April 2021

Looking good? For the buff, the beautiful and the body-hackers, perfection comes at a price

A fit, tanned guy walks into an NSP. Reading from his phone he asks for specific supplies – a fit-pack of 3ml syringes with 23-gauge needles. The NSP worker guesses a mate has told him what to say.

When the NSP worker asks if the man is using performance- and image-enhancing drugs (PIEDs), he is quick to confirm he is, perhaps to distance himself from the other clients. But he’s also quick to say he’s fine, he’s healthy. Like, look at him!

While this is a hypothetical scenario, Quentin Evans, the Health Education Officer at the RUSH Needle and Syringe Program in NSW, says it is a fairly typical one.

PIEDs users are an incredibly challenging cohort for NSP workers – and GPs and pharmacists come to that – because the potential risks of these drugs, especially when combined, are not widely known by health workers.

And as many people using PIEDs consider themselves healthy and well-educated about nutrition and exercise, they might feel a disconnect queuing up at a place that they associate with people taking “unhealthy” drugs.

So how can this population be better engaged?

The broad spectrum of PIEDs

When we think of PIEDs, we probably think of testosterone.

But to properly understand the population of users, it is necessary to appreciate that a raft of other problematic drugs are part of the mix.

Testosterone is an anabolic-androgenic steroid (AAS) in the same family as boldenone, nandrolone and stanozolol – all of which can be injected for “gains” in physique and improvements in energy and exercise recovery time.

But even just focusing on injectable PIEDs that might see someone going to an NSP, the scope goes much further than these steroids.

The use of synthetic analogues of human growth hormone has increased as the price has fallen. Quentin says it is not as expensive now that it is available on the dark web, along with Dehydroepiandrosterone (DHEA). These can be oral or injectable but, as bodybuilder forums point out, orals are more liver-toxic so people often opt to inject despite the health risks.

Then there’s the injectable tanning agent Melanotan.

“Melanotan use has gone down in the last year, which may be COVID-related,” he says, “but, generally it will rise in the summer months.”

The fundamental agreement among the people using these medicines is that health professionals don’t know anything about them so there’s no point in asking them.

Sam Keitaanpaa

Northern Territory community pharmacist and vice president of the South Australia/NT branch of the Pharmaceutical Society of Australia Sam Keitaanpaa provides advice on PIEDs to professionals.

He says some people also inject post-cycle therapy (PCT) agents to mitigate the problems caused by AAS, such as breast growth when the body converts testosterone to estrogen.

In addition, Selective Androgen Receptor Modulators (SARMs) developed to treat cancer and osteoporosis are being sourced from the black market. The prescription-only Schedule 4 drugs are designed to provide the benefits of the steroids with fewer side-effects.

Research chemicals such as peptides are also being imported by some compounding pharmacists, Sam says.

“Because the pharmacy ‘compounds’ it – really they just pour a little in a syringe – it suddenly becomes legal.”

PIEDs might be bought from dealers (who could be a friend at the gym) or via the dark web. Alternatively, they may be prescribed by an “anti-ageing” doctor, an online doctor service or even a GP known for “pushing the boundaries”.

People use PIEDs for a variety of reasons

Although the “gym-bro” stereotype persists, the use of performance- and image-enhancing drugs is much more widespread.

Along with the expected bodybuilders, PIEDs are popular among some athletes, emergency personnel seeking greater bulk and energy – and, concerningly, teenage boys wanting to build their physiques faster.

Quentin says in Sydney the NSP in the beach suburb of Brookvale sees far more people using PIEDs than the St Leonards site, suggesting the presence of clients who use steroids for aesthetic reasons. He said another big group is the active occupational cohort, such as security, military, police and firefighters.

With more women powerlifting and pursuing muscular physiques in recent years, it might be expected there has similarly been an increase in women using PIEDs.

When it comes to women there’s even less research and even less medical support.

Dr Katinka van de Ven

Katinka Van de ven

But Dr Katinka van de Ven, Director of the Human Enhancement Drugs Network (HEDN), which provides evidence-based information about PIEDs and other enhancement drugs, says we really don’t have the data either way.

