Sagoeetal.SubstanceAbuseTreatment,Prevention,andPolicy (2015) 10:12 DOI10.1186/s13011-015-0006-5 REVIEW Open Access Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis Dominic Sagoe1*, Jim McVeigh2, Astrid Bjørnebekk3, Marie-Stella Essilfie4, Cecilie Schou Andreassen1,5 and Ståle Pallesen1 Abstract Background: As far as weare aware, noprevious systematic review and synthesisof thequalitative/descriptive literature on polypharmacy inanabolic-androgenic steroid(s) (AAS) users has been published. Method: Wesystematicallyreviewedandsynthesizedqualitative/descriptiveliteraturegatheredfromsearchesin electronicdatabasesandbyinspectingreferencelistsofrelevantliteraturetoinvestigateAASusers’polypharmacy.We adheredtotherecommendationsoftheUKEconomicandSocialResearchCouncil’squalitativeresearchsynthesis manualandthePRISMAguidelines. Results:Atotalof50studiespublishedbetween1985and2014wereincludedintheanalysis.Studiesoriginatedfrom 10countriesalthoughmostoriginatedfromUnitedStates(n=22),followedbySweden(n=7),Englandonly(n=5), andtheUnitedKingdom(n=4).Itwasevidentthatpriortotheirdebut,AASusersoftenusedotherlicitandillicit substances.Themainancillary/supplementarysubstancesusedwerealcohol,andcannabis/cannabinoidsfollowed bycocaine,growthhormone,andhumanchorionicgonadotropin(hCG),amphetamine/meth,clenbuterol, ephedra/ephedrine,insulin,andthyroxine.Otherpopularsubstanceclasseswereanalgesics/opioids,dietary/nutritional supplements,anddiuretics.OurclassificationofthevarioussubstancesusedbyAASusersresultedin13maingroups. Thesenon-AASsubstanceswereusedmainlytoenhancetheeffectsofAAS,combatthesideeffectsofAAS,and forrecreationalorrelaxationpurposes,aswellassexualenhancement. Conclusions:OurfindingscorroborateprevioussuggestionsofassociationsbetweenAASuseandtheuseof otherlicitandillicitsubstances.EffortsmustbeintensifiedtocombatthedebilitatingeffectsofAAS-associated polypharmacy. Keywords:Anabolic-androgenicsteroids,Ergogenicaids,Doping,Humanenhancementdrugs,IPEDs, Polypharmacy,Stacking,Metasynthesis,Qualitativeresearch Introduction effects,andallowrecoveryofnaturalhormonalfunctioning. Anabolic-androgenic steroid(s) (AAS) refer to testosterone During ‘on cycles’ users sometimes combine different and its synthetic derivatives mainly used nonmedically for injectableandoralAAS.Thisphenomenonisreferredtoas enhancing muscle growth and strength, boosting physical ‘steroidstacking’orsimply‘stacking’[2]. activity or sports performance, and for aesthetic purposes There is also a trend referred to as ‘blast and cruise’ or as well as for enhancing psychological well-being [1]. AAS ‘bridging’ – a continuous ‘on cycle’ whereby many users aretypicallyusedinphasesreferredtoas‘cycles’:‘oncycles’ never go off AAS but alternate between periods of high referringtospecificperiodswhentheusersadministerAAS doseintakeduringa‘blast’phase,andlowdoseintakedur- and ‘off cycles’ referring to an AAS-free phase intended to ing a ‘cruise’ phase. Another way of administering AAS is preventtolerancetowardsAAS,lessenthepossibilityofside called ‘blitz-cycles’, which implies rapidly changing AAS withtheaimofpreventingtoleranceandandrogenreceptor down-regulation. Moreover, many users complement AAS *Correspondence:[email protected] useorstackingwiththeuseofothersubstances.Inthisre- 1DepartmentofPsychosocialScience,UniversityofBergen,Christiesgate12, 5015Bergen,Norway spect, AAS use has been found to be associated with the Fulllistofauthorinformationisavailableattheendofthearticle ©2015Sagoeetal.;licenseeBioMedCentral.