus infection. </p>
<p>Keep in mind that this field of medicine is rapidly evolving as our understanding of the SARS-CoV-2 virus improves. So what I am writing today may change within days or weeks.</p>
<p>Below are the treatments that have been tried and for which we have the best knowledge.</p>
<h2>Hydroxychloroquine or chloroquine – no evidence they work</h2>
<p>There are <a href="http://doi.org/10.1126/science.abd2496">three randomized controlled trials</a> of hydroxychloroquine, all of which have failed to prove or disprove a beneficial or harmful effect on COVID-19 clinical course or clearance of virus. Given this current lack of evidence, these drugs, which normally are used to treat arthritis, should <a href="https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/#toc-5">only be used within the context of a controlled clinical trial.</a> </p>
<h2>Lopinavir/ritonavir – not helpful</h2>
<p>The drug Lopinavir is an inhibitor of an enzyme called HIV protease which is involved in the production of viral particles. Protease inhibitors for HIV were revolutionary, leading to our current ability to effectively treat HIV. Lopinavir also can inhibit enzymes that perform similar functions as the HIV protease in the <a href="https://www.niaid.nih.gov/diseases-conditions/covid-19">SARS and MERS coronaviruses</a>. Ritonavir increases the level of Lopinavir in the blood so the lopinavir/ritonavir combination was tested in a randomized controlled clinical trial for COVID-19. </p>
<p>Unfortunately, there was no impact on the levels of virus in the throat or duration of viral shedding, nor did patients’ clinical course or survival change. There therefore is <a href="http://doi.org/10.1056/NEJMoa2001282">no role for lopinavir/ritonavir in the treatment of COVID-19.</a></p>
<h2>Steroids – yes for almost all COVID-19 patients</h2>
<p>When a synthetic steroid hormone, called dexamethasone, was given to patients with COVID-19 the drug decreased <a href="https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1">28-day mortality by 17% and hastened hospital discharge</a>. </p>
<p>This work was performed in a <a href="http://www.ox.ac.uk/news/2020-06-16-low-cost-dexamethasone-reduces-death-one-third-hospitalised-patients-severe">randomized and controlled clinical trial</a> of over 6,000 patients, and while not replicated in another study or yet peer reviewed, is certainly enough evidence to recommend its use. </p>
<h2>Tocilizumab – too early to judge</h2>
<p>Tocilizumab is an <a href="https://theconversation.com/antibody-injections-could-fight-covid-19-infections-an-infectious-disease-expert-explains-the-prospects-139444">antibody</a>, that blocks a protein, called IL-6 receptor, from binding IL-6 and triggering inflammation. Levels of IL-6 are higher in many patients with COVID-19, and the immune system in general seems to be hyperactivated in those with the most severe disease. This leads many physicians and physicians to think that inhibiting the IL-6 receptor might protect patients from severe disease. </p>
<p>Tocilizumab is currently FDA approved for the treatment of rheumatoid arthritis and several other collagen-vascular diseases and for “<a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690">cytokine storm</a>” – a harmful overreaction of the immune system – that can be caused by certain types of cancer therapy and COVID-19.</p>
<p><a href="https://doi.org/10.1016/S2665-9913(20)30173-9">A retrospective observational study</a> found that COVID-19 patients treated with tocilizumab had a lower risk of mechanical ventilation and death. But we lack a randomized controlled clinical trial so there is no way to ascertain if this apparent improvement was due to tocilizumab or from the imprecise nature of retrospective studies.</p>
<h2>Convalescent plasma – too early to judge</h2>
<p>Convalescent plasma, the liquid derived from blood after removing the white and red blood cells, contains antibodies from previous infections that the plasma donor had. This plasma has been used to prevent infectious diseases including pneumonia, tetanus, diphtheria, mumps and chickenpox for over a century. It is thought to benefit patients because antibodies from the plasma of survivors bind to and inactivate pathogens or their toxins of patients. Convalescent plasma has now been used in thousands of COVID-19 patients. </p>
<p>However, the only randomized clinical trial was small and included just 103 patients who received convalescent plasma 14 days after they became ill. There was <a href="http://doi.org/10.1001/jama.2020.10044">no difference in the time to clinical improvement or mortality</a> between those who did and did not receive treatment. The encouraging news was that there was a significant decrease in virus levels detected by PCR. </p>
<p>It is therefore too early to tell if this will be beneficial and controlled clinical trials are needed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nurse is collecting convalescent plasma from a recovered COVID-19 patient to help the healing process of other COVID-19 patients in Indonesia.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nurse-were-conducting-the-process-of-taking-a-plasma-news-photo/1223515838?adppopup=true&uiloc=thumbnail_more_search_results_adp">Budiono,/ Sijori images/Barcroft Media via Getty Images</a></span>
</figcaption>
</figure>
<h2>Remdesivir – yes, decreases hospital stay</h2>
<p><a href="https://theconversation.com/remdesivir-explained-what-makes-this-drug-work-against-viruses-137751">Remdesivir is a drug that inhibits the coronavirus enzyme</a> that makes copies of the viral RNA genome. It acts by causing premature stoppage or termination of the copying and ultimately blocks the virus from replicating.</p>
<p>Remdesivir treatment, especially for patients who required supplemental oxygen before they were placed on a ventilator <a href="http://doi.org/10.1056/NEJMoa2007764">reduced mortality and shortened the average recovery time</a> from 15 to 11 days. </p>
<h2>ACE inhibitors and ARBs – keep taking them</h2>
<p>There was a concern that drugs called <a href="https://www.webmd.com/heart-disease/guide/medicine-ace-inhibitors#:%7E:text=Angiotensin%2Dconverting%20enzyme%20(ACE),to%20lower%20your%20heart's%20workload.">ACE inhibitors</a> or angiotensin receptor blockers (ARBs), which are used to treat high blood pressure and heart failure, could increase levels of the ACE2 proteins, the receptor <a href="https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928">for SARS-CoV-2,</a> on the surface of cells in the body. This would, physicians hypothesized, allow more entry points for the virus to infect cells and would therefore boost the severity of new coronavirus infections.</p>
<p>However, there is no evidence that this is the case. The American Heart Association, the Heart Failure Society of America and the American College of Cardiology all recommend that patients continue to take these medications during the pandemic as they are <a href="https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19">beneficial in the treatment of high blood pressure and heart failure</a>. </p>
<p>We have made amazing progress in the treatment of COVID-19. Two therapies – steroids and Remdesivir – have already been shown to help. Those who benefit from these treatments owe thanks to patients who volunteered to participate in controlled clinical trials, and the physicians and pharmaceutical companies that lead them. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/141513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Petri receives funding from the NIH and the Gates Foundation.</span></em></p>During the last six months, news reports have mentioned dozens of drugs that may be effective against the new coronavirus. Here we lay out the evidence and reveal which ones are proven to work. Or not.William Petri, Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1409662020-06-17T17:15:31Z2020-06-17T17:15:31ZDexamethasone: what is the breakthrough treatment for COVID-19?<figure><img src="https://images.theconversation.com/files/342420/original/file-20200617-94036-g16rxw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/dexamethasone-drug-syringe-blue-gloved-hands-1757306192">Tobias Arhelger/Shutterstock</a></span></figcaption></figure><p>Six months and <a href="https://covid19.who.int/">eight million positive cases</a> since the COVID-19 pandemic broke out in Wuhan, scientists have announced the first major breakthrough in the search for a drug to fight the disease. </p>
<p>A research team at Oxford University has found that cheap and widely available drug called <a href="https://bnf.nice.org.uk/drug/dexamethasone.html">dexamethasone</a> can be effective in very severe forms of the COVID-19. </p>
<p>Dexamethasone has been around since the early 1960s. It is a steroid often given in low doses as an anti-inflammatory. It is used widely for severe asthma, allergies and when joints are painful and swollen. It is also used in autoimmune conditions such as <a href="https://www.nhs.uk/conditions/lupus/">systemic lupus erythematosus</a> or more commonly in <a href="https://www.nhs.uk/conditions/rheumatoid-arthritis/">rheumatoid arthritis</a>.</p>
<p>It’s this effect on inflammation and our immune systems that makes it useful in fighting off the worst effects of COVID-19. </p>
<h2>How it works</h2>
<p>The majority of people with COVID-19 show no signs of the disease – they are asymptomatic – or they have mild symptoms such as a dry cough, slight fever or loss of taste and smell. But in a small minority, the symptoms are much worse and patients need oxygen therapy or ventilation to help the lungs get oxygen into the body. These are the people for whom dexamethasone was shown to be effective. </p>
<p>In severe cases, the body’s immune system over-reacts to the virus and mounts an attack on the cells that contain it. This is known as a <a href="https://www.newscientist.com/term/cytokine-storm/">cytokine storm</a>, where chemicals called cytokines are released by cells of the immune system, causing excessive inflammation.</p>
<p>Dexamethasone acts on the immune system to dampen the response and reduce the cytokine storm. In effect, it prevents the massive inflammation seen in the lungs and the heart which are responsible for severe respiratory problems in very ill patients.</p>
<p>Dexamethasone has been tested in the largest COVID-19 drug trial to date, the Randomised Evaluation of COVID-19 Therapy or <a href="https://www.recoverytrial.net/">RECOVERY trial</a> for short. As part of the trial, researchers studied the effect of the drug in 2,000 patients and compared that to the outcomes in 4,000 patients who did not receive it. </p>
<p>The <a href="https://www.recoverytrial.net/files/recovery_dexamethasone_statement_160620_v2final.pdf">results of the trial</a>, which have not yet been published in a peer-reviewed journal, show the biggest benefit was in those patients on ventilators, where dexamethasone reduced the risk of death by 30%. For those requiring oxygen, there was a 20% reduction.</p>
<p>This equates to one life saved for every eight on ventilators and every 20-25 treated with oxygen.</p>
<p>As with any drug, there are <a href="https://www.rxlist.com/dexamethasone-side-effects-drug-center.htm#professional">side-effects</a>. These include anxiety, sleep disturbance, weight gain and fluid retention. For patients in intensive care these comparatively minor effects can be managed easily, so the benefits of dexamethasone in COVID-19 far outweigh the negative effects.</p>
<p>The drug is ineffective in those with mild symptoms who do not require respiratory support and should not be used by those at home.</p>
<h2>The first real treatment</h2>
<p>It is significant that the results for dexamethasone were found in a randomised clinical trial – where patients who had the drug are compared with those who didn’t. </p>
<p>Previous drugs which were hailed as potential “cures” for coronavirus have not been through this type of rigorous study before being declared effective in some quarters. This includes the malaria drug hydroxychloroquine, which has been touted by French researcher <a href="https://www.nytimes.com/2020/05/12/magazine/didier-raoult-hydroxychloroquine.html">Didier Raoult</a> and been promoted by the President of the United States. </p>
<p>Despite being advocated for, and even <a href="https://theconversation.com/donald-trump-is-taking-hydroxychloroquine-to-ward-off-covid-19-is-that-wise-139031">taken by</a>, Donald Trump, this drug has actually been linked to an <a href="https://www.bbc.co.uk/news/world-52779309">increased risk of death</a> in COVID-19 patients and is <a href="https://www.covid19treatmentguidelines.nih.gov/whats-new/">not recommended</a> for use. </p>
<p>In fact, the Oxford researchers who identified dexamethasone as an effective treatment stopped the study of hydroxychloroquine due to a “lack of efficacy” and it has recently been <a href="https://www.bbc.com/news/world-us-canada-53054476">withdrawn</a> for use in cases of COVID-19 by the US Food and Drug Administration.</p>
<h2>A cheap fix</h2>
<p>Dexamethasone is cheap, costing approximately US$6 per day. Patients are treated on average for seven to ten days, so lives can be saved for as little as US$44. It is estimated that if the drug was used earlier in the United Kingdom, there could have been <a href="https://www.bbc.co.uk/news/health-53061281">5,000 fewer deaths</a> from COVID-19.</p>
<p>What is more important is the drug is common and there are large global stocks. This means patients from disadvantaged backgrounds in countries without universal health care can be given dexamethasone readily, compared to new drugs that are often in limited supply as well as being expensive.</p>
<p>This important study suggests a common drug used in medicine for 60 years could help in the battle against COVID-19. There will be more discoveries to come, but this is an important first step.</p><img src="https://counter.theconversation.com/content/140966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David C Gaze is affiliated with The Association for Clinical Biochemistry and Laboratory Medicine; The American Association of Clinical Chemistry; Royal Society of Medicine; Pathological Society of Great Britain & Ireland; European Society of Pathology. </span></em></p>Scientists have discovered that a widely used, cheap steroid can fight off COVID-19 in the most severe cases. Here’s how it works.David C. Gaze, Lecturer in Clinical Biochemistry, University of WestminsterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1210972019-07-29T02:38:05Z2019-07-29T02:38:05ZWhat is Ligandrol, the drug swimmer Shayna Jack had in her system?<p>Australian freestyle swimmer Shayna Jack tested positive to the <a href="https://www.wada-ama.org/en/resources/science-medicine/prohibited-list-documents">banned substance</a> Ligandrol in <a href="https://theconversation.com/drafts/121097/edit#">late June</a>, before competing at the <a href="http://www.fina.org/event/18th-fina-world-championships">world swimming championships</a> in South Korea this month. </p>
