The aetiology and trajectory of anabolic-androgenic steroid use initiation: a systematic review and synthesis of qualitative research

Prediction model for anabolic androgenic steroid positivity in forensic autopsy cases - a new tool to the autopsy room

Non-prescription use of anabolic androgenic steroids (AAS) is associated with an increased risk of premature death. However, these substances are seldom screened in connection with forensic cause-of-death investigation, unless the forensic pathologist specifically suspects use, often based on a positive AAS use history. Since AAS use is often concealed from others, this practice may lead to mistargeting of these analyses and significant underestimation of the true number of AAS positive cases undergoing forensic autopsy. Thus, more accurate diagnostic tools are needed to identify these cases. The main objective of this study was to determine, whether a multivariable model could predict AAS urine assay positivity in forensic autopsies. We analyzed retrospectively the autopsy reports of all cases that had been screened for AAS during forensic cause-of-death investigation between 2016-2019 at the Finnish Institute for Health and Welfare forensic units (n = 46). Binary logistic regression with penalized maximum likelihood estimation was used to generate a nine-variable model combining circumferential and macroscopic autopsy-derived variables. The multivariable model predicted AAS assay positivity significantly better than a "conventional" model with anamnestic information about AAS use only (area under the receiver operating characteristic curve [AUC] = 0.968 vs. 0.802, p = 0.005). Temporal validation was conducted in an independent sample of AAS screened cases between 2020-2022 (n = 31), where the superiority of the multivariable model was replicated (AUC = 0.856 vs. 0.644, p = 0.004). Based on the model, a calculator predicting AAS assay positivity is released as a decision-aiding tool for forensic pathologists working in the autopsy room.

Mixed-methods research on androgen abuse - a review

PURPOSE OF REVIEW

This paper reviews the mixed-methods studies from the last 2 years (2021-2022) into androgen use to highlight the most relevant developments within the field.

RECENT FINDINGS

The literature review found seven papers from 2021 to 2022. These seven cover a range of important considerations, including interventions to reduce androgen use, educational tools to increase professionals' knowledge, explorations on the comorbidity of use with other substances, motivations for use, potential risks factors for androgens' initiation, or risks of using androgens. Key findings include a greater understanding of motivations for use, particularly in females and older males; identification of potential risks for starting use/using androgens; benefits of including practical strength exercises in preventive intervention programmes and the efficacy of e-learning tools to increase professionals' knowledge of androgens use, as well as an increase in their confidence to support androgen users.

SUMMARY

The key implications for clinical practice are that we still need to support healthcare professionals to overcome the barriers for increasing their skills and knowledge around androgen use. A recognition that people who have become dependent on androgen use are potentially at risk of considerable harm, with further research needed into sub-groups of androgen users.

VIDEO ABSTRACT

, http://links.lww.com/COE/A35.

Performance- and image-enhancing drug use in the community: use prevalence, user demographics and the potential role of wastewater-based epidemiology

Performance- and image-enhancing drug (PIED) misuse is a significant public health issue. Currently, seizure data, surveys, anti-doping testing, and needle service provider data are used to estimate PIED use in populations. These methods are time consuming, single point-in-time measurements that often consist of small sample sizes and do not truly capture PIED prevalence. Wastewater-based epidemiology (WBE) has been used globally to assess and monitor licit and illicit drug consumption within the general community. This method can objectively cover large populations as well as specific subpopulations (gyms, music festivals, prisons), and has potential as a complementary monitoring method for PIED use. Information obtained through WBE could be used to aid public health authorities in developing targeted prevention and education programmes. Research on PIED analysis in wastewater is limited and presents a significant gap in the literature. The focus is on anabolic steroids, and one steroid alternative currently growing in popularity; selective androgenic receptor modulators. This encompasses medical uses, addiction, prevalence, user typology, and associated public health implications. An overview of WBE is described including its benefits, limitations and potential as a monitoring method for PIED use. A summary of previous work in this field is presented. Finally, we summarise gaps in the literature, future perspectives, and recommendations for monitoring PIEDs in wastewater.

Androgen Misuse and Abuse

Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.