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle, unlessotherwisestated. Sagoeetal.SubstanceAbuseTreatment,Prevention,andPolicy (2015) 10:12 Page2of19 use of both licit and illicit substances in systematic reviews qualitative approaches (interviews, focus groups, or case ofpredominantlyquantitativeliterature[3,4]. studies) in data collection, (b) studies delineated or de- It has been noted that one of the major drawbacks to scribed licit and illicit substances used nonmedically by successful AAS interventions is public health officials’fail- AASusers,and(c)studieswerepublishedinEnglish. ure to recognize AAS users’ extensive pharmacological Weagaininspectedthecharacteristicsofextractedstud- regimen[2].Asynthesisofthequalitativeordescriptivelit- iesforsimilaritiestocurbduplicateextractionandsynthe- erature on polypharmacy by AAS users is, both from a sis.TheliteraturesearchwascompletedinJune2014.The clinicalandresearchperspective,importantinordertoin- literature search strategy adhered to Shaw et al.’s [5] rec- creasetheunderstandingofthepolypharmacyoftenassoci- ommendations for qualitative literature search as well as ated with AAS use. Such a literature review and synthesis thePreferredReportingItems for SystematicReviews and is also valuable in terms of the development and strength- Meta-Analyses(PRISMA)guidelines[6].Figure1presents ening of AAS use and harm reduction interventions as theliteraturesearchprocess. such investigation will deepen existing knowledge on the various substances used and the specific function they Dataextractionandsynthesis serve,whichinsomecasesdeviatessignificantlyfromtheir Thefirstauthorconductedthestudyscrutinyandselection. formal medical indications. Furthermore, results of such Analysis of the studies was conducted using Smith et al.’s investigationwouldcomplementevidenceemanating from [7] Interpretative Phenomenological Analysis (IPA). Each a systematic review of mostly quantitative evidence [3] full-textpaperwasregardedasatranscript.Thefirstauthor in the effort to elucidate the phenomenon of polysub- (DS)readthroughthefull-textpapersseveraltimes,gaining stance use by AAS users. However, as far as we are an overall sense of the themes in the studies through this aware, a systematic review and synthesis of the qualita- process.Thesethemeswerethenhighlighted.Usingastan- tive or descriptive literature on polypharmacy by AAS dardized data extraction form, the first author and another users has notbeen published. reviewer independently extracted the following data from Against this backdrop, we conducted the first system- theincludedstudies: author name and publication year, atic review and synthesis of the qualitative or descriptive country, study type, type of AAS users involved in the studiespresentingdataontheuseofotherlicitandillicit study, and recruitment site or mode. To assess the substances among AAS users. The research questions quality of the extraction, we calculated inter-reviewer guiding the present study were: (a) what substances do reliability for the two reviewers in SPSS version 20 AAS users report consuming prior to their AAS debut? (IBM Corp.) [8]. DS then independently coded the (b) what ancillary or supplementary substances do AAS full-text papers by substance used and reason(s) or users report using? and (c) what reasons do AAS users motive(s) for use. Study characteristics are presented assignfor usingthesesubstances? in Table 1. We have presented all the studies that fall under each substance. Method Searchstrategyandinclusioncriteria We searched in PsycINFO, PubMed, ISI Web of Science, Classificationofsubstances andGoogleScholarforliterature.ForsearchesinPubMed We sought to classify the various non-AAS substances and ISI Web of Science, ‘anabolic steroid’, ‘doping’, and used by AAS users into meaningful groups. First, SP pro- ‘performance enhancing drug’, were each combined with vided a functional categorization of the substances. Ac- ‘interview’,‘focus group’, and ‘qualitative’. These combina- knowledging that some AAS users self-administer these tions were not practical in PsycINFO and Google Scholar substancesforpurposescontrarytotheirconventionaluse, as they produced voluminous redundant hits. Thus,‘ana- DS built on SP’s classification by allocating the substances bolic steroid+doping+performance enhancing drug+ into SP’s groups based on motives for use as presented by interview+focus group+qualitative’ was used in searches usersintheliterature.Forsubstancesforwhichmotivefor in PsycINFO and Google Scholar. From a total of 