A growing problem
Users of anabolic steroids are now the biggest client group in many needle and syringe programmes. David Gilliver talks to Jim McVeigh of Liverpool John Moores University’s Centre for Public Health about how services can meet their needs
If you’re in any way connected to the substance sector then chances are you’ll be familiar with the wide-ranging research of Liverpool John Moores University’s Centre for Public Health. And if that research is about image and performance-enhancing drugs, it’s likely to have had the input of the centre’s acting director, Jim McVeigh, one of the foremost authorities on the subject.
While the centre’s remit is far broader than just substance use, its work is united by themes of vulnerable populations and behaviour change. ‘Obviously substance use, sexual health and violence prevention are key areas, and we often find that many of those issues affect the same populations – families with multiple needs,’ says McVeigh.
He’s been at John Moores since 1998, but had ‘always had an interest in the drugs side of things’, he says. ‘My original background is in general nursing in Liverpool, when we had increasing numbers of people coming in who’d been injecting temazepam, and they had horrendous injuries from poor injecting techniques. That’s how I got into working in drug services, through that desire to get involved in harm reduction.’
There’s a great deal of harm to be prevented when it comes to users of anabolic steroids and associated drugs. As well as putting themselves at risk of a lengthy list of possible physical side effects including liver, heart and blood pressure problems, there are potential mental health issues such as depression or even psychosis. The number of users, however, continues to grow – why aren’t they being put off using these substances?
‘Well, one of the key reasons is that they work,’ he says. ‘People taking large dosages of anabolic steroids and a range of other enhancement drugs – when combined with appropriate exercise and nutrition – will get substantial gains. That’s the first thing to bear in mind. Young men, in particular, will want what they want and not necessarily look beyond that at some of the potential implications.’
While most steroid users will experience some adverse effects, they tend to be things seen as ‘coming with the territory’, he points out, particularly cosmetic side effects such as acne, premature balding or even gynaecomastia – the growth of breast tissue. ‘People will either accept it or they’ll take other drugs to try and counter it. It’s a belief that none of the very serious short-term things will happen. And while there are many different adverse effects, in terms of things like psychosis they’re very, very rare. I could introduce you to hundreds, if not thousands, of steroid users who will never have come across anyone who’s had a life-threatening condition that they’re aware of, or a life-changing set of psychological adverse effects.’
Although users may feel reasonably confident about the lack of immediate risk, what’s still relatively unknown is what could happen in the longer term. But if use starts at a young age, then, as with most things, users will tend to assume they’re basically immortal and that none of these things will ever be an issue. ‘Absolutely,’ he says. ‘But there’s evidence coming out from the states that large dosages for prolonged periods do have detrimental effects on your cardiovascular system. That sounds like an absolute no-brainer, but we’ve actually got that hard and fast evidence now.’
And it does seem to be the case that the steroid-using population is getting younger, with around a quarter of first-time users now in their teens. ‘We have been seeing an increasing number of young people – either in their late teens or early 20s – over the last few years,’ he says. ‘In the early ‘90s the vast majority of steroid users were in their 30s and either body builders or aspiring body builders or doormen. Now the vast majority of steroid users presenting to needle and syringe programmes will just be looking to make some quick gains – put on a bid of muscle mass or improve their definition – so it’s not a “career choice” of people looking at longer-term or occupational use so much. It’s almost a whim.’
The current problem is also on a far bigger scale than it was then, he stresses. ‘I knew a small number of people who were using anabolic steroids in the 1980s, but it was only really when I was working in the needle and syringe programmes in the early ‘90s that we saw that explosion of use, going from literally half a dozen people to what we thought were massive numbers, but which pale into insignificance compared to the numbers we’re seeing now across the country. All of a sudden you had this different group of people presenting with different attitudes, different needs, but the staff there – who were very, very experienced – weren’t experienced in this particular area.’
