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

Case report: Fatal long-term intoxication by 2,4-dinitrophenol and anabolic steroids in a young bodybuilder with muscle dysmorphia

A case of chronic intoxication by 2,4-dinitrophenol (2,4-DNP) is reported in a 21-year-old bodybuilder, also known as an abuser of anabolic steroids, who died after ingesting 2 grams of this substance after 6 months of repeated consumption. The bodybuilder presented the triad of symptoms - tachycardia, tachypnoea, profuse sweating - from 6 months before his death, and was hospitalised for multiple organ failure 4 months before his death. Medical staff attributed this serious episode to his consumption of 2,4-DNP. Although the triad of symptoms persisted, he denied continuing to consume 2,4-DNP during consultations with his general practitioner, who therefore looked into a possible diagnosis of endocrine or tumour disorder. The bodybuilder died of multi-organ failure. The autopsy found diffuse visceral congestion and yellowish colouration of integuments. Toxicology demonstrated not only lethal acute 2,4-DNP intoxication (blood concentration was 88 mg/L), but also chronic intoxication (segmental hair concentrations were 5.1 to 25.5 ng/mg). Different anabolic steroids were also identified in the hair. Continued uncontrolled consumption of 2,4-DNP despite the consequences for his health, combined with an obvious preoccupation with his physical appearance, supported the suspected diagnosis of "muscle dysmorphia", a psychiatric disorder in which dangerous substances are trivialised. Primary care professionals, the first to come into contact with intoxication cases, should receive training on how to detect and manage cases with symptomology that mimics 2,4-DNP use. A large study evaluating the outcomes of acute intoxication cases if "aggressive" management had been immediately implemented may help us determine the optimal course of action that minimises fatalities.

Teachers as first responders: classroom experiences and mental health training needs of Australian schoolteachers

BACKGROUND

Schoolteachers are often the first to respond when a student presents with a mental health issue in the classroom. This places a burden on schools that impacts school staff, healthcare workers and teachers. More broadly, it places a responsibility on the education system to address students' mental health. This study examines Australian teachers' classroom experiences and the training areas identified by teachers as necessary to manage these issues.

METHOD

Interviews were undertaken with 18 in-service teachers between 2020 and 2021 from Catholic, Independent and Public schools. Data were gathered via multiple interviews and analysed using thematic content analysis.

RESULTS

The major mental health issues identified by teachers related to mental disorders, depression, anxiety, and a complex range of negative emotional states. Teachers requested training in child and adolescent mental health, counselling skills, early detection and intervention, and training skills to manage the complex relationship with parents and external health and community personnel. Teachers also reported the need to access mental health resources, support and training, which were differentially accessed along socioeconomic status and postcodes.

CONCLUSION

The data show that teachers are often placed as first responders when a student has a mental health issue but feel inadequately trained to manage these issues in the classroom. We identified mental health issues presenting in Australian classrooms and documented critical features of mental-health training asked for by teachers in order to address those issues. Given the increasing demands on teachers to address the mental health of children and adolescents, we argue that an urgent review of mental health training for teachers is needed.

Sublethal toxicities of 2,4-dinitrophenol as inferred from online self-reports

INTRODUCTION

2,4-dinitrophenol (DNP) is a mitochondrial toxin sometimes used as a weight loss agent. Reports of fatalities from DNP have been increasing since 2000, suggesting an increase in use. Our understanding of DNP toxicity in humans comes from reports to Poison Control and postmortem analyses, sources that are biased to more extreme presentations. This leads to a gap in our knowledge about the adverse effects of DNP at nonlethal doses. Here we investigate the doses and effects of DNP as reported online.

METHODS

We analyzed publicly available Internet posts that we collected from 2017-2019. The posts came from anonymous users or users who voluntarily self-identified. We collected data from websites whose terms of use allow for the secondary analysis of data that their users agree to make public. We used natural language processing techniques that we had previously developed to extract doses, effects, and substances mentioned in each post.

RESULTS

We collected 1,630 posts across 5 online forums and the Reddit forum r/DNP. The posts were from 1,234 unique usernames. The most commonly reported doses were between 150 to 300 mg each day followed by 300 to 450 mg each day. At those doses, the most reported adverse effects were profuse sweating and fatigue. Reports of thermoregulatory (sweating, feeling hot flashes or flushed), fatigue-related, and neurologically related symptoms were statistically significantly more frequent at reported daily doses greater than 150 mg than doses below 150 mg (post-hoc χ2-test with Bonferroni correction). The effects were judged as plausible by two board-certified medical toxicologists. Triiodothyronine, clenbuterol, testosterone, and trenbolone, an androgenic anabolic steroid were the most significantly co-mentioned substances.

CONCLUSIONS

Fatigue, increased body temperature, and paresthesias from DNP are reported more frequently at doses greater than 150 mg each day than at doses less than 150 mg each day. Online discussions of DNP frequently mention androgenic anabolic steroids and other weight loss agents.