10,106 use was not delineated in the literature, DS grouped them hits,7,720articleswereassessedaftertheremovalofdupli- based on Evans-Brown et al.’s [2] classification of human cates.Wealsoinspectedreferencesofrelevant studiesand enhancement substances and a classification by the searchedinonlinedatabasesandwebsites. Norwegian Institute of Public Health [59]. JM inspected This search yielded 15 new articles. Based on titles and thegroupingandprovidedfurtheradvice.Next,DSallo- abstracts, 106 full-text papers were retrieved for screening catedsubstancesthatatthisstagecouldnotbeallocated after initial evaluation of the 7,735 papers. After screening intogroupsbasedonthethreepreviousmethodsbyrefer- ofthe106full-textpapers,79papersweredeemedrelevant ringtoMedscapeDrugReferenceandWikipedia[60].We forinclusion.Thus,ofthe79papersscrutinized,50studies reached consensus on the classification through further satisfied the following inclusion criteria: (a) studies used reviewanddiscussion. Sagoeetal.SubstanceAbuseTreatment,Prevention,andPolicy (2015) 10:12 Page3of19 Figure1Flowdiagramofsystematicliteraturesearch. Results and discussion presentedbytenstudies[17,21,24,26-29,34,47,53].Themost Descriptionofstudiesandinter-reviewerreliability prominent of these substances were alcohol, amphetamine, A total of 50 studies were included in the metasynthesis. cannabis, and cocaine. Others were analgesics/opioids, her- Participants’ ages ranged from 14 [34] to 66 years [51]. oin,stimulants,anddietary/nutritionalsupplementssuchas The year of publication of the studies ranged from 1985 creatine, and protein powder as well as other unspecified [55]to2014[12,13,30].Studiesoriginatedfrom 10coun- licitandillicitsubstances(seeTable2). tries with the highest number from the United States InKanayamaet al.’sstudy[26]: (n=22),followed by Sweden (n=7), England only (n=5), the United Kingdom (n=4), Australia (n=3), and [AAS] usersdisplayedmuchhigherratesofotherillicit Scotland only (n=2). Additionally, one study originated druguse,abuse,ordependencethannon-users,with from Canada, Denmark, France, Iran, and Wales only re- useofotherillicitsubstancesalmostalwayspreceding spectively. One study [16] originated from Australia, firstuseofAAS(p.77). Canada, and USA while another described the sample as European [43]. Thirty studies used interviews A recent study by Cornford, Kean, and Nash [13] also [10-12,17,19-22,24,27,28,30-32,34-38,40-43,45,47,48,51,53, highlightsheroinuseasaprecursor toAASuse: 55,58], seven were case studies [9,23,29,39,49,50,57], one used interviews and focus groups [13], and twelve Aquick way tomakeyourself lookhealthy, isn’tit, [14-16,19,25,26,33,44,46,52,54,56] used interviews sup- withoutbeingembarrassedaboutbeingonheroin [is ported by a questionnaire. For the studies that used both touseAAS],doyou knowwhat Imean.It[heroin] interviews and questionnaires, we relied on the qualitative doestakealotofyour confidence awaydon’titand or descriptive results generated from the interviews. There like Isay, especially,Iloseweightprettyfastwhen I’m wasverygoodagreement(Kappa=0.82,p<0.001)between onheroin,doyouknowwhatImean. It[AASuse]is the two reviewers [61]. Through further analysis and dia- aquick way tojustmakeyourselflookhealthyagain, logueagreementwasreachedondiscrepantextractions. isn’tit(p.2). SubstancesusedpriortoAASinitiation Furthermore, it is important to note that our data also Before their AAS use debut, some users had experimented suggested that AAS use may precede the use of other with or were regular users of other substances. This was substancesfor someindividuals. InHoff’sstudy [24]: Table1Characteristicsofqualitative/descriptivestudiespresentingdataonpolypharmacyinAASusers S a g Firstauthor,year, Country Studytype AASusers Recruitmentsite/mode Non-AASsubstanceseverused o e reference e t a Ahlgrim2009[9] USA Casestudy 41-year-oldmaleformer Hospital Captopril,carvedilol,digoxin,furosemide,growthhormone, l. bodybuilder hydrochlorothiazide,spironolactone,torsemide, Su b Angoorani2009 Iran