Guidance

Services for image and performance enhancing drug (IPED) users: turning evidence into practice

Published 1 January 2014

1. Introduction

This briefing is for commissioners in local areas, based in local authorities or clinical commissioning groups, who are responsible for commissioning services to prevent and treat harms caused by image and performance enhancing drugs (IPEDs) and injecting drug use. The content is drawn from published evidence, guidance, and expert consensus. It has been developed by a group of experts who are experienced in working with IPED users.

IPEDs include substances that promote weight loss, change skin colour, build muscle and allow longer, harder training. In this briefing, IPEDs refers to oral and injectable anabolic steroids and injectable ancillary drugs, typically taken alongside anabolic steroids (for example, human growth hormone, melanotan, insulin and others). These are the IPEDs most likely to be taken by people attending needle and syringe programmes and drug treatment services.

2. The issue

In many parts of the country, IPED users make up a significant proportion of people using needle and syringe programmes and many have complex health needs. The National Institute For Health and Clinical Excellence (NICE) has highlighted that engaging and providing appropriate services for these people is important. ^{[footnote 1]} They are at risk of blood-borne viruses, bacterial and fungal infections and injecting site injuries. There is also evidence that many of them also use alcohol and psychoactive drugs, in particular cannabis and cocaine. ^{[footnote 2] [footnote 3] [footnote 4]}

Although personal possession of most IPEDs is not illegal, users often obtain their drugs from illicit and poorly-controlled sources. There is evidence to show widespread adulteration of these drugs, ^{[footnote 5] [footnote 6] [footnote 7]} with many products containing substances and dose strengths different to what is specified on the label, as well as potential bacterial and fungal contamination. ^{[footnote 8] [footnote 9] [footnote 10]}

If they are sharing injecting equipment, users also face many of the same issues as opiate and stimulant injectors. For instance, a 2013 study ^{[footnote 2]} reported that 1.5% of IPED injectors across England and Wales were HIV positive, which is equivalent to the rate among opiate injectors. A further 8% had been infected with hepatitis B and 5% had hepatitis C, ^{[footnote 10] [footnote 11]} which while lower than the infection rate among opiate injectors, is still higher than the general population. ^{[footnote 2]} In the same study, 8.9% of IPED users said that they had shared injecting equipment. Uptake of blood-borne virus tests and vaccinations is poor among this group.

People who use IPEDs put themselves at risk of other harm to their health, including significant cardiovascular problems, which are potentially life-threatening. ^{[footnote 12]} There can also be significant and permanent disruption of normal sexual function as a result of long-term or heavy use. ^{[footnote 12]} IPED users often take several different drugs simultaneously (‘stacking’) in complex, high-dose regimens. There is little evidence to support the effectiveness of stacking, which can increase the risk of adverse health effects.

There has been a global increase in the number of people reporting IPED use since the 1990s ^{[footnote 13]} but accurate prevalence figures for the UK are difficult to obtain. The Crime Survey for England and Wales (2013-14) suggested 66,000 16-59 year old people had used anabolic steroids in the past year. ^{[footnote 14]} We know from local monitoring that steroid users are widespread in some areas – for instance recent figures from the north of England showed that in 12 out of 14 areas IPED use was reported by more than half of people using needle and syringe programmes (NSPs). ^{[footnote 15]} In 4 of those areas, over 70% of people accessing NSPs were using IPEDs.

3. Blood-borne viruses and injecting-related problems

It is important for needs and syringe programmes (NSPs) and other services to raise awareness of blood-borne virus (BBV) risks with IPED users because they often don’t see themselves as drug users and believe they aren’t at risk. ^{[footnote 15] [footnote 3]} As well as the risk from sharing injecting equipment, BBVs can be transmitted through risky sexual behaviour. This is particularly relevant to people using anabolic steroids, because the drugs may increase their libido. NSPs and drug treatment services should also be able to offer hepatitis B vaccination and referral to treatment for people who have tested positive for hepatitis C or HIV.

3.1 Prompts

• Are IPED users provided with information about BBV transmission, including injecting and sexual routes?
• Do staff in NSPs and other services in contact with IPED users have the knowledge and skills they need to engage with IPED users about BBVs?
• Are there follow-up protocols for communicating the results of BBV testing that offer confidential support services for IPED users?
• Are IPED users offered vaccination for hepatitis B?
• Are there established local treatment pathways for IPED users who test positive for hepatitis C or HIV?
• Are IPED users offered advice about hygienic and appropriate intramuscular and subcutaneous injecting techniques?
• Are IPED users taught about the risks of injecting site infections, how to identify them and how to get help with any infections they develop?
• Are IPED users made aware of possible drug contamination?