The Impact of the COVID-19 Pandemic on Male Strength Athletes Who Use Non-prescribed Anabolic-Androgenic Steroids

Background: One sub-population potentially affected by the COVID-19 pandemic are strength athletes who use anabolic-androgenic steroids (AAS). We examined links between disruption in AAS use and training due to the pandemic and mental health outcomes in this population, hypothesising: (a) the pandemic would be linked with reduced training and AAS use; and (b) athletes perceiving greater impact on their training and AAS use would report increases in detrimental mental health outcomes. Methods: Male strength athletes using AAS (N = 237) from 42 countries completed an online questionnaire in May 2020. A sub-sample (N = 90) from 20 countries participated again 4 months later. The questionnaire assessed pre-pandemic and current AAS use and training, alongside several mental health outcomes. Results: At Time 1, most participants perceived an impact of the pandemic on AAS use (91.1%) and/or training (57.8%). Dependent t-tests demonstrated significant reductions in training frequency (t = 7.78; p < 0.001) and AAS dose (t = 6.44; p < 0.001) compared to pre-pandemic. Linear regression showed the impact of the pandemic on training was a significant positive predictor of excessive body checking (B = 0.35) and mood swings (B = 0.26), and AAS dose was a significant positive predictor of anxiety (B = 0.67), insomnia (B = 0.52), mood swings (B = 0.37). At Time 2, fewer participants perceived an impact of the pandemic on AAS use (29.9%) and/or training (66.7%) than at Time 1. Training frequency (t = 3.02; p < 0.01) and AAS dose (t = 2.11; p < 0.05) were depressed in comparison to pre-pandemic. However, AAS dose had increased compared to Time 1 (t = 2.11; p < 0.05). Linear regression showed the impact of the pandemic on training/AAS use did not significantly predict any mental-health outcomes. However, AAS dose was a significant negative predictor of depressive thoughts (B = -0.83) and mood swings (B = -2.65). Conclusion: Our findings showed impact of the pandemic on the training and AAS use, reflected in reduced training frequency and AAS dose. However, whilst we detected some short-term consequential effects on mental health, these did not appear to be long-lasting.

The impact of social media on self-evaluations of men striving for a muscular ideal

This paper describes an innovative approach combining a content analysis of commentary and images on a Facebook page with a thematic analysis of the subjective experience expressed in interviews of those impacted by the text and images. Interview participants were asked about their perceptions of the representation of the muscularity-focused identity on social media, including the specific Facebook page. Content analysis of the Facebook page comments showed that very muscular male images attracted predominantly negative feedback from the public, a trend supported by the interview participants. Thematic analysis of the interviews indicated that a negative social media representation and commentary can affect young men's self-esteem and increase body concern. Some men represented on the Page found it humorous, which could serve as a form of bonding for the muscularity-focused online community. Other young men acknowledged how harmful such negative feedback can be on their self-evaluations and body image, consistent with the sociocultural framework whereby negative representations can lead to increased body dissatisfaction.

Aggression and Psychological Distress in Male and Female Anabolic-Androgenic Steroid Users: A Multigroup Latent Class Analysis

The relationship between anabolic-androgenic steroid (AAS) use and aggression and psychological distress requires further elucidation. No previous study has examined whether the latent patterns of aggression and psychological distress are the same in male and female AAS users. Multigroup latent class analysis (MLCA) can be used to classify individuals into groups based on their responses on a set of variables, and to investigate measurement invariance across subgroups. We therefore conducted a MLCA to identify discrete subgroups of aggression and psychological distress in AAS users, and used measurement invariance to examine whether the identified subgroups can be applied to both sexes. We also examined the relationship between sex and subgroup belongingness. The sample comprised 206 AAS users (females = 58.30%) aged 14-56 (mean = 26.86, SD = 7.12) years. They completed questionnaires assessing demographics, AAS use, aggression, and psychological distress. Based on the MLCA, five subgroups were identified: high aggression moderate distress users (HAMoD: 07.63%), moderate aggression distress users (18.64%), moderate direct aggression-mild indirect aggression moderate distress users (22.95%), mild direct aggression-moderate indirect aggression-distress users (11.71%), and low aggression mild distress users (LAMiD: 39.06%). Although a homogenous five-class solution was the best model for both sexes, sex was significantly associated with the probability of subgroup membership. In particular, members of the HAMoD subgroup were more likely to be male whereas members of the LAMiD subgroup were more likely to be female. Our study provides novel empirical evidence of the idiosyncratic patterns of aggression and psychological distress among male and female AAS users.

