Steroid Research

Examining the Profile and Perspectives of IndividualsAttending Harm Reduction Services who are Users ofPerformance and Image enhancing Drugs

n CIARÁN J. JENNINGS n EMER PATTEN n MARK KENNEDY n CHRIS KELLY

November 2014

Examining the Profile and Perspectives ofIndividuals Attending Harm Reduction Services

who are Users of Performance and Image

enhancing Drugs

November 2014

Ciarán J. Jennings is an independentresearcher and Counselling Psychologist intraining at Trinity College Dublin.

Emer Patten is a project worker atMerchants Quay Ireland and has competedinternationally in rowing and track events withthe Irish national team.

Mark Kennedy is Head of Day Services atMerchants Quay Ireland and has recentlycompleted a Masters degree in Drug andAlcohol Policy at Trinity College Dublin.

Chris Kelly is an independent researcher andis currently undertaking a Masters degree inApplied Psychology at University of Ulster.

The authors do not endorse the use ofperformance and image enhancing drugs butacknowledge the self-determination of thosewho have made the choice to use. As such,the focus of the present report is onexploring this emerging trend and examiningways in which to address the associated riskof harms.

The suggested reference for this document is:

Jennings, C. J., Patten, E., Kennedy, M., &Kelly, C. (2014). Examining the profile andperspectives of individuals attending harmreduction services who are users ofperformance and image enhancing drugs.Dublin: Merchants Quay Ireland.

Correspondence regarding the present studyshould be addressed to Ciarán J. Jennings([email protected]).

ii merchants Quay Ireland PIEDs Research

Authors’ Statement

Authors’ Statement ii

List of Tables iv

Acknowledgements v

Executive Summary vi

Chapter 1: Review of Literature 1

1.1. Overview of the Research Problem 1

1.2. Defining Key Concepts 1

1.2.1. Performance and image enhancing drugs 1

1.2.2. Harm reduction 1

1.3. Literature Review 2

1.3.1. Socio-demographic characteristics 2

1.3.2. Use of PIEDs 4

1.3.3 Use of other substances. 9

1.3.4. Injecting practices and blood-borne viruses 10

1.3.5. The interaction of harm reduction and users of PIEDs 12

1.4. The Present Study 12

1.4.1. Research context 12

1.4.2. Research questions 13

Chapter 2: Methodology 14

2.1. Research Design 14

2.2. Participants and Sampling 14

2.3. Materials 14

2.4. Procedure 14

2.5. Data Analysis 14

2.6. Ethical Considerations 15

Chapter 3: Findings 16

3.1. Descriptive Statistics 16

3.2. Socio-Demographic Characteristics 16

3.3. Use of PIEDs 19

3.4. Side-Effects Experienced in Association with use of PIEDs 23

3.5. Training and Exercise 23

3.6. Use of Other Substances 24

3.7. Injecting Practices 24

3.8. Blood-borne Viruses 27

3.9. Harm Reduction Service Utilisation 29

3.10. Perspectives on Harm Reduction Services 29

Chapter 4. Discussion 31

4.1. Restatement of Aims and Research Questions 31

4.2. Overview of Key Findings 31

4.3. Interpretation of Findings 33

4.4. Appraisal of Methodology 34

4.5. Recommendations 35

4.5.1. Recommendations for practice 35

4.5.2. Recommendations for research 35

4.6. Conclusion 36

References 37

iiimerchants Quay Ireland PIEDs Research

Table of Contents

Page

Table 1: Overview of Age and GenderVariables in Studies of PEID Users 3

Table 2: Overview of Common Types of AAS 5

Table 3: Overview of Adverse EffectsAssociated with the Use of AAS 6

Table 4: Overview of Common Ancillary Compounds/Post Cycle Treatment Drugs 8

Table 5: Overview of Studies Concerning Polydrug Use Among PIED Users 9

Table 6: Overview of Studies of Blood-Borne Virus Prevalence Among PIED Users 11

Table 7: Descriptive Statistics for the Total Sample 16

Table 8: Nationality 16

Table 9: Ethnic/Cultural Background 16

Table 10: Sexual Orientation 17

Table 11: Current Accommodation Status 17

Table 12: County of Residence 17

Table 13: Area of Residence of Dublin based Participants 18

Table 14: Highest Level of EducationCompleted 19

Table 15: Employment Status 19

Table 16: Occupation 19

Table 17: Motivation for PIED Use 20

Table 18: Descriptive Statistics for AAS Use 20

Page

Table 19: Sequence of AAS Use 20

Table 20: Types of AAS Used During Current Cycle and Previous Cycles 21

Table 21: Number of Current Cycle 21

Table 22: Length of Usual Cycle 22

Table 23: Acquisition of PIEDs 22

Table 24: Use of Ancillary Compounds/Post Cycle Treatment Drugs 22

Table 25: Most Prevalent Side-EffectsExperienced in Association with Use of PIEDs 23

Table 26: Number of Days Exercised per Week 23

Table 27: Frequency of Participation in Weight Training and Cardiovascular Exercise 23

Table 28: Type of Organised Sport 24

Table 29: Other Substances Ever Used, Ever Injected, and Recently Used 24

Table 30: Learning to Inject 24

Table 31: Method of Injection Used 25

Table 32: Injecting Site 25

Table 33: Injecting Related Injuries 25

Table 34: Physical Injecting Environment 25

Table 35: Social Injecting Environment 26

Table 36: Administration of Injection 26

Table 37: Reuse of Injecting Equipment 26

Table 38: Lending of Injecting Equipment 26

Page

Table 39: Borrowing of Injecting Equipment 26

Table 40: HIV Testing 27

Table 41: Length of Time Since Last HIV Testing 27

Table 42: HIV Test Results 27

Table 43: Hepatitis C Testing 27

Table 44: Length of Time Since Last Hepatitis C Testing 28

Table 45: Hepatitis C Test Results 28

Table 46: Treatment Status for Hepatitis C 28

Table 47: Hepatitis B Testing 28

Table 48: Length of Time Since Last Hepatitis B Testing 29

Table 49: Hepatitis B Test Results 29

Table 50: Vaccinated for Hepatitis B 29

Table 51: Motivation for Attending Harm Reduction Services 29

Table 52: Overview of Themes Relating to Experiences of Harm Reduction Services 30

Table 53: Overview of Themes Relating to Perspectives on Future Service Provision 30

iv merchants Quay Ireland PIEDs Research

List of Tables

The present research is indebted to theindividuals who participated in the study.Thank you for showing such reflection,openness and patience during the datacollection process, and for granting us aninsight in to your lives and experiences. Welook forward to advocating for theconsideration of the recommendationsemanating from the study in futuredeliberations around harm reduction forindividuals who use performance and imageenhancing substances.

Special thanks to Jennifer McConnell for herdiligent work as a research assistant on theproject. A debt of gratitude is also owed toKevin Flemen and Gemma Cox who bothlent their considerable expertise to thedesign of an appropriate researchinstrument. Additional thanks to themanagement and staff within MerchantsQuay Ireland for facilitating, assisting andsupporting the research process.

vmerchants Quay Ireland PIEDs Research

Acknowledgements

The present report presents findingsfrom a research project undertakenby Merchants Quay Ireland (MQI).

The evidence emerging from internationalstudies points to a significant increase in theprevalence of individuals attending harmreduction services who are users ofperformance and image enhancing drugs(PIEDs). Given the indicators of a similartrend emerging in an Irish context, therationale underlying the study was based onthe recognition of the growing need toexamine the profile and perspectives of suchindividuals attending services in Ireland.

The study employed a mixed methodresearch design, with 89 clients of harmreduction services, who were users ofPIEDs, completing a comprehensive survey.An overview of the nine primary questions,which the research aimed to address, isprovided below, with a description of themain findings relevant to each question alsopresented.

What is the socio-demographic profile?

The average PIED user in the present studywas approximately 27 years of age, althoughthe age of participants ranged from 18 to 40years old. All participants were male andsignificantly, no female PIED userspresented during the period of datacollection. While the sample was comprisedof eight different nationalities, the vastmajority were Irish nationals (90%). Thedominant ethnic/cultural background wasWhite Irish (80.9%), with few participantsreporting Black or Asian backgrounds. Mostof the participants reported a heterosexualsexual orientation (90.9%). The mostcommon categories of currentaccommodation status reported wereparental home (41.6%) and private rentedaccommodation (38.2%), with almost 85%of participants residing in Dublin. There wasa varied level of education completed amongrespondents with the most widespread levelsof education completed being lowersecondary (34.1%), higher secondary(22.7%) and third level non-degree (20.5%).

Almost half of the participants (48.9%) werecurrently unemployed and just under a fifth(20.7%) were in full-time employment.

What are the motivations for PIED useand the history of use?

Among the most prevalently reportedmotivations for PIED use were to increasemuscle mass (91%), to increase strength(75.3%), to look good (62.9%) and toincrease confidence (51.7%). Almost allparticipants (96.6%) reported lifetimeinjecting use of anabolic-androgenic steroids(AAS), with the average age of initiationbeing approximately 24 years old. Theyoungest onset

of injecting use was sixteen years old andthe oldest was thirty-nine years.Approximately 69% of participants reportedlifetime use of oral AAS. The average age ofinitiation was approximately 23 years old,with the age of first use ranging from 15-36years. In terms of the trajectory of AAS use;the most commonly reported sequence was“starting using oral steroids and thenprogressed to injecting steroids” (38%).

What is the nature of PIED use andtrends in PIEDs use?

There was a wide spread in terms of thenumber of cycles of PIED use respondentshad undertaken over their lifetime. Justunder half of respondents were on eithertheir first cycle or second cycle of PIED use.Almost a fifth of respondents had completedfive or more cycles (18%). The mostcommonly reported length of usual cycle was6-8 weeks (29.2%). However in just over10% of cases, the length of usual cycle wasmore than seventeen weeks. In terms of theAAS being used; while respondents reportedcurrent and past use of a wide variety ofAAS, Testosterone (single/multi esters) wasby far the most prevalently form of AAS usedduring current cycles (84%) and previouscycles (77.5%). Other commonly used AASpreviously/currently included Nandrolonedecanoate and Trenbolone acetate. In terms

of the use of ancillary compounds and postcycle treatment drugs; the substances beingused most prevalently during current cyclesincluded Creatine (23.9%) and AromataseInhibitors/Anti-Oestrogens (10.1%).Substances which had been most commonlyused during previous cycles includedCreatine (37.5%), HCG (27.2%),Clenbuterol (25.8%), AromataseInhibitors/Anti-Oestrogens (24.7%), andClomiphene citrate (21.3%).

What are the side-effects experienced inassociation with the use of PIEDs?

Participants described experiencng a broadrange of side-effects in association with theiruse of PIEDs. Prominent side-effects whichhad been previously experienced includedincreased appetite (49.4%), increased sexdrive (46%), water rentention (44%),increased aggression (38.2%), growth ofexcessive body hair (36%), acne (36%),sudden mood changes (31.5%), testicularatrophy (29.2%), decreased sex drive(33.7%), insomnia (23.6%), muscle/jointpain (22.5%), anxiety (19.1%), anddepression (18%). Although cited with lessfrequency, participants reported currentlyexperiencing a range of side-effects similarto those above.

What are the patterns of poly-substanceuse?

Participants reported the use a wide varietyof substances within their lifetime, withalcohol (95.5%), tobacco (71.6%), cannabis(68.2%), cocaine (56.8%), andbenzodiazepines (35.8%) showing thehighest levels of lifetime use. It is alsonoteworthy that a small number ofparticipants reported having ever injectedheroin (11.4%), cocaine (5.7%), and newpsychoactive substances (2.3%). Recent use(within the past month) of other substanceswas also frequently reported. Again, alcohol(62.5%), tobacco (52.3%), cannabis(39.8%), benzodiazepines (22.7%), andcocaine (17%) were the substances with themost prevalent recent use.

vi merchants Quay Ireland PIEDs Research

executive Summary

What is the training and exerciseprofile?

Almost all participants reported that theywere engaged in a regular training andexercise programme, with over 85% statingthat exercised four or more days a week. Interms of type of training and exercise, 91%of participants reported participation inweight training and approximately 80% ofparticipants reported participation incardiovascular exercise. Approximately 46%of participants reported participation inorganised sport, with the most prevalentlyreported categories being bodybuilding(15.7%), boxing (10.1%), and soccer(10.1%).

What are the injecting practices?

The majority of respondents (55%) hadlearned to inject from other PIED users,while just over 30% of participants hadlearned to inject either through a harmreduction service or medical professional.While intramuscular injection was the mostpopular method of injection amongrespondents, subcutaneous injection wasalso reported. Injection in to the buttockswas by far the most prevalently used site,with deltoids and quadriceps being the nextmost frequently used injecting sites.Respondents had experienced a range ofinjecting related injuries, with muscle pain(47.5%) and bruising (37.5%) among themost commonly cited. In terms of thephysical environment of injection; 80% ofrespondents reported that they alwaysinjected at home, whereas 2% reported thatthey always injected at the gym. In terms ofthe social environment of injection; over halfof the respondents always injected alone,whereas 25% always injected with others. Interms of the administration of injection; 71%of respondents were always injected byanother person and 16% always injectedthemselves. The majority of respondentsstated that they had never reused (84%),lent (95%), or borrowed (98%) used needleor syringes.

What are the levels of testing for blood-borne viruses (BBVs), prevalence ofBBVs, and uptake of treatment forBBVs?

While approximately a third of participantshad last been tested for HIV in the past 12months, just under half of respondents hadnever been tested. Of those respondentswho had been tested for HIV, there were noreports of a positive status. Similar resultsemerged concerning testing for Hepatitis C,which again illustrated that while almost halfof respondents had never been tested,approximately a third had been tested withinthe past year. However, there were reports ofpositive cases, with 4.6% of the overallsample indicating that they had testedpositive for Hepatitis C. When framed interms of participants who had been testedand knew their result; positive statusesrepresented approximately 10% ofrespondents. All participants who reportedbeing positive for Hepatitis C also had a pasthistory of injecting psychoactive drug use.Results pertaining to the treatment status ofparticipants who had tested positive forHepatitis C indicated that they had eithercompleted treatment, were awaitingtreatment or further tests, or had declinedtreatment. Just under half of participants hadever been tested for Hepatitis B, withapproximately a third having last been testedwithin 12 months. There were no reports ofa positive status for Hepatitis B and just overa third of respondents had been vaccinatedagainst the virus.

What are PIED users’ perspectives onharm reduction services?

Overall, participants described theirinteraction with harm reduction services inpositive terms and articulated that serviceswere particularly useful for accessing sterileinjecting equipment and information relatingto PIED use. That being said, service usersalso stated that the presence of users ofother psychoactive substances within harmreduction services and needle exchangescreated an intimidating atmosphere, whichmade them feel uncomfortable. In terms of

service provision, the primary desireexpressed by respondents was for aseparate, specialised service which cateredfor their medical needs and was dedicatedexclusively to PIED use. Other suggestionsfor service provision included having moreinformation on steroids, information availablein other languages, more advertisement ofthe service, longer opening hours, and asupervised injecting room.