<p>Jack said she <a href="https://7news.com.au/sport/swimming/shayna-jack-issues-new-statement-over-failed-drug-test-c-370056">did not knowingly take Ligandrol</a> but noted it could be found in contaminated supplements. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/B0abPFnAmwW","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<p>Ligandrol can help repair and build muscles. While it has been studied as a treatment for cancer and other conditions where patients experience muscle weakness and wastage, it is banned for use by professional athletes. </p>
<p>So how long has this drug been around, and how does it work?</p>
<h2>History of Ligandrol</h2>
<p>Ligandrol, which is also known by the development codes LGD-4033 and VK5211 and the name Anabolicum, was initially developed by the company <a href="https://www.ligand.com/">Ligand Pharmaceuticals</a> in the United States. It was <a href="https://patentimages.storage.googleapis.com/19/a8/9e/13c920a3dad32f/WO2009082437A2.pdf">patented in 2009</a>. </p>
<p>The results of the first human clinical trial were published in 2013, where taking <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4111291/">Ligandrol was found to increase muscle mass</a> without also putting on fat.</p>
<p>The drug rights have since been licensed to the company <a href="https://www.vikingtherapeutics.com/">Viking Therapeutics</a>. In 2018, it completed a clinical trial which examined <a href="http://ir.vikingtherapeutics.com/2018-10-01-Viking-Therapeutics-Presents-Results-from-Phase-2-Study-of-VK5211-in-Patients-Recovering-from-Hip-Fracture-in-Plenary-Oral-Presentation-at-ASBMR-2018-Annual-Meeting">Ligandrol for people aged over 65 who were recovering from a hip fracture</a>. The results showed patients who took Ligandrol significantly increased their muscle mass and could walk further than patients not on the drug.</p>
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<a href="https://theconversation.com/why-is-doping-wrong-anyway-63057">Why is doping wrong anyway?</a>
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<p>The drug has also been examined for <a href="https://reader.elsevier.com/reader/sd/pii/S2050052118301100?token=DE618D928D8A7ECDEDBA37D3BB4BBB726AFD01C434FC7DE90430B108A4883C4E0EBE70D6B84A52B46128CE84B2FB4DE6">other conditions</a>, including as a possible treatment for cancer-related weight loss, enlarged prostates, for patients who have a diminished function of testes and ovaries, and as a potential cure for breast cancer.</p>
<p>Ligandrol is still considered an experimental drug, and as such, is not approved for sale by the Australian Therapeutic Goods Administration (TGA).</p>
<h2>How Ligandrol works</h2>
<p>Ligandrol is taken orally as a tablet at doses between 0.5 and 2 milligrams. </p>
<p>The drug is what pharmacists call a <a href="https://www.ncbi.nlm.nih.gov/pubmed/30503797">selective androgen receptor modulator</a> (SARM). These drugs bind at specific sites on skeletal muscles. There, they initiate a cascade of processes which change the expression of different genes in the DNA of muscle cells. The end effect is an increase in the repair and growth of muscle.</p>
<p>This means Ligandrol works in a similar way to testosterone and anabolic steroids, although SARMs typically have fewer side effects. The typical side effects of anabolic steriods can include short-term aggression and violence, acne, and sleeping difficulties, and long-term effects such as damage to the liver and kidneys, depression, and high blood pressure.</p>
<p>In contrast, in clinical trials of patients taking Ligandrol, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4111291/">the rate of side effects was similar to those in the placebo group</a> and included headache and dry mouth. While clinical trial participants on Ligandrol did have a higher rate of throat infections, it was concluded this was not due to the drug.</p>
<p>Ligandrol <a href="https://onlinelibrary.wiley.com/doi/10.1002/dta.2512">can be detected for up to 21 days</a> in the urine of those who take it.</p>
<h2>In the news</h2>
<p>Because Ligandrol can potentially be used to gain an advantage in competitive sports, the <a href="https://www.wada-ama.org/">World Anti-Doping Agency</a> (WADA) placed the drug on its <a href="https://www.wada-ama.org/en/resources/science-medicine/prohibited-list-documents">prohibited list</a>.</p>
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Read more:
<a href="https://theconversation.com/snubbing-chinese-swimmer-sun-yang-ignores-the-flaws-in-the-anti-doping-system-120895">Snubbing Chinese swimmer Sun Yang ignores the flaws in the anti-doping system</a>
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<p>Shayna Jack’s hypothesis that it must have entered her system through contaminated supplements is not without merit. The TGA regularly bans the import of supposedly natural supplements for <a href="https://www.tga.gov.au/overseas-weight-loss-products">weight loss</a>, <a href="https://www.tga.gov.au/alert/liangzern-dietary-supplements">erectile dysfunction</a>, and body building because they contain prescription-only medicines. </p>
<p>While there have been no instances of body building protein or sports supplements being adulterated with Ligandrol, there are reports of some <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1541-4337.12173">dietary supplements being spiked with anabolic steroids</a> and similar drugs.</p>
<p>For safety and security, athletes should only use supplements from reputable brands bought from reliable stores in their home country. The risk of accidentally taking a banned substance is significant if an athlete buys supplements online.</p><img src="https://counter.theconversation.com/content/121097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate is a Fellow and Chartered Chemist of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association.</span></em></p>Ligandrol is used to help repair and build mass and is banned for use by professional athletes because it can give a competitive advantage.Nial Wheate, Associate Professor | Program Director, Undergraduate Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1201152019-07-10T11:04:32Z2019-07-10T11:04:32ZSix-packs and bulging biceps – how appearance pressures take their toll on men’s mental health<figure><img src="https://images.theconversation.com/files/283331/original/file-20190709-44466-w11z09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Over recent years, “<a href="https://us.macmillan.com/books/9780374527327">body dissatisfaction</a>” – or shame about one’s appearance – has been on the rise in men. This isn’t something just affecting young men either, it’s extensively reported across a range of age groups. And it’s harmful – <a href="https://us.macmillan.com/books/9780374527327">research</a> shows it can lead to depression, steroid abuse and even suicide. </p>
<p>More commonly, though, it coincides with punishing gym routines, overly strict dieting, and repetitive anxious thoughts – all of which can add up to have a severe impact on daily functioning. Indeed, this pressure for men to look “perfect” is one of the reasons why there’s been a rise in the number of <a href="https://theconversation.com/why-more-men-are-wearing-makeup-than-ever-before-88347">men using makeup</a>. </p>
<p>I have spent eight years researching male body dissatisfaction. For my PhD, I carried out focus groups with male university students, to explore the relationship between their appearance and their well-being. </p>
<p>Men in the groups told me that, for them, body dissatisfaction meant spending money on clothes they would never wear – as they felt too conscious of their bodies and that certain clothing exacerbated “problem areas”. They also spoke about not wanting to have sex with their partners as they felt ashamed about how they looked naked. For some men, their body dissatisfaction had also led to them avoiding activities they used to enjoy. One participant explained: “I used to be on a swimming team and now I don’t dare go into the pool.”</p>
<h2>Tackling the problem</h2>
<p>For these men, effective support is needed to combat male body dissatisfaction, but it’s seriously hard to find. For example, just 3% of <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-854">studies</a> published in a leading international eating disorders journal actually attempted to prevent eating disorders. </p>
<p>Similarly, there aren’t <a href="https://www.annualreviews.org/doi/10.1146/annurev.clinpsy.3.022806.091447">many</a> existing programmes to reduce male body dissatisfaction. And the <a href="https://www.annualreviews.org/doi/10.1146/annurev.clinpsy.3.022806.091447">ones that do exist</a> tend to have limited benefits. This is in part because such programmes tend to either <a href="https://www.tandfonline.com/doi/full/10.1080/10640266.2015.1034056#">blame the individual</a> or <a href="https://glenjankowski.wordpress.com/2016/03/31/my-thesis-mens-body-dissatisfaction-a-critical-analysis-of-neoliberal-and-representational-approaches/">blame other people</a>.</p>
<p>These programmes make an assumption that if a man can change his behaviour or his thinking and stop “internalising” appearance pressures – and consuming appearance focused media, such as magazines and <a href="https://www.instagram.com/explore/tags/fitspiration/?hl=en">#fitspiration</a> social media posts – then his body dissatisfaction should reduce. But as Harvard professor, Bryn Austin, <a href="https://www.tandfonline.com/doi/full/10.1080/10640266.2015.1034056#">writes</a>, this “limited” and even “unethical” assumption places “the burden solely on individuals while leaving toxic environments and societal bad actors unchallenged”.</p>
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<p>There is also a tendency to <a href="https://glenjankowski.files.wordpress.com/2019/06/jankowski2019.pdf">blame women</a> for male body dissatisfaction. Mothers are chastised for callously modelling unhealthy food behaviours onto their children. Feminists are depicted as promoting female body positivity on the one hand and cruelly body shaming men on the other. And women generally are blamed for holding men to appearance standards they themselves could not meet.</p>
<p>But not only is this unfair to women –- who have to deal with their own severe body dissatisfaction and bear stricter, more frequent appearance pressures than men –- but it’s also unfair to men, as it ignores the real cause.</p>
<h2>Appearance insecurity</h2>
<p>It’s unsurprising men are feeling this way, given that my research has shown how <a href="http://eprints.leedsbeckett.ac.uk/3002/">most images</a> in popular magazines, dating and porn websites are of muscular lean, young men –- who pretty much always have a full head of hair. So anyone that doesn’t fit this notion of “attractiveness” is going to feel like they’re not good enough.</p>
<p>Men are now feeling dissatisfied not only with their muscles, but also their hairline, wrinkles and body fat – and a heavy cultural and commercial promotion of unrealistic appearance standards is to blame. One of the most compelling examples of this, is the way toy manufacturers have <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/(SICI)1098-108X(199907)26:1%3C65::AID-EAT8%3E3.0.CO;2-D">added muscle and reduced the body fat</a> of successive editions of action dolls over the years. Similar changes have <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/1098-108X(200101)29:1%3C90::AID-EAT15%3E3.0.CO;2-F">also been seen</a> with centrefolds models. </p>
<p>There has also been a rise in brands marketing protein shakes, cosmetic surgery, waxing products, makeup and cellulite creams directly at men. And as the participants I spoke with noted, you see protein shakes at supermarkets and local shops, which makes these products hard to avoid.</p>
<p>Psychotherapist and writer Susie Orbach has written extensively about why people feel dissatisfied with their physical appearance. She has described how “<a href="http://www.any-body.org/anybody_vent/2012/3/6/susie-orbach-speaks-at-the-un-commission-on-the-status-of-wo.html">businesses mine our bodies for profits</a>”. Or, in other words, they promote appearance insecurity to sell products. It is this that must be tackled if both men’s and women’s body dissatisfaction is to be reduced.</p><img src="https://counter.theconversation.com/content/120115/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Glen Jankowski does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Men are feeling more and more pressure to get rid of their love handles and beer bellies – and heavy promotion of unrealistic appearance standards are to blame.Glen Jankowski, Senior Lecturer in the School of Social Sciences, Leeds Beckett UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1149812019-05-19T19:37:30Z2019-05-19T19:37:30ZIt’s not all gym junkies and ‘roid rage’ – people use steroids for a variety of reasons<figure><img src="https://images.theconversation.com/files/275059/original/file-20190517-69169-1nc7blt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Building muscle mass and strength is only one of a number of reasons people might use steroids.</span> <span class="attribution"><span class="source">Scott Webb/Unsplash</span></span></figcaption></figure><p>Most media reports would have you believe steroid users are predominantly young men suffering a “<a href="https://www.pressandjournal.co.uk/fp/news/north-east/1497458/crisis-of-male-ego-could-explain-hundreds-of-north-east-men-taking-steroids-and-other-image-enhancers/">crisis of male ego</a>” who are on a “<a href="https://www.news.com.au/lifestyle/beauty/for-men/the-deadly-crusade-to-get-ripped/news-story/0457a6e5a0e00ea49980e240fb991579">deadly crusade to get ripped</a>”. </p>
<p>The focus tends to be on <a href="https://www.theherald.com.au/story/2115988/steroids-kill-users-as-they-muscle-up/">health harms</a> and the <a href="https://www.thesun.co.uk/news/5166721/how-thousands-of-young-men-are-risking-their-lives-using-steroids-to-look-good/">danger associated</a> with using these substances.</p>
<p>After <a href="https://www.sciencedirect.com/science/article/pii/S2211266918300707">critically assessing</a> the research in this field, we found people use steroids for a variety of reasons. And while steroid use <a href="https://www.ncbi.nlm.nih.gov/pubmed/25986964">does carry risks</a>, not all users will develop personal problems or cause harm to others.</p>
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<a href="https://theconversation.com/scapegoating-steroids-wont-make-for-a-safer-night-out-31062">Scapegoating steroids won't make for a safer night out</a>
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<h2>Steroid use in Australia</h2>
<p><a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/cc3834004f50b372ac57ed330cda8a00/What+are+steroids+%2800498%29+2017.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-cc3834004f50b372ac57ed330cda8a00-meDa4x5">Anabolic-androgenic steroids</a> are synthetic variations of the male sex hormone testosterone. “Anabolic” refers to the drug’s capacity to increase protein synthesis, which results in increased muscle tissue. “Androgenic” refers to its properties in promoting the development of male sex characteristics (for example, deep voice and body hair).</p>
