n The use of steroids in this way has been associated with a diverse number of adverse effects on physical and psychological health, including fatal events. However, our understanding of these pathological processes is limited n Users face risks to health from injecting steroids (and many of the related drugs) and from the large number of counterfeit drugs.

References 1. Nieschlag E, Behre HM. Testosterone: action, deficiency, substitution, 3rd edn. Cambridge University Press 2004. ISBN 0521833809 2. Tausk M. Androgens and anabolic steroids. In Parnham J, Bruinvels, eds. Discoveries in pharmacology, vol. 2: Haemodynamics, hormones and inflammation. Elsevier Science 1984. ISBN 0444805788 3. Wright JE. Anabolic steroids and sport. Sports Science Consultants 1978. ISBN 0960930604 4. Simonson E, Kearns WM, Enzer N. Effect of oral administration of methyltestosterone on fatigue in eunuchoids and castrates. Endocrinology 1941;28:506–512 5. De Kruif P. The male hormone. Harcourt, Brace 1945. ASIN B000WVHF0U 6. **Dimeo P. A history of drug use in sport 1876–1976: beyond good and evil. Routledge 2007. ISBN 0415357713 7. MacQueen. Body Building on drugs. British Medical Journal 1967;4:743–744 8. Moynihan C, Coe S. The misuse of drugs in sport. Department of the Environment 1987 9. Elashoff JD, Jacknow AD, Shain SG, Braunstein GD. Effects of anabolic-androgenic steroids on muscular strength. Annals of Internal Medicine 1991;115:387–393 10. Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government. Clinical Chemistry 1997;43:1262–1279 11. Korkia P, Stimson GV. Anabolic steroid use in Great Britain: an exploratory investigation. Report to the Department of Health, the Welsh Office and the Chief Scientist Office, Scottish Home and Health Department. HMSO 1993 12. Lenehan P, Bellis M, McVeigh J. Anabolic steroid use in the North West of England. Journal of Performance Enhancing Drugs 1996;1:57–70 13. **Dawson RT. Drugs in sport: the role of the physician. Journal of Endocrinology 2001;170:55–61 14. Monahagn L. Bodybuilding, drugs and risk. Routledge 2001. ISBN 0415226821 15. **Grogan S. Body image: understanding body dissatisfaction in men, women and children, 2nd edn. Routledge 2008. ISBN 0415358213 16. HM Government. Drugs: protecting families and communities. The 2008 drug strategy. HMSO 2008 17. Williamson DJ. Anabolic steroid use among students at a British college of technology. British Journal of Sports Medicine 1993;27:200–201 18. Murphy R, Roe S. Drug misuse declared: findings from the 2006/07 British Crime Survey. Home Office 2007 19. McVeigh J, Beynon C, Bellis MA. New challenges for agency based syringe exchange schemes: analysis of 11 years of data (1991 to 2001) in Merseyside and Cheshire, UK. International Journal on Drug Policy 2003;14:353–357 20. McVeigh J, Chandler M, Beynon C, Evans-Brown MJ, Bellis MA. The injectors that harm reduction forgot. 18th International Conference on the Reduction of Drug Related Harm 2007 21. UK Sport. Testing programme. www.uksport.gov.uk/pages/testing_ programme/. (Accessed 11 July 2008.) 22. Kayser B, Smith AC. Globalisation of anti-doping: the reverse side of the medal. British Medical Journal 2008;337:a584 23. UK Sport. 2005 drug-free sport survey. UK Sport 2005 24. House of Commons Science and Technology Committee. Human enhancement technologies in sport. Second report of session 2006–07. The Stationery Office 2007

25. **Hartgens F, Kuipers H. Effects of androgenic-anabolic steroids in athletes. Sports Medicine 2004;34:513–554

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BOX 1: KEY POINTS FOR PRACTITIONERS

n Recognise the potential for steroid use in patients, particularly those who present with mesomorphic or hypermesomorphic body types n Always approach the issue in a non-judgemental way and listen to your patient’s concerns n Recognise that there are diverse drivers of steroid use and look at motivations for use – can their goal be achieved without steroids? n If an individual is intent on using steroids, then basic harm-reduction advice should be given. This includes:

Use the smallest dose of steroids and do not adopt other users’ regimes Limit the length of On cycles Be aware of counterfeit drugs Always use sterile injecting equipment. Never share Know how to inject safely

Spend adequate time on training, nutrition and sleep Know the dangers of recreational drug use Be aware of side effects. At the first sign of them, discontinue use and seek medical advice If you need to take drugs to treat the side effects of your steroid use, it

means your dose of steroids is too high Just because you read something about steroid use on the internet or in a magazine, or heard it from another user, doesn’t necessarily mean it’s true!

26. Dickinson BP, Mylonakis E, Strong LL, Rich JD. Potential infections related to anabolic steroid injection in young adolescents. Pediatrics 1999;103:694 27. Thevis M, Schrader Y, Thomas A, Sigmund G, et al. Analysis of confiscated black market drugs using chromatographic and mass spectrometric approaches. Journal of Analytical Toxicology 2008;32:232–240 28. Van der Kuy PH, Stegeman A, Looij BJ Jr, Hooymans PM. Falsification of Thai dianabol. Pharmacy World and Science 1997;19:208–209 29. Goldberg L, Elliot DL. Prevention of anabolic steroid use. In Yesalis C, ed. Anabolic steroids in sport and exercise, 2nd ed. Human Kinetics 2000. ISBN 0880117869.

Note: References marked with a double asterisk indicate further reading.

THE AUTHORS Michael Evans-Brown B wn BSc (Hons) is a researcher in

performance-enhancing drugs at the Centre for Public Health, erpool John Moores University. His research focuses around the public health implications of performance- and image- enhancing drug use within the general population. Jim McVeigh MS Centre for Public

performance-enhancing drugs at the Centre for Public Liverpool John Moores

eigh M c, RGN is head of substance use at the

Centre for Public Health, Liverpool John Moores University, with extensive experience as a harm-reduction nurse and a researcher in the area of performance- and image-enhancing drugs.

sportEX medicine 2008:38(Oct):20-26