Based on an evaluation of these findings inthe context of previous studies, a number ofkey recommendations were proposed:

RECOMMENDATIONS FORPRACTICE

n As a group, users of PIEDs represent aminority at harm reduction services. Theincreasing prevalence of attendees, whoare using such substances, means thatharm reduction service providers, andindeed drug and health services in thewider context, should expect to interactwith this group.

n PIED users are a diverse group ofindividuals. Service providers shouldanticipate diversity among attendees whoare users of PIEDs and endeavour toprovide accessible, inclusive andculturally competent services, whichrecognise the issues facing individuals.

n The trend of users of PIEDs attendingharm reduction services is a relativelynew phenomenon and represents amajor transition in the client base of suchservices. Professionals engaging withPIED users face several challenges incatering for the needs of this group, andtherefore, the provision of specialisttraining and education is particularlynecessary.

n Given the range of personal and publichealth concerns associated with the useof PIEDs, the need for harm reductionapproaches to be integrated within acontinuum of care is readily apparent.

viimerchants Quay Ireland PIEDs Research

Interventions designed to minimise therisk of harm should include the provisionof sterile injecting equipment, BBVtesting and vaccination, and healthservices, as well as harm reductioneducation and advice on BBV infectionsand vaccinations, use of PIEDs,associated side-effects, injectingtechniques, risk behaviours, diet andtraining, use of other illicit substances,and sexual health.

n Existing harm reduction services aretraditionally geared towards users ofpsychoactive substances. Given thedivergent profile and nature of substanceuse among PIED users, there is a needto develop a tailored approach inresponse to the profile of harm withinthis group. Expanding the range andnature of models of practice may serveto enhance accessibility, engagement,and effectiveness. In particular, theimplementation and assessment of aspecialised PIED clinic on a trial basismay be a beneficial development at thistime.

n The use of PIEDs is associated with awide range of adverse impacts, whichmay manifest in physical, psychological,and/or behavioural domains. The variedneeds of this group require integrative,multi-disciplinary approaches to beconsidered, with emphasis on developinginter-agency links and establishing carepathways between general healthservices, harm reduction services, andmental health services.

RECOMMENDATIONS FORRESEARCH

n The evidence base surrounding theworldwide prevalence of PIED use isgradually expanding. There is however adeficit of knowledge surrounding theepidemiology of use in an Irish context.As such, population based surveys,which examine the national prevalence ofuse among adults and adolescents,would shed light on the patterns of useand provide a basis for policy-makingand planning.

n The findings of the present study maynot be representative of the profile andperspectives of users of PIEDs, who arenot attending harm reduction services.Future research, which samples thewider population of PIED users, wouldprovide a more comprehensive portrait.

n Findings concerning BBVs in the presentstudy were based on self-report. In orderto ascertain a definitive prevalence,future research which incorporatesserological testing is recommended.

n In depth qualitative research wouldprovide a deeper understanding of theexperience and perspectives of PIEDusers, and would further facilitate theelicitation of their views regardingappropriate service provision.

n Future research exploring theperspectives of healthcare and harmreduction professionals would identify thechallenges associated with engaging withPIED users and assess the feasibility ofdeveloping integrative, multi-disciplinaryapproaches.

n Research surrounding the effectivenessof existing harm reduction serviceprovision within an Irish context isrequired to evaluate the capacity ofservices to minimise the harmsassociated with the use of PIEDs.

n Service provision in Ireland, and indeedinternationally, appears to be hindered bythe lack of public health policies andpractice guidelines relating to the use ofPIEDs. Research in this area is essentialin order to inform policy and equipservices with the infrastructure and toolsnecessary to provide effectiveinterventions.

viii merchants Quay Ireland PIEDs Research

THE FINDINGS OF THE PRESENT STUDYMAY NOT BE REPRESENTATIVE OF THEPROFILE AND PERSPECTIVES OF USERSOF PIEDS, WHO ARE NOT ATTENDING

HARM REDUCTION SERVICES.

The initial chapter of this study setsout the contextual landscape whichunderlies the present research. An

overview of the research problem ispresented and key concepts within the topicof study are outlined. Following theseintroductory sections, the extant empiricalliterature surrounding harm reduction and theuse of performance and image enhancingdrugs (PIEDs) is explored. At the conclusionof the chapter, the research context isdescribed and the specific researchquestions of the present study are outlined.

1.1. OVERVIEW OF THE RESEARCH PROBLEM

During the course of the past three decades,harm reduction approaches have graduallyemerged as a central pillar of internationaldrug strategies, and are currently endorsedin policy or practice in approximately ninety-seven countries and territories worldwide(IHRA, 2012). Within the spectrum of harmreduction services, needle and syringeprogrammes (NSPs) play a significant role inminimising harm arising from injecting druguse (Wodak & Cooney, 2004). In recentyears, there has been a marked increase inthe prevalence of individuals attending NSPswho are users of PIEDs. This trend has beendocumented internationally (Iversen, Topp,Wand, & Maher, 2013; McVeigh, Beynon, &Bellis, 2003; Rich et al., 1999) and there arenoticeable indicators of a similar trendemerging in an Irish context (Jennings,2013; Robinson, Gibney, Keane, & Long,2008). Although the level of harm associatedwith the use of PIEDs is generally less overtwhen compared to the risk associated withthe use of psychoactive substances (Aitken,Delalande & Stanton, 2002; Day, Topp,Iversen, & Maher, 2008), there are growingconcerns around the use of PIEDs andrelated physical and psychological harms(Evans-Brown & McVeigh, 2008; Hope etal., 2013). Harm reduction services arefaced with several challenges in attemptingto respond to the expanding range of clientneeds, and in spite of an anecdotal

awareness surrounding the increase of PIEDusers accessing Irish services; there is apaucity of empirical investigation addressingthis emerging trend.

1.2. DEFINING KEY CONCEPTS

As a prelude to exploring the context inwhich the present study is engaged, anexamination of the key concepts is necessaryboth to ground the focus of the study and tospecify the definitional position this researchadopts. As evidenced in the previous section,the key concepts which underpin the presentstudy are performance and image enhancingdrugs and harm reduction.

1.2.1. Performance and Image EnhancingDrugs. Within the literature surrounding thenon-medical use of substances which may beused to enhance aesthetics and/orperformance, much of the research (e.g.,Aitken et al., 2002, Midgley et al., 2000,Peters, Copeland, & Dillon, 1999) hasconventionally focused on the use of anabolic-androgenic steroids (AAS). Traditionally, suchsubstances were generally termed asperformance-enhancing drugs (PEDs), usedto describe the range of substances that couldhave performance benefits for elite athletes(Larance, Degenhardt, Dillon, & Copeland,2005). While AAS remain the mostprominently used substances of this kind,there is an increasing diversity in theprevalence, profile, and motivations ofindividuals who use AAS in conjunction withrelated substances such as peptides, tanningdrugs, hormones, and weight loss agents(Hope et al., 2013). To reflect these emergingheterogeneous variables, much of thecontemporary literature incorporates umbrellaterms such as “performance and imageenhancing drugs” or “image and performanceenhancing drugs” (e.g., Dennington et al.2008; Iversen, et al., 2013).

In an effort to encompass the diverse rangeof substances, the breadth of associatedutilities, and the divergent motivations ofusers, the current study adopts the term

performance and image enhancing drugs,which is defined as substances that are usedto enhance performance (e.g. improvingstrength and/or endurance), improve thebody�s appearance (e.g. increasing musclesize and/or reducing body fat), mask the useof performance-enhancing drugs to avoiddrug testing, and to manage the negativeside effects of substance use. Similardefinitions also appear in previous studies(e.g., Dennington et al., 2008, Larance, etal., 2005).

1.2.2. Harm Reduction. Emerging in theearly 1970s in response to the heighteningawareness around the public health concernsrelated to substance use, harm reductionrepresented a dramatic and controversialparadigm shift in drug policy. While previousmodels of addressing drug issues hadpredominantly concentrated on prevention,control and abstinence, harm reductionapproaches focus on minimising drug relatedharm (Ritter & Cameron, 2005). Accordingly,the philosophy of the harm reduction modelpragmatically accepts that drug use is aprevailing reality and acknowledges the self-determination of those who choose to usedrugs.

However, while the reduction of harm may bedelineated as the focal objective, the notionsof abstinence and harm reduction are notconsidered mutually exclusive ordichotomous extremes. Indeed,contemporary visions of harm reductionconceptualise it as a “combinationintervention” that is comprised of a variety ofinterventions adapted to the diversity ofsettings, systems and populations in which itis operationalised (Rhodes & Hedrich,2010). The present study draws from thisconceptualisation outlined by Rhodes andHedrich (2010; p. 19) and defines harmreduction as “interventions, programmes andpolicies that seek to reduce the health, socialand economic harms of drug use toindividuals, communities and societies”.

1merchants Quay Ireland PIEDs Research

Chapter 1: Review of Literature

1.3. LITERATURE REVIEW

The adoption of harm reduction approachesin Ireland emerged in the late 1980s,whereby needle exchange programmes andoutreach services were introduced, inresponse to the identification of persons whoinject drugs (PWIDs) as a high risk group forcontracting and transmitting blood-borneviruses (BBVs) and the corresponding risk topublic and personal health (Butler, 1991).Shortly thereafter, harm reductionapproaches were endorsed on a policy levelby the

Government Strategy to Prevent DrugMisuse (1991) and have remained aconsistent feature of Irish drug policies formore than two decades. Harm reductionrepresented a primary pillar within theNational Drugs Strategy outlined in Buildingon Experience 2001-2008 and is furtheradvocated in the National Drugs Strategy(Interim) 2009-2016.

NSPs are recognised internationally anddomestically as a key component ofinterventions designed to minimise drugrelated harms and often act as the first pointof contact for drug users, facilitating initialconnection with drug services in a non-judgmental interaction (Kuo et al., 2003).Specifically, NSPs aim to engage withPWIDs and attempt to limit the prevalence ofBBVs through the provision of sterileinjecting equipment, as well as offeringeducation around the risks associated withdrug use, providing access to healthservices, and opening referral pathways in todrug treatment (Cox & Robinson, 2008).

In the past, NSPs were traditionally gearedtowards users of psychoactive substancessuch as opiates. However, evidence from theinternational literature indicates that users ofPIEDs appear to be an increasing subgroupamong NSP attendees. While this may notnecessarily be indicative of an overallincrease in use of PIEDs within the generalpopulation, it does highlight the fact that aconsiderable amount of individuals are using

these substances, and moreover, speaks to asignificant trend within the domain of harmreduction (McVeigh et al., 2003). A recentstudy based in Australia, highlighted that theprevalence of PIED injectors attending NSPsin Queensland and New South Wales rosefrom 2.4% in 2010 to 4.6% in 2011(Iversen et al., 2013). Evidence points to asimilar trend in the United States (e.g., seeRich et al., 1999) and the United Kingdom,where Evans-Brown & McVeigh (2008)reported a 2000% increase in the number ofsteroid injectors attending NSPs based inMerseyside and Cheshire between 1991 and2006. In Ireland, almost two-thirds of NSPshave reported the presence of clients whoare injecting PIEDs (Robinson et al., 2008)and a recent study in a Dublin based NSPindicated that approximately 7% of a sampleof attendees were steroid users (Jennings,2013). Overall, the results emanating frominternational and domestic studies suggestthat although there is a substantial rise in theprevalence of PIED users attending NSPs,they remain a minority within the overall clientbase. In light of their marginal profile, there isthe risk that the needs of this group are notcurrently being wholly met in harm reductionservices (Larance, Degenhardt, Copeland, &Dillon, 2008).

Viewed within a wider framework; PIEDusers are also typically overlooked withinpublic health initiatives (Larance et al.,2008). In an Irish context, while there hasbeen recent deliberation surrounding theapplication of amended legislative controls(Department of Health, 2013), there hasbeen little consideration afforded to the useof PIEDs within any of the major Irish publichealth policy documents such as the NationalDrugs Strategy (Interim) 2009-2016, theNational Hepatitis C Strategy 2011-2014 orthe National Drug RehabilitationImplementation Committee protocols(NDRIC; Doyle & Ivanovic, 2010). Given thelack of current policy basedrecommendations and the low coverage ofspecialist service provision, there is theindication that the developing trend

concerning PIED use in Ireland is beingrelatively overlooked.

In addition, there is a severe paucity ofgermane research relating to PIED use inIreland. However, looking to the widerliterature, there is a growing number ofinternational studies which have examinedthe phenomenon of PIED use. Within thefollowing sections, the empirical researchsurrounding users of PIEDs, with anemphasis on a harm reduction perspective, isreviewed in a number of areas: socio-demographic characteristics of PIED users,use of PIEDs, use of other substances,injecting practices and BBVs, and theinteraction between PIED use and harmreduction services.

1.3.1. Socio-demographiccharacteristics. Traditionally, the non-medical use of performance enhancing drugssuch as anabolic-androgenic steroids (AAS)was primarily associated with elite athletesand professional bodybuilders (Yesalis &Bahrke, 1995). However, in thecontemporary landscape, elite athletes usingPIEDs to enhance performance represent asmall minority (Bahrke & Yesalis, 2004), withmost PIED users being recreational and non-elite athletes whose motivations are gearedmore towards increasing strength, buildingmuscle mass, and improving physicalappearance (Aitken et al., 2002; Cohen,Collins, Darkes, & Gwartney, 2007). Assuch, the socio-demographic profile ofindividuals using PIEDs has becomeincreasingly diverse.

A synthesised summary of the variable ofage, in studies concerned with PIED use, isportrayed in Table 1. Although this table doesnot offer a comprehensive review of studies,and does not include population/schoolbased surveys, it does provide a usefuloverview of the previous findings concerningthe age of PIED users, particularly in thecontext of harm reduction services. While insome countries such as the United States,Scandinavia, Australia and Canada there has

2 merchants Quay Ireland PIEDs Research

been considerable research attention andpublic concern in relation to adolescent AASuse, with some studies suggesting a higherprevalence of use among adolescents whencompared to the general population (Dunn &White, 2011; Pallesen, Josendal, Johnsen,

Larsen, & Molde, 2006), much of the widerliterature has focused on adult PIED users.The selected studies in Table 1 highlight thatthe age of participants across studies haveranged from 17 to 79 years old, with theaverage age of PIED users ranging from

twenty-seven to almost thirty three years old.In terms of individuals accessing NSPs,studies suggest that PIED users are morelikely to be younger when compared to otherpopulations of injecting drug users (Day etal., 2008; Jennings, 2013).