<p>Steroids are available via prescription, for example <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109795/">to treat testosterone deficiency in men</a>. But as many people use steroids for non-medical reasons, they are <a href="https://link.springer.com/article/10.1007/s12117-018-9348-5">often illegally obtained</a>.</p>
<p><a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/2016-ndshs-detailed/report-editions">Population studies</a> (for example, surveys and waste water tests) show the use of steroids and other performance and image enhancing drugs in Australia is relatively low – <a href="https://www.sciencedirect.com/science/article/pii/S1047279714000398">between 0.1-0.8%</a>.</p>
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Read more:
<a href="https://theconversation.com/australia-should-stop-beefing-up-its-steroid-laws-that-wont-help-users-77343">Australia should stop beefing up its steroid laws – that won't help users</a>
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<p>But other indicators, such as the volume of <a href="https://www.acic.gov.au/sites/default/files/iddr_2016-17_050718.pdf?v=1536906944">steroids confiscated</a> at the country’s borders and the number of steroid users accessing <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/ANSPS_National-Data-Report-2013-2017.pdf">needle and syringe programs</a>, paint a different picture. </p>
<p>So we don’t know exactly how many people use steroids in Australia and whether this number is increasing.</p>
<h2>Many different types of users</h2>
<p>The caricature of non-medical steroid users as narcissistic “gym bros” suffering from body image issues provides a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29968372">simplistic account</a> of user motivations. It ignores the <a href="https://www.tandfonline.com/doi/abs/10.1080/09687637.2016.1231173">spectrum of people</a> who use steroids.</p>
<p>Typically, a person’s first experience using steroids occurs in <a href="http://www.ipedinfo.co.uk/resources/downloads/2016%20National%20IPED%20Info%20Survey%20report%20FINAL.pdf">their mid to late 20s</a>. Many users have an above average education and income, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2131752/">are not involved in professional sports</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275061/original/file-20190517-69213-1peij2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People tend to associate steroid use with aggression, but we don’t have clear evidence of a causal link.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>Certainly many people use steroids for body image/cosmetic purposes, and to develop athletic performance – bodybuilding can encompass both.</p>
<p>But people also take steroids to support occupational performance. For example, <a href="https://www.amazon.com/Dopers-Uniform-Hidden-Police-Steroids/dp/0292759487">police officers</a>, <a href="https://academic.oup.com/her/article/22/6/854/641893">security personnel</a> and prison guards have been reported to use steroids to improve physical performance on the job.</p>
<p>Research has also found some people <a href="http://www.ipedinfo.co.uk/resources/downloads/2016%20National%20IPED%20Info%20Survey%20report%20FINAL.pdf">use steroids</a> to achieve a youthful appearance, to increase sex drive and energy levels, or to aid recovery from illness or injury.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/muscling-up-are-steroids-an-emerging-criminal-threat-21636">Muscling up: are steroids an emerging criminal threat?</a>
</strong>
</em>
</p>
<hr>
<h2>Steroids and health harms: what do we know?</h2>
<p>The most <a href="https://www.ncbi.nlm.nih.gov/pubmed/20153798">commonly identified side effects</a> are <a href="https://www.ncbi.nlm.nih.gov/pubmed/29994823">cosmetic in nature</a> (for example, acne) which are often reversible once steroid use is halted.</p>
<p>But several serious <a href="https://www.ncbi.nlm.nih.gov/pubmed/25986964">health harms</a> have been linked with steroid use, too. </p>
<p>There’s a growing body of evidence showing an association between the continued use of steroids and long-term health risks including <a href="https://www.ncbi.nlm.nih.gov/pubmed/28533317">heart disease and stroke</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25986964">cognitive deficiencies</a>.</p>
<p>Most knowledge about the harmful effects of steroids is at this stage based on low level evidence, such as expert opinion, case reports or small observational studies, so we still need stronger evidence. <a href="https://www.ncbi.nlm.nih.gov/pubmed/29845939">Prospective clinical trials</a> which examine the efficacy and long-term effects of recreational steroid use are absent, but there are some <a href="https://europepmc.org/abstract/med/29845939">important studies</a> underway.</p>
<p>In a number of studies <a href="https://www.ncbi.nlm.nih.gov/pubmed/25922421">comparing harms from a variety of drugs</a>, relative to other drugs steroids consistently appear low on the list for general health harm as well as for physical, psychological and social harm to both users and society.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=815&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=815&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=815&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1024&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1024&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275078/original/file-20190517-69169-12008vn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1024&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Compared with other drugs, the harm resulting from steroid use is low.</span>
</figcaption>
</figure>
<p>We must also appreciate the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.12831">circumstances in which people</a> use steroids can contribute to <a href="https://www.tandfonline.com/doi/abs/10.1080/09687637.2016.1231173">their risk of harm</a>. For example, a person could be taking multiple substances simultaneously, or they might be using unverified products sourced illegally.</p>
<p>The type of steroids used, the dosage and the length of time someone has been using steroids are all relevant factors. So depending on their patterns of use, some people who use steroids will run greater health risks than others.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/muscle-mania-young-men-arent-alone-with-body-image-concerns-28385">Muscle mania: young men aren't alone with body image concerns</a>
</strong>
</em>
</p>
<hr>
<h2>‘Roid rage’</h2>
<p>Another frequently cited side effect of non-medical steroid use is aggression and violence. In the mid-1980s, the notion steroid use leads to aggressive or violent behaviour became widespread, giving rise to the term “<a href="https://www.ncbi.nlm.nih.gov/pubmed/25515831">roid rage</a>”.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/15817752">Studies on animals</a> have found a direct link between testosterone and increased aggressive behaviour. We need further research to see <a href="https://www.ncbi.nlm.nih.gov/pubmed/27671627">whether or not this phenomenon translates to humans</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-debates-about-drug-use-fun-is-important-110696">In debates about drug use, fun is important</a>
</strong>
</em>
</p>
<hr>
<p>There are likely to be <a href="https://www.sciencedirect.com/science/article/pii/S1359178916300040?via%3Dihub">many factors</a> influencing the relationship between drugs (including steroids) and aggressive behaviour. This includes personality traits, neuropsychological risks, environmental influences, socioeconomic status, and/or the use of multiple substances at once.</p>
<p>While some people who use steroids report <a href="http://www.ipedinfo.co.uk/resources/downloads/2016%20National%20IPED%20Info%20Survey%20report%20FINAL.pdf">increased irritation</a>, the complexity of the relationship between hormones and behaviour suggests violent outbursts can’t simply be accorded to using steroids.</p>
<h2>Acknowledging pleasure</h2>
<p>A narrative centred on public health harms, the potential for violent behaviour and psychological disturbance naturally prioritises <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2581558">repressive means</a> to combat the issue (for example, <a href="https://link.springer.com/article/10.1007%2Fs12117-018-9348-5">the criminalisation of drug users</a>). </p>
<p>This tends to exclude evidence-based approaches based in <a href="https://journals.sagepub.com/doi/full/10.1177/0091450917694268">public health and harm reduction</a> such as the provision of tailored safe injection advice, drug testing services, and medical monitoring for people who use steroids for non-medical reasons.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275062/original/file-20190517-69204-vaht4u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Steroids are often obtained illegally without a prescription.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p><a href="https://onlinelibrary.wiley.com/doi/10.1111/add.12545">Research</a> in the field of alcohol and psychoactive drugs has highlighted the importance of acknowledging the <a href="https://theconversation.com/drugs-researchers-shouldnt-just-focus-on-the-harms-110852">benefits</a> and <a href="https://theconversation.com/in-debates-about-drug-use-fun-is-important-110696">pleasurable effects</a> of drug use by healthy individuals. </p>
<p>For example, studies exploring motivation for party drug use show fun and pleasure <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.12545">are central for users</a>. Participants in these studies report using drugs gives them energy and confidence, reduces inhibitions, enhances feelings of connection to others, and intensifies sexual experience.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/history-not-harm-dictates-why-some-drugs-are-legal-and-others-arent-110564">History, not harm, dictates why some drugs are legal and others aren't</a>
</strong>
</em>
</p>
<hr>
<p>Similarly, bodybuilders <a href="https://www.ncbi.nlm.nih.gov/pubmed/12190264">derive aesthetic pleasure</a> from their body modification practices. Steroid users have also reported <a href="https://www.ncbi.nlm.nih.gov/pubmed/27955960">positive</a> and <a href="http://www.ipedinfo.co.uk/resources/downloads/2016%20National%20IPED%20Info%20Survey%20report%20FINAL.pdf">pleasurable</a> feelings such as increased libido, greater confidence and increased well-being and strength. </p>
<p>While the effects of steroid use differ from the “highs” of traditional drugs, they are nonetheless seen as pleasure-inducing and form part of the appeal of taking drugs in this context.</p>
<h2>Progressing drug policy</h2>
<p>Like all drugs, steroid use has the potential to cause harm. If you’re someone who uses steroids, it’s safest to do so under the advice and guidance of a medical professional.</p>
<p>At the same time, we need to acknowledge the role of pleasure and other benefits in the use of steroids. Failing to do so may hinder our ability to address the phenomenon and explore alternative regulatory models.</p>
<p>Rational and critical debates on this topic are particularly important in a world that appears increasingly eager to explore the opportunities for <a href="https://www.researchgate.net/publication/233726940_Human_Enhancement_Drugs_-_The_Emerging_Challenges_to_Public_Health">human enhancement</a>.</p><img src="https://counter.theconversation.com/content/114981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When you think of steroid users, it’s likely you picture a male in the gym with huge muscles. But all sorts of people use steroids for all sorts of reasons.Katinka van de Ven, Research Fellow, Drug Policy Modelling Program, SPRC, UNSW SydneyKyle J.D. Mulrooney, Lecturer in Criminology, University of New EnglandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1027732018-12-09T19:08:17Z2018-12-09T19:08:17ZHow researchers assess whether medications work<figure><img src="https://images.theconversation.com/files/248953/original/file-20181205-186073-byqw7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ear infections are no fun. The OSTRICH clinical trial looked at whether oral steroid medications might help. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/view-abovebaby-crying-bed-before-bedtime-772323976?src=awe6dqAVYr9zrU9frzOTyA-1-22">from www.shutterstock.com </a></span></figcaption></figure><p><em>This article is in the series <a href="https://theconversation.com/au/topics/this-is-research-61770">This is research</a>, where we ask academics to share and discuss open access articles that reveal important aspects of science. Today’s piece explains how clinical trials assess drug effectiveness.</em></p>
<hr>
<p>Ear infections, or “<a href="https://www.childrens.health.qld.gov.au/fact-sheet-middle-ear-disease/">otitis media</a>”, can cause of a lot of pain and discomfort in youngsters. In some children, persistent infections result in hearing loss. </p>
<p>But what sort of treatment should these children have, and how can doctors work out what is actually effective? </p>
<p>Here’s where a type of research called a clinical trial is useful. </p>
<p>Let’s take a look at the “<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31490-9/fulltext">OSTRICH</a>” clinical trial, which investigated the impact of a short course of oral steroids (prednisolone) in children with persistent ear infection leading to fluid build-up in the ear, and hearing loss. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/bulging-ear-drums-and-hearing-loss-aboriginal-kids-have-the-highest-otitis-media-rates-in-the-world-64165">Bulging ear drums and hearing loss: Aboriginal kids have the highest otitis media rates in the world</a>
</strong>
</em>
</p>
<hr>
<h2>What is a clinical trial?</h2>
<p>Clinical trials are the favoured type of study for showing cause and effect. They sit near the top of the study <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124652/">pecking order</a>, only outdone in importance by summaries of lots of clinical trials put together. </p>
<p>Clinical trials can assess impact of a medication on a disease or condition. Researchers generally test a particular treatment, and compare the outcome to a different treatment or no treatment (if it’s ethical to do so). </p>
<p>The ideal design is one when the researchers and participants do not know who is assigned to the different treatments being tested. This is referred to as blinding. </p>
<p>Blinding may not always be possible. In food trials for example (where we do most of our work), it is very hard to blind a participant from a food they need to eat. Measures can be taken to minimise the impact of this, though.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/randomised-control-trials-what-makes-them-the-gold-standard-in-medical-research-78913">Randomised control trials: what makes them the gold standard in medical research?</a>
</strong>
</em>
</p>
<hr>
<h2>The OSTRICH trial</h2>
<p>The OSTRICH trial used an approach where they tested a real medication, in this case a steroid, and compared it to a treatment that was almost the same but without the active ingredient – called a placebo. </p>
<p>The researchers worked with 389 children aged two to eight years with ear infection symptoms, fluid build up for at least three months, and with confirmed hearing loss in both ears. Two hundred kids were allocated to received oral steroids, and 189 to receive placebo for seven days. </p>
