Prevalence and correlates of androgen dependence: a meta-analysis, meta-regression analysis and qualitative synthesis

Feasibility of implementing current best clinical practice for people who are using anabolic androgenic steroids within a Swiss primary care practice: a quality assurance study

BACKGROUND

The non-medical use of anabolic androgenic steroids for the improvement of aesthetic and sports performance purposes has become a global substance use disorder, particularly among men in recreational sports. Health outcomes among people who are using anabolic androgenic steroids may be detrimental, yet healthcare services for these users are scarce. Therefore, the aim of this project was to conduct a quality assurance study to evaluate the feasibility of providing current best clinical practice for anabolic androgenic steroids users based on the published literature within a primary care practice in Zurich (Switzerland).

METHODS

A primary healthcare practice for current or past anabolic androgenic steroids use was established at the Arud Centre for Addiction Medicine in Zurich providing specialised medical care for this population. The reporting and methodology to evaluate feasibility of this quality assurance study follow a checklist for pilot studies. The primary feasibility outcomes for this study were satisfaction with the services received (customer satisfaction score), as well as loyalty towards the services (net promoter score). These customer metrics have been used successfully in the medical field to measure patient experiences, as well as infer future word-of-mouth advertisement (i.e. return and refer). Furthermore, the objective was to describe patient characteristics and substance use behaviours in a Swiss context. Patients could access these services in Zurich from 1 June 2023 onwards. The recruitment strategy was word-of-mouth advertising among anabolic androgenic steroids users and paper advertisement (i.e. flyers) about the healthcare service. Eligibility criteria were based on legal restrictions regarding doping laws and professional ethical principles of medicine. In an initial visit at the practice, a focused patient history was assessed, and patients received a physical, psychometric, instrumental as well as laboratory examination. Datasets are summarised using descriptive statistics.

RESULTS

Overall, 34 eligible patients were seen over the period from June until December 2023. Excellent results regarding loyalty towards the service (net promoter score: 100; integer) as well as patient satisfaction with the received services (customer satisfaction score: 100%) were achieved. Patients were commonly young professional males (mean: 38.5 years, standard deviation: 8 years), with educational level beyond compulsory schooling. The main motivation for using anabolic androgenic steroids was aesthetic purposes. Acquisition of these substances occurred mostly through non-medical sources. Patterns of anabolic androgenic steroids use were complex with extensive polypharmacy and concomitant illicit substance use. Most patients suffered from side effects with multiple physical as well as mental health complications. Many abnormal findings were found regarding the physical as well as laboratory and instrumental examination, although mostly mild and transient, some possibly severe regarding health outcomes.

CONCLUSION

With this first quality assurance study, we demonstrate that integration of current best clinical practice for anabolic androgenic steroids users in recreational sports appears to be feasible with high acceptance in a Swiss primary care practice. Furthermore, those patients may engage in high-risk behaviours and a high prevalence of comorbid medical conditions was demonstrated. Anabolic androgenic steroids users likely benefit from integrated medical care provided and coordinated in a primary health care setting. On the basis of the initial study results, these services were continued at a larger scale to further assess as well as mitigate health risks among this user population. Importantly, current doping legislation was demonstrated to be a major limitation to provision of adequate medical care for this user population, thus changes in legislation are crucial to avert this growing public health threat.

The world's first anabolic-androgenic steroid testing trial: A two-phase pilot combining chemical analysis, results dissemination and community feedback

BACKGROUND AND AIMS

The clandestine production and distribution of anabolic-androgenic steroids (AAS) poses health risks due to the uncertainty of their contents. This study aimed to test the chemical content of AAS samples and provide aggregate results back to the community, exploring how these results influenced usage decisions and risk management.

DESIGN

A mixed-methods approach was used, combining chemical analysis of AAS samples with qualitative interviews. Participants submitted samples for testing, and the results were later shared with them. Semi-structured interviews explored participants' perceptions of AAS risks and the impact of testing results on their behaviour.

SETTING

The study was conducted at CheQpoint drug checking service in Brisbane, Australia.

PARTICIPANTS

Thirty-two samples were submitted for testing between 19 April and 7 June 2024, with 23 samples analysed. A total of 25 active AAS users participated in interviews.