Anabolic-androgenic steroid administration increases self-reported aggression in healthy males: a systematic review and meta-analysis of experimental studies

RATIONALE

Aggression and irritability are notable psychiatric side effects of anabolic-androgenic steroid (AAS) use. However, no previous study has systematically reviewed and quantitatively synthesized effects reported by experimental studies on this topic.

OBJECTIVE

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effect of AAS administration on self-reported and observer-reported aggression.

METHODS

Twelve RCTs comprising a total of 562 healthy males were identified through systematic searches of MEDLINE, PsycInfo, ISI Web of Science, ProQuest, Google Scholar, and the Cochrane Library.

RESULTS

After excluding one outlier, AAS administration was associated with an increase in self-reported aggression under a random-effects model, albeit small (Hedges' g = 0.171, 95% CI: 0.029-0.312, k = 11, p = .018), and when restricting the analysis to the effect of acute AAS administration on self-reported aggression under a fixed-effect model (g = 0.291, 95% CI: 0.014-0.524, p = .014). However, the above effects were neither replicated in the analysis of observer-reported aggression nor after restricting the analysis to the effects of the administration of higher (over 500 mg) and long-term (3 days to 14 weeks) doses.

CONCLUSIONS

The present meta-analysis provides evidence of an increase, although small, in self-reported aggression in healthy males following AAS administration in RCTs. Ecologically rational RCTs are warranted to better explore the effect of AAS administration on aggression in humans.

Help-Seeking Beliefs Among Anabolic Androgenic Steroid Users Experiencing Side Effects: An Interpretive Phenomenological Analysis

Recreational athletes comprise the most prevalent population using illegal Anabolic Androgenic Steroids (AAS). Despite regulatory efforts, substances are widely accessible, and most users report the experience of harmful side effects. It remains unclear why few users seek professional medical help. The aim of this study was to determine AAS users’ experience of side effects and help-seeking beliefs using an Interpretative Phenomenological Analysis of six interviews. Participants were from the United Kingdom (n = 5) and United States (n = 1), had all experienced side effects, with some reporting prolonged use of AAS (>10 years) and self-manufacturing the drugs from raw ingredients. Results showed that AAS users discredit medical professionals’ competencies, and practice cognitive dissonance by avoiding challenging situations. A microculture for information-sharing has developed among AAS users who initially self-treat to counteract side effects, leaving them vulnerable to further harm. To conclude, there is an urgent need for educational interventions that outline the risky practice of unregulated AAS use and self-treatments, and the need to seek professional help. Such interventions could be developed through a co-production basis, and be implemented by current/former AAS users alongside the medical community.

FACTORS ASSOCIATED WITH ANABOLIC STEROID USE BY EXERCISE ENTHUSIASTS

ABSTRACT Introduction Synthetic anabolic-androgenic steroids (AAS) were developed with the purpose of obtaining drugs capable of increasing protein synthesis associated with a lower degree of virilization. Its use is common among bodybuilders who aim to increase physical strength and muscle mass in the short term. However, AAS cause side effects, which restrict their therapeutic use. Objective To identify factors associated with AAS use by exercise enthusiasts at gyms in São Luís, MA. Methods A cross-sectional study was carried out at 17 gyms. The sample totaled 723 exercise enthusiasts, who answered a structured questionnaire with multiple choice questions related to their lifestyle and the consumption of nutritional supplements and AAS use. Logistic regression analysis was used to verify the association of socioeconomic, demographic and behavioral factors with AAS use. Results Of the 723 exercise enthusiasts, 10.65% reported having used AAS. Of these, 97.4% declared their awareness of some side effect caused by AAS use. Factors associated with AAS use were: being male, age between 20 and 29 years, consumption of food supplements and participation in exercise for over a year. Conclusion The prevalence of AAS use by exercise enthusiasts at gyms in São Luís is high, and the risk factors identified enable us to target specific populations with preventive actions. Level of Evidence IIC; Cross-sectional study.