<p>With this approach they recorded the impact of the treatments on the ear canal and middle ear, and also conducted clinical tests for hearing. The parents kept a diary of symptoms, and completed questionnaires.</p>
<p>The children were followed up five weeks weeks, six months and 12 months after completion of the treatment. The primary outcome for the trial was acceptable hearing confirmed by an <a href="https://medlineplus.gov/ency/article/003341.htm">audiometry test</a> at five weeks. </p>
<p>Both the families and the researchers did not know who had the real medication until the study was finished – this is called double blinding. This time period meant that researchers had to be careful with the information they collected to avoid <a href="http://ebooks.iospress.nl/volumearticle/40076">potential errors</a>. </p>
<h2>Kids are unpredictable</h2>
<p>Even with the best laid plans, children are hard to predict. As well as looking at the effect of a medication on a disease, the number of study participants who follow all instructions and finish the study as per the plan is an important outcome. </p>
<p>Not all of the starting 389 kids finished the full 12 months of the OSTRICH trial, and this was due to a variety of reasons. Some families withdrew consent to take part, some children didn’t meet the hearing loss criteria at the outset, and some families couldn’t be contacted as time moved on. Some children didn’t always take their medication. This won’t surprise you if you have ever needed to give a child medicine – of any sort. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1066&fit=crop&dpr=1 600w, https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1066&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1066&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1339&fit=crop&dpr=1 754w, https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1339&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/249122/original/file-20181205-186055-11fqaje.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1339&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Lots of things happen during a clinical trial that reduce your sample size.</span>
<span class="attribution"><a class="source" href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31490-9/fulltext">Francis and colleagues, Lancet Volume 392, Issue 10147, p557-568, August 18, 2018</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In children who did complete the trial, the results showed no statistically significant difference between children treated with the steroid and those treated with the placebo drug. Assessed at five weeks, hearing was only slightly improved in the group assigned the real medication compared to the group given the placebo. </p>
<p>The study authors wrote: </p>
<blockquote>
<p>A short course of oral prednisolone is not an effective treatment for most children aged 2–8 years with persistent otitis media with effusion, but is well tolerated. One in 14 children might achieve improved hearing but not quality of life. </p>
</blockquote>
<h2>What didn’t they find?</h2>
<p>Clinical trials can only make conclusions regarding the effect of what they are testing on the group they have tested it with. </p>
<p>This study quite simply shows that in children aged two to eight, a one-week course of oral steroids has minimal impact on hearing loss in children who had hearing loss due to ear infection and fluid build up, and assessed five weeks after the treatment started. </p>
<p>The study authors can’t conclude that this same finding will apply to children outside of the two- to eight-year age group, or to other types of medications, or steroids given for different time periods. </p>
<p>The researchers commented at the end of their study report that perhaps a clinical trial of oral steroids plus antibiotics is required for children with infection and hearing loss in this age group. </p>
<hr>
<p><em><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31490-9/fulltext">The open access research paper for this analysis is Oral steroids for resolution of otitis media with effusion in children (OSTRICH): a double-blinded, placebo-controlled randomised trial</a>.</em></p><img src="https://counter.theconversation.com/content/102773/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yasmine Probst receives funding from the NSW Ministry of Health and has been an investigator on previously published clinical trials with the Smart Foods Centre, University of Wollongong. </span></em></p><p class="fine-print"><em><span>Lauren Houston conducted this research with the support of the Australian Government Research Training Program Scholarship.</span></em></p>Clinical trials can assess impact of a medication on a disease. The ideal design is ‘blind’ – when the researchers and participants do not know who is assigned to the different treatments.Yasmine Probst, Senior lecturer, School of Medicine, University of WollongongLauren Houston, PhD Candidate, University of WollongongLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/904002018-02-15T11:55:40Z2018-02-15T11:55:40ZWinter Olympics: why many athletes will be struggling with asthma<p>As the world’s best winter athletes compete in PyeongChang for the 2018 Winter Olympic Games, the heavy demands of both training and competition will leave many of them with breathing problems. </p>
<p>Exercise-induced asthma is the most common medical problem among winter Olympic athletes, especially among cross-country skiers. Nearly <a href="https://www.ncbi.nlm.nih.gov/pubmed/10776890">50%</a> of these athletes suffer from the condition, closely followed by short-track speed skaters at 43%. For figure skaters it’s 21%, Nordic combined it’s 17%, and for ice hockey it’s 15%. By comparison, <a href="https://www.asthma.org.uk/about/media/facts-and-statistics/">around 9%</a> of the UK general population suffers from asthma. </p>
<p>The combination of sustained high breathing combined with cold, dry air increases winter athletes’ risk of asthma-related conditions. (Indoor speed skaters also have to deal with increased pollution in the form of particulate matter from ice resurfacing vehicles.) Cross-country skiers, for example, increase their breathing rate from about six litres per minute at rest, to 180 litres per minute during a race. This huge increase in breathing results in large volumes of cold, dry air being drawn into the lungs. This can cause the smooth muscle in the airway to narrow, reducing the athletes’ ability to breathe normally. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205527/original/file-20180208-180808-136ema9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Ice resurfacing machines release particulate matter.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=TBPfg_Ndf_afOgoukdKQiw-1-0">njene/Shutterstock</a></span>
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<p>This happens by two processes. The first relates to <a href="https://www.ncbi.nlm.nih.gov/pubmed/2767426">the airway becoming dehydrated</a> which causes a release of inflammatory cytokines – messenger molecules that cause the airway to become narrow and inflamed. </p>
<p>The second process relates to respiratory heat loss which results in airway narrowing through nerve stimulation. When the athlete stops exercising, the airway narrows even further by a dilation of blood vessels as the <a href="https://www.ncbi.nlm.nih.gov/pubmed/1969985">airways warm up again</a>.</p>
<p>Although we know that exercise-induced asthma is common in winter athletes, it can be confused with other conditions, such as dysfunctional breathing patterns and <a href="https://en.wikipedia.org/wiki/Exercise-induced_laryngeal_obstruction">exercise-induced laryngeal obstruction</a>, that have <a href="https://www.ncbi.nlm.nih.gov/pubmed/25398497">similar symptoms to asthma</a>. </p>
<p>If an athlete is diagnosed with exercise-induced asthma, they are usually given the standard treatment for asthma: a preventer asthma inhaler, containing steroid medication. This works by reducing the inflammation and sensitivity of the airways, helping them breathe. However, athletes have to be careful about the type of inhaler they use as some drugs – such as salbutamol – could put them at risk of an anti-doping violation. </p>
<h2>Alternative therapies</h2>
<p>As well as using drugs to treat exercise-induced asthma, athletes can supplement their inhaler therapy with:</p>
<p><strong>Heat-and-moisture face masks:</strong> Face masks worn during training and prior to competition are able to capture the heat and moisture in exhaled breath and use it to warm and moisten the inhaled air as a <a href="https://www.ncbi.nlm.nih.gov/pubmed/16685008">defence</a> against airway dehydration and subsequent narrowing. </p>
<p><strong>Fish oils:</strong> <a href="https://www.ncbi.nlm.nih.gov/pubmed/16424411">Studies suggest</a> that the use of omega-3 fish oils can reduce airway inflammation and provide a protective effect against asthma associated with exercise. </p>
<p><strong>Prebiotics:</strong> <a href="https://www.ncbi.nlm.nih.gov/pubmed/27523186">Recent evidence</a> suggests that a dietary prebiotic supplement that targets the good bacteria in the gut can reduce the severity of asthma in physically active asthma patients and reduce airway inflammation.</p>
<p>Winter athletes who suffer from exercise-induced asthma can use an inhaler alone, or in combination with one or more of the above treatments. By doing this, athletes can maintain their airway health and function, allowing them to compete without compromising their performance.</p><img src="https://counter.theconversation.com/content/90400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nearly 50% of cross-country skiers suffer from exercise-induced asthma.Neil Williams, Lecturer in Exercise Physiology and Nutrition, Nottingham Trent UniversityJohn Dickinson, Head of the Respiratory Clinic and Reader in Sport and Exercise Sciences, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/831732017-09-01T12:53:10Z2017-09-01T12:53:10ZAnti-inflammatory drug cuts risk of heart attack and lung cancer – but at what cost?<figure><img src="https://images.theconversation.com/files/184335/original/file-20170901-26053-b55li5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/372343618?src=-Kfl-BKFhjSXcUdjL9Ln0A-1-4&size=medium_jpg">wavebreakmedia/Shutterstock</a></span></figcaption></figure><p>A drug, currently licensed to treat a rare form of arthritis, has been found to significantly reduce the risk of heart attack and lung cancer, according to a <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1707914?query=featured_home&utm_source=STAT+Newsletters&utm_campaign=9c153e3f48-MR&utm_medium=email&utm_term=0_8cab1d7961-9c153e3f48-149591317&#t=articleTop">report</a> in the New England Journal of Medicine. The drug is being hailed as the biggest breakthrough in preventing heart attacks since the introduction of statins, 30 years ago.</p>
<p>The four-year trial, called CANTOS, involved 10,000 participants, each of whom had suffered an initial heart attack. The researchers wanted to know if an anti-inflammatory drug – approved to treat juvenile arthritis – could prevent a subsequent heart attacks in the participants randomised to receive the drug. It did – by 24%. And that was over and above the benefit of the statins the participants took throughout the trial. </p>
<p>The drug, called canakinumab, also reduced the risk of the patient being hospitalised with unstable angina (37%), and reduced the risk of needing bypass surgery (32%). Many smokers are at risk of heart disease, <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1707914?query=featured_home&utm_source=STAT+Newsletters&utm_campaign=9c153e3f48-MR&utm_medium=email&utm_term=0_8cab1d7961-9c153e3f48-149591317&#t=articleTop">so the news</a> that the drug also reduced the risk of developing lung cancer by half, was encouraging. </p>
<p>Cardiovascular disease is still the leading cause of death in the world, accounting for about <a href="https://www.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_470704.pdf">17m deaths a year</a>. That figure is expected to grow to more than 23m by 2030, so finding new ways to tackle heart disease is critical. </p>
<p>Statins play an important role in preventing cardiovascular disease in those at risk, but they only help people who have high cholesterol. But about half the people who have a heart attack don’t have high cholesterol, so a fresh approach is needed. That’s where tackling inflammation comes into the picture.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184338/original/file-20170901-26017-1rchhho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Statins have been a boon, but they only benefit those who have high cholesterol.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/199388345?src=S8h05CZGsLtdzZg0TxZnbg-1-3&size=medium_jpg">roger ashford/Shutterstock</a></span>
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<h2>Fighting inflammation</h2>
<p>Most people understand the risk of having high levels of lipids, such as cholesterol, in cardiovascular disease, but people are often unaware of the part that inflammation plays in giving us heart disease. </p>
<p>For many years, doctors have suspected that inflammation plays an important role in heart disease and in <a href="http://www.nhs.uk/conditions/atherosclerosis/Pages/Introduction.aspx">atherosclerosis</a> (the build-up of fatty material inside the arteries). CANTOS is the first trial to show that blocking inflammation can prevent heart attacks.</p>
<p>Acute inflammation is part of the body’s normal protection against injury or infection. It usually disappears as the infection is treated or the injury is repaired. What is much less recognised, is that a whole range of diseases, including many <a href="https://www.ncbi.nlm.nih.gov/pubmed/28859112">cancers</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1087185/">diabetes</a>, <a href="http://circres.ahajournals.org/content/96/9/939.short">heart disease</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858674/">stroke</a> and even mental health disorders, such as <a href="https://www.ncbi.nlm.nih.gov/pubmed/26357876">depression</a>, often involve a level of low, long-standing inflammation. </p>
<p>This chronic low-level inflammation is probably caused by our modern lifestyle, which often includes a poor diet, lack of exercise, alcohol consumption and smoking. Doctors and researchers increasingly accept that preventing or reducing this type of inflammation is an important weapon in preventing cardiovascular disease.</p>
<p>The results of the CANTOS trial are very exciting, as they demonstrate that controlling inflammation may be as important in cardiovascular disease as controlling blood cholesterol through statins has been. </p>
<p>It also presented results that canakinumab could play a role in slowing the development of cancers. Canakinumab, works by blocking the action of a cytokine called interleukin-1. Cytokines are a very <a href="http://www.sciencedirect.com/topics/neuroscience/cytokines">powerful group of proteins</a> that the body use to control inflammation, and interleukin-1 has a particularly important role in the development of wide range of inflammatory diseases.</p>