Interview 843bodybuildersaged16to Gymnasium Amphetamine sta n [10] 40years c e A Bilard2011[11] France Interview 203bodybuilders Voluntary Beta-2-agonists,cannabinoids,glucocorticosteroids, b u peptidehormones se T Chandler2014[12] UK Interview 8persons Onlineforums,syringe Aromataseinhibitors,clenbuterol,2,4-dinitrophenol,clomiphene, re a exchangecenter diuretics,ephedrine,growthhormonereleasingpeptide,growth tm hormone,humanchorionicgonadotropin(hCG),insulin- en likegrowthfactor1,insulin,mechanogrowthfactor,melanotan, t, P mephedrone,tamoxifen,thyroidhormones,viagra®/cialis® re v e Cornford2014[13] England fInotceursvigewrouapnd 30malesaged20to40years Syringeexchangecenter Heroin ntion , a Davies2011[14] England Interviewand 9malebodybuilders Gymnasium Creatine,dietarysupplements n questionnaire† dP o Dunn2010[15] Australia Interviewand 70persons Community Alcohol,cannabis,cocaine,ecstasy,gammahydroxybutyrate, licy questionnaire† hallucinogens,inhalants,ketamine,amphetamine (2 0 Filiault2010[16] Australia,Canada, Interviewand 16gaymaleathletesaged18 Gaysportinggroups Creatine,dietarysupplements,growthhormone,recoverydrinks 15 USA questionnaire† to52years ) 1 0 Fudala2003[17] USA Interview 7malesaged22to33years Gymnasiumandcommunity Alcohol,analgesics,cannabis,cocaine,stimulants,growth :12 hormone,humanchorionicgonadotropin(hCG),insulin-like growthfactor1 Gårevik2010[18] Sweden Interview 45offenders;meanage30years Policestation Amphetamine,anti-oestrogens,benzodiazepines,cannabis, clenbuterol,cocaine,diazepam,ephedra,ephedrine,growth hormone,humanchorionicgonadotropin(hCG),heroin, insulin,sildenafil Goldfield2009[19] Canada Interviewand 8femalebodybuilders Gymnasium Diuretics,laxatives questionnaire† Gruber1998[20] USA Interview 19femaleweightlifters Gymnasium Clenbuterol,ephedrine,narcotics/otherdrugs Gruber1999[21] USA Interview 5femalebodybuilders Gymnasium Alcohol,cannabis,cocaine,clenbuterol,dietarysupplements,other drugs,otherperformance-enhancingdrugs Gruber2000[22] USA Interview 25femaleweightlifters;mean Gymnasium Aminogluthemide,amphetamine,caffeine,clenbuterol,diuretics, age31years ephedrine,hydroxylbutyrate,humanchorionicgonadotropin (hCG),growthhormone,laxatives,nalbuphine,otheropioids, tamoxifen,thyroidhormones,yohimbine Hegazy2013[23] USA Casestudy 28-year-oldmale Clinic Alcohol,amphetamine,opioids Hoff2012[24] Sweden Interview 11male(10powerlifters,1 SwedishSports Alcohol,amphetamine,cocaine,narcotics,others P weightlifter) Confederation a g e Hope2013[25] Englandand Interviewand 340injectingdrugusers Syringeexchangecenter 2,4-dinitrophenol,alcohol,amphetamine,anti-oestrogens, 4 Wales questionnaire† clenbuterol,cocaine,ephedrine,erythropoietin,growth of hormone,humanchorionicgonadotropin(hCG),insulin, 19 Table1Characteristicsofqualitative/descriptivestudiespresentingdataonpolypharmacyinAASusers(Continued) S a g o melanotanII,nalbuphine,thyroidhormones,diuretics,PDE5i, e viagra®/cialis® et a Kanayama2003 USA Interviewand 48maleweightlifters;meanage Gymnasiumandsports Alcohol,cannabis,cocaine,opioids,othernarcotics/illicitdrugs l.S [26] questionnaire† 29years supplementstore ub sta Kanayama2003 USA Interview 24maledrugusers;meanage Clinic Alcohol,cocaine,heroin,nalbuphine,opioids,oxycodone n c [27] 32years e A b Kanayama2009 USA Interview 62maleweightlifters Gymnasiumandsports Alcohol,cannabis,cocaine,opioids,otherperformance- u [28] supplementstore enhancingdrugs,otherdrugs se T re Katz1990[29] USA Casestudy 23-year-oldmalebodybuilder Gymnasium Alcohol,cocaine a tm Kimergård2014 Englandand Interview 24malesaged21to61years; Gymnasium,prison,steroid Amphetamine,clenbuterol,growthhormone,ephedrine,human en [30] Wales meanage34years clinicandcharity,syringe chorionicgonadotropin(hCG),insulin,melanotanII,sildenafil, t, P exchangecentre tamoxifen re v e Klötz2010[31] Sweden Interview 5323ymeaalresprisonersaged21to Prison Acanftfeidineep,recsasnannatsb,isa,nctei-notersatlrostgimenu,laatsipnigrind®r,ubges,nczloednibauzeteprionle,sc,reatine, ntion