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  • Increase in AS injectors – Decrease in “other” injectors

Performance Performance Presentation Transcript

  • Performance & Image Enhancing Drugs in Syringe Exchange: Implications for Practice Martin Chandler Inter Agency Drug Misuse Database (IAD) Manager Centre for Public Health Liverpool John Moores University
  • Objectives
    • To explore recent findings on the prevalence of AAS use amongst NeX clients in the UK
    • Discuss possible reasons why the prevalence appears to be changing
    • Review the pharmacology and use of AAS and associated substances (PIEDs), including legal issues
    • Discuss the key dangers in AAS use
    • Review and discuss the implications for practice
  • ‘ All’ & ‘new’ clients attending agency based SEPs in Cheshire & Merseyside (1991 to 2005)
    • Results of the “straw poll” of Syringe Exchanges in the UK
    • 15 responses, representing a total of 36(ish!) syringe exchange sites around the UK (Not including sites reporting directly to the IAD)
    • All sites report an increase in the number of new injectors using AAS
    • All sites report a perception of the average age decreasing (but few can prove it)
    • Many sites reporting 17 year old clients, some suggestion of younger clients but unconfirmed
    • Some sites reporting younger AAS users who train in isolation
  • Anabolic steroid injectors in contact with syringe exchange schemes in Cheshire & Merseyside 600% increase in new steroid injectors between 1991 and 2001 1,800% increase in the number of individual anabolic steroid injectors At the largest Merseyside agency: 60% increase in the number of anabolic steroid injectors between 2002 and 2006 Agency based sites in Cheshire & Merseyside are reporting 70-80% of new clients as AAS users. One site has nearly 90%. “ Tip of the Iceberg” The extent of peer distribution is unknown but in just one site on Merseyside there are four clients taking an average of 3-500 packs per visit….each.
  • Why is this happening?
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  • Internet Sites for Steroid Use
  • Internet Sites for Steroid Use
  • Internet Sites for Steroid Use
  • What are Anabolic Steroids? How are they used?
  • Definition
    • Mimic the effects of testosterone
    • Testosterone - anabolic & androgenic
    • Anabolic - growth & development of tissue
    • Androgenic - secondary male sexual characteristics
    • Not to be confused with corticosteroids (School surveys in the USA)
  • Clinical uses
    • Aplastic anaemias
    • Muscle wasting
            • Trauma/burns
            • HIV/AIDS
    • Post menopausal osteoporosis
    • HRT for men
    • Delayed male puberty
    • Male contraceptive
    • Rarely indicated or used – superceded by other drugs or not part of the diagnosis (Depression vs Male menopause)
  • Performance enhancement (or image enhancement)
    • Increase lean body mass/decrease body fat ratio
    • Increase size and strength
    • Increase aggression
    • Increase stamina
    • Increase sex drive
  • Nandrolone Decanoate Commonly used Anabolic Steroids Methandrostenolone Oxandrolone Oxymetholone Methenolone Stanozolol Sustanon 250 Formebolone Boldenone Testosterone Cypionate Testosterone Enanthate Testosterone Propionate Testosterone Undecanoate Methyltestosterone
  • Common anabolic steroids
  • Common anabolic steroids * Indicates C17 alpha-alkylated Inject Android Andriol, Restandol Testovis Testoviron Testex Leo, Testex Equipoise Esiclene Sostenon Halotestin Stromba, Winstrol Primobolan Nilevar Anadrol, Anapalon Anavar Pronabol Dianabol Deca, Anabolin Common trade names Norethandrolone
    • *
    Fluoxymesterone Oral Generic Nandrolone
    • *
    • *
    • *
    • *
    Stanozolol Sustanon
    • *
    Methyltestosterone Testosterone Undecanoate Testosterone Propionate Testosterone Enanthate Testosterone Cypionate Boldenone Formebolone
    • *
    • *