<p>Given its importance in inflammation, the potential for an antibody against interleukin-1 to be used in a wide range of chronic inflammatory diseases – including some cancers – is little short of huge. Since cardiovascular disease is also closely linked to the development of dementia, the use of canakinumab in preventing this critical public health problem must be a serious consideration. </p>
<h2>Drawbacks</h2>
<p>One of the problems with reducing inflammation – the body’s natural response to infection – is that you increase the risk of infection. Sepsis was one of the deadly side effects of canakinumab. However, this was mainly a problem at the highest dose. </p>
<p>All drugs have side effects, and whether or not the drug is approved for use in preventing cadiovascular disease will depend on a careful risk-versus-harms analysis. The factor that is more likely to put the brakes on wide adoption of the drug is price.</p>
<p>Canakinumab is <a href="https://www.forbes.com/sites/johnlamattina/2017/06/22/novartis-cantos-heart-trial-results-could-lead-to-drastic-drop-in-arthritis-drug-price/#5cccc5576bf3">estimated to cost</a> US$60,000 (£46,258) annually per patient. It is very likely that the cost of the drug will come down, given the size of the market – but it is still likely to be very expensive, even for wealthy countries where health budgets are often already stretched to breaking point.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184339/original/file-20170901-27284-pfq2cc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A cheap alternative.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/248426698?src=IrNE4eyGWlqMXBmGTRpJuw-1-3&size=medium_jpg">Novikov Alex/Shutterstock</a></span>
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<h2>Get walking</h2>
<p>It has been known for a long time that simple changes in our daily lives, such as regular brisk walking, can control inflammation and prevent heart disease, cancer and even depression – possibly in a similar way to canakinumab. And it’s free.</p>
<p>However, given that it was recently revealed that 41% of middle-aged people in the UK don’t even do <a href="http://www.bbc.co.uk/news/health-41030630">ten minutes of brisk walking</a> a month, there is a risk that a drug such as cankinumab will be seen by many as an easy, albeit expensive, alternative to exercise.</p><img src="https://counter.theconversation.com/content/83173/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Morris receives funding from NHISHR. </span></em></p>An expensive drug is hailed as the biggest breakthrough since statins. But there is a cheaper alternative.Keith Morris, Professor of Biomedical Sciences and Biostatistics, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/822052017-08-29T03:34:49Z2017-08-29T03:34:49ZDoping among amateur athletes like CrossFitters is probably more common than you’d think<figure><img src="https://images.theconversation.com/files/181897/original/file-20170814-28408-gg7zsz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It is is a misperception to think that performance-enhancing drug use is only an issue in elite sport.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Earlier this month the 11th annual CrossFit Games <a href="http://www.abc.net.au/news/2017-08-08/tia-clair-toomey-wins-world-crossfit-games/8784360">took place in the US</a>. While the event has come a long way from humble beginnings, the prizemoney and fame now attached to it have <a href="https://www.t-nation.com/powerful-words/crossfit-and-steroids">led to concerns</a> that competitors may be doping to gain an unfair advantage.</p>
<p>CrossFit is a fitness regime practised by people all around the world. But the majority of those who take part in its high-intensity competitive workouts are not elite athletes: they do so on an amateur level or recreationally.</p>
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<figcaption><span class="caption">CrossFit explained.</span></figcaption>
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<p>The first CrossFit Games, in 2007, had 70 registered athletes competing for US$500 in prizemoney. By 2017, it had more than 300,000 athletes competing for the possibility of winning US$275,000. Games organisers have signed multimillion-dollar sponsorship and marketing contracts, and secured a multi-year TV deal with ESPN.</p>
<p><a href="http://www.mheducation.com/highered/product/sports-society-issues-controversies-coakley/M0073523542.html">Evidence suggests</a> that when sport becomes more commercialised, the prizes more lucrative and the competition fiercer, doping becomes more attractive for athletes. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/25169441">prevalence of doping</a> among elite athletes in general is between 14% and 39%. The uncovering of recent scandals, such as the one revealed in <a href="https://www.theglobeandmail.com/arts/film/netflixs-icarus-opens-our-eyes-to-the-world-of-doping-in-atheltics/article36089891/">the documentary Icarus</a>, is further evidence that doping is widespread. </p>
<p>Similarly, given the growing pressure to compete, its heavy physical demands and the quest for self-improvement and a winning edge, it is not unreasonable to think that similar percentages may exist in CrossFit. </p>
<h2>Doping is not exclusive to elite athletes</h2>
<p>It is a misperception to think that performance-enhancing drug use is an issue in elite sport only. Most people who <a href="http://www.ipedinfo.co.uk/resources/downloads/2015%20National%20IPED%20Info%20Survey%20report.pdf">use these substances</a> do so to improve their appearance, general wellbeing and/or performance (non-elite). </p>
<p>In the UK, steroid use among 16-to-24-year-old men <a href="http://www.independent.co.uk/life-style/health-and-families/love-island-young-men-steroid-use-muscles-reality-tv-beach-holiday-a7864376.html">increased fourfold</a> in the last year. In Australia, the <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813">dramatic increase in steroids</a> detected at the borders and the number of <a href="https://www.ncbi.nlm.nih.gov/pubmed/26644363">users of needle and syringe programs</a> suggest a similar story.</p>
<p>As such, there are concerns that performance-enhancing drug use is quickly becoming a public health crisis.</p>
<p>In our soon-to-be-published UK study on CrossFit, 13% of 123 participants reported ever having used performance- or image-enhancing drugs (mainly weight-loss drugs and steroids).</p>
<p>Participants mainly used these substances not to enhance their sport performance but to develop body image and/or for cosmetic purposes (50%), to lose weight (41.6%) and to put on size/gain weight (25%).</p>
<h2>Doping as a public health problem</h2>
<p>Tackling doping has been largely left to the sporting arena. Sporting authorities mainly rely on testing and surveillance to combat doping. But the rise of doping among the general public has required governments to rethink their approach.</p>
<p>Some have simply applied elite sports’ testing and surveillance model to recreational athletes. For example, in <a href="https://theconversation.com/doping-controls-in-gyms-ineffective-costly-and-more-common-than-you-think-68797">Denmark and Belgium</a>, everyday gym-goers can be subjected to drug testing. If they test positive they can receive similar sanctions to professional athletes.</p>
<p>Other jurisdictions have gone the criminal justice route, enacting and intensifying laws against the consumption, possession and/or trafficking of these drugs.</p>
<p><a href="https://theconversation.com/australia-should-stop-beefing-up-its-steroid-laws-that-wont-help-users-77343">Queensland in Australia</a>, for instance, reclassified steroids as a schedule-one drug in 2014. This means they are classed alongside heroin, cocaine and ice in the highest category of dangerous illicit drugs, with penalties of up to 25 years’ imprisonment for possession or supply of steroids. </p>
<p>Similar tough penalties apply in other Australian states.</p>
<h2>From anti-doping to health promotion</h2>
<p>The government must tackle the needs of this rapidly growing drug-using population. But simply copying failed sport policy, or taking two steps back via criminal justice measures, is the wrong approach. </p>
<p>Many <a href="https://www.ncbi.nlm.nih.gov/pubmed/28619395">sport researchers</a>, including <a href="https://theconversation.com/doping-controls-in-gyms-ineffective-costly-and-more-common-than-you-think-68797">ourselves</a>, have argued for an approach centred on public health that seeks to tackle the wider sociocultural reasons behind the rise in drug use, while seeking to reduce the harms associated with such use.</p>
<p>For example, it is increasingly recognised that social pressure to conform to idealised beauty standards, coupled with the growth of social media, has led to growing numbers of young people being unhappy with how they look. </p>
<p>A harm-reduction-based program would accept that the use of performance- and image-enhancing substances occurs. Therefore, such an approach would focus on minimising harms of use, using strategies such as peer education, prevention strategies, testing of the quality of drugs, and medical advice. </p>
<p>The current controls against anti-doping in sport are largely incompatible with this approach. It would require sport officials to accept doping as part of sport and to shift concerns away from the purity of sport and to the health of the athlete. We are a long way from having these sober discussions.</p>
<p>Thus, for now, our policy approach to this growing public health problem must learn to differentiate between the CrossFit Games athletes and the amateur/recreational CrossFitter, shifting from a punitive model largely reliant on deterrence to one centred on <a href="http://www.tandfonline.com/doi/full/10.1080/09687637.2016.1208732">health promotion</a>.</p><img src="https://counter.theconversation.com/content/82205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katinka van de Ven and Kyle Mulrooney received funding from Birmingham City University to conduct the CrossFit study. </span></em></p><p class="fine-print"><em><span>Kyle J.D. Mulrooney does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are concerns that performance-enhancing drug use is quickly becoming a public health crisis.Kyle J.D. Mulrooney, PhD Fellow, Doctorate in Cultural and Global Criminology, University of KentKatinka van de Ven, Research Fellow, National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/773432017-05-15T20:07:49Z2017-05-15T20:07:49ZAustralia should stop beefing up its steroid laws – that won’t help users<figure><img src="https://images.theconversation.com/files/168686/original/file-20170510-7904-9futrr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There has been a dramatic increase in the amount of steroids seized at the Australian border over time.</span> <span class="attribution"><span class="source">AAP</span></span></figcaption></figure><p>The use of image and performance enhancing drugs – in particular steroids – is a growing area of concern <a href="https://www.ncbi.nlm.nih.gov/pubmed/24582699">globally</a>. </p>
<p>The use of these drugs has traditionally been limited to elite athletes and professional bodybuilders. But now their use is becoming normalised as part of a <a href="http://onlinelibrary.wiley.com/doi/10.1111/hsc.12326/pdf">fitness and beauty regime</a> for people who want to gain muscle, become leaner, and improve their appearance.</p>
<p>Several <a href="http://www.tandfonline.com/doi/abs/10.3109/09687637.2015.1061975">population studies</a> have shown the use of image and performance enhancing drugs in Australia is relatively low. However, the dramatic increase of <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813">steroids detected</a> at the country’s borders, and the number of users <a href="https://www.ncbi.nlm.nih.gov/pubmed/26644363">accessing needle and syringe programs</a>, seem to indicate otherwise. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=273&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=273&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=273&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=344&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=344&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168825/original/file-20170510-21593-cled6x.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=344&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Number of performance- and image-enhancing drug detections at the Australian border, 2005–06 to 2014–15.</span>
<span class="attribution"><span class="source">DIBP</span></span>
</figcaption>
</figure>
<p>If Australia is to respond to image and performance enhancing drug use effectively, we need to improve our prevention and harm-reduction strategies – and not merely further criminalise users.</p>
<h2>Potential health harms</h2>
<p>The most-researched (and targeted) image and performance enhancing drugs are steroids. But other examples include <a href="https://theconversation.com/health-warning-about-body-sculpting-drug-clenbuterol-23815">clenbuterol</a> (to lose weight) and <a href="http://www.news.com.au/lifestyle/health/health-problems/melanotan-ii-sold-illegally-online-to-people-desperate-for-a-tan/news-story/878a895097e72cfe6b723e5d9f4234ed">melanotan II</a> (a tanning agent).</p>
<p>The inappropriate and excessive use of these drugs has been associated with a range of negative <a href="http://www.sciencedirect.com/science/article/pii/S0376871608001919">physical</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/19769977">psychological</a> health consequences. Steroid use, for example, has been linked to high blood pressure, heart attack, stroke, acne and skin infections, liver damage, tendon rupture, premature baldness and stunted bone growth in adolescents. There are also psychological implications such as addiction, mood syndromes, and body image disorders. </p>
<p>Another issue is that the widespread use of <a href="https://www.ncbi.nlm.nih.gov/pubmed/20355210">illicitly manufactured products</a> sourced through the black market puts drug users at risk of adverse reactions to tainted products.</p>
<p>In addition, as many of these substances are injected, there are potential harms from unsafe injecting practices. For example, <a href="http://www.tandfonline.com/doi/abs/10.1080/09595230802392568">research</a> has found that 41% of Australian men who injected steroids reported an injection-related health problem such as such as fevers, scarring and abscesses. </p>
<h2>Beefing up steroid laws</h2>
<p>In Australia, increases in the detection of these drugs at the border, coupled with <a href="https://theconversation.com/why-organised-crime-should-not-be-used-to-shape-anti-doping-policy-42385">contested concerns</a> about <a href="http://www.tandfonline.com/doi/abs/10.1080/09595230802392568">links to organised crime</a>, has led to greater levels of law enforcement. </p>
<p><a href="https://www.legislation.qld.gov.au/Bills/54PDF/2014/SafeNightOutLAB14E.pdf">Queensland</a>, Australia’s steroid capital, reclassified steroids a <a href="https://www.tga.gov.au/scheduling-basics">schedule-one drug</a> in 2014. This means they are now classed alongside heroin, cocaine and ice in the highest category of dangerous illicit drugs. </p>