Generating evidence on the use of Image and performance enhancing drugs in the UK: results from a scoping review and expert consultation by the Anabolic Steroid UK network

BACKGROUND

The use of anabolic androgenic steroids (AAS) and associated image and performance enhancing drugs (IPEDs) is now a global phenomenon. There is a need to develop evidence to support the development of interventions to prevent the commencement of use, to minimise the potential harms or to support those in their cessation of use. While the United Kingdom (UK) is no exception to this issue, its public health and legislative response to the phenomenon differs to other countries and requires the examination of research specific to the UK. Therefore, a scoping review has been conducted to examine the recent relevant literature to help inform the development and evaluation of effective interventions to reduce the harmful use of IPEDs.

METHODS

A comprehensive search strategy was developed for multiple bibliographic databases, supported by and iterative citation searching process and complimented by expert input from the Anabolic Steroid UK Network. Research conducted by or UK academics or within the UK were eligible, if published in the previous five years.

RESULTS

In total 87 eligible outputs were identified, including 26 review articles, 25 qualitative papers and 24 quantitative papers. together with small numbers of clinical studies/case reports (6) and commentaries/correspondence (6). The most common topics of research were public health, treatment and harm reduction (41), followed by studies focusing on epidemiology, sub-groups of people using IPEDs and motivations for use (34). The studies illustrated the diverse populations of people who use a range of enhancement drugs including concomitant psychoactive drug use. A number of papers focused on blood borne viruses and associated issues, while others reported on the uptake of needle and syringe programmes. No effectiveness evaluations related to any aspect of treatment, harm reduction or other intervention were published during study period.

CONCLUSION

There is a need for the development of effectiveness evaluations of current interventions and any future service provision for people using image and performance enhancing drugs. While there have been no studies of this nature to date, this review illustrates the rich data that has been gathered through diverse methodologies, that will assist in the development of future effectiveness evaluations.

Harm Reduction in Male Patients Actively Using Anabolic Androgenic Steroids (AAS) and Performance-Enhancing Drugs (PEDs): a Review

Anabolic androgenic steroid (AAS) and performance-enhancing drug (PED) use is a prevalent medical issue, especially among men, with an estimated 2.9-4 million Americans using AAS in their lifetime. Prior studies of AAS use reveal an association with polycythemia, dyslipidemia, infertility, hypertension, left ventricular hypertrophy, and multiple behavioral disorders. AAS withdrawal syndrome, a state of depression, anhedonia, and sexual dysfunction after discontinuing AAS use, is a common barrier to successful cessation. Clinical resources for these patients and training of physicians on management of the patient using AAS are limited. Many men are hesitant to seek traditional medical care due to fear of judgment and lack of confidence in physician knowledge base regarding AAS. While proposed approaches to weaning patients off AAS are published, guidance on harm reduction for actively using patients remains sparse. Medical education regarding the management of AAS use disorder is paramount to improving care of this currently underserved patient population. Management of these patients must be non-judgmental and focus on patient education, harm reduction, and support for cessation. The approach to harm reduction should be guided by the specific AAS/PEDs used.

Long-term intake of the illegal diet pill DNP reduces lifespan in a captive bird model

2,4-Dinitrophenol (DNP), a molecule uncoupling mitochondrial oxidative phosphorylation from oxygen consumption, is illegally used by humans as a diet pill, but is nonetheless investigated as a potential human medicine against 'metabesity'. Due to its proven acute toxicity and the scarceness of long-term studies on DNP administration in vertebrates, we determined the impact of a long-term DNP treatment (~4 mg.kg^-1.day^-1, i.e. within the range taken illegally by humans) on body mass, metabolism, ageing and lifespan in a captive bird model, the zebra finch. The chronic absorption of DNP over life (>4 years) led to a mild increase in energy expenditure (ca. +11% compared to control group), without significantly altering the normal slight increase in body mass with age. DNP did not significantly influence the alteration of physical performance, the rise in oxidative damage, or the progressive shortening of telomeres with age. However, DNP-treated individuals had a significantly shorter lifespan (ca. -21% in median lifespan compared to control group), thereby raising potential concerns about DNP use as a diet pill or medicine.

2,4 dinitrophenol: It's not just for men

BACKGROUND

2,4 dinitrophenol (DNP) is an organic compound which causes thermogenesis resulting in fat burning and weight loss. Although not licensed for human consumption, the globalised access to and information about this compound on the internet has prompted a renewed interest in DNP making it readily available to purchase online.  Studies into user experiences remain scarce and much of the previous literature has focused on DNP use in male dominated bodybuilding communities. While online accounts of female DNP use are plentiful, this group are under researched.

METHOD

Ten online forums containing female discussion of DNP were identified and 440 threads subjected to a thematic analysis. Semi structured interviews were conducted with four forum moderators (all men) and one woman who reported use of DNP.