MEASUREMENTS

Chemical analyses identified substances present and assessed active ingredient concentrations. Qualitative interviews gathered participants' perceptions, and these data were analysed through iterative categorisation, guided by the Health Belief Model.

FINDINGS

Chemical analysis identified that 13% of samples contained substances different from what was expected. Concentrations of active ingredients were close to expected levels [e.g. testosterone propionate at 96.2 mg/mL (range = 91.39-101.01 mg/mL)]. Interviews identified four key theme categories. Participants sought testing primarily for substance verification, expressing concerns about contamination and dosage. Barriers to testing included limited access and fear of disclosure. While testing was seen as a valuable harm reduction tool, gaps in health guidance and follow-up support were identified as areas for improvement.

CONCLUSIONS

Thirteen percent of 23 anabolic-androgenic steroid (AAS) samples analysed contained substances different from what was expected. Interviews with active AAS users highlighted the need for reliable information, accessible testing services and tailored health approaches for AAS use.

Off-label use of clomiphene citrate to treat anabolic androgenic steroid induced hypogonadism upon cessation among men (CloTASH) - A pilot study protocol

Background

Non-prescribed anabolic androgenic steroid (AAS) use is associated with AAS-induced hypogonadism (ASIH), and metabolic, cardiovascular, and mental health risks. Symptoms of ASIH (fatigue, depression, anxiety, sexual dysfunction) are hard to endure following cessation, but there is no consensus on whether endocrine treatment should be used to treat ASIH. This proof-of-concept study aims to explore safety of off-label clomiphene citrate therapy, whether the treatment will reduce the symptoms of androgen deficiency, and to study changes in health risks after cessation.

Methods

In this open-labeled non-randomized off-label hormone intervention pilot study, we shall include males with AAS dependence intending to cease use. The 16-week intervention included clomiphene citrate, transdermal testosterone gel for the first four weeks and optional human chorionic gonadotropin (hCG) from week 4 if low treatment response. Measures of physical and mental health will be examined from ongoing AAS use, during the intervention, and at 6- and 12 months post cessation. Change in self-reported symptoms of hypogonadism and other withdrawal symptoms will be compared with data from a group of men who ended AAS use temporarily without the medical intervention. The study may provide valuable clinical insights and may be used to inform the design of future intervention studies.

"The compounds for females are really commonly faked!": Women's challenges in anabolic steroid acquisition and the place of drug checking interventions

INTRODUCTION

Women who use drugs, particularly those using anabolic-androgenic steroids (AAS), encounter heightened social risks influenced by the legal status of AAS, varying regionally. In jurisdictions where AAS are legal, medical guidance and prescription are common, while in illegal regions, there are challenges associated with acquisition and safer usage. Therefore, we aimed to explore the experiences of women who use AAS in Australia, where these substances are criminalised, with a focus on the challenges they encounter in acquiring and using these drugs.

METHODS

We focused on data from six women in a broader study interviewing 15 AAS users. The data were subjected to iterative inductive analysis, resulting in two theme-categories.

RESULTS

Women who use AAS face distinct challenges in accessing reliable suppliers, with men seemingly having 'easier' access. Women experience this disparity as increasing their vulnerability to unsafe products, further compounded by their lack of knowledge regarding these substances. Moreover, mislabelling and counterfeiting of female-specific AAS substances is described to further compound these risks, reflecting the participants' expressed need for enhanced intervention and quality control in the AAS market.

DISCUSSION AND CONCLUSIONS

Ensuring product reliability, transparency and accountability are perceived as essential for the health and safety of women who use AAS. To address these issues, interventions should provide women with comprehensive drug checking services tailored to their health needs. 'Steroid literacy' must be an integral component, equipping women with knowledge to make informed decisions in the gendered AAS market.