<p>Under this legislation, the maximum penalty for possession or supply of steroids is 25 years’ imprisonment. Similar tough penalties apply in <a href="http://www.criminallawyers.net.au/reclassification-of-steroids-as-narcotics/">New South Wales</a> and <a href="https://www.sentencingcouncil.vic.gov.au/sites/default/files/publication-documents/Major%20Drug%20Offences%20Current%20Sentencing%20Practices.pdf">Victoria</a>. </p>
<p>However, there is little evidence that tougher penalties have resulted in reductions in steroid availability. The total number of seizures at the border fell in 2013-14. But <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813.">there is evidence</a> of increases in recent years. </p>
<p>The <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/06/oca2015.pdf">Australian Crime Commission</a> suggested in 2015 that any decrease in border interceptions could be the result of an increase in domestic production, coupled with increasingly easy access to drugs over the internet. </p>
<p>Despite having the toughest legislation, Queensland accounts for the greatest proportion of <a href="https://www.acic.gov.au/sites/g/files/net1491/f/2016/08/acic-iddr-2014-15.pdf?v=1470178813">national steroid arrests</a> (58% in 2014-15). But the greatest proportion of those arrested are steroid consumers – not suppliers. This suggests the current criminal justice approach may have limited capacity to limit distribution. </p>
<p>That growth in steroid use is most apparent in jurisdictions where recent legal changes have increased penalties suggests enhancing law enforcement measures may be an ineffective response to steroid use. <a href="https://theconversation.com/australias-recreational-drug-policies-arent-working-so-what-are-the-options-for-reform-55493">Other research</a> on the impact of drug policies on other illicit substances have reached similar conclusions. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=324&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=324&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=324&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=407&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=407&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168826/original/file-20170510-21620-1c28tgl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=407&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Number of national steroid arrests, 2005-06 to 2014-15.</span>
<span class="attribution"><span class="source">ACIC</span></span>
</figcaption>
</figure>
<h2>Consequences of a tough law enforcement approach</h2>
<p>As is the case with drug use broadly, users of enhancement drugs can be considered rational consumers who make a deliberate choice to use steroids to achieve a desired outcome.</p>
<p>But social and cultural factors are also very influential in the decision to use drugs. <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421139&libID=10737421138">Research</a> suggests people considering drug use rarely take the illegality of a particular substance into consideration. </p>
<p>Increasing penalties associated with the use and possession of image and performance enhancing drugs are unlikely to prevent uptake or encourage users to stop. Instead, this may result in several unintended negative consequences. For one, it can hinder <a href="https://link.springer.com/article/10.1007%2Fs12117-014-9235-7">access to medical services</a> and information by discouraging both users and healthcare practitioners from talking about drug use.</p>
<p>Tougher penalties can also distract from key harm-minimisation measures, such as safe injecting practices. </p>
<p>Other unintended negative consequences of criminal justice responses to such drug use include:</p>
<ul>
<li><p><a href="http://www.springer.com/gb/book/9781461482406">a growing black market</a>;</p></li>
<li><p><a href="http://www.sciencedirect.com/science/article/pii/S2211266915300086">geographical displacement</a> of users and suppliers; and </p></li>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pubmed/20355187">increased risk of bad-quality drugs</a>. </p></li>
</ul>
<h2>What about harm-reduction strategies?</h2>
<p>Victoria’s existing harm-reduction initiative, the <a href="http://www.publish.csiro.au/py/pdf/PY02022">Steroid Education Project</a>, lags far behind services for alcohol and other illicit drugs in its funding and resources. It provides face-to-face and over-the-phone counselling to steroid users, and delivers training to needle and syringe program staff. </p>
<p>Greater resourcing is required to extend this program to allow for training in needle and syringe programs across Australia, and to deliver training to GPs. Given the reluctance of users to engage <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-11-19">with traditional drug services</a>, GPs may be an <a href="https://www.youtube.com/watch?v=IQiZ4gGflKo">important avenue</a> for providing harm-minimisation messages to this group.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/IQiZ4gGflKo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>There is an urgent need to reconsider steroid use as a public health issue, as opposed to a criminal justice concern. Harsher penalties will do nothing to tackle misinformation about steroids or underlying issues of body image dissatisfaction, depression and mental health concerns among users.</p><img src="https://counter.theconversation.com/content/77343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is an urgent need to reconsider steroid use as a public health issue as opposed to a criminal justice concern.Katinka van de Ven, Research Fellow, National Drug and Alcohol Research Centre, UNSW SydneyRenee Zahnow, Postdoctoral Research Fellow, Faculty of Humanities and Social Sciences, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/687972016-12-13T15:03:22Z2016-12-13T15:03:22ZDoping controls in gyms – ineffective, costly and more common than you think<figure><img src="https://images.theconversation.com/files/149398/original/image-20161209-31383-ooto6p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/pic-518703730/stock-photo-muscular-man-injecting-steroids-closeup.html?src=mT7S0nfs4_5Bv9k-zG2CZA-1-52">Africa Studio/Shutterstock.com</a></span></figcaption></figure><p>Anti-doping is not just something that exists in elite sports; it’s increasingly being applied to recreational gym users. While most countries focus on <a href="https://www.virke.no/globalassets/bransje/bransjedokumenter/ehfa.pdf/">prevention and education</a>, a handful have taken the drastic step of introducing doping controls in commercial gyms. In 2003, Belgium became the first country to introduce such measures. Sweden, Denmark and Norway soon followed their lead. </p>
<p>Since the early 2000s, recreational trainers in Belgium – especially in Flanders – have been forbidden from using substances banned by the World Anti-Doping Code (WADC), which governs elite athletes. They also face the same sanctions as elite athletes. To vet people, anti-doping officials use <a href="https://deviantleisure.wordpress.com/2015/01/21/muscle-profiling-anti-doping-policy-and-deviant-leisure/">muscle profiling</a>. Although doping controls are meant to be random, it is often male weight trainers with a more muscular appearance who are tested for the use of steroids. </p>
<p>Police are able to conduct a home search based on a positive test, and an athlete may be subject to both a doping and a drug investigation for the same offence. These people face criminal prosecution for the use or possession of illegal substances and they also face sanctions from the Flemish national anti-doping organisation (NADO). If a person tests positive, and it’s a first offence, they may be banned by NADO Flanders for two years from every gym and any form of organised sport in the region. They may also receive a fine of, on average, €1,000-2,000, although fines can be as high as €25,000. </p>
<p>In <a href="http://journal-tes.dk/vol_14_no_2_page_25/No_7_Nocole_Thualagant.pdf">Denmark</a> any person training in a gym that has entered into a collaboration agreement with Anti-Doping Denmark (the country’s national anti-doping organisation) may be subject to doping controls. Gyms in Denmark must indicate at their entrance and on their website by means of a happy or frowning icon whether or not they are part of this agreement. </p>
<p><a href="http://www.west-info.eu/files/Strategy-for-Stopping-Steroids.pdf">Sweden</a> also has doping controls at training facilities and Norway’s anti-doping strategies have an element of <a href="https://www.virke.no/globalassets/bransje/bransjedokumenter/ehfa.pdf/">monitoring and policing</a>. For instance, fitness centres that adopt the anti-doping programme in Norway receive a licence to carry out tests on members suspected of doping. There is no legal obligation to sign up to be a “Clean Centre”, but gyms that do are perceived to have a reputational advantage. <a href="http://www.antidoping.no/english/news-in-english/clean-centres-on-the-rise/">About half</a> of Norway’s fitness centres now have a Clean Centre certificate. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149403/original/image-20161209-31370-c9jgh4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anti-doping officials often use muscle profiling to guess who might be using steroids.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/530968282?src=-G0GgUonxgkhDrnZzNYxbQ-2-77&id=530968282&size=medium_jpg">xmee/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Not a deterrent</h2>
<p>The goal of these doping controls is to deter people from using substances that may be detrimental to their health. But, aside from privacy and human rights issues, such as undressing in front of a doping officer and targeting certain groups, <a href="http://www.sciencedirect.com/science/article/pii/S2211266915300086">recent research shows</a> that doping tests in gyms may <a href="http://scholar.valpo.edu/cgi/viewcontent.cgi?article=1071&context=vulr">be ineffective</a> anyway at preventing or reducing doping use. Rather, there are <a href="http://www.playthegame.org/uploads/media/Ask_Vest_Christiansen_-_Testing_recreational_athletes_01.pdf">possible unintended negative outcomes</a> that may increase health risks. For instance, users may train in basements and private clubs, stop training altogether, displace to other countries with no doping controls, or undertake more dangerous doping practices to avoid a positive test. </p>
<p>Drug testing in schools – including for doping – has proved ineffective in preventing students from <a href="http://www.jsad.com/doi/abs/10.15288/jsad.2014.75.65">trying drugs</a> or <a href="http://www.tandfonline.com/doi/abs/10.3109/10826084.2015.1010832">doping substances</a>. Not only do doping tests appear to have little deterrent effect, but it also is an <a href="https://sports.vice.com/en_us/article/why-did-texas-blow-10-million-to-catch-40-high-school-steroid-users">extraordinarily expensive process</a>. </p>
<p>While it is true that people are <a href="https://theconversation.com/in-a-bid-for-the-perfect-profile-pic-young-men-are-increasingly-turning-to-steroids-60874">increasingly using steroids and other image enhancing drugs</a>, testing in gyms does not seem to be the answer. If we have learned anything from the war on drugs, it is that repression does little to curb drug use. Instead, it contributes significantly to <a href="http://www.countthecosts.org/sites/default/files/Health-briefing.pdf">health and societal</a> problems. </p>
<p>Criminalising recreational users and elite athletes not only leads to increased stigmatisation and marginalisation, but it maximises the risks associated with use (<a href="http://www.sciencedirect.com/science/article/pii/S2211266915300050">unsafe products</a>) and hinders the <a href="http://www.sciencedirect.com/science/article/pii/S2211266912000084">implementation of harm-reduction initiatives</a>. </p>
<p>As it becomes clear that doping use among the general public is a growing phenomenon, we must confront the issue head on. However, the use of performance enhancing drugs in society must be addressed not as a sporting issue nor as a criminal one, but rather as a matter of <a href="http://www.tandfonline.com/doi/abs/10.1080/09687637.2016.1245713">public health</a>. We should focus attention on methods that have proved to be successful in addressing the use of performance and image enhancing drugs within the general population such as <a href="http://ec.europa.eu/sport/news/2014/docs/doping-prevention-report_en.pdf">prevention and education</a>, while seeking to reduce the <a href="https://kclpure.kcl.ac.uk/portal/files/49404361/McVeigh_2016_Harm_reduction_interventions_should_encompass_people_who_inject_image_and_performance_enhancing_drugs.pdf">harm associated with its use</a>. <a href="http://www.sciencedirect.com/science/article/pii/S221126691530013X">One study</a> of 15 to 21-year-olds found that combining anti-doping education with practical strength training can help prevent doping. Let’s go with the evidence and put an end to punitive measures.</p><img src="https://counter.theconversation.com/content/68797/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A handful of countries have introduced anti-doping measures in high-street gyms. Let’s nip it in the bud.Katinka van de Ven, Lecturer in Criminology, Birmingham City UniversityKyle J.D. Mulrooney, Ph.D. Fellow, Doctorate in Cultural and Global Criminology, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/608742016-06-23T09:46:33Z2016-06-23T09:46:33ZIn a bid for the perfect profile pic, young men are increasingly turning to steroids<figure><img src="https://images.theconversation.com/files/127545/original/image-20160621-13036-1t0giaj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=fvWkq8poNeynySuEkugwbA&searchterm=gym%20mirror&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=8486536">Kzenon/Shutterstock.com</a></span></figcaption></figure><p>The Crime Survey for England and Wales estimates that around 60,000 people are using steroids to gain muscle, to become leaner and fitter, or to get stronger. But <a href="http://www.ipedinfo.co.uk/resources/downloads/SIEDs%20Survey%20report%202014%20FINAL.pdf">academics and experts who work with steroid users</a> believe the real figure is much higher – probably in the hundreds of thousands. </p>
<p>Needle-exchange clinics across the UK report that steroids users are a growing group and, in some cases, even exceed other illegal drug-using groups. Recently, <a href="http://www.irishtimes.com/life-and-style/people/ireland-s-steroid-boom-among-young-gym-goers-1.2671574">Merchants Quay Ireland</a>, the largest needle-exchange clinic in Ireland, reported that over the past two years 50% more people have come to the service for needles and other equipment to inject steroids. </p>
<p>What is even more alarming is that a significant number of young men are consuming a range of performance and image enhancing drugs, including steroids and human growth hormone. While the use of steroids has traditionally been limited to professional athletes, bodybuilders, soldiers and police, it is increasingly becoming a mainstream choice for young men looking to bulk up or lose weight.</p>