RESULTS

The findings highlighted diverse motivations for why women use DNP as well as differences in experiences, dosing regimens, willingness to take risks and adverse effects. Many women reported using online forums to seek advice and trusted the information they received. However, much of the discussion and protocols for use online is perpetuated by and geared towards men, with DNP seen as a 'hard core' drug that is not suitable for women. Female DNP use was frequently stigmatised because the potential risks were seen to be at odds with women's roles as mothers and caregivers. Women who used DNP were often ignored, ridiculed or seen as novice users, while men were viewed as the DNP experts.

CONCLUSION

This study provides an overview of female experiences of DNP use. There is a growing body of evidence as to the harms associated with this compound and there are no guaranteed 'safe' regimens that can be advocated for any potential user. Users equate deaths or ill harms from DNP with incorrect dosing or insufficient knowledge of the impact of the drug on the body. This leads women to incorrectly assume that if they are not suffering ill effects they are using DNP safely. Of key concern from this study is that within a vacuum of harm reduction advice, women are reported to be accepting DNP advice circulating in male-dominated forums and adopting the protocols of male bodybuilders with potentially fatal consequences. Furthermore, women using DNP are doing so without any 'real world' support, gender sensitive treatment pathways or interventions in place.

Analysis of 2,4-Dinitrophenol in Postmortem Blood and Urine by Gas Chromatography-Mass Spectrometry: Method Development and Validation and Report of Three Fatalities in the United States

2,4-dinitrophenol (2,4-DNP) is a compound used in the early 1900s as a weight-loss drug but later prohibited due to its severe adverse effects, including death. It has however been attracting interest, due to its weight-loss properties, and appears to be re-emerging in forensic casework. As 2,4-DNP is available for use in industry and as a pesticide and easily accessible online, the dissemination of this drug can be fast. The compound exerts its effects through inhibition of ATP synthesis, and corresponding thermogenic energy loss which can be fatal. A method for qualitative and quantitative analysis of 2,4-DNP in blood and urine specimens using GC-MS with hydrogen as carrier gas is described. The method was validated and displayed acceptable performance parameters with linearity (R² higher than 0.998), inter-assay imprecision (lower than 10.6%), intra-assay imprecision (lower than 10.7%), and extraction efficiency (92.1%). Stability of 2,4-DNP in blood and urine was studied, and the drug was stable up to 30 days refrigeration or frozen. Six cases in United States suspected to be related to 2,4-DNP were analyzed. Three cases were found to be positive for 2,4-DNP. Concentrations of 2,4-DNP were in the range of 61.6-220 mg/L in urine and <3-114 mg/L in blood. Based on our findings, we suggest that medical examiners and forensic toxicologists be aware of the reappearance of 2,4-DNP, including this compound as a target in death investigations related to weight-loss drugs.

Would You Use It With a Seal of Approval? Important Attributes of 2,4-Dinitrophenol (2,4-DNP) as a Hypothetical Pharmaceutical Product

BACKGROUND

2,4-Dinitrophenol (2,4-DNP) is an effective but highly dangerous fat burner, not licensed for human consumption. Death cases reported for 2,4-DNP overdose, particularly among young adults, have raised concerns about the ineffective regulatory control, lack of education and risks associated with impurity, and the unknown concentration of 2,4-DNP purchased on the Internet.

METHODS

Using a sequential mixed method design and based on a hypothetical scenario as if 2,4-DNP was a licensed pharmaceutical drug, first we conducted a qualitative study to explore what product attributes people consider when buying a weight-loss aid. Focus group interviews with six females and three males (mean age = 21.6 ± 1.8 years) were audiorecorded, transcribed verbatim, and subjected to thematic analysis. Sixteen attributes were identified for the Best-Worst Scale (BWS) in the quantitative survey with 106 participants (64% female, mean age = 27.1 ± 11.9 years), focusing on 2,4-DNP. Demographics, weight satisfaction, and risk for eating disorder data were collected.

RESULTS

In contrast to experienced users such as bodybuilders, our study participants approached 2,4-DNP cautiously. Attributes of 2,4-DNP as a hypothetical weight-loss drug comprised a range of desirable and avoidable features. Of the 16 selected attributes, BWS suggested that long-term side effects were the most and branding was the least important attribute. Effectiveness and short-term side effects were also essential. Those in the >25 year group showed least concerns for legality. Neutral BWS scores for cost, treatment, degree of lifestyle changes required, and specificity required for the hypothetical weight-loss drug to be effective were likely caused by disagreement about their importance among the participants, not indifference.

CONCLUSION

With advances in research, 2,4-DNP as a pharmaceutical drug in the future for treating neurodegenerative diseases and potentially for weight loss is not inconceivable. Caution is warranted for interpreting the BWS scores. Owing to the difference in what data represent at individual vs. population levels, with pooled data, the method correctly identifies attributes by which most people are satisfied but misrepresents attributes that are individually very important but not universally agreed. Whilst this may be an advantage in marketing applications, it limits the utility of BWS as a research tool.