diuretics,ephedrine,Gammahydroxybutyrate,insulin-likegrowth ,a n factor1,insulin,genotropine,musclerelaxingdrugs,myoblast, d opiates,otherdrugs,potencyincreasingdrugs, Po somatotropine,testicularfunctionrecoveringhormones lic y Korkia1993[32] England,Scotland, Interview 110persons(13female)aged16 Clinic,gymnasium,syringe Antibiotics,corticosteroids,dietarysupplements,diuretics, (2 0 andWales to63years exchangecentre esiclene,humanchorionicgonadotropin(hCG),oestrogen- 1 5 antagonistdrug,growthhormone,thiomucase,thyroxine ) 1 0 Korkia1996[33] England Interviewand 15females;meanage28years Notspecified Clenbuterol,growthhormone,nolvadex,nubain®, :12 questionnaire† thiomucase,triacana Kusserow1990 USA Interview 72(6female)persons(mostly Notspecified Alcohol,bloodpressureregulators,‘downers’,estrogen [34] adolescents);14to25years;mean inhibitors,growthhormone,cannabis,Recreationalsubstances/drugs,‘uppers’ age20years Larance2008[35] Australia Interview 60malesaged17to59years Gymnasium,internet Anti-oestrogenicagents,aspirin®,benzodiazepines,caffeine, forums,supplementshops cannabis,cocaine,clenbuteroldehydroepiandrosterone(DHEA), diuretics,ecstasy,hallucinogens,heroin,humanchorionic gonadotrophin(hCG),ephedrine,growthhormone, inhalants,insulin-likegrowthfactors,insulin,meth/amphetamine, thyroxine Lenehan1996[36] England Interview 386personsaged17to56years; Gymnasium Clenbuterol,corticosteroids,diuretics,growthhormone,human meanage28years chorionicgonadotropin(hCG),thyroxine,insulin-likegrowth factor1,nubain®,tamoxifen Lundholm2010 Sweden Interview 924(20female)persons Prison Benzodiazepines,cannabis,cocaine,meth/amphetamine,opiates [37] Malone1995[38] USA Interview 77(6female)powerliftersand Gymnasium Alcohol,cocaine,hallucinogen,opioids,sedatives,stimulants, bodybuilders tetrahydrocannabinol,tobacco McBride1996[39] Wales Casestudy 3males:1AASdealerandroofer Notspecified Amphetamine,cannabis,clenbuterol,humanchorionic P aged27years,1bodybuilder gonadotropin(hCG),nalbuphine,tamoxifen,temazepam ag e aged22years,and1gymowner 5 aged26years) o f 1 9 Table1Characteristicsofqualitative/descriptivestudiespresentingdataonpolypharmacyinAASusers(Continued) S a g o McKillop1987[40] Scotland Interview 8malebodybuildersaged17to Gymnasium Furosemide,thiazides,thyroxine,humanchorionicgonadotropin e 32years (hCG) et a Moss1992[41] USA Interview 50malebodybuilders Gymnasium Clomiphenecitrate,humanchorionicgonadotropin(hCG) l.S u b Moss1993[42] USA Interview 30malebodybuilders Gymnasium Clomiphenecitrate,humanchorionicgonadotropin(hCG) sta n Pappa2012[43] Europe Interview 9athletesaged19to26years Communityviasnowball Analgesics,amphetamine,caffeine,cannabis,dietarysupplements, c e sampling diuretics,erythropoietin. A b u Perry1990[44] USA Interviewand 20maleweightliftersaged18 Gymnasium Humanchorionicgonadotropin(hCG) se questionnaire† to28years Tre a Perry2003[45] USA Interview 10maleweightliftersaged21 Gymnasium Aspirin®,caffeine,clomiphene,creatine,dietarysupplement, tm to40years ephedrine,glutamine,liothyronine,proteinpowder,yohimbine en t, Peters1997[46] Australia qInuteersvtiioenwnaanirde† 1to0050peyresaornss(6female)aged18 Aindtevrevriteiswesm,reandtiso,,gsypmorntasssiuhmop,s Abllocockheorls,,acmafifneoingelu,tchainmniadbei,s,acmhprohmetiaumminpei,caonlintibatioe,ticclse,nbbeutaterol, Prev e aenxcdhaasnsgoeciacetinotnrse,syringe cgorocwainthe,hdoaromnoiln®,ed,hieutamryansucphpolreimoneicntg,odniuardeotictrso,peicnst(ahsCyG,e),phedrine, ntion hydroxocobalamin,insulin-likegrowthfactor1,insulin,oestrogen ,a n antagonist,pregnyl®,proviron®,teroxin(T3),thyroxine d P Pope1988[47] USA Interview 41malebodybuildersand Gymnasium Alcohol,cannabis,cigarettes,cocaine,humanchorionic olic footballers gonadotropin(hCG) y (2 Pope1994[48] USA Interview 88athletes;meanage26years Gymnasium Alcohol,cannabis,tobacco 0 1 5 Rashid2000[49] USA Casestudy 40-year-oldmale Clinic Cocaine,cannabis,‘uppers’,‘downers’,lysergicaciddiethylamide ) 1 0 (LSD) :1 2 Schäfer2011[50] Denmark Casestudy 26-year-oldmalebodybuilder Clinic Erythropoietin