<h2>Distorted body image</h2>
<p>A rising number of young people are <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986904/">unhappy with the way they look</a>. Although social pressure to conform to idealised beauty standards is nothing new, the growth of social media sites such as Instagram, Snapchat and Facebook has <a href="http://www.sciencedirect.com/science/article/pii/S2352250X15002249">exacerbated this focus on appearance</a>. Young people spend several hours a day using social media, <a href="http://is.muni.cz/el/1423/podzim2014/PSY221P121/um/Perloff2014.SocialMediaEffectsBodyImage.BID.pdf">interacting with and comparing themselves with their peers</a>, often in the pursuit of the perfect profile picture or to increase their number of followers and “likes”.</p>
<p>While it is widely known that a distorted body image affects many females, there is growing evidence that males are under similar pressure – not to be thin but to be muscular. Television programmes such as “<a href="http://www.channel4.com/programmes/obsessed-with-my-body">Obsessed with my body</a>” and “<a href="http://www.bbc.co.uk/programmes/b06svrw2">Dying for a six pack</a>” illustrate that there is a huge growth in male teenage vanity, from boys seeking to “get ripped” in the gym to men having invasive plastic surgery. For instance, <a href="http://www.theprivateclinic.co.uk/blog/2016/02/08/how-2015-was-the-year-for-cosmetic-plastic-surgery-in-the-uk">the number of men opting for cosmetic surgery</a> has almost doubled in the past decade in the UK, from 2,440 treatments in 2005 to 4,614 in 2015. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/127561/original/image-20160621-13025-136xzd6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In pursuit of ‘likes’.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=ooKgsXaIM8u3Tk5BZdVdJQ-2-60&clicksrc=download_btn_inline&id=172002716&size=medium_jpg&submit_jpg=">Linda Moon/Shutterstock.com</a></span>
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<p>There is mounting concern in the UK among healthcare professionals that males suffer from poor body image and its subsequent detrimental effects on health, well-being and confidence. For example, an <a href="http://www.ncb.org.uk/media/861233/appg_body_image_final.pdf">All-Party Parliamentary Group on Body Image</a> reported that there are high levels of body image dissatisfaction among adults and young people in the UK. It is estimated that roughly two-thirds of adults suffer from negative body image and that 34% of adolescent boys have been on a diet to change their body shape or to lose weight.</p>
<p><a href="http://www.bbc.co.uk/newsbeat/article/34307044/muscle-dysmorphia-one-in-10-men-in-gyms-believed-to-have-bigorexia">In the UK</a> and <a href="https://theconversation.com/anabolic-steroids-a-serious-global-health-problem-amid-boom-in-cosmetic-use-24238">in other countries</a> there is an alarming rise in obsessive weight training, with young men spending large amounts of money on <a href="http://www.ncbi.nlm.nih.gov/pubmed/18091024">supplements</a>, exhibiting <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986904/#B9">abnormal eating patterns</a> and, for some, even the use of steroids and other image enhancing drugs such as <a href="https://en.wikipedia.org/wiki/Clenbuterol">clenbuterol</a> (to lose weight) and <a href="https://en.wikipedia.org/wiki/Melanotan_II">melanotan II</a> (tanning agent). </p>
<h2>Not safe</h2>
<p>Steroid use can cause major health problems including liver malfunction, heart problems and skin infections. They can cause psychological disturbances too, such as dependence, depression and body-image disorders. Also, in the UK there is <a href="https://www.gov.uk/government/news/steroid-users-at-risk-of-hiv-hepatitis-b-and-hepatitis-c">evidence of HIV among steroid users</a>, with an HIV prevalence of 1.5% in men who inject steroids, which is comparable to that in those who inject heroin, amphetamine and other street drugs. </p>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0376871610004072">Several studies</a> show that steroid users often use other enhancement drugs, such as human growth hormone and weight-loss drugs, and recreational or psychoactive substances, such as cocaine and ecstasy. Mixing drugs can be harmful. For example, taking oral steroids and alcohol can cause liver damage. And, so-called “roid rage” can be exacerbated by mixing steroids and psychoactive substances, such as cocaine and amphetamine (speed).</p>
<h2>Helping steroid users</h2>
<p><a href="http://www.theguardian.com/society/2015/jul/19/health-workers-urged-to-increase-help-for-anabolic-steroid-users">Health workers</a> and <a href="http://www.cph.org.uk/SteroidConference2016/">academics</a> in the UK are urging organisations and politicians to increase help for steroid users. <a href="http://www.nta.nhs.uk/uploads/providing-effective-services-for-people-who-use-image-and-performance-enhancing-drugs.pdf">Public Health England</a> has also advised local councils and healthcare professionals to engage more effectively with young men using these substances. But it is difficult to reach this group as they often don’t see themselves as drug users. As such, users, especially younger ones, tend not to use local services because of the stigma of being seen as a drug injector. </p>
<p>To make matters worse, GPs often <a href="http://www.drugs.ie/resourcesfiles/ResearchDocs/Europe/Research/2015/Steroids_and_Image_Steroid_Image_Enhancing_Drugs_2013_Survey_Results_FINAL.pdf">lack the specialist knowledge</a> to meet the needs of people who use steroids. This forms a significant barrier for users to get the help they need. Instead, they tend to turn to the internet or their friends in the gym for advice. </p>
<p>What is needed are specialist steroid clinics run by local councils. As well as providing needles and syringes, such clinics should also provide education and health checks for steroid users. </p>
<p>There are some prevention and harm-reduction initiatives in the UK, such as the <a href="http://www.wales.nhs.uk/sitesplus/888/page/75064">Steroid Educational Toolkit</a>, the <a href="http://inef.ie/?p=6691">SMART method</a>, the <a href="https://humanenhancementdrugs.com/">Human Enhancement Drug website</a>, <a href="http://www.ninezerofive.org/">Nine Zero Five</a> and several <a href="http://www.mylife4me.co.uk/services/needle-exchange.php">needle exchange clinics</a> that provide such services. </p>
<p>Still, prevention and harm reduction measures lag far behind those for alcohol and other street drugs, not just in the UK but <a href="http://apo.org.au/resource/understanding-and-responding-rise-steroid-injecting-australia-recommendations-national">in most countries</a>. The government needs to address the needs of this rapidly growing drug-using population and include steroid users in health interventions.</p><img src="https://counter.theconversation.com/content/60874/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kyle J.D. Mulrooney holds an Erasmus Mundus Fellowship for the joint doctoral programme, the Doctorate in Cultural and Global Criminology (DCGC), and receives funding from the Educational, Audiovisual and Cultural Executive Agency of the European Union.</span></em></p><p class="fine-print"><em><span>Katinka van de Ven does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A growing number of young men are using steroids, but there are few public services to help this vulnerable group.Katinka van de Ven, Lecturer in Criminology, Birmingham City UniversityKyle J.D. Mulrooney, Ph.D. Fellow, Doctorate in Cultural and Global Criminology, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/487742015-10-13T05:21:14Z2015-10-13T05:21:14ZSteroids in sport: zero tolerance to testosterone needs to change<figure><img src="https://images.theconversation.com/files/97640/original/image-20151007-7335-s8fbg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Muscle magic</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=testosterone&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=243168082">BLACKDAY</a></span></figcaption></figure><p>After he injured his shoulder, Ryan Zimmerman <a href="http://mlb.nbcsports.com/2012/09/13/cortisone-injection-saved-ryan-zimmermans-season/">was described</a> as “one of baseball’s worst hitters”, but that didn’t affect his value as a stand-out third-baseman. In 2012, he <a href="https://www.washingtonpost.com/blogs/nationals-journal/post/ryan-zimmerman-nationals-agree-to-contract-extension/2012/02/24/gIQAnHgabR_blog.html">signed a six-year contract</a> extension with the Washington Nationals worth $100m (£65m), making him one of the <a href="https://www.baseballprospectus.com/compensation/cots/league-info/highest-paid-players/">highest-paid players</a> in Major League Baseball. By that summer, a shoulder injury had left his season in ruins. </p>
<p>He then began a series of injections of cortisol, a performance-enhancing steroid, which <a href="http://nats.dcsportsnexus.com/2012/07/ryan-zimmerman-cortisone-and-whats-next.html">turned his fortunes around</a> almost instantly. Between his third and fourth injections, Zimmerman went from being one of baseball’s worst hitters to one of its best, turning a batting average of 0.244 into <a href="http://mlb.nbcsports.com/2012/09/13/cortisone-injection-saved-ryan-zimmermans-season/">0.33</a> (the record for the 2013 season <a href="http://www.baseball-almanac.com/hitting/hibavg3.shtml">was 0.3477</a>). Far from being banned for using a performance enhancer, Zimmerman’s turnaround <a href="http://mlb.nbcsports.com/2012/07/23/ryan-zimmerman-is-on-fire-since-getting-a-cortisone-shot/">was lauded</a>. </p>
<p>Compare this to fellow baseballer Barry Bonds. He <a href="https://www.youtube.com/watch?v=cL3vNXIsEPM">smashed</a> lifetime home-run records in the 2000s but now lives under the cloud of having used anabolic steroids. He <a href="http://edition.cnn.com/2013/10/31/us/balco-fast-facts/">was outed</a> as part of the scandal around Californian laboratory BALCO, which was supplying numerous athletes with the drug. </p>
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<p>Needless to say, we divide steroids into good and bad categories. Cortisol, which is an anti-inflammatory, is sanctioned as legal in many sports if the athlete first obtains a therapeutic-use exemption. It functions in times of stress to allow the body to use stored energy in the muscles, liver and fat tissue. </p>
<p>The anabolic steroid testosterone is chemically very similar. Like cortisol, it is produced in the body from cholesterol. It functions <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686341/">to help</a> build muscle and bone, which is particularly important for older adults. Aside from some sports such as power lifting and bodybuilding which have non-tested federations where anything goes, anabolic steroids are banned throughout sport. Medical exemptions are rarely, if ever, issued. </p>
<h2>The testosterone effect</h2>
<p>Of course the <a href="https://www.wada-ama.org">World Anti Doping Agency</a> has good reason to be suspicious of potential abuse of testosterone therapy. Large doses of testosterone can <a href="http://www.nejm.org/doi/full/10.1056/NEJM199607043350101">significantly increase</a> a person’s strength and muscle mass even without training. Train at the same time and the effects <a href="http://www.nejm.org/doi/full/10.1056/NEJM199607043350101">are remarkable</a>. </p>
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<p>Yet the performance-enhancing effects of a cortisol injection can be no less impressive, as we saw with Ryan Zimmerman’s 35% batting improvement. The difference is that cortisol is judged as a recovery drug, which in ethical terms is not strictly performance enhancement. It’s not so cut and dried, though. Injecting cortisol into a joint does not heal the injury. It simply allows the athlete to play through it, which <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61160-9/abstract">can have</a> long-term health implications. In short, the line between the purpose of the rules and the health outcomes is blurred.</p>
<p>At the same time, testosterone is commonly used to treat hypogonadism, a condition in which sufferers produce low levels of the hormone. They are prone to low energy, bone and muscle problems, low libido and erectile dysfunction. The benefits of treatment <a href="http://www.ncbi.nlm.nih.gov/pubmed/24274081">can be</a> huge, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686341/">especially for</a> bone mass. </p>
<p>It is worth considering the health problems that the former British Olympic champion cyclist <a href="http://www.chrisboardman.com">Chris Boardman</a> is now suffering. He developed hypogonadism, probably brought on by his high training loads, and continued to compete without taking testosterone medication. The fact that he is <a href="http://www.dailymail.co.uk/health/diets/article-1227777/CHRIS-BOARDMAN-I-cycling-32-I-bones-old-woman.html">now suffering</a> from bone thinning confirms that he probably competed “clean”. In a sport where no medical exemption certificate was ever granted by the anti-doping authorities, accepting the treatment <a href="http://www.theguardian.com/sport/story/0,3604,380917,00.html">advised by</a> several experts would have risked a career ban. </p>
<h2>More inconsistencies</h2>
<p>At the other end of the scale is a group of drugs called short-acting beta2-agonists. They are used to treat <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445098/">exercise-induced bronchoconstriction</a> (EIB), a common condition among athletes, but the rules of the anti-doping authorities seem not to be as strictly applied. Even though EIB is <a href="http://www.ncbi.nlm.nih.gov/pubmed/22175650">commonly misdiagnosed</a>, therapeutic-use exemptions are <a href="https://wada-main-prod.s3.amazonaws.com/resources/files/wada-medical-info-asthma-5.1-en.pdf">no longer required</a> for therapeutic doses of the drug. Why do the anti-doping authorities apply one rule for one drug and disregard it for another?</p>
<p>The answer may lie with the three stated aims of the World Anti-Doping Agency: to protect athletes’ health, preserve the level playing field and protect the spirit of sport. The doses of beta2-agonists allowed by WADA are not considered <a href="http://www.ncbi.nlm.nih.gov/pubmed/24790479">performance enhancing</a>, so you can certainly argue that regulating this drug would not serve any of WADA’s anti-doping aims. But what about testosterone? Considering the negative health effects associated with low testosterone, surely refusing therapeutic-use medications for the steroid in hypogonadal men contravenes their first aim. And supplementing testosterone to below or approximately normal levels <a href="http://ajpendo.physiology.org/content/281/6/E1172.full.pdf+html?">does not increase</a> strength in any case. </p>