Median Age

25 years

27 years

31 years

29 years

—

—

28 years

—

—

TABLE 1Overview of Age and Gender Variables in Studies of PIED Users

Study

Crampin etal.,1998

Peters et al.,1999

Aitken, et al.,2002

Cohen et al.,2007

Day et al., 2008

Larance et al.,2008

Hope et al.,2013

Jennings (2013)

Chandler &McVeigh, 2014

Location

England andWales

Australia

Victoria,Australia

United States

New SouthWales,Australia

New SouthWales, Australia

England andWales

Ireland

UnitedKingdom &Ireland

Participants (gender)

149 AAS injectors (2 female) recruitedthrough Anonymous HIV PrevalenceMonitoring Survey self-completedquestionnaire

100 AAS users (6 female) recruited throughgyms, needle exchanges, & magazinescompleted questionnaire (both self-report &interview)

63 PIED injectors, (9 female) recruited fromSteroid Peer Education Program completedquestionnaire

1,955 (all male) adult non-medical AASusers recruited online completed an internetbased survey

318 PIED injectors (12 female) recruitedfrom NSP Survey participants during theyears 1995 – 2004 self-completedquestionnaire

60 (all male) PIED users recruited throughadvertisement completed face-face interview

395 (all male) PIED users recruited fromacross 19 NSPs self-completedquestionnaire

25 (all male) AAS users sampled from NSPattendees completed face-face questionnaire

94 PIED users (15 female) recruited throughonline forums and NSPs completed aninternet based survey

Age Range

17 – 48 years

18 – 50 years

21 – 60 years

18 – 76 years

—

17 – 59 years

—

21 – 43 years

16 – 56 years

Mean Age

—

29.2 years

—

31.1 years

27 years

32 years

<25 27%25-34 34%≥35 27%No report 12%

28.84 years

32.5 years

In terms of gender; research has consistentlydemonstrated a significantly higher level ofPIED use among males. A recent globalepidemiological study estimated a lifetimeprevalence rate of AAS use of 6.4% for malesand 1.6% for females (Sagoe, Molde,Andreaseen, Torsheim, & Pallesen, 2014).Although there are variations in estimates, acomparable pattern of elevated lifetime andrecent AAS usage amongst males have beenfound internationally across population basedsurveys (Australian Institute of Health andWelfare, 2011; NACD, 2012), college studentsurveys (Berning, Adams, Stamford, &Finewman, 2004; McCabe, Brower, West,Nelson, & Wechsler, 2007), and secondaryschool based surveys (Dunn & White, 2011;Hibell et al., 2011; Lorang, Callaghan,Cummins, Achar, & Brown, 2011; Pallesen etal., 2006). Table 1 illustrates that studies whichhave recruited samples of PIED users throughonline advertisement or education programmes,have attracted an overwhelming majority ofmale participants, and research within thecontext of NSPs also show a vastly higherconcentration of male participants

(see “Participants” column in Table 1). Anumber of studies have also demonstrated thatPIED users attending harm reduction servicesare significantly more likely than other drugusing attendees to be male (Day et al., 2008;Iversen et al., 2013). Given the convergence ofevidence noted above, the indicators suggestthat while a proportion of PIED users arefemale, PIED use tends to be a predominantlymale phenomenon.

Additional socio-demographic variables ofinterest in the domain of PIED use includesexual orientation, occupation, level ofeducation, and socio-economic status. Sexualorientation has received particular researchattention with a number of studies showing; asmuch as one third of respondents being menwith a homosexual/bisexual orientation (e.g.Larance et al., 2008; Peters et al., 1999), highlevels of AAS use among homosexual malegym goers (Bolding, Sherr, & Elford, 2001),and higher prevalence rate of lifetime AAS

misuse among adolescent homosexual/bisexual boys when compared to theirheterosexual peers (Blashill & Safren, 2014). Ithas been suggested that the basis of suchelevated prevalence of PIED use among sexualminorities may be linked to an enhancedemphasis on physical attractiveness andincreased body image concerns within somesections of their culture (Larance et al., 2005).

Occupation has also been proposed as aninfluential socio-demographic variable, with thesuggestion that PIED use may be perceived asbeneficial in the execution of employmentduties among certain occupations such assecurity personnel, door staff, fitnessconsultants, actors, bodyguards, fire fighters,and members of the armed forces (Maycock,1999; Monaghan, 2002; Peters et al., 1999).Qualitative findings have described that whileoccupation may have a bearing on underlyingmotives; it is not an isolated factor, with PIEDuse in these cases stemming from aconfluence of personal and occupationalmotivations (Dennington et al., 2008).

Thus, it has been put forth that the majority ofPIED users are generally concerned withimproving both their physical appearance andfunctioning (Peters et al., 1999).

In terms of level of education and socio-economic characteristics, a number of studieshave found PIED users to be well-educatedprofessionals, with samples showing high ratesof employment and above average levels ofincome (Cohen et al., 2007; Dennington et al.,2008; Peter et al., 1999). However, alternativestudies have reported variables such asrelatively high level of recent involvement incrime (Larance et al., 2008). Such seemingincongruity is reflective of the generalheterogeneity apparent in the socio-demographic profile of users of PIEDs acrossstudies, and implies that although key socio-demographic characteristics such as gender,age, sexual orientation, occupation, level ofeducation, and socio-economic status areuseful markers, it is difficult to typify such adiverse group.

1.3.2. Use of PIEDs. Heightened awarenessaround the increasing prevalence of PIED useamong a wider population within recentdecades had led to the emergence of asignificant evidence base exploring whyindividuals use, what the trajectory of use is,what substances are used, and howsubstances are used.

A recent synthesis of the body of qualitativeresearch concerning the aetiology of AAS usesummarised that factors such as participation insports, maladaptive relationships,psychopathology, negative self and bodyimage, deviant behaviour, and abuse of otherdrugs, were prominent features of users priorto initiation (Sagoe, Andreassen, & Pallesen,2014). In terms of when adult userscommence PIED use; single studies havefound average age of initiation to be 25.1 yearsold (Peters et al., 1999), 25.8 years old(Cohen et al., 2007), and 24 years old(Larance et al., 2008), which would appear tosupport the epidemiological evidence that hasestimated that approximately 80% of AASusers initiate use before the age of 30 yearsold (Pope et al., 2014).

Within the literature, much attention had beenpaid to the question of why individuals chooseto use PIEDs, with users typically delineated into three broad categories based on underlyingmotivation for use (e.g., see Evans-Brown &McVeigh 2008; Peters et al., 1999). Thesegroupings of users have included professionalathletes (those who use in order to enhanceperformance), occupational users (those whouse in order to support/enhance occupationalfunctioning), and body image users (those whouse in order to improve physical aesthetic).Quantitative studies which have examinedindividuals� motives report a range ofmotivations such as to improve physicalappearance, to become stronger, to increasesize, to enhance performance, to increaseconfidence, to decrease fat, and/or to improvemood (Aitken et al., 2002; Cohen et al.,2007). While motivations described within thequalitative literature support these principalmotives, there is the indication that a further


range of more nuanced psychosocial elementsincluding psychological well-being, family/peerinfluence, social status, and social norms, mayalso play a role in motivating and maintainingPIED use (Dennington et al., 2008; Sagoe, etal., 2014).

With regard to what substances are prevalentlyused; Larance and colleagues (2005) detailthat PIEDs refer to a range of substanceswhich are generally used to enhance musclegrowth (anabolic effects) and/or to reducebody fat (catabolic effects). Within thespectrum of these substances, AAS (a groupof drugs which include testosterone, the malehormone, as well as several synthetic

derivatives, which imitate male sex hormones)are the most prominently used, and widelyinvestigated, form of PIEDs (Larance et al.,2005; Pope, & Bower, 2009). Suchsubstances may have anabolic effects(promoting the development of muscle growth)and/or androgenic effects (promoting thedevelopment of male sex characteristics suchas body hair, deepening of voice, developmentof male sex organs and sex drive). While theavailable evidence suggests that all forms ofAAS possess both anabolic and androgenicproperties, there are variances in ratio of theseproperties between different types of AAS(Larance et al., 2005).

Table 2 provides an overview of common typesof AAS and illustrates the route ofadministration and primary effect of each type.While few empirical studies have detailedpatterns of specific AAS use, Cohen andcolleagues (2007) found that within their largesample of male adult PIED users, single estertestosterones (78.2%), methandrostenolone(64.9%), and nandrolone decanoate (63.5%),multi ester testosterones (56%), and stanozolol(56%) were the most commonly used agents.The available evidence also suggests that theuse of injectable forms of AAS is generallymore prevalent than the use of oral compounds(Hope et al., 2013; Larance et al., 2008).


Chemical Name

Boldenone undecyclenate

Chlorodehydromethyltestosterone

Drostanolone Propionate

Fluoxymesterone

Formebolone

Mesterolone

Methandrostenolone

Methenolone Enanthate

Nandrolone decanoate

Nandrolone laurate

Nandrolone undecanoate

Oxandrolone

Oxymetholone

Stanozolol

Testosterone Suspension, Esters &Blends (e.g. Cypionate, Propionate,Suspension, Undecanoate)

Trenbolone acetate

Trenbolone hexahydrobencylcarbonate

Brand Name(s)

Equipoise, Boldebal

Turinabol, Turanabol

Masteron

Halotestin

Esiclene

Proviron

Dianabol, Anabol,Metanabol, Naposim

Primobolan

Deca Durabolin,Extraboline

Laurabolin

Dynabolon

Anavar

Anadrol, Anapolon

Winstrol, Stromba

Testa C, TestovironSustanon, Andriol

Trenbolone, Finaplix

Parabolan

Administration

Injection

Oral

Injection

Oral

Injection

Oral

Primarily oral but alsoinjectable forms

Injection

Injection

Injection

Injection

Oral

Oral

Oral & Injection

Injection

Injection, Transdermal & Nasal

Injection

Description

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic

Primarily Androgenic

Primarily Anabolic (wandrogenic properties)

Primarily Anabolic

Primarily Anabolic(moderately androgenic)

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic

Primarily Anabolic(different varieties oftestosterone)

Primarily Anabolic

Primarily Anabolic

Note. Adapted from “Performance Enhancing Drugs Resource Pack” by K. Flemen, 2011.

TABLE 2Overview of Common Types of AAS

The use of AAS has been associated with ahost of adverse side-effects. Several authorshave reviewed the evidence regarding theseassociated effects (e.g. Bahrke & Yesalis,2004; Kanayama, Hudson, & Pope Jr.,2008, 2010; van Amsterdam, 2010), whichare illustrated in Table 3. In spite of theevidence which indicates that AAS use maybe associated with such adverse healtheffects, it should be noted that theknowledge base surrounding the prevalenceand magnitude of these short-term and long-term effects is limited (Kanayama, et al.,2008). In particular, a consistent causal linkbetween AAS use and the majority ofadverse effects has not been wellestablished, and related investigation in to

health effects is confounded by the diversityof variables such as the range of AASsubstances used, dose, frequency, age ofinitiation, period of use, and use of other illicitsubstances (Bahrke & Yesalis, 2004). Assuch, several authors have suggested thatthe dangers of AAS use are generallyoverstated (Cohen et al., 2007; Evans,2004). That being said, AAS users within theempirical literature typically reportexperiencing side-effects (Larance et al.,2005). Given the recent proliferation of useand the lack of longitudinal studies, it may bethe case that the adverse public healthconsequences of long-term AAS use arebeing underestimated rather thanoverestimated (Kanayama et al., 2008).


Cardiovascular effects Hypertension (elevated blood pressure) Cardiomyopathy (heart disease)Myocardial hypertrophy (enlargement of the heart)Myocardial ischemia (decreased blood flow to heart due to blockage of arteries) Dyslipidemia (decreased highdensity lipoprotein and increased low density lipoprotein) Arrhythmia (irregular heartbeat)Thrombosis (blood clotting)

Hepatic effects JaundicePeliosis hepatis (development of multiple blood-filled cystic spaces in the liver)Hepatocellular hyperplasia (abnormal multiplication of cells in the liver)Hepatocellular adenomas (benign tumours in the liver)

Dermatologic effects AcneStretch marksAlopecia (hair loss)

Psychological effects Depressive symptomsHypomania/maniaDependencePersonality disturbancesOther psychiatric disorders

Behavioural effects Increased aggression/violence

Male–specific effects Gynaecomastia (abnormal enlargement of the male breast tissue)Changes in the male reproduction systems (which may include reduction in levels ofendogenous testosterone,testicular atrophy, reduction in sperm count and spermmotility, and alterations in sperm morphology)

Female-specific effects Menstrual abnormalitiesDeepening of the voiceShrinkage of the breastsIncrease in clitoris size

THE USE OF AAS HAS BEENASSOCIATED WITH A HOST OF ADVERSE SIDE-EFFECTS

TABLE 3Overview of Adverse Effects Associated with the Use of AAS

While a number of the aforementioned side-effects may be permanent, some effectsmay be experienced temporarily whilst usingAAS (Larance et al., 2005). As such, thenature of AAS use is typically cyclical,whereby users undertake periods of use,interspersed with periods of non-use,designed to facilitate the endocrine systemsof the body to return to homeostasis (Cohenet al., 2007). Although there is little empiricalclinical evidence supporting the notion thatthe practice of cycling may reduce the risk ofadverse effects, or indicating ideal cyclelength, users are generally guided byanecdotal evidence generated by previousexperience, internet forums, or informationwebsites (Chandler & McVeigh, 2014).Studies which have examined cycling showusers differ significantly in the length of theircycles. An example of this variability isindicated in Cohen and colleagues (2007)wherein participants� cycle length rangedfrom 1 week to 728 weeks, with a medianlength of 11 weeks. This median lengthappears to be relatively consistent with thatfound in other studies (e.g., see Aitken et al.,2002; Larance et al., 2008).

Within this cycle of substance use, typicalpatterns suggest that in addition to AAS,PIED users may also use a number ofancillary compounds and/or post cycletreatment drugs. An overview of the range of

common auxiliary substances is outlined inTable 4. Such substances may be used inorder to achieve anabolic or catabolic effectsand/or minimise potential adverse side-effects. Studies show that although thesesubstances appear to be used lessprevalently than AAS, there is significant useof other hormones (e.g. human growthhormone), beta agonists (e.g. clenbuterol),stimulants (e.g. ephedrine), drugs for weightloss (diuretics), drugs believed to stimulatetestosterone (e.g. clomiphene), and agentsused to counteract unwanted physical side-effects (e.g. tamoxifen) among AAS users(e.g., see Chandler & McVeigh, 2014;Cohen et al., 2007; Hope et al., 2014;Larance et al., 2008).

In short, the features underlying the use ofPIEDs appear to an interconnected set ofnuanced psychological, social, behavioural,and physical factors, with the predominantconscious motivations for use revolvingaround the size, shape, and performance ofthe body. Initiation of use typically occurs inthe mid-twenties, with individuals usingmultiple steroids and ancillary substances ina cyclical fashion, with significant levels ofinjecting use occurring within this regime. Adefinitive portrait of the side-effects relatedto PIED use remains relatively unclear butusers frequently report experiencing adversehealth effects.