Some for a Good Time, Some for a Long Time: Women's Ratings of the Mate Value of Men with Different Addictions - An Experimental Study

Background: The present study aimed to explore women's perception of men with different addictions in terms of their short- and long-term mate value. Objectives: 2,525 women (age range: 18-40, M = 28.35, SD = 6.39) were randomized to six conditions in a vignette-based experiment where a male of otherwise high mating value was described as suffering from either gambling, gaming, cannabis, anabolic androgenic steroid, and alcohol addiction or as not suffering from addiction (control). Results: Regarding long-term mate value of the target, the control target was rated higher than each of the targets. The gaming target was rated higher than the alcohol, cannabis, and gambling targets. Finally, the AAS target was rated as higher on long-term mate value than the alcohol and gambling addiction targets. Conclusions: Overall, women seem to perceive risk-taking in the face of uncertainty, reflected by gambling addiction, as an attractive behavioral tendency in men in terms of short-term mating. In contrast, potential long-term mates with gaming or chemical addictions are viewed more negatively, probably because it signals inadequate time and resources to be invested in a relationship.

A study of long-term supraphysiologic-dose anabolic-androgenic steroid use on cognitive function in middle-aged men

Background: Long-term use of supraphysiologic doses of anabolic-androgenic steroids (AAS) has been associated with impaired visuospatial memory in young men but little is known about its cognitive effects in middle-aged men.Objectives: We compared cognition in middle-aged men with histories of long-term AAS use and age-matched non-users.Methods: We administered cognitive tests from the CANTAB battery to 76 weightlifters aged 37-60 years (mean [SD] 48.5 [6.5] years), of whom 51 reported at least 2 years of cumulative AAS use and 25 reported no AAS exposure.Results: We found no significant AAS user versus non-user group differences on visuospatial, verbal memory, emotional recognition, or executive function tasks (corrected p's ≥ .00089; effect sizes ≤ .5).Conclusions: Our null visuospatial task findings contrast with our prior younger cohort study (mean age 37.1 [7.1] years), in which we found impaired visuospatial task performance in people who use AAS, and with other reports of cognitive impairments in younger men use AAS. Men who use AAS may develop early visuospatial memory deficits that stabilize by middle age while middle-aged non-users' performance may "catch up" due to normal age-related visuospatial declines. Similar effects could contribute to our null findings on other tasks. Between-study cohort substance use differences or environmental factor differences that modify cognition, such as study geographical location and time of year, also could contribute to our discordant findings. Since young adult male AAS users experience increased mortality from unnatural causes, improving our understanding of AAS cognitive effects in this age group is important.

Exploring the role of community pharmacies as a harm reduction environment for anabolic-androgenic steroid consumers: triangulating the perspectives of consumers and pharmacists

BACKGROUND

While community pharmacies have been successful in providing harm reduction support for illicit substance consumers, little research has explored their role in addressing the needs of anabolic-androgenic steroid (AAS) consumers.

OBJECTIVE

This study aimed to triangulate the attitudes and experiences of AAS consumers and community pharmacist's regarding AAS harm reduction.

METHODS

Semi-structured interviews were conducted with AAS consumers (n = 8) and community pharmacists (n = 15) between December 2022 and August 2023 in Australia. Interview data were analysed using reflexive thematic analysis.

RESULTS

While consumers emphasised easy access to pharmacies, particularly in urban areas, challenges were noted in rural regions. AAS consumers expressed a preference for community pharmacies, perceiving them as less confronting and a feasible avenue for accessing professional advice, highlighting the potential role of pharmacists in nurturing therapeutic alliances with AAS consumers. Similarly, pharmacists expressed receptivity to providing harm reduction information but acknowledged knowledge gaps, suggesting a need for tailored education programs to support AAS consumers effectively.

CONCLUSIONS

Community pharmacies can be an important environment for AAS harm reduction. Strategies include utilising private spaces for open discussions with AAS consumers and enhancing pharmacists' understanding of AAS to foster trust and support. Further research is needed to address knowledge gaps and training needs for pharmacy staff, with the aim of creating a safer environment for AAS consumers.

Long-term Outcomes of Testosterone Treatment in Men: A T4DM Postrandomization Observational Follow-up Study

CONTEXT

The T4DM study randomized 1007 men with impaired glucose tolerance or newly diagnosed diabetes to testosterone undecanoate (TU, 1000 mg) or matching placebo (P) injections every 12 weeks for 24 months with a lifestyle program with testosterone (T) treatment reducing diabetes diagnosis by 40%.