4. Poly-drug and alcohol use

Some IPED users report also using alcohol and psychoactive drugs, particularly stimulants. ^{[footnote 2] [footnote 3] [footnote 4]} This may be a problem because using alcohol and psychoactive drugs alongside IPEDs can lead to harmful interactions, either physiologically (for example, oral anabolic steroids and alcohol can impact on liver function) or psychologically (for example, increased aggression or other emotional issues are often exacerbated by psychoactive drug use). It is important to discuss these harms with IPED clients and to offer support services (or referral to support services) for alcohol and psychoactive drug use where appropriate.

4.1 Prompts

• Are staff in needle and syringe programmes and other services in contact with IPED users aware of the potential problems that can result from using alcohol and psychoactive drugs alongside IPEDs?
• Are IPED users given information about the potential harm caused by their drug or alcohol use?
• Are IPED users informed in a supportive and positive way about drug and alcohol treatment options available to them?
• Are there established care pathways for IPED users to access alcohol and drug treatment if they have been assessed as needing it?

5. Providing services to IPED users

Providing services to IPED users can prevent blood-borne viruses and many of the existing methods used for working with opiate and stimulant injectors are relevant to people who use IPEDs. The main type of drug services available to this group are needle and syringe programmes (NSPs) and provision of these should be based on existing NICE guidance for NSPs. ^{[footnote 1]} Other services integrated or aligned with NSPs can also support improved health outcomes for IPED users.

A recent study highlighted substantial variability in NSP provision across different areas and services. It found that some IPED users do not engage with local services because of the stigma of being seen as a drug injector. ^{[footnote 15]} Others do not want to mix with people who inject opiates or stimulants. They may also find it difficult to access services because of their own working hours. Providing specialist IPED clinics, especially out-of-hours, may lead to better engagement. Offering a range of services and interventions, such as health checks and dietary advice, beyond basic needle and syringe provision may also increase uptake. ^{[footnote 15]} Local gyms could be able to facilitate referrals to local drug treatment and other support services.

5.1 Prompts

• Do your services provide a supportive, confidential, welcoming and non-judgemental environment?
• Are local IPED users consulted about service provision?
• Are there consistent and accurate information sources available for people who use IPEDs (for example, leaflets, posters, web resources) at your service?
• Are your services accessible outside of normal working hours? Are your services promoted through local venues such as gyms, or on web-based forums?
• Is there a mixture of community pharmacy-based and specialist NSP services available to IPED users? Are there established care pathways for referral from pharmacies to specialist services?
• Do your services highlight the full range of services available to IPED users, for example, health checks and dietary advice?
• Do your services have resources to provide basic health checks for IPED users such as blood-pressure testing?

5.2 Case study: The Pump Clinic, Manchester

The Pump Clinic is a confidential service based around a needle and syringe programme that is designed to engage IPED users and offer them specialist advice and information. The clinic offers a basic health screen, including biochemical and hormonal analysis, as well as access to blood-borne virus (BBV) testing. The service employs a specialist harm reduction worker, with expertise in the use of IPEDs, to perform the testing and discuss results with clients. The clinic has directed clients to their own GPs to further investigate health issues which have been identified through testing.

A number of clients have reported stopping IPED use after testing and advice received at the clinic. The clinic reports that about half of their clients had not accessed NSPs prior to engaging with the clinic. They are engaging a difficult-to-reach population of people who inject drugs and providing appropriate harm reduction and BBV prevention advice.

6. Outreach services

Many IPED users are reluctant to engage with healthcare services about their drug use. ^{[footnote 14]} A recent study showed that the majority of IPED users who reported adverse effects from their IPED use chose to treat themselves, or just wait until the effects went away, rather than engage with healthcare services. ^{[footnote 15]} Engaging with IPED users through other routes, such as outreach services to gyms, can increase service uptake and help overcome the stigma they may associate with drug services. Also, outreach workers can make links with local gym staff and athletes who may be prepared to become involved in providing information to IPED users.