Silvester1995[51] USA Interview 22formerathletesaged36to Notspecified Growthhormone 66years Skårberg2007[52] Sweden Interviewand 18maledrugusers;meanage Clinic Alcohol,narcotics/otherdrugs questionnaire† 35years Skårberg2008[53] Sweden Interview 6drugusers(2female) Clinic Alcohol,amphetamine,analgesics,anti-catabolics,anti-oestrogens, aspirin®,benzodiazepines,bronchodilators,buprenorphine, caffeine,cannabis,cocaine,codeine,conjugatedlinoleicacid, creatine,dietarysupplements,ecstasy,ephedra,ephedrine,growth hormone,Herbalproducts,insulingrowthfactor1,insulin,protein powder,testosteronereleasers Skårberg2009[54] Sweden Interviewand 32maledrugusers Clinic Alcohol,amphetamine,anti-oestrogen(clomid),analgesics, questionnaire† anti-acnedrug,anti-catabolics,anti-depressants,anti-hypertensive drugs,anti-oestrogens,benzodiazepines,bronchodilators,cannabis, cocaine,creatine,dietarysupplements,diuretics,ephedrine,fat-loss agents,gammahydroxybutyrate,growthhormone,heroin,insulin, insulin-likegrowthfactor1,levodopa,muscleoil(synthol), non-steroidalanti-inflammatorydrugs,opioid,plantsteroid compounds,proteinpowder,stimulants,testosteroneboosters, P thyroidhormone ag e Strauss1985[55] USA Interview 10weight-trainedfemale Personalcontact Acetaminophen,aspirin®,benoxaprofen,Ben-Gay®,caffeine, 6 o athletes;meanage33years calcium,cholineandinositol,dietarysupplements,dimethyl f 1 9 Table1Characteristicsofqualitative/descriptivestudiespresentingdataonpolypharmacyinAASusers(Continued) S a g o sulfoxide,codeine,electrolytesolution,epinephrine,furosemide, e growthhormone,levodopa,lidocaine,naproxen,oxycodone et hydrochloride,phenylbutazone,piroxicam,potassium,suntan al. pills,thyroglobulin,vitamins Su b Tallon2007[56] Scotland Interviewand 30malesaged18to43years; Gymnasium Alcohol,cannabis,cocaine,clenbuterol,dietarysupplements, sta questionnaire† meanage27years diuretics,ecstasy,growthhormone,insulin,tamoxifen nc e A Wilson-Fearon England Casestudy 29-year-oldbodybuilder Notspecified Clenbuterol,dietarysupplements,diuretics,growthhormone, b u 1999[57] humanchorionicgonadotropin(hCG),thiomucase se T Wines1999[58] USA Interview 11weightlifters(5female)aged Gymnasium Alcohol,buprenorphine,heroin,hydrocodone,nalbuphine,other re a 19to42years drugs tm e †Wereliedonthequalitativeresultsgeneratedfromtheinterview. nt, P re v e n tio n , a n d P o lic y (2 0 1 5 ) 1 0 :1 2 P a g e 7 o f 1 9 Sagoeetal.SubstanceAbuseTreatment,Prevention,andPolicy (2015) 10:12 Page8of19 Table2Non-AASsubstancesusedbeforeAASusedebut,reason(s)/motive(s)foruse,andstudies Substance Reason(s)foruse Studies(Firstauthor,reference) Alcohol Bettersleepandrelaxation Fudala[17];Gruber[21];Hoff[24];Kanayama[26];Katz[29]; Kusserow[34];Perry[47];Skårberg[53] Amphetamine Boostingtraining,alertness, Hoff[24];Skårberg[53] psychologicalwellbeing Analgesics/opioids† Painrelief Kanayama[26] Cannabis NS Fudala[17];Hoff[24];Kanayama[26];Kusserow[34];Perry[47] Cocaine NS Fudala[17];Gruber[21];Kanayama[26];Katz[29];Perry[47] Creatine Boostingtraining Skårberg[53] Dietary/nutritionalsupplements† Boostingtraining,energy Skårberg[53] Heroin NS Cornford[13] Proteinpowder Boostingtraining Skårberg[53] Stimulants† NS Kusserow[34] OtherIPEDs,licitandillicitsubstances NS Gruber[21];Hoff[24];Kanayama[27,28];Perry[47] IPEDs:Imageandperformance-enhancingdrugs. NS:Notspecified. †Substanceclass-notspecified. Respondent8reportedusingnarcoticsafterhehad Lifetimepolypharmacy startedusingAAS.Inthiscase,alcoholanddrugabuse We also investigated lifetime use of other substances by cannotexplainwhyhestarteddoping[usingAAS]. AAS users. The most popular substances (declared in However,AASuseseemstohaveledhimintodruguse multiple studies) were: 2,4-dinitrophenol (DNP), alcohol, andcriminalityinordertofinancehisextensiveAASuse aminogluthimide,amphetamine/meth,aspirin®,buprenorphine, andinvestmentinelitepowerlifting.Thisrespondent caffeine, cannabis/cannabinoids, clenbuterol, clomiphene becameaggressiveandviolentwhenhecombinedAAS