  • Nandrolone Decanoate Most commonly used injectable steroid Relatively low androgenic properties so does not aromatise easily Not C17 alpha alkylated so not strongly associated with liver dysfunction Associated with fluid retention. Available in 25mg/ml to 200mg/ml Therapeutic dosage Male: 50-100mg per week Female: 50mg every 3 weeks Typical dosage Male: 200-400mg per week Female: 50-100mg per week
  • Methandrostenolone Usually referred to as Dianabol and almost identical to Methandienone (Pronabol). C17 alpha alkylated Short acting – half-life: 3.2 to 4.5 hours Dramatic gains in size & strength reported but associated with hypertension, aromatisation, male pattern baldness & acne. Virilisation occurs easily in women Available in range of tablets – usually 5mg Therapeutic dosage 2-5mg daily. 6 weeks on, 4 weeks off Typical dosage Male: 15-30mg per day Female: 10-20mg per day
  • Performance Enhancing Drugs & common trade names Common trade names Generic Spiropent, Ventolase Clenbuterol Somatropin Growth Hormone HCG Chorionic Gonadotrophin Actrapid, monotard, humulin Insulin IGF (Long R3) Insulin Like Growth Factor 1 Nolvadex Tamoxifen
  • Fakes & Counterfeits
    • Many products contain active ingredients different to that labelled or at significantly different strengths
    • 40 products tested: 37.5% not as stated (Germany)
    • 4 products tested: 43%-73% of stated dosage (Liverpool)
    • 14 products tested: Between 0-169% of stated dosage (Wales)
    • (Ritsch & Musshoff 2000, McVeigh and Lenehan 1994, Perry, 1995
  • Common physical side effects of anabolic steroids
    • Acne
    • Heart disease
    • Hypertension
    • Liver disorders
    • Blood disorders
    • Sexual/reproductive dysfunction
    • Hormone imbalance
    • Hair
    • Infections
  • Potential side effects Gender specific
    • Male
    • Gynaecomastia .
    • Testicular atrophy
    • Male pattern baldness
    • Increased body hair
  • Potential side effects Gender specific
    • Female
    • Menstrual irregularities
    • Clitoral enlargement
    • Smaller breasts
    • Reproductive dysfunction
    • Deepening of voice
    • Body/facial hair
    • Aggression
    • Depression
    • Anxiety
    • Social/behavioural problems
    • Mood swings
    • Insomnia
    • ?Psychosis
    • ?Violence
    • ?Dependence
    • ?Suicide
    Potential psychological side effects of anabolic steroids
    • Diet
    • Changes in physique come from the diet
    • Should watch out for high levels of sugars and saturated fats “Eat clean” (Lipid levels)
    • Training
    • Needs to be consistent and well though out
    • Only a signal for the body to adapt
    • Damages the body
    • Recovery
    • This is when the body adapts (grows)
    • Most forgotten aspect but crucial to success
    • Reduced time on cycle
    The cornerstones of an exercise program
  • Anabolic steroids: Legal status
    • 1/9/96 - Came under Misuse of Drugs Act (previously under the Medicines Control Act
    • Named steroids (46) plus chemical definition
    • Clenbuterol/HGH/HCG also covered by legislation
    • Class C Schedule 4 part 1
    • Simple possession in medicinal form - legal
    • Supply, possession with intent to supply - illegal
    • Max penalty - 14 years and/or unlimited fine
    • Import/export license required - not personal use in medicinal form
  • Anabolic steroids: Legal status The definition of "medicinal product" is provided by section 130 of the Medicines Act 1968 as "any substance or article which is manufactured, sold, supplied, imported or exported for use wholly or mainly .... as an ingredient in the preparation of a substance . . . which is to be administered . . . for a medicinal purpose." "Medicinal purpose" means one or more of the following: (1 ) treating or preventing disease; (2) diagnosing disease or ascertaining the existence, degree or extent of a physiological condition; (3) contraception; (4) inducing anaesthesia; (5) otherwise preventing or interfering with the normal operation of a physiological function, whether permanently or temporarily, and whether by way of terminating, reducing or postponing, or increasing or accelerating, the operation of that function or in any other way. Sub-paragraph (5) provides the basis on which anabolic steroids are classed as a medicinal product.