A DEFINITIVE PORTRAIT OF THE SIDE-EFFECTS RELATED TO PIED USE

REMAINS RELATIVELY UNCLEAR BUT USERSFREQUENTLY REPORT EXPERIENCING

ADVERSE HEALTH EFFECTS.


PIED Related Use

Used to block or inhibit the actions of oestrogen,andreduce risk of feminisation

Used to stimulate production of testosterone inmen andreduces risk of testicular atrophy

Used to trigger natural testosterone production

A synthetic compound of naturally occurringhormonewith strong anabolic effects

A stabilised analogue of the growth hormone-releasingfactor (GRF), used to build leanmuscle while burningexcess fat

Pancreatic hormone which regulates blood-sugarlevelsused to increase the amount of glycogentransported tomuscles

An analogue of the liver-produced substanceInsulinGrowth Factor, primarily used toincrease burning of fat

Medication used to treat thyroid insufficiency,used toincrease metabolism and burn fat

A beta-2 agonist used as a stimulant to aid fatburningand muscle definition

A stimulant used to speed up metabolism and burn fat

Used to increase amount of melanin produced

Used to help reduce water retention and increasemusclehardness and definition

Used to delay fatigue and aid recovery

A mixture of fatty acids, alcohol and lidocainewhichcauses muscles to swell

Used to prevent or treat acne

Sedative/relaxant used to promote sleep and tostimulatenatural production of growth hormone

Chemical Name

Aromatase Inhibitors/Anti-Oestrogens (e.g. Anastrozole,Exemestane)

Human Chorionic Gonadotrophin(HCG)

Clomiphene citrate

Human Growth Hormone (HGH)

Growth Hormone Fragment

Insulin

Insulin Growth Factor (IGF)

Thyroid Agents

Clenbuterol

Ephedrine

Tanning Agents

Diuretics

Creatine

Synthol

Anti-acne medication

Gammahydroxybutyrate (GHB)

Brand Name(s)

Tamoxifen,Arimidex,Letrozole

Clomid

Somatropin

Humulin R

Somatomedin C

Thyroxin,Cytomel

Spiropent

Melanotan,Epitan

Aldactone,Lasix

Accutane

Administration

Oral

Injected

Oral

Injected

Inject

Injected

Injected

Oral

Oral

Oral

Injected

Oral

Oral

Injected

Oral

Oral

TABLE 4Overview of Common Ancillary Compounds/Post Cycle Treatment Drugs

Note. Adapted from “Performance Enhancing Drugs Resource Pack” by K. Flemen, 2011.


1.3.3. Use of other substances. Inaddition to examining the use of AAS andancilliary compounds, previous research hasalso investigated the levels of polydrug useamong PIED users. Table 5 provides anillustrative example of the prevalence of useof other substances found in selectedprevious studies. Within the study by Petersand colleagues (1999), 14% of participantshad ever injected an illicit substance other

than AAS, whereas 27% of participants inthe study from Larance and colleagues(2008) reported having ever injected otherillicit drugs. However, a comparative studyconducted in Australia with a small samplefound no significant difference between AASusers and non-users regarding use of illicitsubstances in the past six months (Dunn,2009). Within a recent Irish study concerningattendees at a Dublin based harm reduction

service, 40% of AAS users sampledreported use of at least one other illicit drugwithin the past month (Jennings, 2013). Incombination, while the results of theaforementioned studies suggest that arelatively high proportion of users of PIEDsalso use other illicit substances, it remainsunclear whether this pattern of polydrug useis within a problematic range.

Drug Type Lifetime Ever Injected Recent UseUse (%) (%) (%)^*

Marijuana 70 - 17

Amphetamines 51 6 11

Ecstasy 49 3 18

Cocaine 43 4 5

Hallucinogens 36 - -

Inhalants 20 - 4

Heroin 9 5 1

Methadone 2 1 -

Cannabis 80 0 50

Methamphetamine powder 78 20 31

Crystal methamphetamine 53 17 28

Ecstasy 77 8 56

Cocaine 75 13 40

Heroin 17 12 10

Inhalants 45 0 15

Benzodiazepines 8 2 8

Hallucinogens 45 5 3

TABLE 5Overview of Studies Concerning Polydrug Use Among PIED Users

Study

Peters etal., 1999

Larance etal., 2008

Location

Australia

Australia

Participants

100 AASusers (6female)recruitedthroughgyms,needleexchanges,magazines

60 malePIED usersrecruitedthroughadverts

^ In Peters et al., 1999 “recent use” was defined as one or more times per month* In Larance et al., 2008 “recent use” was defined as use in the last 6 months

1.3.4. Injecting practices and blood-borne viruses. Evidence from internationalstudies highlights that a high volume of PIEDusers are injecting substances (e.g. see;Cohen et al., 2007; Hope et al., 2013;Larance et al., 2008). The World HealthOrganisation (WHO; 2010, 2012) outlinethat injecting drug use (IDU) has beenconsistently linked with the risk of blood-borne viruses (BBVs) such as humanimmunodeficiency virus (HIV), hepatitis Cvirus (HCV) and hepatitis B virus (HBV).Research over the past two decades hasdetailed that injecting risk behaviours, suchas sharing of injecting equipment andparaphernalia, as the principal mechanism ofcontracting and transmitting BBVs (Cox &Robinson, 2008). Furthermore, IDU isassociated with a number of additional healthconsequences such as bacterial infections,vascular damage and abscesses (HealthProtection Agency, 2012). Traditionally,much of the attention around the risks ofIDU has focused on persons who injectpsychoactive drugs but given the increasingprevalence of PIED use, there areheightening concerns around the potentialfor BBV transmission and injecting relatedinjuries among PIED injectors.

Looking to the literature, research hasconsistently found that when compared topsychoactive drug injectors, PIED users

engage in a much lower rate of injecting riskbehaviours such as borrowing, lending orreusing used injecting equipment, or injectingwith other people (Aitken et al., 2002;Cohen et al., 2007; Crampin et al., 1998;Day et al., 2008; Hope et al., 2013;Larance et al., 2008). Possible factorsunderlying this lower level of risk behavioursmay include the lack of craving for AAS, thelower risk associated with intramuscularinjection, and less frequent injection (Midgleyet al., 2000). Given the long established linkbetween injecting risk behaviours and thespread of BBVs, the safer injectingbehaviours practiced by PIED users mayunderlie the comparatively low prevalence ofBBVs among PIED users.

While there has been limited researchconcerning rates of BBVs among PIEDusers in Ireland, international studies havefound the prevalence to be much lower thanthat typically found among those who injectpsychoactive drugs. Table 6 provides asummary of international studies which haveassessed BBV prevalence among PIEDusers. In Australia, studies which haveemployed serological testing have found noevidence of HIV (Aitken, et al., 2002; Day etal., 2008). Conversely, in a study whichincorporated self-report measures, a rate of12% HIV was found (Larance et al., 2008).Rates of HCV found in the aforementioned

Australian studies ranged from 5-10% andrates of HBV ranged from 3-12%.

A small number of studies have beenconducted in the UK, with a recent studyfrom Hope and colleagues (2013) findingseroprevalence rates of HIV (1.5%), HCV(5.5%), and HBV (8.8%). Such resultssuggested that although BBVs remainedrelatively low, it indicated an elevatedprevalence of HIV and HBV compared toprevious research (Crampin et al., 1998) in aUK context. It is however noteworthy thatwithin these studies, the positive cases ofBBVs found were often associated withfactors such as a bisexual or homosexualorientation, incarceration, injectingpsychoactive drug use, and number oftattoos. As such, it is difficult to ascertainwhether contraction of BBVs was aconsequence of injecting PIED use. A furthercomplication in attempting to extrapolateBBV prevalence among PIED users may bethat users are less likely to get screened(Day et al., 2008). Given the high prevalenceof injecting PIED use, coupled with the riskfactor for BBVs, the apparent lack ofscreening access/uptake, and the potentialfor injecting related injuries; the importanceof harm reduction services engaging withPIED users has been emphasised across anumber of studies (Hope et al., 2013;Larance et al., 2008).


HIV

0%

0%

0%

12%

1.5%

HBV

2%

12%

N/A

3%

8.8%


Factors Associated with Positive Status

—

HCV associated with heroin injection,imprisonment, sharing needles to inject otherdrugs, no. of tattoos, and HBV exposure.HBV associated with hepatitis C virusexposure, past imprisonment and age of firstinjection

HCV associated with homo/bisexualorientation and a history of tattooing.

All HIV were bisexual or homosexualorientation. HBV positive self-reports wereassociated with HIV positive self-reports. HCV associated with having ever injectedother illicit drugs and lifetime use of heroin.

HIV associated with having male sexualpartners, having sought advice from STIclinic, having abscess/open wound atinjection site.HCV associated with having ever injectedpsychoactive drug/having taken aphosphodiesterase type 5 inhibitor in thepreceding year. HBV associated with having obtained advicefrom an SH/STI clinic and having not injectedoneself subcutaneously in the preceding year.

Study

Crampin etal., 1998

Aitken, etal., 2002

Day et al.,2008

Larance etal., 2008

Hope etal., 2013

Location

Englandand Wales

Victoria,Australia

NewSouthWales,Australia

NewSouthWales,Australia

Englandand Wales

Participants

149 AASinjectorsrecruitedthrough HIVPrevalenceMonitoringSurvey

63 PIEDinjectorsrecruited fromSteroid PeerEducationProgram

318 PIEDinjectorsrecruited fromNSP Surveyparticipantsduring the years1995 –2004

60 PIED usersrecruitedthroughadvertisement

395 PIED usersrecruited fromacross 19 NSPs

Test Type

Biologicaltesting

Biologicaltesting

Biologicaltesting

Self-report

Biologicaltesting

HCV

—

9.5%

10%

5%

5.5%

TABLE 6Overview of Studies of Blood-borne Virus Prevalence Among PIED Users

1.3.5. The interaction of harm reductionand users of PIEDs. Given the furtivenature of PIED use, users are reluctant toseek medical treatment and furthermore,they often lack trust in health careprofessionals (Chandler & McVeigh, 2014;Dunn, 2002; Pope, Kanayama, Ionescu-Pioggia, & Hudson, 2004). Thus, the mainagencies which are likely to maintain regularcontact with this group are NSPs (Larance etal., 2008). The evidence indicates that NSPsin many regions are providing services toPIED users (Day et al., 2008; McVeigh etal., 2003; Rich et al., 1999; Robinson et al.,2008). That being said, the relatively suddeninflux of a client group whose characteristics,range of substance use, and injectingpractices differ significantly from thetraditional client base means that harmreduction service providers are faced withseveral challenges in attempting to respondto the corresponding shift in client needs.Such challenges are manifest in a recentstudy from Dunn and colleagues (2014),which explored the perspectives of staffworking in NSPs with regard to providingservices to steroid users. In particular,workers described the difficulty in acquiringspecialised knowledge around the nature andeffects of PIED use, associated injectingpractices, and the provision of appropriateinjecting equipment. Accordingly, a commonrecommendation proposed within theliterature is for the provision of specialisttraining and education for NSP workers(Dunn, McKay, & Iversen, 2014; Iversen etal., 2013).

The wider recommendations emanating fromstudies concerning harm reduction and PIEDusers emphasise the need for further servicedevelopment and support a targetedintervention for this group. In terms of therequirements of PIED users, research hasadvocated the need for education and harmreduction advice around BBV infections,vaccinations, injecting techniques, riskbehaviours, dose and frequency of PIEDuse, adverse physical effects associated withPIED use, diet and training, use of other illicit

substances, sexual health, and theimportance of monitoring physical andpsychological health, as well as access tosterile injecting equipment, BBV testing,HBV vaccination, and sexual health services(Aitken et al., 2002; Hope at al., 2013;Iversen et al., 2013; Larance et al., 2008).However, in reality, there is a high level ofvariability in the delivery of harm reductionprogrammes for PIED users across services,which highlights the lack of best practicepolicy guidelines (Kimergård & McVeigh,2014),

A number of additional concerns are evidentin attempting to apply existing programmesof harm reduction as a method ofintervention for PIED users. This group donot perceive themselves as

„drug users�, and therefore, the stigmaassociated with conventional drug services,such as NSPs, is likely to impede serviceuptake and reduce engagement amongstPIED users (Dunn et al., 2014; Kimergård &McVeigh, 2014; Simmonds & Coomber,2009). The manner in which PIED userstypically utilise services would appear tosupport this assertion, as although themajority of clients who attend NSPs obtaininjecting equipment, few appear to use theseservices for seeking information (Larance etal., 2008). Further concerns, which havebeen discussed by service providers withinthe literature, include the extent of theboundaries around interventions for PIEDusers (e.g. whether or not to provideinformation on specific types of AAS), andindeed, whether harm reduction servicesshould cater for PIED users at all asresourcing their needs shifts funding andfocus away from the traditional client base(Dunn et al., 2014; Kimergård & McVeigh,2014). In the effort to address theaforementioned concerns and enhance theinteraction between PIED users and harmreduction, a small number of specialist,steroid-specific services, have beenimplemented in the United Kingdom andAustralia. While such programmes appear to

show potential, there remains limitedempirical evaluation of their effectiveness inminimising harm (Kimergård & McVeigh,2014).

1.4. THE PRESENT STUDY

The literature has highlighted the growingincidence of users of PIEDs accessing harmreduction services, the diverse profile andharm reduction needs of this group, and thechallenges faced by public health initiativesand service providers in responding to thisemerging trend. Given the lack of previousresearch in an Irish context, there exists aneed to develop an evidence base whichexplores the profile of PIED users and theirperspectives on Irish harm reductionservices, in order to inform interventionswhich aim to address the risk of harm withinthis group.

1.4.1. Research context. The presentstudy is being conducted in conjunction withMerchants Quay Ireland (see www.mqi.ie),an Irish based organisation which offers avariety of services for individuals who arehomeless and /or drug users. Within thespectrum of facilities offered, MQI DayServices provide frontline drug services. Acornerstone of the drug service is the HealthPromotion Unit - Needle Exchange. Themain objectives of the Health Promotion Unitare concerned with minimising the harmsassociated with drug use and educating drugusers on the potential risks. Accordingly, theprimary focus is on HIV and Hepatitisprevention, promoting safer injectingbehaviours and techniques, providinginformation on associated risks and offeringdrug users a pathway in to treatment.


1.4.2. Research questions. The presentstudy aims to examine the profile andperspectives of users of PIEDs accessingIrish based harm reduction services.Accordingly, the research is focused on thePIED using client base of services, with thespecific research questions being:

n What is the socio-demographic profile?

n What are the motivations for PIED useand the history of use?

n What is the nature of PIED use andtrends in PIEDs use?

n What are the side-effects experienced inassociation with use of PIEDs?

n What are the patterns of poly-substanceuse?

n What is the training and exercise profile?

n What are the injecting practices?

n What are the levels of testing for BBVs,prevalence of BBVs, and uptake oftreatment for BBVs?

n What are PIED users� perspectives onharm reduction services?