‘Sis Science’ and Fitness Doping: Ethnopharmacology, Gender and Risk

This article is part of a larger investigation looking into recent changes in the demographics of fitness doping and the possible consequences of such changes. Contesting the historical alliance between masculinity and fitness doping, the article focuses on women’s narratives and experiences of fitness doping in a male-dominated open online community called Flashback. The article builds upon a qualitative and netnographic approach to the research. Employing the lens of the potential emergence of a woman-based ethnopharmacological culture, this article investigates the ways in which women talk about and rationalise their use of performance and image enhancing drugs (PEIDs), their potency and potential gendered side-effects. The results show that although fitness doping can be largely understood in terms of hegemonic patterns, women have gained ground in the context of online fitness doping, heralding a changing doping demography and a movement towards a ‘sis science’ ethnopharmacology. Although critiqued by men, the context enables women to freely discuss harm reduction, risks and the potential potencies of various drugs, and to share knowledge that is relevant to female biology and discuss their own experiences, an activity that also makes visible the negotiation of new gender positions.

Health care engagement behaviors of men who use performance- and image-enhancing drugs in Australia

Background: Although people who inject performance- and image-enhancing drugs (PIEDs) report fewer unsafe injecting practices, stigma and discrimination may negatively impact their access to help and information. Engagement with health care services, compared with social networks (friends, relatives, and gym associates) and the Internet and media (steroid user forums, information sites, and magazines), may be important for harm minimization. Methods: A cross-sectional Internet or in-person survey of men who use PIEDs in Australia in 2014-2015 examined differences in sources for PIEDs, injecting equipment, and anabolic-androgenic steroids (AAS) information and factors associated with having periodical medical checks related to PIEDs issues using multivariate logistic regression. Results: In total, 267 men (mean age: 25 years, SD: 8.7 years; 246 of 267 [92%] reported recent AAS injection) were recruited. Most participants sourced injecting equipment from health professionals, PIEDs from their social networks, and AAS information from the Internet and media. Self-reported AAS knowledge was high and frequent. Higher income (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.03, 4.00), ≥2 different PIEDs used in addition to AAS (AOR: 1.94, 95% CI: 1.08, 3.49), and sourcing AAS information from health care professionals (AOR: 3.14, 95% CI: 1.81, 5.46) were independently associated with periodical medical checks. Participants nominated preference for improved health services through needle-syringe programs, primary care services, and peer educator support groups. Conclusion: Men who use PIEDs in Australia consider themselves well informed but tend to use Internet and media sources, providing potentially misleading or inaccurate information. Increasing trust between men who use PIEDs and health care providers may enable delivery of PIEDs-specific information to those at greatest need.

Support for people who use Anabolic Androgenic Steroids: A Systematic Scoping Review into what they want and what they access

BACKGROUND

Since there is a paucity of research on support for people using Anabolic Androgenic Steroids (AAS), we aimed to identify and synthesise the available evidence in this field. Gaining an understanding of the support both accessed and wanted by recreational AAS users will be of use to professionals who provide services to intravenous substance users and also to those working in the fields of public health and social care, with the aim to increase engagement of those using AAS.

METHODS

A systematic scoping review of the literature to explore and identify the nature and scope of information and support both accessed and wanted by non-prescribed AAS users. Any support services or information designed to help people who use AAS were considered.

RESULTS

We identified 23 papers and one report for review, which indicated that AAS users access a range of sources of information on: how to inject, substance effectiveness, dosages and side effects, suggesting this is the type of information users want. AAS users sought support from a range of sources including medical professionals, needle and syringe programmes, friends, dealers, and via the internet, suggesting that, different sources were used dependent on the information or support sought.

DISCUSSION

AAS users tended to prefer peer advice and support over that of professionals, and access information online via specialist forums, reflecting the stigma that is experienced by AAS users. These tendencies can act as barriers to accessing services provided by professionals.

CONCLUSIONS

Support needs to be specific and targeted towards AAS users. Sensitivity to their perceptions of their drug-use and the associated stigma of being classified in the same sub-set as other illicit drug users is relevant to facilitating successful engagement.