“When it comes to women there’s even less research and even less medical support,” she says. To this end, the January 2021 issue of the regular periodical HED Matters was dedicated to women’s use.

Although research shows that the average age for people starting to use PIEDs is 20–24 years, it can begin much earlier. The 2017 Australian Secondary Students’ Alcohol and Drug Survey (ASSAD) report found that of 20,000 students, two per cent had used AAS or other enhancement drugs, with one per cent reporting use in the past month.

Further, Katinka says, there is a growing number of men over 40 using steroids to fight ageing – for increased energy and sex drive.

Since many people who use PIEDs will not see an NSP or GP – particularly if they get their needles from whoever supplies the drug – it is hard to gauge the true figures.

The National Drug Strategy Household Survey shows that the prevalence of non-prescribed steroids in Australia is steadily rising, from 0.3 per cent in 2001 to 0.8 per cent in 2019. Similarly, the Australian Needle Syringe Program Survey National Data Report shows a significant increase in PIEDs as the “last drug injected” in NSW over the period 1995–2019 – from one per cent to 10 per cent.

The figures for 2020 will be complex: Quentin says the number of clients using PIEDs slowed down during lockdown in NSW, followed by a flurry of action when gyms reopened.

The complex risk factors?

The pursuit of strength and beauty can exact a heavy toll. Several complications are associated with PIEDs use.

Anabolic-androgenic steroids have a cardiovascular risk, ranging from high blood pressure to blood clots, strokes, artery damage and even an enlarged heart. Katinka recommends asking clients if they have a family history of cardiovascular problems.

Mood changes are common, from increased aggression while using the hormones to depression after having ceased use. A recent Icelandic study polled 10,300 secondary school students and 1.6 per cent reported using steroids. Of those, 78 per cent reported more anger issues, anxiety and depression and lower self-esteem than non-users and 30 per cent said they had attempted suicide, compared to 10 per cent of non-users.

Men using PIEDs to boost or reclaim their virility might find it backfires. Infertility is a potential side-effect of testosterone, which decreases sperm production.

People might not be aware that sharing a vial can increase the risk of transmission. They may both put their needles in there.

Dr Katinka van de Ven

“It is also really important to talk about infertility,” Katinka says. “They might not be thinking about children now but they might want children in the future and they might be advised to store their sperm.”

Hypogonadism (the decreased functioning of the testes or ovaries) can cause of low mood and low energy. Another sexual side-effect, priapism (prolonged erection, often unconnected with sexual arousal), can result from taking Melanotan.

Dr Beng Eu, a GP who practises out of Prahran Market Clinic in Melbourne, has extensive experience treating people who use PIEDs through a harm-reduction lens. He says there is a testosterone risk connected with prostate cancer.

“I don’t think there’s a suggestion that testosterone causes it, but a lot of prostate cancers are sensitive to testosterone,” Beng says.

“So if you happen to have prostate cancer with high levels of testosterone, you’re probably promoting the cancer to grow,” he says.

“There are (also) more controversial things like human growth hormone. The problem is, we know about it in terms of supplementing it to someone with a deficiency, but there’s not that much known about people using it for the anabolic (muscle-enhancing) effects.”

Although some PIEDs users might fear becoming stigmatised, Beng says PIEDs users can benefit greatly from visiting their doctor.

“They can get free blood tests. It’s like any other substance: if there are significant risks of side-effects you would test for them, just like someone who’s injecting heroin could be tested for hepatitis C and someone who’s drinking too much could have their liver function tested,” Beng says.

Now a lot more people are using the ‘blast and cruise’ approach where you use a larger amount for a while, then cut back but keep using the steroids.

Quentin Evans

Quentin says referrals by NSPs to GPs are infrequent because of the stigma people using PIEDs expect to encounter. However, the NSP where he works has referred one person to an AOD counsellor.

“He wanted to stop but was having trouble,” Quentin says.