This chapter describes the specificmethodology incorporated in thepresent study. An outline of the

research design and the correspondingrationale is included, as well as informationrelating to the sampling and characteristics ofthe participants. In addition, the chapterprovides a description of the materials used,the procedure of data collection, and themethod of data analysis. In the concludingsection, the ethical issues associated withthe study, and the steps taken to addressthese, are also presented.

2.1. RESEARCH DESIGN

A mixed method research design wasemployed in the present study. A mixedmethod approach is focused on the collection,analysis, and mixing of both quantitative andqualitative data, with an underlying principlethat the use of quantitative and qualitativeapproaches in concert facilitates a more indepth understanding of the research problemthan the use of either approach exclusively(Creswell & Plano-Clark, 2011). Johnson andOnwuegbuzie (2004) assert that researchapproaches should be blended in a mannerwhich affords the best opportunities forachieving important research objectives. Giventhat the present study aimed to examine theprofile of PIED users accessing harmreduction services, while concurrently elicitingtheir perspectives on harm reduction serviceprovision, a mixed method research paradigmwas considered to be the optimal fit.

2.2. PARTICIPANTS AND SAMPLING

Purposive sampling (e.g. see, Teddlie &Tashakkori, 2009) was utilised for thepresent study in order to identify individualsattending harm reduction services, who wereusers of PIEDs. The sample was drawn fromclients presenting to harm reduction servicesin Ireland. Staff at Merchants Quay Ireland(MQI) Day Services, which are primarilybased in Dublin, were asked to identifyattendees who were current PIED users andparticipants were recruited through theorganisation. The sample consisted of 89

participants, all of whom were male. The ageof participants ranged from 18-40 years(M=26.91, Mdn=26, SD=5.87). Eighteenparticipants were currently on their first cycleof PIEDs usage, and 71 participants hadcompleted at least one cycle of PIEDs use.

2.3. MATERIALS

A mixed method questionnaire wasdeveloped for the purposes of datacollection. Items included within thequestionnaire were informed by the extantliterature surrounding PIED use and injectingdrug use (e.g., van Amsterdam et al., 2010,Brunsdon, 2010, Flemen, 2011,Hildebrandt, Langenbucher, Lai, Loeb, &Hollander, 2011, Jennings, 2013, Peters,Copeland, & Dillion, 1999). Thequestionnaire included nine sections whichfocused on: socio-demographiccharacteristics (age, gender, nationality,sexual orientation, ethnic background,county/type of residence, occupation,employment status, level of education), useof PIEDs (use of AAS, use of ancillarycompounds and post-cycle substances,nature of use, history of use, motivation foruse), side-effects experienced in associationwith PIED use (either during, post, orbetween cycles), use of other substances(substance use, history of use, route ofadministration), training and exercise (natureand intensity), injecting practices (method,site, related injuries, environment, riskbehaviours), blood-borne viruses (testing,status, and treatment), harm reductionservice utilisation (attendance, motivation)and perspectives on harm reduction services(experience of services, suggestions forservice provision, general commentary).

2.4. PROCEDURE

A pilot study was conducted with twoparticipants in order to examine elementsinvolved in the research process. Followingthis pilot study, issues around the materials,procedure, and logistics were discussed andrefined. Data collection for the main studytook place over a period of 8 weeks. Clients

presenting to MQI harm reduction services,who were users of PIEDs, were invited toparticipate in the research study. Informationsheets, which outlined the nature, purpose,and conditions of the study, were providedto all potential participants. Written consentwas obtained from individuals who decidedto take part in the study. Data collection wasconducted within the needle exchange,safer injecting, and outreach departments ofthe health promotion unit in MQI DayServices. Participants were offered thequestionnaire, prompted to read theinstructions, and given the opportunity toask questions. Participants then self-completed the instrument. The average timefor completion for the questionnaire wasapproximately 15-20 minutes and allquestionnaires were completed in thepresence of a member of the researchteam. In any instances where participantshad issues around literacy or languagediversity, data administrators assisted themin filling out the questionnaire. In thisscenario, data administrators wereinstructed to avoid asking participantsleading questions or influencing responses.

2.5. DATA ANALYSIS

Analyses of quantitative data were primarilydescriptive in nature, with appropriatestatistical data analyses carried out usingthe Statistical Package for the SocialSciences (SPSS; V.20.). Prior to analysis,missing responses were identified andcoded. The results presented herein areadjusted for these missing data. Qualitativedata were analysed using the inductivethematic analysis framework described byBraun and Clark (2006): data weretranscribed verbatim; coded in a systematicfashion and collated in to initial themes;themes were reviewed and checked inrelation to the coded extracts; a formativeinter-rater reliability check was conducted,with a consensus-percent of 76% reached;following discussion around problematicthemes, a number of elements were refined;and finally themes were defined. In order toassess reliability of the findings, a


Chapter 2: Methodology

summative inter-rater reliability check wasconducted, which showed an overallconsensus level of approximately 92%. Allqualitative data analyses were completedmanually.

2.6. ETHICAL CONSIDERATIONS

A number of ethical issues presented withinthe current study. In order to address issuesaround informed consent; an informationsheet was provided to all participants toensure that they were fully aware of thenature of the study and the terms ofparticipation. Within this information sheet, itwas also emphasised that participation wascompletely voluntary, and non-participationwould not negatively impact their relationship

with MQI in any way. Participants were alsomade aware that all information provided wasconfidential and would be used in a publishedresearch study. Written consent was obtainedfrom all participants to document that theyunderstood the conditions of the study andagreed to participate voluntarily. Additionally,participants were encouraged to askquestions at all stages during the researchprocess. Due to the nature of the researchand the content of the questionnaire, the datacollection process included the potential forsensitive data to be elicited. In order toaddress issues around sensitivity, trainingaround the collection of sensitive data wasprovided to all administrators, and aftercareprotocols, such as the provision of on-sitecounselling and medical services, wereimplemented.


WITHIN THIS INFORMATION SHEET, ITWAS ALSO EMPHASISED THAT

PARTICIPATION WAS COMPLETELYVOLUNTARY, AND NON-PARTICIPATIONWOULD NOT NEGATIVELY IMPACT THEIRRELATIONSHIP WITH MQI IN ANY WAY.

The aim of the present study was toexamine the profile and perspectivesof individuals accessing harm

reduction services who are users of PIEDs.Data collected consisted of participants�self-reported responses on a mixed methodquestionnaire. Quantitative data includedsocio-demographic characteristics, use ofPIEDs, side-effects experienced inassociation with use of PIEDs, training andexercise, use of other substances, injectingpractices, blood-borne viruses, and harmreduction service utilisation. Qualitative datawere comprised of participants� perspectiveson harm reduction services. Within thischapter, results gleaned from quantitativeanalyses are presented at the outset, and arethen followed by a description of thequalitative findings.

3.1. DESCRIPTIVE STATISTICS

The descriptive statistics for the total sampleare illustrated in Table 7. Eighty-nineparticipants took part in the study and allparticipants were male. Significantly, nofemale clients, who were users of PIED,presented to services during the period ofdata collection. The age of participantsranged from 18-40 years old, with theaverage age being approximately 27 yearsold (M=26.91, Mdn=26, SD=5.87). Infurther delineating the age profile;approximately 38% of participants wereaged 18-24 years old, 30% were aged 25-29 years old, 17% were aged 30-34 yearsold, and 14% were aged 35-40 years old.

3.2. SOCIO-DEMOGRAPHICCHARACTERISTICS

The socio-demographic characteristicsexamined within the questionnaire includednationality, ethnicity/cultural background,sexual orientation, current accommodationstatus, county and area of residence, level ofeducation, employment status, andoccupation. The results for each of thesevariables are presented in the tables below.

As depicted in Table 8, the samplecomprised 8 different nationalities, with alarge majority of participants being Irishnationals.

Table 9 illustrates the ethnic/culturalbackground of the sample. While the majority ofparticipants were White Irish (80.9%), there wasa diverse mix of ethnicities among the sample.


Chapter 3: Findings

Total Sample

Participants (N) 89

Range (age) 18-40

Mean (age) 26.91

Median (age) 26

Std. Deviation (age) 5.87

TABLE 7 Descriptive Statistics for the Total Sample

n %

Irish 80 89.9

Brazilian 3 3.4

Spanish 1 1.1

Latvian 1 1.1

British 1 1.1

Dutch 1 1.1

Iranian 1 1.1

Polish 1 1.1

Total 89 100

TABLE 8 Nationality

n %

White Irish 72 80.9

Any other (including mixed background) 7 7.9

White Irish Traveller 3 3.4

Any other white background 3 3.4

Black or black Irish – African Origin 1 1.1

Black or Black Irish - any other Black background 1 1.1

Asian or Asian Irish – Chinese origin 1 1.1

Asian or Asian Irish - any other Asian background 1 1.1

Total 89 100

TABLE 9 Ethnic/Cultural Background

Table 10 displays the sexual orientation ofparticipants. Just over 90% of respondentsreported a heterosexual orientation, whereasless than 10% reported a homosexual orbisexual orientation.

As illustrated in Table 11, the most commoncategories of accommodation statusreported were parental home and privaterented accommodation. Otheraccommodation types included councilhousing (n=3), partner�s residence (n=2),and aunt/uncle�s residence (n=2).

Table 12 highlights that the majority ofrespondents resided in Dublin (89.3%).Overall, less than 3% of respondentsresided in counties outside of Leinster.


n %

Heterosexual 80 90.9

Homosexual 5 5.7

Bisexual 3 3.4

Total 88 100

TABLE 10 Sexual Orientation

*Missing Observations=1


n %

Parental home 37 41.6

Private rented accommodation 34 38.2

Own home 7 7.9

Emergency accommodation 3 3.4

Staying with friends (non-tenant) 1 1.1

Other accommodation 7 7.9

Total 89 100

TABLE 11 Current Accommodation Status

TABLE 12 County of Residence

n %

Dublin 75 89.3

Rest of Leinster 7 8.3

Outside of Leinster 2 2.4

Total 84 100

As illustrated in Table 13, participants, whowere residing in Dublin, reported a widerange of areas of residence. Postcodeswhich were noted most prevalently includedDublin 7 (14.7%) and Dublin 8 (12%).

There was a varied level of educationcompleted among respondents. Table 14illustrates that the most common level ofeducation completed was lower secondary(34.1%), followed by higher secondary(22.7%) and third level non-degree(20.5%).


n %

D1 4 5.3

D2 1 1.3

D3 4 5.3

D4 1 1.3

D5 6 8

D6 1 1.3

D6W 1 1.3

D7 11 14.7

D8 9 12

D9 5 6.7

D11 6 8

D12 7 9.3

D13 4 5.3

D14 2 2.7

D15 1 1.3

D16 1 1.3

D17 4 5.3

D22 3 4

D24 1 1.3

County Dublin 3 4

Total 75 100

TABLE 13 Area of Residence of Dublin based Participants

n %

Third level degree or higher 11 12.4

Third level non-degree 18 20.5

Higher Secondary 20 22.7

Lower Secondary 30 34.1

Primary education 7 8

No formal education 2 2.3

Total 88 100

TABLE 14 Highest Level of Education Completed


As shown in Table 15, approximately two-fifths of participants reported currently beingin some category of employment. However,almost half of participants reported currentlybeing unemployed.

Respondents reported a broad assortmentof occupations, which are displayed in Table 16.

Skilled trade was the most prevalentlyreported class of occupation with just undera third of respondents reporting vocationssuch as carpenter, electrician, plumber ormechanic. Occupations within the spectrumof the health industry (e.g. gymmanagement, fitness instructor, nutritionist),were reported by just over 10% ofrespondents, as were occupations within theretail/sales industry, and the securityindustry. A large number of participantsneglected/declined to state an occupation.

3.3. USE OF PIEDs

Within the use of PIEDs section of thequestionnaire, participants were askedquestions around motivation for PIED use,use of AAS, history of use, nature of use,and use of ancillary compounds and post-cycle substances. Results pertaining toPIED use are presented below.


n %

Unemployed 45 48.9

Employed full-time 19 20.7

Employed part-time 10 10.9

Student 10 10.9

Self-employed 5 5.4

Employed on employment scheme 2 2.2

Other employment status 1 1.1

TABLE 15 Employment Status

*3 participants reported being students and employed part time

n %

Skilled Trade 21 30.9

Health Industry 8 11.8

Retail/Sales 8 11.8

Security 7 10.3

Hospitality 6 8.8

Engineering/IT 4 5.9

Manual Labour 4 5.9

Logistics/Driver 3 4.4

Public Service 2 2.9

Student 2 2.9

Modeling 2 2.9

Social Care 1 1.5

Total 68 100

TABLE 16 Occupation


Table 17 highlights motivations for PIEDuse. Among the most prevalently reportedmotivations were to increase muscle mass(91%), to increase strength (75.3%), tolook good (62.9%) and to increaseconfidence (51.7%).

Table 18 outlines the descriptive statisticsrelating to use of oral AAS and injectedAAS. Sixty-one participants reported use oforal AAS, with the age of first use rangingfrom 15-36 years old (M=22.71,SD=4.64). Eighty-six participants reportedinjecting use of AAS, with the age of firstuse ranging from 16-39 years old(M=23.84, SD=5.04).

Table 19 illustrates the sequence of AASuse reported. Approximately 37% ofrespondents started using oral steroids andthen progressed to injecting steroids, 18%started using steroids orally and injectingsteroids at the same time, and 11% startedinjecting steroids and then later usedsteroids orally.


n %

Increase muscle mass 81 91

Increase strength 67 75.3

To look good 56 62.9

Increase confidence 46 51.7

Dissatisfied with body shape 43 48.3

Recreational weightlifting 36 40.4

Bodybuilding 38 42.7

Decrease fat 33 37.1

Increase endurance 33 37.1

Occupational reasons 14 15.7

Rehabilitate injury 13 14.6

Sport 12 13.5

Prevent injury 9 10.1

TABLE 17 Motivation for PIED Use

Oral Injected

Participants (n) 61 86

Mean (age of first use) 22.77 23.84

Median (age of first use) 22 22

Std. Dev. (age of first use) 4.64 5.04

Range (age of first use) 15-36 16-39

TABLE 18 Descriptive Statistics for AAS Use

n %

Started oral steroids and then later injected steroids 33 37

Only ever injected steroids 27 30.3

Started oral and injected steroids at the same time 16 18

Started injecting and then later oral 10 11.2

Only ever used oral steroids 3 3.4

Total 89 100

TABLE 19 Sequence of AAS Use

Table 20 illustrates the types of AAS whichparticipants reported using during theircurrent cycle and during their previouscycles. While respondents reported currentand past use of a wide variety of AAS,Testosterone (single/multi esters) was by farthe most prevalently used AAS duringcurrent cycle (84%) and previous cycles(77.5%). Other AAS which were commonlybeing used during current cycles includedNandrolone decanoate (31.3%) andTrenbolone acetate (19.3%). Although otherAAS such as Oxandrolone, Drostanolone,Methandrostenolone, Boldenone, andOxymetholone appeared to have beenfrequently used during previous cycles,respondents reported little use of thesesubstances during their current cycles.

