Gym users and abuse of prescription drugs

Anabolic steroids are synthetic derivatives of naturally occurring testosterone. According to surveys and media reports, androgenic anabolic steroid use is widespread.¹ In 1991, data from the National Household Survey on Drug Abuse indicated that there were more than one million users in the USA.² Steroids became controlled drugs in America in 1990 and in the UK in 1996, but the most recent data suggest that their use has increased.^3,4

Current estimates indicate that there are as many as three million ‘steroid’ users in the USA and that 2.7%-2.9% of young American adults have taken them at least once in their lives.⁵ Surveys in the American field indicate that use among community weight trainers attending gyms and health clubs is 15%-30%.⁴ In the UK, the majority of use was by non-competitive recreational bodybuilders or non-athletes, who use these drugs for cosmetic purposes.¹

Self-image in obesity, as a consequence of media attention focusing on clinical and public health implications, leads us to comment on a number of possible explanations for the progressive increases observed. The prevalence of abuse of certain prescription medicines amongst health-club attendees has dramatically increased in the UK. The non-therapeutic use of such medicines was previously considered to be restricted to the professional athlete or recreational bodybuilder. As a consequence of the internet revolution, steroid abuse is becoming challenged by the more expensive designer drugs, particularly growth hormone.

The first nation-wide survey for steroid abuse in the UK surveyed 21 gyms throughout Britain, and found that 8% of respondents admitted having taken them at some time: 5% of these were current users; 9.1% were men; and 2.3% were women.⁶ A survey of 100 steroid abusing athletes conducted in three South Wales counties,⁷ reported high rates of polypharmacy (80%). In addition to an increase in abuse, 20% reported needle sharing utilizing hazardous injection techniques, which included injection site pain, and the reusing of needles.⁸ Steroid abuse has continued, despite the advertising campaigns by successive governments, highlighting the risks of contracting serious diseases such as HIV, hepatitis B and C.

Bodybuilders have been described as suffering from an altered perception of body image, leading to psychopathology.⁹ Bulimia nervosa is an eating disorder characterized by eating binges, vomiting, laxative and/or diuretic abuse and prolonged fasting. Some patients with anorexia nervosa also manifest bulimia. There has been a link established between bulimia nervosa, anorexia nervosa and bodybuilding, related to perception of body image. Unrealistic, muscular male, and slim female body ideals, put individuals at risk for negative body images, resulting in low esteem, unhealthy eating and exercise habits. Some individuals resort to drug-taking to counteract their altered body images.

Anorectics, have been publicly on trial in the USA and surreptitiously on trial in the UK, for some time now. The pharmaceutical manufacturing giants must demonstrate that a drug's benefit outweigh its risks. Expenditures by the pharmaceutical industry for direct-to-consumer advertising have increased dramatically from $1.8 billion in 1999, to $4.2 billion in 2004.¹⁰ What are the chances of the medical profession adhering to its maxim ‘first do no harm’, when the source of the problem appears to have no degree of accountability?

In 2005, in male and female health club attendees,³ we observed significant increases in the use of the following drugs: diuretics (10%), thyroxine (10%), insulin (14%), clenbuterol (21%), tamoxifen (22%), human chorionic gonadotrophin (11%), growth hormone (24%) and ephedrine (44%). The study indicated that steroids were still the most abused drug. It would seem that both sexes are at risk, with 7% of users being female. Clenbuterol, ephedrine and thyroxine, abused by bodybuilders as a training stimulant and to increase metabolic rate and induce lipolysis, were associated with palpitations and caused extrasystoles, during functional exercise electrocardiography. Their use had increased by 3%, 2% and 6%, respectively. Insulin, abused by bodybuilders to increase total body mass, had increased by 14%. This accounted for several individuals suffering from hypoglycaemia in bodybuilding competitions, resulting in emergency rehabilitation with glucose drinks. One such subject confessed to taking 70 international units of insulin, under the presupposition that he was taking 7 IU, on two separate occasions, 1 week apart, and suffered the consequences.

Tamoxifen, abused by bodybuilders to prevent gynaecomastia had increased by 10%. Human chorionic gonadotrophin, abused by bodybuilders to stimulate the testes, when withdrawing from their exogenous androgens, was the only drug to have decreased and had diminished by 4%. Diuretics, abused by bodybuilders to counteract the adverse water retention of both steroids and growth hormone, had increased by 6% and had accounted for several bodybuilders suffering severe muscle cramps and collapsing on stage in competitions. Growth hormone, abused by bodybuilders to induce lipolysis and in the belief that it enhances muscle mass and strength, had increased by 18%: it accounted for less severe side effects, such as muscle weakness, carpal tunnel syndrome, water retention and headaches.

The results of our survey corroborate the research undertaken in the USA, which demonstrated several trends in the non-medical use of androgenic anabolic steroids. The recent results of this American survey⁴ reveal several trends in the non-medical use of steroids. Nearly four out of five users are non-athletes who take these drugs with the sole intention of improving physical appearance. Steroid users are taking larger doses than previously recorded, with more than half the respondents using a weekly dose in excess of 1000 mg. Close to 100% of steroid users surveyed admitted to self-administering by intramuscular injection, with approximately 1 in 10 users reporting hazardous injection techniques. An 89% majority of users obtain drugs from aberrant sources, with more than 50% admitting to the use of drugs manufactured in back-street laboratories. Poly-pharmacy is practised by more than 95% of steroid users surveyed. One in four users takes growth hormone and insulin, suggesting that the use of adjuvant anabolic agents is rising. Nearly 100% of steroid users experience subjective side effects suggesting that concern over health risks does not influence the patterns of drug use.

Awareness of the psychological reasons for use is the first step in an attempt to providing the counselling and then appropriate medical treatment required.