<p>An Australian <a href="https://www.mja.com.au/system/files/issues/199_08_211013/han10111_fm.pdf">study</a> has shown that using testosterone for both “real” medical problems and anti-ageing has increased more or less globally. This has created a dilemma for the US Anti-Doping Agency. Amateur athletes as old as 60 with medical prescriptions for testosterone <a href="https://theconversation.com/forget-lance-armstrong-the-next-big-cycling-doper-could-be-your-dad-36734">have either</a> tested positive and been banned or told that they cannot compete while taking the drug. The rules developed to stop cheating in the upper echelons of professional sport don’t make sense in such circumstances. </p>
<p>In sum, it is difficult to draw a convincing distinction between anabolic steroids and these other drugs. If the latter are permitted for medical exemptions, arguably anabolic steroids should be as well. There is a caveat. </p>
<p>One sport which has allowed exemptions for testosterone replacement therapy in the past is UFC (Ultimate Fighting Championship). It has been <a href="http://espn.go.com/espn/otl/story/_/id/10500652/therapeutic-use-exemptions-testosterone-mma-outpace-other-sports-lines-finds">suggested that</a> competitors have taken advantage of this to effectively “cheat legally”. This illustrates the risks if medical exemptions are not policed tightly. Refuse them altogether, on the other hand, and the inconsistencies and health risks are the price that some athletes have to pay.</p><img src="https://counter.theconversation.com/content/48774/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Anti-doping authorities divide steroids into good and bad ones. Yet the more you look at them close up, the more similar they actually are.Lee Hamilton, Lecturer in Sport, Health and Exercise Science, University of StirlingPaul Dimeo, Senior Lecturer in Sport, University of StirlingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/423852015-08-10T15:44:56Z2015-08-10T15:44:56ZWhy organised crime should not be used to shape anti-doping policy<figure><img src="https://images.theconversation.com/files/89157/original/image-20150721-24298-195opzd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Social networks gotta lotta cheek.</span> <span class="attribution"><span class="source">Boss by Shutterstock</span></span></figcaption></figure><p>The use of <a href="http://www.druginfo.adf.org.au/drug-facts/pieds-facts">performance and-image enhancing drugs</a> has traditionally been viewed as <a href="http://www.routledge.com/books/details/9780415619233/">a problem in sport</a> and one for <a href="http://www.universitypress.dk/shop/elite-sport-doping-2718p.html">sporting officials to tackle</a>. As a result, methods to combat doping have predominately focused on testing and surveillance in sport. However, more recently the use of performance and image-enhancing drugs (PIEDs) have been reported as a <a href="https://theconversation.com/using-anabolic-steroids-harms-your-health-and-social-image-37605">wider social problem</a> – <a href="http://uk.reuters.com/article/2012/09/22/us-doping-health-idUSBRE88L06E20120922">a threat to public health</a> and a criminal justice issue. </p>
<p>While some attention has been paid to the criminalisation of <a href="https://deviantleisure.wordpress.com/2015/01/21/muscle-profiling-anti-doping-policy-and-deviant-leisure/">recreational users</a> and <a href="https://sports.vice.com/en_us/article/criminalized-doping-and-sending-cheaters-to-jail">athletes</a>, anti-doping has tended to focus on those who traffic PIEDs. </p>
<p>Armed with evidence from <a href="http://sports.espn.go.com/oly/news/story?id=2840433">various scandals</a> and a <a href="https://www.wada-ama.org/en/what-we-do/investigation-trafficking/trafficking/donati-report-on-trafficking">growing body of research</a>, <a href="https://theconversation.com/not-fun-and-games-organised-crime-and-sport-12062">the media</a>, <a href="http://nypost.com/2014/10/07/organized-crime-controls-25-of-world-sport-wada-director/">sport officials</a> and <a href="https://www.crimecommission.gov.au/publications/intelligence-products/unclassified-strategic-assessments/organised-crime-and-drugs">government agencies</a> have reported a black market for PIEDs, driven and controlled by “mafia-type” organised criminals. </p>
<h2>The policy response</h2>
<p>However, there are still <a href="http://www.unesco.org/shs/sport/addbase/media/docs/doc-506aac23e2af9.pdf">great inconsistencies</a> among countries in the how they tackle the consumption, possession, production, and distribution of doping substances, which confounds international efforts to stem trafficking. The anti-doping movement has called for greater coordination among law enforcement, and the establishment of legal frameworks at the domestic level aimed at the trafficking of PIEDs.</p>
<p>Cross-border bodies such as the <a href="http://www.publications.parliament.uk/pa/cm200708/cmselect/cmcumeds/347/347.pdf">EU</a> and <a href="http://www.unesco.org/new/en/social-and-human-sciences/themes/anti-doping/international-convention-against-doping-in-sport/">UNESCO</a> have supported and advocated for the application of criminal law to anti-doping. Meanwhile anti-doping authorities have formed <a href="https://www.wada-ama.org/en/what-we-do/investigation-trafficking/trafficking/interpol-cooperation">alliances with law enforcement agencies</a> such as Interpol. </p>
<p><a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2013/April/Where_in_the_world_is_doping_a_crime_doping_in_sports_pt_6">Numerous countries</a> have also begun to criminalise doping (<a href="http://www.bbc.com/sport/0/30007100">in Germany athletes now risk jail time</a>) and governments around the world are paying more attention to the doping phenomenon by committing more resources to the <a href="http://www.dopingautoriteit.nl/media/files/Strategy_for_Stopping_Steroids_Report_WEB.pdf">consumption</a> (for example, <a href="http://www.playthegame.org/uploads/media/Ask_Vest_Christiansen_-_Testing_recreational_athletes_01.pdf">doping controls in gyms</a>) and illegal distribution of <a href="https://theconversation.com/steroid-seizures-and-arrests-soar-to-record-highs-in-australia-41955">PIEDs</a> (<a href="http://www.abc.net.au/news/2014-08-27/qld-beefs-up-steroid-laws-after-drastic-rise-in-seizures/5698532">Australia recently reclassified steroids as schedule one drugs</a>). </p>
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<span class="caption">German athletes now risk jail time for doping.</span>
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<h2>The market for these drugs</h2>
<p>But what is the extent of the problem and is there a market for so called “organised” criminals to capitalise on? There is evidence to suggest that PIEDs are <a href="http://www.telegraph.co.uk/men/active/mens-health/10796402/Steroids-supersizing-the-man-in-the-mirror.html">being increasingly consumed</a> and that there is potential for criminal organisations to capitalise on this demand. But we still know very little about the claims made by anti-doping regarding extensive and organised criminal networks who trade in these drugs. </p>
<p><a href="https://wada-main-prod.s3.amazonaws.com/resources/files/2013-Paoli-Donati-Report-Executive-Summary-EN.pdf">Contrary evidence exists</a> which suggests that organised crime plays a limited role in this market which is driven by a broad supply base. For instance, according to the <a href="https://www.crimecommission.gov.au/publications/intelligence-products/organised-crime-australia/organised-crime-australia-2011">2011 report</a> of the Australian Crime Commission: “The ready availability of these drugs [PIEDs] reduces opportunities for organised crime groups to control or have significant influence in this market”. </p>
<p>So, while organised groups may produce and supply PIEDs, they are just one section of the broader market. Additionally, where busts have been made in connection with groups identified as organised criminals they have often been in relation to <a href="https://www.wodc.nl/onderzoeksdatabase/evaluatie-wet-op-geneesmiddelenvoorzieninghandel-in-dopinggeduide-middelen.aspx?nav=ra&l=inspectiedienst">other</a> criminal <a href="https://www.researchgate.net/publication/264333953_Bodily_Violations_testing_citizens_training_recreationally_in_gyms">activities</a>, as opposed to the primary criminal enterprise.</p>
<p>Much of the available evidence would suggest that the problem of doping supply is <a href="http://link.springer.com/article/10.1007%2Fs12117-014-9235-7">internal to the world of sport</a>. Looking at several recent large-scale doping scandals such as <a href="http://www.cyclingnews.com/features/index-of-lance-armstrong-doping-allegations-over-the-years">the Lance Armstrong affair</a>, <a href="https://presse.wdr.de/plounge/tv/das_erste/2014/12/_pdf/English-Skript.pdf">anti-doping corruption in Russia</a>, as well as <a href="http://www.theguardian.com/sport/2015/jun/30/mo-farah-alberto-salazar-doping">the recent allegations</a> surrounding Mo Farah’s coach Alberto Salazar, accused suppliers are predominately <a href="http://www.theguardian.com/sport/2013/may/10/spanish-doping-doctor-reveal-sports">sport physicians</a>, <a href="http://www.iwf.net/2014/12/04/weightlifting-coach-banned-for-attempted-trafficking-of-steroids/">coaches</a>, and the athletes themselves, and in the Russian case, anti-doping officials were <a href="http://www.bbc.co.uk/sport/0/athletics/31485481">accused of covering up test results</a>.</p>
<p>Moreover, contrary to claims of organised criminals in the pursuit of profit, some <a href="http://www.tandfonline.com/doi/abs/10.1080/07418820902814013#.VbI-2CpViko">research</a> has pointed out that outside the world of sport, PIED dealing networks are often the <a href="https://www.academia.edu/9118768/The_Symbiotic_Evolution_of_Anti-Doping_and_Supply_Chains_of_Doping_Substances_How_criminal_networks_may_benefit_from_anti-doping_policy._Trends_in_Organized_Crime._DOI_10.1007_s12117-014-9235-7">product of social networks</a>, that stem from an individual’s involvement in particular <a href="https://theconversation.com/anabolic-steroids-a-serious-global-health-problem-amid-boom-in-cosmetic-use-24238">subcultures</a> such as bodybuilding or cycling. </p>
<h2>Distorted policy</h2>
<p>Claims of organised crime in control of supply are based on <a href="https://www.ncjrs.gov/nathanson/organized.html">popular mythologised media stereotypes</a>, of “mafia-style” godfathers and lieutenants, who direct specialised divisions. However, this model seems to be the exception rather than the rule and has been <a href="http://www.springer.com/gp/book/9781402026157">largely rejected</a> in scientific research and by law enforcement groups. </p>
<p>It is well established that <a href="http://www.theguardian.com/commentisfree/2013/apr/24/crime-falling-reduce-fear-crime">fear of specific crimes</a> usually outweigh their actual prevalence – some things are disproportionately feared, not because of objective risks but because the way they are <a href="http://www.sagepub.com/haganintrocrim8e/study/chapter/handbooks/42347_1.2.pdf">framed and understood</a>. </p>
<p>In general, the narrative of organised criminal gangs has also been used by politicians and law enforcement agencies <a href="http://bjc.oxfordjournals.org/content/49/1/106.abstract">throughout history</a> and, more recently sport officials, as a way to pass legislation that may otherwise meet resistance. The failure to apply claims about PIEDs according to the scientific method, coupled with the employment of selective evidence that supports the interests of the anti-doping policy regime and politicians has resulted in a <a href="https://www.academia.edu/2117732/Drug_trends_and_policy_responses_Explaining_the_drug_policy_ratchet">systematic distortion of drug policy</a>.</p>
<h2>Unintended consequences</h2>
<p>Public health claims against doping <a href="http://www.biomedcentral.com/1472-6939/8/2/">are by no means new</a> – and the calls for law enforcement agencies to <a href="https://www.wada-ama.org/en/media/news/2013-02/intelligence-experts-emphasize-importance-of-legislation-and-information-sharing">play a larger role</a> in anti-doping are seen as a means to protect athletes and society from the dangers of doping, and to safeguard the integrity of sport. </p>
<p>But <a href="http://www.cph.org.uk/wp-content/uploads/2012/08/human-enhancement-drugs---the-emerging-challenges-to-public-health---4.pdf">as scientific evidence is scarce</a> about the prevalence and health risks of doping (for example, the long-term effects, or PIED-related deaths), national governments should take pause to reflect on the implications of taking a hardline stance on doping products. The reality is that we know very little about the harms associated with PIEDs.</p>
<p>While the war on doping has yet to reach the extent of the war on drugs, a similar policy trend can be seen as the anti-doping policy elite around the world (in particular Europe) continue to ratchet up their response to doping. But is zero tolerance and criminalisation really the best way to protect public health and decrease the market share of any organised criminals that do exist in the PIED market? History would suggest that the answer to both questions is a resounding no. </p>
<p>Not only are criminal justice measures <a href="http://www.theglobeandmail.com/news/british-columbia/war-on-drugs-an-expensive-failure-bc-study-says/article14667754/">expensive</a>, but evidence from the “war on drugs” suggests this approach reduces neither consumption nor supply and has a limited effect on the protection of public health. </p>
<p>Increasing legal risk to traffickers may even <a href="http://evolvecms.webfreelancersuk.co.uk/sites/default/files/Making%20drug%20control%20fit%20for%20purpose%20-%20Building%20on%20the%20UNGASS%20decade.pdf">attract more dangerous groups</a>. Indeed, a zero-tolerance drug policy has led to several <a href="http://issuu.com/gcdp/docs/global_commission_report_english/1?e=4620863/2855236">unintended negative consequences </a> one of which is <a href="http://www.countthecosts.org/sites/default/files/Crime-briefing.pdf">growing black markets</a>. </p>
<p>This is by no means a denial of problems posed by PIEDs, but rather a call for a <a href="http://www.tandfonline.com/doi/abs/10.1080/19406940.2012.756824">sober, unadulterated look</a> at the issues presented by the growing use of a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22868973">broader spectrum of human enhancement drugs</a> and those who supply them.</p><img src="https://counter.theconversation.com/content/42385/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kyle J.D. Mulrooney holds an Erasmus Mundus Fellowship for the joint doctoral programme, the Doctorate in Cultural and Global Criminology (DCGC), and receives funding from the Educational, Audiovisual and Cultural Executive Agency of the European Union.</span></em></p><p class="fine-print"><em><span>Katinka van de Ven does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Easy media stereotypes rather than clear evidence attributes performance enhancing drug supplies to organised criminals.Kyle J.D. Mulrooney, Ph.D. Fellow, Doctorate in Cultural and Global Criminology, University of KentKatinka van de Ven, Ph.D. candidate, Doctorate in Cultural and Global Criminology , University of KentLicensed as Creative Commons – attribution, no derivatives.