There was a wide spread in terms of thenumber of cycles of PIED use respondentshad undertaken over their lifetime. Asdisplayed in Table 21, just under half ofrespondents were on either their first cycleor second cycle of PIED use. Almost a fifthof respondents were currently on their sixthor higher cycle (18%).


Current Cycle (%) Previous Cycles (%)

Testosterone (single/multi esters) 84.3 77.5

Nandrolone Decanoate 31.3 53.5

Trenbolone Acetate 19.3 35.2

Stanozolol 10.8 22.5

Oxandrolone 7.2 33.8

Drostanolone 7.2 22.5

Methandrostenolone 6 49.3

Boldenone 4.8 19.7

Oxymetholone 3.6 22.5

Trenbolone hexahydrobencylcarbonate 2.4 8.5

Mesterolone 1.2 8.5

Methenolone 1.2 14.1

Chlorodehydromethyltestosterone 0 14.1

Nandrolone Undecanoate 0 7

Fluoxymesterone 0 2.8

Formebolone 0 1.4

TABLE 20 Types of AAS used During Current Cycle and Previous Cycles

n %

First cycle 18 21.4

Second cycle 20 23.8

Third cycle 12 14.3

Fourth Cycle 12 14.3

Fifth Cycle 7 8.3

Sixth or Higher Cycle 15 18

Total 84 100

TABLE 21 Number of Current Cycle


Table 22 shows that there was a widevariance in the length of participants� usualcycles. While the most commonly reportedlength of usual cycle was 6-8 weeks, someparticipants cycled for less than 5 weekswhereas, others cycled PIEDs for a periodlasting more than 17 weeks.

Table 23 details where participants sourcedtheir AAS and highlights that almost two-fifths of participants sourced their AAS fromfriends (38.6%). Other sources whichfeatured prominently included through directcontact with a supplier (25%), through asupplier in gym (20.5%), and through theinternet (17%).

Table 24 depicts use of ancillary compoundsand post cycle treatment drugs used duringcurrent cycle and during previous cycles.Just over half of participants reported thatthey engaged in post cycle therapy (n=48;53.9%), whereas just under half reportedthat they did not (n=41; 46.1%). Again,participants reported use of a wide variety ofsubstances. The substances being usedmost prevalently during current cyclesincluded Creatine (23.9%) and AromataseInhibitors/Anti-Oestrogens (10.1%).

Substances which were most commonlyused during previous cycles includedCreatine (37.5%), HCG (27.2%),Clenbuterol (25.8%), AromataseInhibitors/Anti-Oestrogens (24.7%), andClomiphene citrate (21.3%).


n %

Less than 5 weeks 16 186-8 weeks 26 29.29-11 weeks 17 19.112-14 weeks 14 15.715-17 weeks 7 7.9More than 17 weeks 9 10.1

Total 89 100

TABLE 22 Length of Usual Cycle

n %

Friends 34 38.6Direct contact with supplier 22 25Supplier in gym 18 20.5Internet 15 17Direct contact with laboratory 2 2.3Family 2 2.3Tanning Salon 1 1.1Other Source 4 4.5

TABLE 23 Acquisition of PIEDs


Current Cycle (%) Previous Cycles (%)

Creatine 23.9 37.5Aromatase Inhibitors/Anti-Oestrogens 10.1 24.7Human Chorionic Gonadotrophin (HCG) 8 27.2Human Growth Hormone (HGH) 6.7 7.9Clomiphene citrate 5.6 21.3Testosterone Boosters 4.5 9.1Clenbuterol 3.4 25.8Ephedrine 2.2 18Thyroid Agents 2.2 11.2Tanning Agents 1.1 7.9Growth hormone releasing hexapeptide/hormone 1.1 3.4Insulin 1.1 2.2Diuretics 1.1 2.2Growth Hormone Fragment 1.1 1.1Insulin Growth Factor (IGF) 1.1 0Pro-hormones (PH) 0 5.6Anti-acne medication 0 3.4Gammahydroxybutyrate (GHB /GBL) 0 1.1

TABLE 24 Use of Ancillary Compounds/Post Cycle Treatment Drugs

3.4. SIDE EFFECTS EXPERIENCEDIN ASSOCIATION WITH USE OFPIEDs

Participants were asked to detail the side-effects which they had experienced (eitherduring, post, or off cycle) in association withtheir use of PIEDs. A broad range of side-effects were noted with Table 25highlighting the most prevalent side-effectsexperienced currently and previously.

3.5. TRAINING AND EXERCISE

Within this section of the questionnaire,participants were asked questions aroundparticipation in training and exercise, whichincluded type of exercise, frequency ofexercise, and participation in organisedsport. Results relating to the training andexercise are presented below.

Almost all participants reported that theyparticipated in a regular training andexercise programme (n=87; 97.8%). Thenumber of days participants participated intraining and exercise is illustrated in Table26, which shows that just under half ofparticipants reported that they exercisedmore than 5 days a week (46.1%).

In terms of type of training and exercise,91% of participants reported participation inweight training (n=81) and approximately80% of participants reported participation incardiovascular exercise (n=71). The numberof sessions respondents participated inweight training and cardiovascular exerciseis presented in Table 27. The mostfrequently cited number of weight trainingsessions per week was 5-7 (n=46) and themost common number of cardiovascularexercise sessions per week was 2-4(n=49).


Currently (%) Previously (%)

Increased sex drive 42.7 46

Increased appetite 41.6 49.4

Testicular atrophy 26 29.2

Increased aggression 23.6 38.2

Growth of excessive body hair 23.6 36

Sudden mood changes 22.5 31.5

Water retention 20.2 45

Acne 16.9 36

Anxiety 13.5 19.1

Insomnia 10.1 23.6

Muscle/Joint pain 10.1 22.5

Decreased sex drive 9 33.7

Depression 9 18

TABLE 25 Most Prevalent Side-Effects Experienced in Association with use of PIEDs

n %

None 2 2.2

Once a week 1 1.1

2-3 days a week 10 11.2

4-5 days a week 35 39.3

More than 5 days a week 41 46.1

Total 89 100

TABLE 26 Number of Days Exercised per Week

Weight Training (%) Cardiovascular Exercise (%)

None 9 20.2

One session a week 1.1 14.6

2-4 sessions a week 36 55.1

5-7 sessions a week 51.7 9

8-10 sessions a week 2.2 1.1

Total 100 100

TABLE 27 Frequency of Participation in Weight Training and Cardiovascular Exercise

Approximately 46% of respondents (n=41)reported participation in organised sport, withsome participants engaging in more than onecategory of sport. All of the participants�engagement in sport was at anamateur/recreational level, with the exceptionof 1 participant, who competed professionally.Table 28 illustrates the types of sport playedand indicates that the most prevalentlyreported types included bodybuilding (15.7%),boxing (10.1%), and soccer (10.1%).

3.6. USE OF OTHER SUBSTANCES

Within the questionnaire, participants wereasked whether they had ever used othersubstances, if used, what was the route ofadministration, and which substances they hadused in the past month. The results emanatingfrom participants responses are describedbelow.

Table 29 shows that participants reported useof an assortment of other substances.Substances such as Alcohol (95.5%),Tobacco (71.6%), Cannabis (68.2%), Cocaine(56.8%), and Benzodiazepines (35.8%)showed particularly high levels of lifetime use.Recent use (defined as use during the pastmonth) of the aforementioned substances wasalso relatively prevalent. It is also noteworthythat participants reported injecting use ofHeroin (11.4%), Cocaine (5.7%), and Newpsychoactive substances (2.3%).

3.7. INJECTING PRACTICES

Within the questionnaire, participants wereasked questions around where they learnt toinject, method of injecting, injecting site,injecting related injuries, physical injectingenvironment social injecting environment,administration of injection, and injecting riskbehaviours. Results pertaining to theseinjecting practices are presented below.

As detailed in Table 30, the majority ofrespondents (55%) reported learning to injectfrom other PIED users. Just over 30% ofparticipants learnt to inject through a harmreduction service or medical professional.


n %

No participation in organised sport 48 53.9

Bodybuilding 14 15.7

Boxing 9 10.1

Soccer 9 10.1

Mixed martial arts 7 7.9

Kickboxing 4 4.5

Rugby 4 4.5

Swimming 4 4.5

Other sport 4 4.5

TABLE 28 Type of Organised Sport

n %

Other PIED users 44 55

Internet 20 25

Harm reduction service 19 23.8

Drug supplier 13 16.3

Medical Professional 7 8.8

Self-taught 4 5

Family/Friends 2 2.5

TABLE 30 Learning to Inject

Lifetime Use (%) Ever Injected (%) Recent Use (%)

Alcohol 95.5 0 62.5

Tobacco 71.6 0 52.3

Cannabis 68.2 0 39.8

Cocaine 56.8 5.7 17

Benzodiazepines 35.2 0 22.7

Ecstasy 23.9 0 3.4

Anti-depressants 19.3 0 8

New psychoactive substances 17 2.3 1.1

Methadone 13.6 0 9.1

Crack 11.4 0 1.1

Heroin 12.5 11.4 3.4

Methamphetamine 9.1 0 1.1

TABLE 29 Other Substances Ever Used, Ever Injected, and Recently Used


Table 31 illustrates the method of injectionused currently and previously. Whileintramuscular injection was the most popularmethod of injection among respondents,subcutaneous and intravenous injection wasalso reported, with some respondents usingmultiple methods. All participants whoreported intravenous injection also reportedcurrent/previous injecting use of heroin.

Table 32 displays the injecting site usedcurrently and previously by respondents.Injection in to the Buttocks was by far themost prevalently used site both currently andin the past, with Deltoids and Quadricepsbeing the next most frequently usedinjecting sites.

A number of respondents had experiencedinjecting related injuries. As shown in Table33, Muscle pain (47.5%) and Bruising(37.5%) were the most commonlyexperienced injuries.

Table 34 illustrates the physicalenvironment, in which, respondents reportedinjecting. Four-fifths of respondentsreported that they always injected at home,whereas 2% reported that they alwaysinjected at the gym.



Intramuscular 93.6 94.4

Subcutaneous 14.1 19.7

Intravenous 1.3 11.3

TABLE 31 Method of Injection Used

*Missing Observations=11 *Missing Observations=18

Home (%) Gym (%) Other (%)

Always 80 2 2

Sometimes 16 14 8

Never 4 84 90

TABLE 34 Physical Injecting Environment



Buttocks 91 90.1

Deltoids 25.6 36.6

Quadriceps 20.5 22.5

Triceps 3.8 8.5

Biceps 2.6 4.2

Chest 1.3 2.8

Calves 1.3 1.4

Lower Back 0 2.8

TABLE 32 Injecting Site

*Missing Observations=11 *Missing Observations=18

n %

Muscle pain 38 47.5

Bruising 30 37.5

Abscesses 14 17.5

Scarring 6 7.5

Infections 4 5

Nerve damage 2 2.5

TABLE 33 Injecting Related Injuries


Table 35 depicts the social environment, inwhich, the respondents� reported injecting.Over half of the respondents always injectedalone, whereas a quarter always injectedwith others. Approximately two-fifths ofrespondents sometimes injected withothers.

Table 36 shows that 71% of respondentsalways injected themselves and 16% werealways injected by another person.Approximately 13% sometimes injectedthemselves and sometimes were injected byanother person.

Table 37 illustrates respondents� level ofreuse of injecting equipment and indicatesthat while the vast majority never reusedtheir injecting equipment, there wererespondents who sometimes reused, andalways reused.

As displayed in Table 38, there were fewreports of respondents lending their usedinjecting equipment to other parties, with thebulk of respondents stating that they neverlent used needles, syringes, or otherinjecting equipment to others.

Table 39 illustrates rates of borrowinginjecting equipment and suggests very lowlevels, with 98% of respondents reportingthat they never borrowed used needles,syringes, or other injecting equipment fromother people.


Inject Alone (%) Inject with Others (%)

Always 56 25

Sometimes 19 19

Never 25 56

TABLE 35 Social Injecting Environment


Yourself (%) Another Person (%)

Always 71 16

Sometimes 13 13

Never 16 71

TABLE 36 Administration of Injection


Needles/Syringe (%) Other Equipment (%)

Always 2 3

Sometimes 14 11

Never 84 86

TABLE 37 Reuse of Injecting Equipment



Always 0 0

Sometimes 5 5

Never 95 95

TABLE 38 Lending of Injecting Equipment



Always 0 0

Sometimes 2 2

Never 98 98

TABLE 39 Borrowing of Injecting Equipment


3.8. BLOOD-BORNE VIRUSES

Within the questionnaire, participants wereasked whether they had been tested forHIV, Hepatitis C, and Hepatitis B, whenthey were last tested, the results of testing,and whether they were receiving treatmentin the case of positive cases. The resultsemanating from participants responses aredescribed below.

Table 40 shows the data relating to testingfor HIV. Approximately 48% of respondentshad ever been tested for HIV. However, anequivalent amount had never been tested.

In terms of length of time since last HIVtesting, Table 41 displays that while almosthalf of respondents had never been tested;just over 30% had been tested within thepast year.

Table 42 illustrates that of thoserespondents who had ever been tested forHIV, there were no reports of a positivestatus.

Table 43 presents the data regardingparticipants� testing for Hepatitis C.Approximately 48% of respondents hadbeen tested for Hepatitis C, whereas aslightly higher proportion (49%) had neverbeen tested.


n %

Tested 42 47.7Never tested 42 47.7Not known if tested 4 4.5

Total 88 100

TABLE 40 HIV Testing


n %

Tested 42 47.7Never tested 43 48.9Not known if tested 3 3.4

Total 88 100

TABLE 43 Hepatitis C Testing


n %

Never tested 42 47.7Less than 6 months 12 13.66-12 months 17 19.31-2 years 8 9.1More than 2 years 5 5.7Unknown 4 4.5

Total 88 100

TABLE 41 Length of Time Since Last HIV Testing


n %

Never tested 42 48.3Negative 39 44.8Positive 0 0Unknown 6 6.9

Total 87 100

TABLE 42 HIV Test Results


Table 44 depicts the length of time sincelast Hepatitis C testing and illustrates thatwhile almost half of respondents had neverbeen tested, approximately a third had beentested within the past year.

Table 45 presents the Hepatitis C testresults of participants. Overall, 4.6% ofrespondents reported a positive status.When framed in terms of participants whohad been tested and knew their result;positive statuses represented approximately10% of these respondents. All participantswho reported being positive for Hepatitis Chad a past history of injecting drug use (allfour had previously injected heroin, one hadalso previously injected cocaine and newpsychoactive substances).

Table 46 shows the treatment status ofparticipants who had tested positive forHepatitis C and indicates that oneparticipant had completed treatment,whereas other participants were eitherawaiting treatment (n=1), awaiting furthertests (n=1), or had declined treatment(n=1).