citrate, cocaine, codeine, creatine, ephedra/ephedrine, andalcohol.Duetothesesideeffectshechangedfrom erythropoietin(EPO),furosemide,gammahydroxybutyrate alcoholtococaineashisprimarysocialdrugwhenhe (GHB), growth hormone, heroin, human chorionic wasonAAS(p.63). gonadotropin (hCG), insulin, insulin-like growth factor 1 (IGF-1), ketamine, levodopa, lysergic acid diethylamide (LSD),melanotan,nalbuphine/nubain®,oxycodone,protein Useofsupplementary/ancillarysubstances powder, sildenafil/viagra®/cialis®, tamoxifen, thiomucase, AASusers often engaged instacking and the use of vari- thyroxine, and yohimbine. Other popular classes of ous licit and illicit substances during their ‘on cycles’ as substances presented were analgesics/opioids, antibiotics, previously shown. For instance, in a study by McBride anti-catabolics, anti-oestrogens, benzodiazepines, blood [39], “…Mr B had initially used nalbuphine in conjunc- pressure regulators, bronchodilators, dietary/nutritional tion with anabolic steroids, clenbuterol, ephedrine, and supplements,diuretics,hallucinogens,inhalants,stimulants, tamoxifen, all to aid bodybuilding” (p. 69). Indeed, in a andtestosteronereleasers/boosters. study [46] of 100 AAS users: “A number of other drugs Of the above substances, the most commonly identified were used in addition to AAS as part of their training in studies include alcohol, cannabis/cannabinoids, cocaine, routineby49%ofthesample”(p.49). growth hormone, human chorionic gonadotropin (hCG), The most popular supplementary/ancillary substances amphetamine/meth,clenbuterol,ephedra/ephedrine,insulin, declared by AAS users in multiple studies were: alcohol, and thyroxine. Commonly identified classes of substances amphetamine/meth, aspirin®, caffeine, cannabis/cannabi- include analgesics/opioids, dietary/nutritional supplements, noids,clenbuterol,clomiphenecitrate,cocaine,codeine,cre- diuretics,andanti-oestrogens(seeTable3). atine,ephedra/ephedrine,erythropoietin,furosemide,gamma hydroxybutyrate (GHB), growth hormone, heroin, human chorionic gonadotropin (hCG), insulin, insulin-like growth Groupsofnon-AASsubstancesusedbyAASusers factor 1 (IGF-1), melanotan, nalbuphine/nubain®, protein Our classification of the various substances used by AAS powder, tamoxifen, thyroxine, and tobacco. Other popular users resulted in13maingroups: analgesics/non-steroidal classes of substances presented were analgesics/opioids, anti-inflammatory drugs/opioids, anti-oestrogens, cardio- anti-oestrogens, benzodiazepines, dietary/nutritional supple- vascular drugs, central nervous system depressants, cen- ments,diuretics,hallucinogens,andstimulants(seeTable3). tral nervous system stimulants, cosmetic drugs, dietary/ Sagoeetal.SubstanceAbuseTreatment,Prevention,andPolicy (2015) 10:12 Page9of19 nutritional supplements, diuretics, fat burning/weight loss Fatburning/weightlossdrugs drugs,muscle/strength-enhancementhormones,non-hor- These drugs include 2,4-dinitrophenol (DNP), conju- mone muscle/strength-enhancement drugs, recreational gated linoleic acid, and teroxin (T3) and were used for substances/drugs, and sexual enhancement drugs (see suppression of appetite, increased metabolism, and re- Table 4). These groups of substances are briefly discussed duced absorption of body fat as a means to burning below. body fatandlosingweight. Analgesics/non-steroidalanti-inflammatorydrugs/opioids Muscle/strength-enhancementsubstances Thesedrugsincludeaspirin®,codeine,andoxycodone.This Two types of muscle/strength-enhancement substances group of drugs was used for relieving inflammation, pain, were presented in the literature: hormones and non- and fever emanating from exercise, sports participation or hormones. Examples of muscle/strength-enhancement therecreationalandoccupationalactivitiesofAASusers. hormones are growth hormones, growth hormone re- leasing peptide (GHRP), and insulin. Non-hormone Anti-oestrogens muscle/strength-enhancement drugs include clenbuterol Anti-oestrogens include aminogluthimide, clomiphene, used by some in an attempt to enhance the size and and tamoxifen. These