6.1 Prompts

• Are local gyms and fitness centres aware of IPED use among their client base and are they supported to respond appropriately?
• Are there existing links between NSPs and other drug and alcohol services and local gyms (either private or council-run) that can be built upon to develop multi-agency responses?
• Have local gyms been asked to work with drug services to deliver harm reduction information to IPED users?
• Do local gym staff provide dietary and exercise advice for IPED users?
• Do local gym staff or athletes contribute to NSP staff training around diet, exercise and IPED use?
• Are there protocols in place to provide confidential referral routes and signposting from local gyms to NSPs and other drug and alcohol services?
• Are there outreach NSP services provided in local gyms?

6.2 Case study: Bridge Project, Bradford

The Bridge Project identified a number of gyms that could benefit from outreach, based on feedback from needle and syringe programme users and local bodybuilders and powerlifters. One gym was prioritised on the basis of significant problems with injecting related litter and high-risk behaviour by attendees. This included needle reuse, people starting injecting at a young age, and people injecting each other, sometimes injecting several people with the same needle.

Outreach work consists of a weekly drop-in session at the gym where, besides needle and syringe provision, advice is offered to gym members on nutrition and weight training. Regular work with this gym has led to relationships being developed with key gym staff and members, who in turn now refer people to the Bridge Project.

6.3 Case study: The Cambridge Centre, Scarborough

The Cambridge Centre has substantial experience of working with IPED users. The centre was in contact with known IPED injectors, but was aware of a growing number of other IPED injectors who had no contact with their services and were at risk of bloodborne infection.

They developed a partnership with a local gym by initially offering sharps collections. They then set up a scheme within the gym for IPED users to supply each other with clean injecting equipment. This highlighted a lack of staff competence and the need for IPED training. Courses were attended by staff from the Cambridge Centre and the gym which, as well as filling gaps in knowledge, developed good relationships between centre and gym staff.

The Cambridge Centre also set up a gym clinic when the gym owner allowed their mobile needle exchange to use facilities at the gym. It takes place weekly, with the gym clinic worker offering interventions such as dry blood spot testing for BBVs, safer injecting and other harm reduction advice, and referral to other services at the Cambridge Centre, such as wound care and sexual health services.

7. Staff competence in working with IPED users

It is also important that staff are suitably trained to feel confident engaging with IPED users and to help the users feel confident in receiving their support. Many experienced IPED users have specific dietary and training regimes to complement their IPED use to achieve their goals, but novice users are often unaware of the importance of diet and training and rely on the drugs alone. Staff who know about these issues, and can address them with IPED users, can gain the users’ confidence more effectively and provide advice on health harms.

7.1 Prompts

• Are NSP staff provided with training on IPED use?
• Are NSP staff provided with training on intramuscular and subcutaneous injecting?
• Do local services have trained staff available to do specific health checks such as cardiac function or liver function and other blood tests?
• If these health checks aren’t available, is there a care pathway into services that can provide them?
• Is specialist training on diet and exercise, related to IPED use, provided for staff?

7.2 Case study: Lifeline Kirklees

Lifeline Kirklees support their frontline needle and syringe programme staff to complete a Northern Council for Further Education (NCFE) Level 2 Certificate in Nutrition and Health. This has helped staff to engage with steroid users more confidently in relation to their health and nutritional needs. Alongside the health and nutrition certificate, Lifeline Kirklees also regularly provides updated training on IPED use to their staff and external partners in Kirklees.

Lifeline provides training and advice to staff in local council-managed gyms who are likely to work with IPED-using clients. The training is primarily focused on fitness and personal trainers working in the gyms, but also includes managers in the leisure department. This partnership makes staff aware of IPED use issues and the pathways into support. It also helps Lifeline to work alongside gym staff to provide information sessions to clients and the general public, raising the profile of the support services and information available to IPED users in the area.

8. Engaging IPED users in prison

The use of IPEDs in prisons has the potential to be significant but there is a lack of evidence available. Anecdotal evidence suggests that oral anabolic steroids may be the most used IPED in prison settings but there is the potential for use of injectable anabolic steroids with associated risks of BBV transmission in these settings. IPED interventions need to be provided in prisons by healthcare staff who are competent to work with IPED users, and custodial staff may need awareness of risks and issues.

8.1 Prompts

• Has there been an assessment of the need for specialist IPED interventions in local prisons?
• Are prison staff and drug workers trained together about IPED use?
• Are prisoners provided with current and accurate information on the risks associated with IPED use?
• Are prisoners able to discuss IPED use with staff in confidence?
• Are there working arrangements between prison custodial and healthcare staff so that prisoners can be referred to a drug worker for advice and help?
• Are there established care pathways with IPED interventions in the community after release from prison?

