The use of performance- and image-enhancing drugs such as steroids is on the rise in Australia, with more users accessing sterile injecting equipment from needle and syringe programs (NSPs).
Between 1995 and 2010, 1% to 2% of NSP users reported that the last drug they injected was steroids. In 2011, this rose to 5%, and in 2012 this increased further to 7%. There was also an increase in the number who reported the first drug they injected was steroids or another PIED.
But despite a growing proportion of PIED users, our knowledge of this group – the substances they are using, the harms they may be experiencing, and the health services that they may (or may not be) accessing – is low.
Who uses steroids and why?
The term performance- and image- enhancing drugs (PIEDs) is a broad term which includes substances used to enhance (body) image or (athletic) performance. The most widely used PIED is steroids; others include growth hormones, other reproductive hormones, diuretics, stimulants, and even supplements such as creatine, a supplement that is used to help gain muscle mass.
Some PIEDs may be used explicitly to enhance performance or image, while others may be used to counteract the negative or undesired effects of other PIEDs.
In the early days, PIED use was thought to be limited to body builders and professional athletes. This no longer appears to be the case: some use to enhance their physical appearance, such as increased muscle size and muscle mass; some use to enhance their sporting performance; and some use for work-related reasons, such as those in physically demanding jobs.
These reasons do not sit in isolation. A personal trainer at the gym may use because he or she wants to look good, and looking good may mean more clients. Being stronger on the football field may be someone’s primary reason for use, and looking more muscular may be an added bonus.
The National Drug Strategy Household Survey – Australia’s general population survey of alcohol and other drugs – suggests that between 0.3% and 0.4% of the population have used steroids for non-medical purposes in their lifetime, and that 0.1% have used steroids for non-medical purposes in the past year.
But while general population surveys are good for estimating the prevalence of use and harm from such substances as tobacco and alcohol, they’re less good at capturing use of more niche substances, such as steroids. Therefore, these numbers are likely to be an underestimate.
It’s unclear exactly how many Australians use steroids, but sources indicate increased usage. There has been an increase in the number of PIED seizures at the Australian border by Customs, for instance. Between 2009/10 and 2010/2011 there was a 106% increase in detections at the border, with a further 57% increase between 2010/2011 and 2011/2012.
What does this mean for health services?
My colleagues and I recently interviewed NSP workers to understand the unique challenges they face in liaising with this client group.
First, they are using substances that many of the NSP workers had not heard of. NSP clients are generally using substances such as heroin, methamphetamine or cocaine. But Nandrolone?
Second, many of the workers were unsure what equipment this client group needed. PIEDs that are injected are usually injected intramuscularly, not intravenously, meaning that different equipment is needed.
Third, many of the clients using PIEDs were identified as different from other client groups – both physically and in terms of their lifestyles. This meant they were less engaged with the NSP and the staff.
Finally, this group tended to obtain equipment in bulk, as steroids are typically used in “cycles” – taking the substance for a period of time, stopping for a period, then starting again – and because clients frequently obtained equipment for other PIED users, in a form of peer distribution.
The use of illicit substances tends to polarise people, but it seems that PIEDs do so more than others because they’re taken for reasons deemed superficial. It’s therefore tempting to think that we should perhaps not allocate our health dollars to providing injecting equipment to this group.
From a risk perspective, studies with this group have shown that they engage in few risk behaviours which may expose them to blood borne viruses. But studies have also shown that a proportion of PIED users report injecting other substances, such as methamphetamine. And injecting substances other than PIEDs among this group has been associated with being hepatitis C and/or HIV positive.
NSPs have played a major role in the low prevalence of HIV among people who inject drugs in Australia and are endorsed as an important harm-reduction initiative by the World Health Organization and other health promotion agencies.
We need to consider how we reach this specific group. In the mean time, continued access to sterile injecting equipment for those who require it, including PIED users, will not only help keep the spread of bloodborne viruses low, but will also keep this group in contact with health professionals should they ever need them.