Table 47 shows the data relating to testingfor Hepatitis B. Approximately 48% ofrespondents had ever been tested forHepatitis B. However, an equivalent amounthad never been tested.


n %


Total 88 100

TABLE 44 Length of Time Since Last Hepatitis C Testing


n %

Not tested 43 49.4Negative 36 41.4Positive 4 4.6Unknown 4 4.6

Total 87 100

TABLE 45 Hepatitis C Test Results


n %

Tested 42 47.7Not tested 42 47.7Not known if tested 4 4.5

Total 88 100

TABLE 47 Hepatitis B Testing


n %

Completed treatment 1 25Awaiting treatment 1 25Awaiting further tests 1 25Declined treatment 1 25

Total 4 100

TABLE 46 Treatment Status for Hepatitis C

Table 48 displays that while almost half ofrespondents had never been tested forHepatitis B; over 30% had been testedwithin the past year.

Table 49 illustrates that of thoserespondents who had ever been tested forHepatitis B, there were no reports of apositive status.

Table 50 illustrates that approximately 34%of respondents had been vaccinated forHepatitis B, whereas 62% of respondentshad not been vaccinated.

3.9. HARM REDUCTION SERVICEUTILISATION

Approximately three-fifths of respondentshad previously attended a harm reductionservice (n=52; 59.8%), whereas two-fifthswere attending for the first time (n=35;40.2%). As illustrated in Table 51,respondents� primary motivations forattending services included to obtaininjecting equipment (98.8%) and for saferinjecting advice (67.1%).

3.10. PERSPECTIVES ON HARMREDUCTION SERVICES

A further aim of the present study was toexplore participants� perspectives aroundtheir experience and interaction with harmreduction services. Accordingly, qualitativedata were collected which consisted ofparticipant responses on three open-endedquestions; “what has your experience beenlike so far interacting with harm reductionand needle exchange services”; “have youany suggestions for services you would liketo see offered to you in the future”; and “arethere any other comments you would like tomake”. A large majority of the sample(n=85, 95%) provided responses to thesequestions. Data were analysed usinginductive thematic analysis, which wasconducted in line with the frameworkoutlined by Braun and Clark (2006).


n %


Total 88 100

TABLE 48 Length of Time Since Last Hepatitis B Testing


n %

Yes 30 34.5No 54 62.1Unknown 3 3.4

Total 87 100

TABLE 50 Vaccinated for Hepatitis B


n %

Obtain injecting equipment 84 98.8Safer injecting advice 57 67.1Obtain condoms 7 8.2Medical service 6 7.1

Total 87 100

TABLE 51 Motivation for Attending Harm Reduction Services


n %

Never tested 42 50Positive 0 0Negative 40 47.6Unknown 2 2.4

Total 84 100

TABLE 49 Hepatitis B Test Results

In total four prominent themes emergedduring the course of analysis. Two of thesethemes related to participants� experiencesof harm reduction services and areillustrated in Table 52. Participants�interactions with harm reduction and needleexchange services were generally describedin terms of being a positive and usefulexperience. Within this theme,respondents expressed that their experiencehad been “positive” and outlined that theyhad found services useful for “information”,“getting sterile injecting equipment”, as wellas learning about safer injecting practices.One respondent also referenced that hefound the non-judgmental position of harmreduction services helpful, stating that“workers do not judge you”. While a majorityof respondents expressed positivesentiments towards services, a numberdetailed that there was also a negativeaspect to their experiences. In particular,individuals who used PIEDs indicated thatthe presence of users of other substanceswithin harm reduction services and needleexchanges created an intimidatingatmosphere, which was described asbeing “uncomfortable”, “nerve wracking” and“off-putting”.

The additional two themes which emergedwere related to participants� perspectives onfuture service provision and are presented inTable 53. Respondents proposed a range ofimprovements to existing serviceprovision. Within this theme, the mostprominently emphasised suggestions werefor “increased medical services” and “moreinformation on steroids”. Additionalpropositions for service enhancement, whichwere less prevalently articulated, includedthe provision for more injecting equipment tobe supplied within the needle exchange,“more needle variety”, “information availablein other languages” and a supervised“injecting room”. Respondents alsodescribed that there should be moreadvertisement of the service in order toenhance awareness among the generalcommunity of PIED users.

The final theme which emerged wascentered on respondents� desire for a PIEDspecific service. As illustrated in Table 53,service users remarked that they would like asteroid specific service, which was

specialised to cater for their particular needsand medical issues. For some, this was alliedwith the desire for a facility, which operated aseparate service for users of PIEDs.


Theme Sample Quotes Frequency

Positive and useful experience “Very useful service – got learned a thing or two” 75

“found out new information and I found out the correctway to inject”

Intimidating atmosphere “uncomfortable in service with other substance 11users”

“General environment is difficult and wouldstop people coming”

TABLE 52 Overview of Themes Relating to Experiences of Harm Reduction Services

Theme Sample Quotes Frequency

Improvements to existing “Improved medical service and improved 38service provision information”

“Opening hours in the evening”

Desire for a PIED specific service “Having a specific steroid service” 17

“separate steroid users from other substance users”

TABLE 53 Overview of Themes Relating to Perspectives on Future Service Provision

RESPONDENTS ALSO DESCRIBED THAT THERESHOULD BE MORE ADVERTISEMENT OF THE SERVICEIN ORDER TO ENHANCE AWARENESS AMONG THE

GENERAL COMMUNITY OF PIED USERS.

The concluding chapter of this studywill recount and summarise theprincipal aspects of the present

research, and provide an integrativeassessment of the findings. Accordingly, theaims and research questions are presented,and the main findings are outlined. Followingthis overview, findings are interpreted in thecontext of previous research and evaluated interms of their implications. The elements ofdesign and methodology are appraised froma critical perspective and suggestions forfuture research are proposed.

4.1. RESTATEMENT OF AIMS ANDRESEARCH QUESTIONS

The objective of the present study was toexamine the profile and perspectives ofindividuals attending harm reduction serviceswho are users of PIEDs. Specifically, thestudy aimed to address nine primaryquestions:

n What is the socio-demographic profile?

n What are the motivations for PIED useand history of use?

n What is the nature of PIED use andtrends in PIEDs use?

n What are the side-effects experienced inassociation with use of PIEDs?

n What are the patterns of poly-substanceuse?

n What is the training and exercise profile?

n What are the injecting practices?

n What are the levels of testing for BBVs,prevalence of BBVs, and uptake oftreatment for BBVs?

n What are PIED users� perspectives onharm reduction services?

4.2. OVERVIEW OF KEY FINDINGS

Within this section, the key findings aredescribed in accordance with the researchquestions posed within the current study.

What is the socio-demographic profile?

The average PIED user in the present studywas approximately 27 years of age, althoughthe age of participants ranged from 18 to 40years old. All participants were male andsignificantly, no female PIED userspresented during the period of datacollection. While the sample was comprisedof eight different nationalities, the vastmajority were Irish nationals (90%). Thedominant ethnic/cultural background wasWhite Irish (80.9%), with few participantsreporting Black or Asian backgrounds. Mostof the participants reported a heterosexualsexual orientation (90.9%). The mostcommon categories of currentaccommodation status reported wereparental home (41.6%) and private rentedaccommodation (38.2%), with almost 85%of participants residing in Dublin. There wasa varied level of education completed amongrespondents with the most widespread levelsof education completed being lowersecondary (34.1%), higher secondary(22.7%) and third level non-degree (20.5%).Almost half of the participants (48.9%) werecurrently unemployed and just under a fifth(20.7%) were in full-time employment.

What are the motivations for PIED useand the history of use?

Among the most prevalent motivations forPIED use were to increase muscle mass(91%), to increase strength (75.3%), to lookgood (62.9%), and to increase confidence(51.7%). Almost all participants (96.6%)reported lifetime injecting use of AAS, withthe average age of initiation beingapproximately 24 years old. The youngestonset of injecting use was sixteen years oldand the oldest was thirty-nine years.Approximately 69% of participants reportedlifetime use of oral AAS. The average age ofinitiation was approximately 23 years old,with the age of first use ranging from fifteento thirty-six years. In terms of the sequenceof AAS use; approximately 38% ofrespondents started using oral steroids and

then progressed to injecting steroids, 18%started using steroids orally and injectingsteroids at the same time, and 11.5%started injecting steroids and then later usedsteroids orally.

What is the nature of PIED use andtrends in use?

There was a wide spread in terms of thenumber of cycles of PIED use respondentshad undertaken over their lifetime. Justunder half of respondents were on eithertheir first cycle or second cycle of PIED use.Almost a fifth of respondents had completedfive or more cycles (18%).

The most commonly reported length of usualcycle was 6-8 weeks (29.2%). However injust over 10% of cases, the length of usualcycle was more than seventeen weeks. Interms of the AAS being used; whilerespondents reported current and past use ofa wide variety of AAS, Testosterone(single/multi esters) was by far the mostprevalently used AAS during current cycle(84%) and previous cycles (77.5%).

Other AAS used previously/currentlyincluded Nandrolone decanoate andTrenbolone acetate. Although other AASsuch as Oxandrolone, Drostanolone,Methandrostenolone, Boldenone, andOxymetholone appeared to have beenfrequently used during previous cycles,respondents reported little use of thesesubstances during their current cycles.

In terms of the use of ancillary compoundsand post cycle treatment drugs; thesubstances being used most prevalentlyduring current cycles included Creatine(23.9%) and Aromatase Inhibitors/Anti-Oestrogens (10.1%). Substances whichwere most commonly used during previouscycles included Creatine (37.5%), HCG(27.2%), Clenbuterol (25.8%), AromataseInhibitors/Anti-Oestrogens (24.7%), andClomiphene citrate (21.3%).


Chapter 4: Discussion

What are the side-effects experienced inassociation with the use of PIEDs?

Participants described experiencng a broadrange of side-effects in association with theiruse of PIEDs. Prominent side-effects whichhad been previously experienced includedincreased appetite (49.4%), increased sexdrive (46%), water rentention (44.1%),increased aggression (38.2%), growth ofexcessive body hair (36%), acne (36%),sudden mood changes (31.5%), testicularshrinkage (29.2%), decreased sex drive(33.7%), insomnia (23.6%), muscle/jointpain (22.5%), anxiety (19.1%), anddepression (18%). Although cited with lessfrequency, participants reported currentlyexperiencing a range of side-effects similarto those above.

What are the patterns of poly-substanceuse?

Participants reported the use a wide varietyof substances within their lifetime, withalcohol (95.5%), tobacco (71.6%), cannabis(68.2%), cocaine (56.8%), andbenzodiazepines (35.8%) showing thehighest levels of lifetime use. It is alsonoteworthy that a small number ofparticipants reported having ever injectedheroin (11.4%), cocaine (5.7%), and newpsychoactive substances (2.3%). Recent use(within the past month) of other substanceswas also frequently reported. Again, alcohol(62.5%), tobacco (52.3%), cannabis(39.8%), benzodiazepines (22.7%), andcocaine (17%) were the substances with themost prevalent recent use.

What is the training and exerciseprofile?

Almost all participants reported that theywere engaged in a regular training andexercise programme, with over 85% statingthat exercised four or more days a week. Interms of type of training and exercise, 91%of participants reported participation inweight training and approximately 80% ofparticipants reported participation in

cardiovascular exercise. The most frequentlycited number of weight training sessions perweek was 5-7 and the most commonnumber of cardiovascular exercise sessionsper week was 2-4. Approximately 46% ofparticipants reported current participation inorganised sport, with some participantsengaging in more than one category of sport.All of the participants� engagement in sportwas at an amateur/recreational level, withthe exception of 1 participant, who competedprofessionally. The most prevalently reportedcategories of organised sport includedbodybuilding (15.7%), boxing (10.1%), andsoccer (10.1%).

What are the injecting practices?

The majority of respondents (55%) hadlearned to inject from other PIED users,while just over 30% of participants hadlearned to inject through a harm reductionservice or medical professional. Whileintramuscular injection was the most popularmethod of injection among respondents,subcutaneous and intravenous injection wasalso reported, with some respondents usinga combination of methods. Injection in to thebuttocks was by far the most prevalentlyused site, with deltoids and quadriceps beingthe next most frequently used injecting sites.Respondents had experienced a range ofinjecting related injuries, with muscle pain(47.5%) and bruising (37.5%) among themost commonly experienced injuries. Interms of the physical environment ofinjection; four-fifths of respondents reportedthat they always injected at home, whereas2% reported that they always injected at thegym. In terms of the social environment ofinjection; over half of the respondents alwaysinjected alone, whereas 25% always injectedwith others. In terms of the administration ofinjection; 71% of respondents were alwaysinjected by another person and 16% alwaysinjected themselves. The majority ofrespondents stated that they had neverreused (84%), lent (95%), or borrowed(98%) previously used needle or syringes.

What are the levels of testing for BBVs,prevalence of BBVs, and uptake oftreatment for BBVs?

While approximately a third of participantshad last been tested for HIV in the past 12months, just under half of respondents hadnever been tested. Of those respondentswho had ever been tested for HIV, therewere no reports of a positive status. Similarresults emerged concerning testing forHepatitis C, which again illustrated that whilealmost half of respondents had never beentested, approximately a third had been testedwithin the past year. However, there werereports of positive cases, with 4.6% ofrespondents indicating that they had testedpositive for Hepatitis C. When framed interms of participants who had been testedand knew their result; positive statusesrepresented approximately 10% of theserespondents. Significantly, all participantswho reported being positive for Hepatitis Chad a past history of injecting psychoactivedrug use. Results pertaining to the treatmentstatus of participants who had tested positivefor Hepatitis C indicated that they had eithercompleted treatment, were awaitingtreatment or further tests, or had declinedtreatment. Just under half of participants hadever been tested for Hepatitis B, withapproximately a third having last been testedwithin 12 months. There were no reports ofa positive status for Hepatitis B and just overa third of respondents had been vaccinatedagainst the virus.

What are PIED users’ perspectives onharm reduction services?

Overall, participants described theirinteraction with harm reduction services inpositive terms and articulated that serviceswere particularly useful for accessing sterileinjecting equipment and information relatingto PIED use. That being said, service usersalso stated that the presence of users ofother psychoactive substances within harmreduction services and needle exchangescreated an intimidating atmosphere, whichmade them feel uncomfortable. In terms of


service provision, the primary desireexpressed by respondents was for aseparate, specialised service which cateredfor their medical needs and was dedicatedexclusively to PIED use. Other suggestionsfor service provision included having moreinformation on steroids, information availablein other languages, more advertisement ofthe service, longer opening hours, and asupervised injecting room.