Aggression and Anabolic-Androgenic Steroid Use Intent in Adolescents: A Longitudinal Study

Background: There is a dearth of longitudinal studies on risk factors for anabolic-androgenic steroid (AAS) use and intent. Objectives: We conducted a longitudinal investigation of factors associated with AAS use intent from age 18 to 19, examining particularly the role of physical and verbal aggression. A sample of Norwegians completed questionnaires containing demographic, AAS use and intent, other addictions, aggression, and health measures at ages 18 (N = 1333, females = 58.9%) and 19 (N = 1277, females = 61.7%). The data were analyzed using descriptive statistics, correlations, and hierarchical multiple regression. Results: Results show that AAS use prevalence increased from 1 person at age 18 to 4 persons at age 19. Intent to use AAS, being male, living alone, and AAS use (all at 18 years) were associated with higher AAS use intent at 19 years. We found no associations between physical or verbal aggression and AAS use intent from ages 18 to 19. Conclusions: Our findings indicate temporal stability in AAS use intent, as well as the influence of demographic and health factors on AAS use intent from ages 18 to 19. Implications of findings for practice and future research are discussed.

Psychosocial correlates of gap time to anabolic-androgenic steroid use

OBJECTIVE

Theoretically, legal supplement use precedes and increases the risk for illicit appearance and performance enhancing drug (APED) use-also referred to as the gateway hypothesis. Little is known about associations between the speed of progression, or gap time, from legal to illicit APED use, and psychological risk factors, such as sociocultural influence, eating disorders, body image disturbance, and impulsivity.

METHOD

The sample taken from two studies included 172 active steroid users (n = 143) and intense-exercising healthy controls (n = 29) between the ages of 18 and 60 (M = 34.16, SD = 10.43), the majority of whom were male (91.9%). Participants, retrospectively, reported APED use and completed measures assessing psychological and behavioral factors, including eating concern, muscle dysmorphia, and impulsivity. Participants had a gap time from initial APED use to anabolic-androgenic steroid (AAS) use that ranged from 0 to 38 years.

RESULTS

Continuous survival analysis indicated that interactions between self- versus other sociocultural influence on APED onset and both higher eating concern and impulsivity are associated with a shorter gap time from initial legal to illicit APED use.

DISCUSSION

The results indicate the potential value in developing different strategies for individuals with other sociocultural versus self-influence on illicit APED use, and among more impulsive and eating-concerned APED users. Future research is needed to assess different trajectories of APED use, such that eating-concerned and impulsive individuals who perceive less other sociocultural influence may be at greatest risk for a speedier progression to AAS use.

Public health impact of androgens

PURPOSE OF REVIEW

To summarize recent findings regarding the public health impact of androgen abuse.

RECENT FINDINGS

Abuse of androgens (also called 'anabolic-androgenic steroids') has grown into a major worldwide substance abuse problem involving tens of millions of individuals, of whom about 98% are men. Most androgen abusers are still under age 50 today, and thus, the long-term effects of these drugs are only beginning to be understood. Recent studies confirm that long-term supraphysiologic androgen exposure produces cardiovascular toxicity, characterized especially by cardiomyopathy and atherosclerotic disease. Withdrawal from androgens after long-term use may produce prolonged and sometimes irreversible hypogonadism in men. Supraphysiologic androgen levels may sometimes cause irritability, aggressiveness, and violence, whereas androgen withdrawal may cause depression. However, these psychiatric effects are idiosyncratic, affecting only a minority of users. Emerging evidence now also suggests that long-term androgen exposure may cause neurotoxicity, raising the possibility that aging androgen abusers may be at increased risk for dementia. Several recent studies have also described androgen-induced hepatotoxicity, nephrotoxicity, and adverse musculoskeletal effects.

SUMMARY

Recent studies have demonstrated marked adverse effects of long-term androgen abuse. As increasing numbers of androgen abusers reach middle age, these effects will likely represent an emerging public health problem.

Being in control? A thematic content analysis of 14 in-depth interviews with 2,4-dinitrophenol users

BACKGROUND

2,4-Dinitrophenol (2,4-DNP) is a compound with multiple industrial purposes. Currently unlicensed for human consumption, it is used by the gym-going population for drastic, short-term body fat loss. Nonetheless, physiological mechanisms can lead to potentially fatal hyperthermia. Reported fatal incidents have caused concern and highlighted the need for intervention. Understanding decision-making leading to 2,4-DNP use alongside the perceived outgroup attitudes is vital to forming effective harm minimisation policies targeting current and potential users. First-hand accounts from this elusive population are scarce.