“I think that could become more of an issue, because traditionally people would use steroids in 12-week cycles. Now a lot more people are using the ‘blast and cruise’ approach where you use a larger amount for a while, then cut back but keep using the steroids.”

A call to arms

There is no official training program around steroid use, and presentations about PIEDs at AOD conferences tend to be basic. Experts says there is an urgent need for better understanding of this complex area.

The Human Enhancement Drugs Network has produced a range of educational posters, infographics, pamphlets and videos suitable for NSPs. Quentin uses some of the booklets from Exchange Supplies in the UK, such as A Pocket Guide to Steroids.

“They have the typical doses and frequencies of use for steroids and other substances, which is good because we don’t ourselves want to advise them on what dose to use,” Quentin says.

Beng says it is vital that the health sector deepens its engagement with people who use PIEDs “because there are millions of online tutorials and information about how you cycle and how to stack all this stuff, but then there’s very little that concentrates on side-effects”.

And yet, he admits, it can be a confronting task for some health workers.

“You have a very mobilised, well-educated population coming in who are probably going to challenge you if you sound like you’re not really sure,” Beng says. “They often educate me about things like checking for kidney function and what are the right tests to order because they have a high creatinine level.”

Sam Keitaanpaa is blunter still.

“The fundamental agreement among the people using these medicines is that health professionals don’t know anything about them so there’s no point in asking them,” he says.

“In my experience, when people have opened up to me about these substances, they’re generally looking for the safest way to use them, and if you meet them at that level they’ll actually engage really readily. There’s a lot of harm reduction and great conversations we could have, dispelling myths and rumours.”

How NSPs can engage PIED users

When a client goes to an NSP asking for larger needles, or looking like they might be using PIEDs, Quentin suggests asking: “Is this equipment for anabolic steroids or other PIEDs? Have you used them before? Where are you intending to inject?”.

He asks the last question because sometimes clients want to inject testosterone into their calves or pectorals, wrongly believing that the agent works on the area where it’s injected. At other times people worry about the size of the larger needles needed for intramuscular injections.

“They’ll say they want to use thin, short needles, so we’ll advise them against doing that and explain why they need this needle for the consistency of the drugs they’re injecting.”

Poor hygiene and injection technique could result in abscesses and nerve damage, so sometimes Quentin’s team might draw diagrams showing where to inject.

“We also have a foam sponge, used for training nurses, which replicates the layers of skin, fat and muscle,” he says. “We can show what it feels like to go through those layers – the different levels of resistance.”

Katinka van de Ven says people who use steroids, in particular, need to be warned about potentially dangerous behaviours.

Firstly, they may engage in sexually risky behaviour so a conversation could be had about safer sex, and secondly, blood-borne virus transmission can occur if they share vials.

“We do see that within this population the infection rate is lower because we don’t see a lot of needle sharing,” she says.

“Having said that, people might not be aware that sharing a vial can also increase the risk of transmission. They may both put their needles in there.”

– Jenny Valentish

Changing the attitude of GPs

Dr Beng Eu sees his mission as not so much trying to reach PIEDs users as educating medical professionals to ask the right questions of their patients.

“If someone is a clearly a really keen gym goer and looking quite fit – without necessarily looking really, really large – as part of my general questions I might ask them about whether they take any sort of supplements or protein powders, if they experiment with peptides, if they consider steroids,” he says.

“It’s warming up to ‘Have you used them in the past? Are you thinking about using them in the future?’ as well.”

Beng and other researchers launched PUSH, a health audit of people using PIEDs that has been running for around 20 months.

“We want to collect some data about patients being seen in general practice who we don’t know much about,” he explains.

“We’d like to flesh out more information about this population that presents to GP clinics: who they are, how large they are, whether they’re heavy users, if they have a lot of side-effects.”

Beng and Dr Katinka van de Ven have also produced a GP Guide to harm minimisation for patients using non-prescribed anabolic-androgenic steroids (AAS) and other performance and image enhancing drugs (PIEDs).