In some needle and syringe programmes, particularly in the north of England, steroid users represent the biggest client group. So are workers up to speed in terms of meeting their needs now? ‘I think so, particularly in the last few years, where there’s been a groundswell of people working within those environments joining up, contacting each other, exchanging experience,’ he says. ‘It’s been driven from the ground up in relation to the practitioners and also users, much more so in many cases than from, say, commissioners, managers or those tasked with developing strategy.’
Recent years have seen the treatment sector having to adapt to new patterns of drug use – the dramatic rise of new psychoactive substances, as well growing problems with people injecting drugs such as mephedrone and crystal meth. Is there any sense that the focus on these new issues has meant services taking their eye off the ball when it comes to steroids?
‘I don’t think so,’ he states. ‘I think the movement away from just opiates and crack cocaine to this much wider area encompassing both enhancement drugs and the novel psychoactives isn’t to the detriment of either. It’s important that we don’t take our eye off the ball in terms of the complex needs of heroin injectors, but we’ve got to accept the fact that we’ve got a much more varied population of injectors now, and they can move between those groups quite easily. It’s not one clear-cut population. Injectors are injectors, and HIV doesn’t really care what drug you’re using.’
Indeed, a 2013 study by John Moores and Public Health England (PHE) found that one in ten steroid drugs had been exposed to one or more of hepatitis C, B or HIV. Is there enough awareness of those risks? ‘Well, what we’ve found repeatedly has been a comparable level of HIV in anabolic steroid injectors to heroin injectors, and I don’t think that population of steroid users are aware of that,’ he states. ‘What we don’t know is exactly how those steroid users contracted HIV – it could be from previous injecting behaviours or it could be sexual contact – but in some ways that’s very much secondary to the fact that HIV is within that population. Unsafe injecting practices will put you at the same kind of risk.’
Despite the sizeable crossover between people injecting steroids and those injecting other drugs, one issue that services need to address is that many steroid users see themselves as completely distinct from the traditional view of a ‘drug user’. ‘It’s quite ironic really when you consider the substances they’re using and the fact that the vast majority of them are injecting,’ he says. ‘But it is a barrier. A lot of them don’t feel they fit into the stereotypical view of what they consider a drug user to be – they feel their attitudes or their whole outlook on life are different. But we know that up to half of anabolic steroid users presenting to needle and syringe programmes have used cocaine in the last year, for example – there really is a massive crossover.’
As well as the potential side effects and the very real risk of blood-borne viruses, another issue is that most users of performance-enhancing drugs have very little idea what they’re actually taking. ‘There’s very few examples of people being able to obtain legitimately produced pharmaceutical grade anabolic steroids, or any of the enhancement drugs. The vast majority of them are illicitly manufactured. That doesn’t mean that they don’t have active ingredients in them, but you don’t know the strength of that particular active ingredient or what contamination may be in there.’
While people now buy from a mixture of local black markets and the internet, the latter has completely revolutionised the steroid scene, he stresses. ‘It’s always somewhere there in the background, whether at the commercial level of links between importers here and manufacturers in the Far East or whether it’s people just buying them from a website. The internet has made a massive difference.’
There are also reports of a growing market in the prison estate, which ‘isn’t really surprising’, he points out. ‘You’ve got the gym culture there – relatively long periods of boredom where the gym is perhaps the main escape – and people often feel that they want to make a new start when they’re in prison. They’ll start exercising and it can get to a point where people want to get those gains quickly.’
So is there anything that commissioners or services can be doing to better tackle the problem? ‘There’s a couple of important things. One is ensuring that services really do engage with this population of injectors. It’s not sufficient just to have clean injecting equipment for people to pick up – you have to engage with them and see exactly what they want. It’s important that we translate the lessons we’ve learned from injecting heroin users to this group. We found very quickly that it was important for services to be designed around needs, with non-judgemental attitudes, and having services where people wanted to use them and at the times they wanted to use them.
‘Those users were the best source of intelligence and information about the public health issues. It really is important that it’s not seen just as “we’re also letting steroid users come to the service”. You really do need engagement.’
Liverpool John Moores has a range of educational programmes, including an MSc in addictions. For more information visit www.cph.org.uk