METHODS

Fourteen novel and experienced users (13 male, 1 female) were recruited via "snowballing" techniques. Semi-structured interviews were conducted, comprising 28 questions. Thematic content analysis was conducted using 37 codes.

RESULTS

Four characteristic themes emerged: 1. Users considered the Internet to be a crucial multifunctional resource directly impacting their 2,4-DNP use. 2. Users "respected" 2,4-DNP, proactively taking harm reduction measures. 3. Attitudinal polarisation towards 2,4-DNP within the gym-going community was consistent in all accounts. 4. Users perceived outgroup populations to have inherently negative attitudes towards their use. These themes fell under the all-encompassing theme of "being in control".

CONCLUSION

For the first time, this study offers a rich detail of attitudes toward 2,4-DNP use by giving a collective voice to users. The element of control over every aspect of the users' life appears to be a significant contributor to the successful risk-management of 2,4-DNP use. In the absence of an established safe upper limit and effective regulatory control, education is critical to harm minimisation.

Understanding Appearance-Enhancing Drug Use in Sport Using an Enactive Approach to Body Image

From an enactive approach to human activity, we suggest that the use of appearance-enhancing drugs is better explained by the sense-making related to body image rather than the cognitive evaluation of social norms about appearance and consequent psychopathology-oriented approach. After reviewing the main psychological disorders thought to link body image issues to the use of appearance-enhancing substances, we sketch a flexible, dynamic and embedded account of body image defined as the individual’s propensity to act and experience in specific situations. We show how this enacted body image is a complex process of sense-making that people engage in when they are trying to adapt to specific situations. These adaptations of the enacted body image require effort, perseverance and time, and therefore any substance that accelerates this process appears to be an easy and attractive solution. In this enactive account of body image, we underline that the link between the enacted body image and substance use is also anchored in the history of the body’s previous interactions with the world. This emerges during periods of upheaval and hardship, especially in a context where athletes experience weak participatory sense-making in a sport community. We conclude by suggesting prevention and intervention designs that would promote a safe instrumental use of the body in sports and psychological helping procedures for athletes experiencing difficulties with substances use and body image.

A systematic review investigating the behaviour change strategies in interventions to prevent misuse of anabolic steroids

We examined intervention effectiveness of strategies to prevent image- and performance-enhancing drug use. Comprehensive searches identified 14 interventions that met review inclusion criteria. Interventions were predominantly educational and delivered within school sport settings, but targeted a wide range of mediating factors. Identification of effective components was limited across studies by brief or imprecise descriptions of intervention content, lack of behavioural outcome measures and short-term follow-up times. However, studies with components in addition to information provision may be more promising. Interventions outside of sport settings are required to reflect the transition of this form of substance use to the general population.

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review

Injecting use of image and performance-enhancing drugs (IPED) in the general population is a public health concern. A wide and varied range of IPED are now easily accessible to all through the online market. A comprehensive literature review was undertaken according to Critical Appraisal Skills Programme (CASP) guidelines for systematic review, to identify the relevant literature. No date restrictions were placed on the database search in the case of human growth hormone melanotan I and II, and oil and cosmetic injectables. In the case of anabolic androgenic steroids search dates were restricted to January 2014-2015. Publications not in English and with a lack of specificity to the topic were excluded. The review yielded 133 relevant quantitative and qualitative papers, clinical trials, clinical case presentations and editorials/reports. Findings were examined/reviewed under emergent themes which identified/measured extent of use, user profiling, sourcing, product endorsement, risk behaviours and health outcomes in users. Motivation for IPED use may be grounded in appearance, pursuit of health and youth, and body image disturbance. IPED users can practice moderated use, with pathological use linked to high-risk behaviours, which may be normalised within IPED communities. Many IPED trajectories and pathways of use are not scientifically documented. Much of this information may be available online in IPED specific discussion forums, an underutilised setting for research, where uncensored discourse takes place among users. This review underscores the need for future internet and clinical research to investigate prevalence and patterns of injecting use, and to map health outcomes in IPED users. This paper provides community-based clinical practice and health promotion services with a detailed examination and analysis of the injecting use of IPED, highlighting the patterns of this public health issue. It serves to disseminate updated publication information to health and social policy makers and those in health service practice who are involved in harm reduction intervention.