BACKGROUND

The long-term effects on new diagnosis of diabetes, cardiovascular and prostate disease, sleep apnea, weight maintenance trajectory and androgen dependence were not yet described.

METHODS

A follow-up email survey after a median of 5.1 years since last injection obtained 599 (59%) completed surveys (316 T, 283 P), with participants in the follow-up survey compared with nonparticipants in 23 anthropometric and demographic variables.

RESULTS

Randomization to was TU associated with stronger belief in study benefits during (64% vs 49%, P < .001) but not after the study (44% vs 40%, P = .07); there is high interest in future studies. At T4DM entry, 25% had sleep apnea with a new diagnosis more frequent on TU (3.0% vs 0.4%, P = .03) during, but not after, the study. Poststudy, resuming prescribed T treatment was more frequent among TU-treated men (6% vs 2.8%, P = .03). Five years after cessation of TU treatment there was no difference in self-reported rates of new diagnosis of diabetes, and prostate or cardiovascular disease, nor change in weight maintenance or weight loss behaviors.

CONCLUSION

We conclude that randomized T treatment for 24 months in men with impaired glucose tolerance or new diabetes but without pathological hypogonadism was associated with higher levels of self-reported benefits and diagnosis of sleep apnea during, but not after, the study as well as more frequent prescribed poststudy T treatment consistent with androgen dependence in some men receiving prolonged injectable TU.

Systematic reviews and meta-analyses on androgen administration in humans: an umbrella review

PURPOSE OF REVIEW

The present umbrella review systematically searches and synthesizes recent (2021-2023) systematic reviews and meta-analyses (SRMA) on androgen administration in humans.

RECENT FINDINGS

Results from 19 SRMA are synthesized. Four themes were identified: market for androgens, prevalence of androgen abuse, psychological effects of androgens, and clinical/therapeutic effects of androgens. One of three androgens on the illicit market are fake or substandard. Whereas one of three androgen users experiences dependence and various serious disorders, only one of three androgen users seeks physician support. Additionally, androgen administration increases self-reported aggression in healthy male individuals, and abuse positively correlates with interpersonal violence. Furthermore, androgen therapy is beneficial in treating persons suffering from various chronic diseases.

SUMMARY

In this umbrella review, we identified 19 SRMA on androgen use and abuse. Results show a high prevalence of fake androgens on the illicit market, a high prevalence of androgen abuse and dependence, and that a huge proportion of androgen users tend to avoid seeking support from clinicians. Also, androgen administration increases self-reported aggression among healthy male, and there is a positive correlation between androgen abuse and violent behavior. Finally, androgens have multiple therapeutic effects on various pathology.

Characteristics of the Online Market for Anabolic-Androgenic Steroids in Central Asia: A Netnographic Analysis

Background: With the online proliferation of illegal substances, the Internet offers a wide variety of information on the acquisition and intake of anabolic-androgenic steroids (AAS) and other performance and image enhancing drugs. This study focuses on investigating the characteristics of the online AAS market in Central Asia.

OBJECTIVES

The primary objectives of this study were to investigate the accessibility and features of the online market for AAS in Central Asia. To achieve this, we employed a netnographic approach for a systematic exploration of websites advertising and selling AAS. The study aimed to conduct a comprehensive analysis of several key aspects, including the variety of AAS products offered, the quality of health advice provided the level of product availability, the procedures involved in making purchases, and the pricing structures within this market.

RESULTS

Twenty-one websites supplying AAS in Central Asia met our inclusion criteria. Using content analysis, data were gathered on AAS offerings, quality of health advice provided, availability, purchase process, and prices. Data were synthesized using descriptive statistics. Results indicate that AAS are easily accessible for purchase without valid medical prescription in the Central Asia online market. Most websites advertised the aesthetic and ergogenic benefits of AAS use without indicating the potential complications and adverse effects.

CONCLUSIONS

Public health efforts to mitigate AAS use in Central Asia should consider both the online accessibility of AAS and the lack of accompanying information on potential complications as well as adverse effects associated with their use. Efforts must be intensified to curtail the proliferation of AAS and related misleading information on the Central Asian online market.