4.3. INTERPRETATION OF FINDINGS

Interpretation of the age and gender profile ofthe sample indicates congruence withprevious research (see Table 1), in that, themajority of participants were males in theirtwenties. This accumulation of evidence maysuggest that this demographic range isrepresentative of the core group of adultPIED users. While a proportion of the widersocio-demographic characteristics ofparticipants were perhaps reflective of thecontext in which the research was engaged(i.e. individuals who are White Irish, residingin close proximity to the target service), therange in nationality, cultural background,sexual orientation, level of education, andoccupation evident in the findings, supportsthe notion that users of PIEDs attendingharm reduction services represent anincreasingly diverse group of individuals.Given that stigma, discrimination, and otherbarriers may impede groups such as females,members of the travelling community, foreignnationals, and sexual minorities in accessingand connecting with drug and health services(Gibbons, Manandhar, Gleeson, & Mullan,2014; HSE, 2007; Lawless, 2003), theissues of cultural competence, inclusiveness,and accessibility would appear to be pertinentsubjects for those services engaging withusers of PIEDs.

The profile of individuals, who use PIEDs fornon-medical purposes, was once associatedwith elite athletes but now encompasses amore wide-ranging population of users(Bahrke & Yesalis, 2004). The cohort ofPIED users sampled in the present studyappears to be consistent with the results

from international studies (e.g. Aitken et al.,2002; Cohen, et al., 2007) which havedemonstrated that a high proportion of usersof PIEDs are recreational and non-eliteathletes, whose primary motivations for usingsuch substances revolve around increasingmuscle mass, enhancing physical strengthand improving physical appearance. Althoughrespondents reported being heavily engagedin training, exercise, and organised sport,participation in sport did not appear to be asignificant motivation associated with use ofPIEDs, whereas involvement in recreationalweightlifting and bodybuilding did seem to behigh motivators.

In terms of the trajectory PIED use, theresults concerning age of initiation also showsimilarity to the previous evidence (e.g.Cohen et al., 2007; Larance et al., 2008;Peters et al., 1999), which has proposedthat the onset of PIED use typically occursaround the mid-twenties. Almost allparticipants had used injectable AAS, withthe popularity of injectable AAS over oralcompounds also being the dominant trendwithin the wider literature. From a harmreduction perspective this presents adilemma as although intramuscular injectionof AAS may reduce the likelihood of liverdamage (when compared to use of oralAAS), injecting use presents the risk ofrelated injuries and BBV infections (Cohen etal., 2007). As such, the use of oral orinjectable forms presents the risk of harmand highlights the difficulty in attempting toformulate harm reduction strategies relatingto the use of specific PIEDs, andaccentuates the challenges services face insetting the boundaries of harm reductionadvice. With regard to the nature of PIEDuse, the findings imply that varieties ofsingle/multi ester testosterone were themost prevalently used AAS, whichcomplements the results from previousresearch (Cohen et al., 2007). That beingsaid, the vast range of AAS and ancilliarycompounds being used by this group servesto further convolute the development of harmreduction programmes, and the training ofharm reduction professionals.

The broad range of side-effects experiencedby participants, which they attributed to theiruse of PIEDs, show similarity to the physical,behavioural, and psychological effectsdescribed within the literature (see Table 3).However, the findings of the present studydid not examine any causal links betweenuse of substances and side-effects, andthere remains a lack of definitive clinicalevidence surrounding the side-effects ofsteroids. While this ambiguity may hinder thedevelopment of interventions designed tominimise the harm associated with side-effects, the present study, as well as thewider empirical evidence highlights that PIEDusers perceive themselves as experiencing abroad range of adverse effects.Consequently, it would appear that in orderto effectively reduce the harm stemmingfrom the adverse side-effects of PIED use, amulti-tiered approach may be required.

Poly-drug use, including the combination ofillicit drugs with alcohol, and sometimes,medicines and non-controlled substances,has become the dominant pattern of druguse in Europe (EMCDDA, 2011). Evidencefrom previous studies suggests PIED usersfrequently use other illicit substances (seeTable 5) and the findings of the presentstudy signify that a relatively high proportionof participants recently used illicit drugs,particularly cannabis, benzodiazepines, andcocaine. While examination of specific trendsof concomitant use of PIEDs and other illicitsubstances were outside the scope of thepresent study, the accumulation of findingssuggest that the harm reduction needs ofthis group may extend to the use of othersubstances.

The low rates of re-using, borrowing, orlending used injecting equipment andassociated paraphernalia found in thepresent study are consistent with findingsfrom international studies (e.g. Aitkens et al.,2002; Cohen et al., 2007; Day et al., 2008;Hope et al., 2013). Considering theassociation between such injecting riskbehaviours and BBV infections, thesefindings are a positive sign. A possible


manifestation of the minimal level of injectingrisk behaviours is the low prevalence of BBVinfections found among the sample, whichagain is consistent with the low rates foundin other studies (see Table 6). That beingsaid, a high proportion of the sample had notbeen tested for BBVs previously meaningthat the prevalence reported herein mayrepresent a conservative estimate.Furthermore, the small proportion ofindividuals engaging in sharing of injectingequipment, coupled with the numbersinjecting with other people and being injectedby another person, suggest that there is thepotential for hazardous injecting practicesand a corresponding risk of BBVtransmission. Additionally, the most prevalentinjecting sites being used by participants(buttocks and deltoids) are hard to reach andintramuscular injection in to these areasrequires a forceful injecting technique (Aitkenet al., 2002). As such, injection tends to beimprecise and can lead to bleeding puncturewounds, thus heightening the risk for BBVinfection. Such injecting practices may alsocause injecting related injuries, as wasevident in the experiences of individuals inthe present study.

Taken in combination, the results emphasisethe continued need for harm reductioninterventions, such as education aroundinjecting risk and safer practices, andproviding access to regular BBV screening,in minimising the threat of personal andpublic health concerns related to injectingPIED use. As the establishment of harmreduction approaches emerged in responseto the heightening incidence of BBVs andthe identification of injecting psychoactivedrug users as a high risk group (Butler,1991), this development was primarilyreactive in nature, and it has proved difficultto curtail the high prevalence of BBVs,particularly HCV, within this population(Ashton, 2003; & 2012). The current lowprevalence of BBVs among PIED usersrepresents the opportunity for a proactiveapproach to be taken in order to maintainthis low prevalence, rather than reacting to

the prospective scenario when prevalencehas escalated (Aitken et al., 2002).

The findings in the present study concerningthe interaction between PIED users andharm reduction services highlighted that ahigh proportion of participants were attendingservices for the first time, which may besuggestive of further increases in theprevalence of PIED using attendees. Giventhat previous research has indicated thatPIED users are reticent to use services forseeking information (e.g. Larance et al.,2008), a further significant finding of thepresent study was the relatively highproportion of attendees who were motivatedto use services for the purposes of harmreduction advice. The qualitative findingsdescribe that while interactions with harmreduction services were experienced aspositive; there was a salient desire amongparticipants for a specialist service, whichwas separate from other groups of IDUs.Such findings are indicative of debate withinthe wider literature as although there isrelative general consensus regarding thepotential for harm reduction approaches tobe employed with users of PIED, the mostappropriate and effective form ofinterventions remains a point of contention(e.g., see Kimergård & McVeigh, 2014).

4.4. APPRAISAL OFMETHODOLOGY

In order to draw conclusions regarding theutility and reliability of the findings reported inthe present study, an assessment of theresearch design and methodology isrequired. In this section, the contribution ofthese factors in arriving at findings isconsidered, and an evaluation of themethodological strengths and limitations ispresented.

The utilisation of a mixed method approachwas a considerable strength of the presentstudy as the use of quantitative andqualitative approaches in concert facilitatedexamination of the profile of PIED users

accessing harm reduction services, whilealso exploring their perspectives around harmreduction service provision. The use ofpurposive sampling within the present studymeant that the research was focused onPIED users who presented to harmreductions services. While this was astrategic decision made in the attempt tocompile an evidence base which could beused to inform service provision, it meantthat the pool of potential participants to drawfrom was relatively small, and moreover,limits the generalisability of findings to thewider population of PIED users.

The design of the research instrument wasaugmented by critically appraisinginstruments used in previous research andadopting appropriate items. Confidence inthe research instrument is further bolsteredby the inclusion of multiple researchers, withdiverse areas of expertise, within the designphase. That being said, the instrument reliedon self-report, and although this method isgenerally considered to be a reliable and validform of gathering data relating to drug useand associated variables (Bell, 1998), thereremains debate regarding the accuracy ofself-report. Furthermore, it has beensuggested that self-reported data regardingsocially undesirable, illegal behaviours, orsocially marginal attitudes, may generateinaccuracy and bias (Harrison, 1995).However, considering the data werecollected in the context of a low threshold,non-judgmental harm reduction service, suchconcerns may have been somewhat offset.An area in the present study which may havebeen impacted by self-report was the resultsconcerning BBVs. Given the lack ofbiological testing, coupled with the relativelysmall proportion of participants who hadbeen tested, the results herein should beinterpreted with caution.

A further limitation of the present study wasthat quantitative analyses were descriptive innature and therefore, do not provide anyinferential information. Similar limitations areevident with regard to the qualitative findings


presented as they were drawn from openended questions rather than interview baseddata, which led to a lack in depth ofperspective. Furthermore, individuals in thecurrent study who were attending servicesfor the first time may not have had theopportunity to fully experience services. Thatbeing said, the systematic approach toanalysing qualitative data, as well as theinclusion of multiple researchers in theprocess of analyses, does contribute to ahigh level of confidence in these findings.

In summary, the research design, sampling,and instrument employed herein representkey strengths of the present study. However,there were also a number of noteworthymethodological concerns regarding thegeneralisability of findings, reliance on self-reported data, and lack of depth in terms ofstatistical analyses and qualitative data. Inlight of the dearth of previous researchconcerning harm reduction and users ofPIEDs in an Irish context, the present studyintended to provide an exploratory overviewand serve as an initial building block fromwhich to base further investigation. As such,it provides a useful examination of thephenomenon of PIED use, the divergent usercharacteristics and perspectives, and asdiscussed within the next section, speaks toa number of significant implications for futurepractice and research.

4.5. RECOMMENDATIONS

The findings of the present study spotlightthe trend around the increasing prevalence ofusers of PIEDs attending harm reductionservices. Within the following section,consideration is given to the implications ofthese findings in the form of a number ofrecommendations.

4.5.1. Recommendations for practice.

n As a group, users of PIEDs represent aminority at harm reduction services. Theincreasing prevalence of attendees, whoare using such substances, means thatharm reduction service providers, and

indeed drug and health services in thewider context, should expect to interactwith this group.

n PIED users are a diverse group ofindividuals. Service providers shouldanticipate diversity among attendees whoare users of PIEDs and endeavour toprovide accessible, inclusive andculturally competent services, whichrecognise the issues facing individuals.

n The trend of users of PIEDs attendingharm reduction services is a relativelynew phenomenon and represents amajor transition in the client base of suchservices. Professionals engaging withPIED users face several challenges incatering for the needs of this group, andtherefore, the provision of specialisttraining and education is particularlynecessary.

n Given the range of personal and publichealth concerns associated with the useof PIEDs, the need for harm reductionapproaches to be integrated within acontinuum of care is readily apparent.Interventions designed to minimise therisk of harm should include the provisionof sterile injecting equipment, BBVtesting and vaccination, and healthservices, as well as harm reductioneducation and advice on BBV infectionsand vaccinations, use of PIEDs,associated side-effects, injectingtechniques, risk behaviours, diet andtraining, use of other illicit substances,and sexual health.

n Existing harm reduction services aretraditionally geared towards users ofpsychoactive substances. Given thedivergent profile and nature of substanceuse among PIED users, there is a needto develop a tailored approach inresponse to the profile of harm withinthis group. Expanding the range andnature of models of practice may serveto enhance accessibility, engagement,and effectiveness. In particular, the

implementation and assessment of aspecialised PIED clinic on a trial basismay be a beneficial development at thistime.

n The use of PIEDs is associated with awide range of adverse impacts, whichmay manifest in physical, psychological,and/or behavioural domains. The variedneeds of this group require integrative,multi-disciplinary approaches to beconsidered, with emphasis on developinginter-agency links and establishing carepathways between general healthservices, harm reduction services, andmental health services.

4.5.2. Recommendations for research.

n The evidence base surrounding theworldwide prevalence of PIED use isgradually expanding. There is however adeficit of knowledge surrounding theepidemiology of use in an Irish context.As such, population based surveys,which examine the national prevalence ofuse among adults and adolescents,would shed light on the patterns of useand provide a basis for policy-makingand planning.

n The findings of the present study maynot be representative of the profile andperspectives of users of PIEDs, who arenot attending harm reduction services.Future research, which samples thewider population of PIED users, wouldprovide a more comprehensive portrait.

n Findings concerning BBVs in the presentstudy were based on self-report. In orderto ascertain a definitive prevalence,future research which incorporatesserological testing is recommended.

n In depth qualitative research wouldprovide a deeper understanding of theexperience and perspectives of PIEDusers, and would further facilitate theelicitation of their views regardingappropriate service provision.


n Future research exploring theperspectives of healthcare and harmreduction professionals would identifythe challenges associated with engagingwith PIED users and assess thefeasibility of developing integrative,multi-disciplinary approaches.

n Research surrounding the effectivenessof existing harm reduction serviceprovision within an Irish context isrequired to evaluate the capacity ofservices to minimise the harmsassociated with the use of PIEDs.

n Service provision in Ireland, and indeedinternationally, appears to be hinderedby the lack of public health policies andpractice guidelines relating to the use ofPIEDs. Research in this area is essentialin order to inform policy and equipservices with the infrastructure and toolsnecessary to provide effectiveinterventions.

4.6. CONCLUSION

The present study aimed to examine theprofile and perspectives of individualsattending harm reduction services who areusers of PIEDs. The findings highlight thatthe profile of service users is made up of adiverse range of individuals, with themajority client group being males in theirtwenties, who initiated use of steroids intheir late teens to mid-twenties. The groupwere using a wide range of injectable andoral steroids and ancillary substances, withthe primary motivation of enhancing physicalappearance.

The sample reported experiencing a range ofside-effects, which they associated with theiruse of PIEDs. Although relatively frequentuse of other illicit drugs was documentedamong a proportion of the sample, theprevalence of injecting risk behaviours andBBVs appears to be low. In theirperspectives, experiences of harm reductionservices had been predominantly positive,although there was a desire expressed forservices to be enhanced, particularly aroundthe provision of medical facilities. For many,attending services was an intimidatingexperience, which may have contributed tothe desire for a facility that provides aseparate service for users of PIEDs.

The present study has provided empiricalevidence concerning the emerging trend ofPIED users accessing services in an Irishcontext, and emphasises that this group hasmultiple harm reduction needs. Although thesignificant levels of risk behaviours andBBVs evidenced among other groups ofinjecting drug users do not appear to havebeen realised in this sample of PIED users,it may not be representative of the widerpopulation of users, who are not attendingservices. Considering the methodologicallimitations of the present study and thesparse evidence base surrounding theinteraction of harm reduction and PIED usein an Irish context, this research provides aninitial overview and presents a number ofpotential directions for addressing the needsof this group. As such, it offers a usefulplatform in future deliberations surroundingthe effective minimisation of harmassociated with the use of PIEDs.


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Steroid Research