Aggression Is Associated With Increased Anabolic-Androgenic Steroid Use Contemplation Among Adolescents

We investigated the relationship between aggression and anabolic-androgenic steroid (AAS) use intent among adolescents. A nationally representative sample of Norwegian 18-year-olds (N = 1,334, females = 58.7%) took part in a survey in 2013 (response rate = 64.9%). Participants completed the physical and verbal subscales of the Short-Form Buss-Perry Aggression Questionnaire, the Intent to use AAS Scale, the Alcohol Use Disorders Identification Test-Consumption, and the Hospital Anxiety and Depression Scale. They also provided demographic information and answered questions about AAS use, gambling participation, as well as cigarette and snus use. Descriptive statistics and multinomial logistic regression were used to analyze the data. Lifetime and past year prevalence of AAS use was 0.1%. Between 0.4% and 1.7% of participants disclosed intent to use while between 1.1% and 2.5% expressed neutral intent to initiate AAS use. Compared to persons low on aggression, individuals high on aggression were more likely to report intent and curiosity towards initiating AAS use. Our findings indicate that aggression is a risk factor for AAS use contemplation among adolescents.

Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis

Background

As far as we are aware, no previous systematic review and synthesis of the qualitative/descriptive literature on polypharmacy in anabolic-androgenic steroid(s) (AAS) users has been published.

Method

We systematically reviewed and synthesized qualitative/descriptive literature gathered from searches in electronic databases and by inspecting reference lists of relevant literature to investigate AAS users’ polypharmacy. We adhered to the recommendations of the UK Economic and Social Research Council’s qualitative research synthesis manual and the PRISMA guidelines.

Results

A total of 50 studies published between 1985 and 2014 were included in the analysis. Studies originated from 10 countries although most originated from United States (n = 22), followed by Sweden (n = 7), England only (n = 5), and the United Kingdom (n = 4). It was evident that prior to their debut, AAS users often used other licit and illicit substances. The main ancillary/supplementary substances used were alcohol, and cannabis/cannabinoids followed by cocaine, growth hormone, and human chorionic gonadotropin (hCG), amphetamine/meth, clenbuterol, ephedra/ephedrine, insulin, and thyroxine. Other popular substance classes were analgesics/opioids, dietary/nutritional supplements, and diuretics. Our classification of the various substances used by AAS users resulted in 13 main groups. These non-AAS substances were used mainly to enhance the effects of AAS, combat the side effects of AAS, and for recreational or relaxation purposes, as well as sexual enhancement.

Conclusions

Our findings corroborate previous suggestions of associations between AAS use and the use of other licit and illicit substances. Efforts must be intensified to combat the debilitating effects of AAS-associated polypharmacy.

Prevalence and correlates of anabolic-androgenic steroid use in a nationally representative sample of 17-year-old Norwegian adolescents

BACKGROUND

Anabolic-androgenic steroid (AAS) use has been identified as a serious public health problem.

OBJECTIVES

This study investigates the prevalence and correlates of AAS use among Norwegian adolescents.

METHODS

In 2012, a nationally representative sample of 2,055 17-year-old adolescents (963 males and 1,088 females) participated in a survey. The response rate was 70.4%. In addition to questions about AAS use, participants completed the Parental Monitoring Scale, the Family Relations/Cohesion Scale, the Alcohol Use Disorders Identification Test C, the Mini-International Personality Item Pool-Five-Factor Model, the Eysenck Narrow Impulsiveness Subscale, the Arnett Inventory of Sensation Seeking, the Short-Form Buss-Perry Aggression Questionnaire, the Hospital Anxiety and Depression Scale, and the UCLA Loneliness Scale. They also answered questions about demography, gambling, smoking, snus, and narcotic use. Descriptive statistics and logistic regression were used to analyze the data.

RESULTS

The lifetime prevalence of AAS use was 0.30% (0.52% in males and 0.09% in females), while current prevalence was 0.25%. Moreover, 19.39% of the sample reported having an acquaintance who used or had used AAS. Having an acquaintance who used or had used AAS was significantly related to snus use, depression, aggression, extraversion, and conscientiousness in both univariate and multivariate logistic regression analyses. Conclusions/Importance: Our findings suggest a high prevalence of AAS use among Norwegian adolescents and denote the significance of social, personality, and health factors in adolescents' exposure to AAS milieu.