8.2 Case study: Lifeline Kirklees in prisons

A Lifeline Kirklees drug worker, with specialist knowledge of IPED use, attends Armley prison on a weekly basis and prisoners are encouraged to speak to them on any substance use issues, including IPEDs. Lifeline also provides a session where inmates can attend an IPED training session, focusing on harm reduction. Alongside the training, prisoners are offered an additional gym session, supervised by gym staff and a personal trainer.

There is a similar scheme in Wealstun prison, where one-off training sessions are provided in partnership with the prison staff.

9. References

1. National Institute for Health and Care Excellence. Needle and syringe programmes. March 2014. www.nice.org.uk/guidance/ph52 ↩ ↩²

2. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergård A, Croxford S, Beynon CM, Parry JV, Bellis MA, Ncube F. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open 2013, 3:e003207 ↩ ↩² ↩³ ↩⁴

3. Chandler M and McVeigh J. Steroids and Image Enhancing Drugs: 2013 Survey Results Centre for Public Health, Liverpool John Moores University. Unpublished report for Public Health Wales 2014 ↩ ↩² ↩³

4. Sagoe D, McVeigh J, Bjørnebekk A, Essilfie MS, Andreassen CS and Pallesen S. Polypharmacy among anabolic androgenic steroid users: a descriptive metasynthesis. Substance Use, Treatment, Prevention and Policy 2015 10(12) ↩ ↩²

5. Stensballe A, McVeigh J, Breindahl T and Kimergård A. Synthetic growth hormone releasers detected in seized drugs: new trends in the use of drugs for performance enhancement, Addiction 2015 (110) 368–369, doi: 10.1111/add.12785 ↩

6. Graham MR, Ryan P, Baker JS, Davies B, Thomas NE, Cooper SM, Evans P, Easmon S, Walker CJ and Kickman AT. Counterfeiting in performance and image enhancing drugs. Drug Testing and Analysis 2009 Mar 13: 135-42, doi: 10.1002/dta.30 ↩

7. Evans-Brown MJ, Kimergård A and McVeigh J. Elephant in the room? The methodological implications for public health research of performance-enhancing drugs derived from the illicit market Drug Testing and Analysis 2009 Jul;1(7):323-6, doi: 10.1002/dta.74 ↩

8. Breindahl T, Evans-Brown M, Hindersson P, McVeigh J, Bellis M, Stensballe A and Kimergård A. Identification and characterization by LC-UV-MS/MS of melanotan II skin-tanning products sold illegally on the internet, Drug Testing and Analysis, 2015: 7, 164-172, doi: 10.1002/dta.1655 ↩

9. Kimergård A, McVeigh J, Knutsson S, Breindahl T and Stensballe A. Online marketing of synthetic peptide hormones: poor manufacturing, user safety, and challenges to public health. Drug Testing and Analysis, 2014 6: 396-398, doi: 10.1002/dta.1636 ↩

10. Hope VD, McVeigh J, Marongiu A, Evans-Brown M, Smith J, Kimergård A, Parry JV, Ncube F. Injection site infections and injuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking. Epidemiology and infection, 2015 143(1):132-140. ISSN 0950-2688, doi: 10.1017/S0950268814000727 ↩ ↩²

11. Public Health England, Health Protection Scotland, Public Health Wales, and Public Health Agency Northern Ireland. Shooting Up: Infections among people who inject drugs in the United Kingdom 2013. London: Public Health England, November 2014. ↩

12. Pope HG Jr, Wood RI, Rogol A, Nyberg F, Bowers L and Bhasin S. Adverse health consequences of performance enhancing drugs: an Endocrine Society scientific statement. Endocr Rev 2014 Jun: 35(3):341-75, doi: 10.1210/er.2013-1058 ↩ ↩²

13. Sagoe D, Molde H, Andreassen CS, Torsheim T and Pallesen S. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Annals of Epidemiology 24(2014) 383- 398 ↩

14. Drug Misuse Declared: Findings from the 2012/13 Crime Survey for England and Wales July 2014 ↩ ↩²

15. Kimergård A and McVeigh J. Variability and dilemmas in harm reduction for anabolic steroid users in the UK: a multi-area interview study. Harm Reduction Journal, 2014 11:19 www.harmreductionjournal.com/content/11/1/19 ↩ ↩² ↩³ ↩⁴ ↩⁵