  • Steroid users in Syringe Exchange: Implications for practice
  • SES visits per year (mean) by drug group (Cheshire & Merseyside 1991 –2005)
    • Sterile equipment/basic hygiene/safe disposal
    • Correct equipment
    • max. 2ml syringe
    • 21g x 1.5” (green) or 23g x 1.25” (blue)
    • Double amount of needles provided
    • Rotation of sites
    • Needle = quickly / injection = slowly
    Information for anabolic steroid injectors
  • Information for anabolic steroid injectors Sites for intramuscular injections Sciatic nerve
  • Barriers to engagement with AAS clients Don’t perceive themselves as drug users Conflict with other client groups Trust Awareness of service Accessibility Value placed on services Lack of expertise/specialist knowledge Competing information sources Reduced opportunity to build relationships Unclear care & referral pathways Lack of hierarchy of harm reduction
  • General Practitioner contact with anabolic steroid users
    • 43% of steroid users had informed their GP of their anabolic steroid use
    • 22% were receiving regular medical checks from their GP
    • 45% of those not receiving medical checks would pay for this service if available (Lenehan & McVeigh 1996)
    • 32% had informed their GP of their anabolic steroid use
    • Only 15% had received health related information regarding anabolic steroid use from their GP
    • Sample of 85 anabolic steroid users attending Merseyside syringe exchanges September 2005 – February 2006
  • Public health responses Public health responses Basic syringe exchange provision Few other interventions available across the country Some examples of good practice relating to clinics, outreach and services Little involvement from general practitioners Lack of credible information due to scarcity of evidence Lack of evidence base for harm reduction or drug prevention
  • Ideal service provision
    • Multi-disciplinary approach within a harm reduction philosophy
    • Appropriately experienced physician
    • Specialist information
    • Sports scientist/physiologist
    • Sports nutritionist
    Does this model exist?
  • Harm reduction messages
    • Look at motivation for use
    • Existing health status
    • Dosage – smallest – do not adopt other users regimes
    • Stacking – minimal benefit
    • Cycles – limit the on cycle – ensure off cycle
    • Drugs to combat side effects – if you need them - Too high dosage of steroids
    • Injecting Vs Oral
    • Dangers of recreational drug use
    • Injecting techniques
    • Training, Nutrition & Sleep
    • Counterfeit & fakes – check – if in doubt don’t use
    • Warn of side effects including potential for irritability & aggression
  • What anabolic steroid users should monitor Nutrition Meals including: Protein Fat Carbohydrates Calories Body weight Weekly – same time Sleep Hours slept each night Mood Irritability, triggers, energy levels
  • What anabolic steroid users should monitor Training Daily record of Sets Weights Reps Bodyparts exercised Perceived intensity (scale) Perceived difficulty (scale) Injuries/pain – specify Input/advice received Progress towards targets
  • Medical examination should include Medical history (Including steroid related) Age Height Weight Pulse Blood pressure Social and lifestyle assessment Full drug use history (Including non performance enhancing drugs) Age first used Age first injected Reasons for use Side effects experienced
  • Investigations may include Routinely Full Blood count Serum urea and electrolytes Liver function tests Lipid and cholesterol profiles Thyroid function Testosterone Glucose   Offered/indicated/requested Prostate specific antigen Antibody tests for: HIV Hepatitis C Hepatitis B
  • Resources available/in progress from LJMU
    • Steroid user triage/assessment form
    • Steroid research forum (forthcoming)
    • Anabolic Steroid Research Network
    • In-house training (other people also provide training)
    • Ad hoc brief consultation/advice for NeX workers (with caveats!)
  • Contact details: Martin Chandler Inter Agency Drug Misuse Database Manager Jim McVeigh Reader in Substance Use Epidemiology Centre for Public Health Liverpool John Moores University Castle House, North Street Liverpool, L3 2AY Tel: 0151 231 4531/4512 Email: [email_address] Email: [email_address]