drugs were used for reducing the structureofmuscles,aswellasboostingstrength. oestrogen-likesideeffectsofAASusesuchaspreventing gynecomastia. They were also used for endurance, im- proved testosteroneproduction,andburning bodyfat. Recreationalsubstances/drugs Recreationalsubstances/drugssuchascannabis/cannabinoids, Cardiovasculardrugs cocaine,andlysergicaciddiethylamide(LSD)wereusedto These drugs such as captopril, carvedilol, and digoxin alter experiences, elevate mood, and create psychological were used for improved functioning of the cardiovascular wellbeingaswellasforrelaxation. system such as lowering blood pressure and reducing the riskofmyocardialinfarction,aswellasburningbodyfat. Sexualenhancementdrugs Centralnervoussystemdepressants These drugs such as phosphodiesterase-5 inhibitors Examples of depressants are buprenorphine, hydrocodone, (PDE5i), melanotan II, and sildenafil were used for deal- and oxycodone. The purposes for which these drugs were ing with testicular atrophy, improved sexual desire or usedwereimprovedsleep,relaxation,andelevationofmood. arousalaswellaserectilefunctioning. Centralnervoussystemstimulants Insum,theabovegroupsofsubstanceswereusedtoen- Stimulants includingepinephrine, amphetamine/metham- hance the effects ofAAS, combat the side effects of AAS, phetamine, and yohimbinewereusedforalertness, boost- andforrecreationalorrelaxationpurposes,aswellassex- ing training, burning body fat, increased aggression and ual enhancement. It is important to note that there is strength(includingsexual),andpsychologicalwellbeing. overlap between some of the groups. For instance, some central nervous system depressants may be misused for Cosmeticdrugs promoting sleep as well as their analgesic properties. Cosmetic or aesthetic drugs such as esiclene, melanotan Again,some muscle/strength-enhancement hormones are II, and thiomucase were used in order to deal with acne, used for direct muscle enhancing properties and others and for: inflammatory effects on smaller muscles, skin for counteracting shutdown of endogenous testosterone tanning, and a leaner physique thus enhancing physical production.Additionally,someofthesubstancesare used appearance. for multiple purposes. For instance, melanotan II is used fortanningtheskinandalsoasself–treatmentforerectile Dietary/nutritionalsupplements dysfunction resulting from long-term AAS use. Others These supplements such as calcium, glutamine, and po- mayusemelanotanIItoself-treatspecificconditionssuch tassium were consumed to provide essential nutrients to as rosacea or fibromyalgia and others may use melanotan supplementthe dietandcombattheriskofillness. for the self-reported weight loss effects due to appetite suppression. It is also important to note that some of the Diuretics alleged properties or uses are not scientifically well docu- Diuretics such as furosemide, hydrochlorothiazide, and mented such as the use of insulin for burning body fat spironolactone were used for combating side effects of [54]. Furthermore, the quality, safety, and efficacy of sub- AAS use such as water retention, together with masking stancesobtained fromtheillicitmarketcannotbeknown, theuseofAASandotherdopingagents. withadulterationusuallycommonplace[2,63]. Table3Useofnon-AASsubstances,reason(s)/motive(s)foruse,andstudies S a g Currentpolypharmacy(CombinedwithAAS) Lifetimepolypharmacy(Everuse) o e e Substance Reason(s)foruse Studies(First Reason(s)foruse Studies(First Numberof t a author,reference) author,reference) studies l. S u 2,4-dinitrophenol NS Chandler[12] NS Chandler[12];Dunn[15];Hope[25];Larance 4 b [35] sta n c Acetaminophen NS Strauss[55] NS Strauss[55] 1 e A b Alcohol Bettersleepandrelaxation Chandler[12];Hegazy[23]; Bettersleepandrelaxation Chandler[12];Dunn[15];Fudala[17];Gruber 23 u Kanayama[28];Kusserow[34]; [21,22]; se T Lundholm[37];Malone[38]; Hegazy[23];Hoff[24];Hope[25];Kanayama re a Peters[46];Perry[48];Skårberg [26-28]; tm [52-54] Katz[29];Kusserow[34];Malone[38]; e n Peters[46]; t, P Perry[48];Skårberg[52-54];Tallon[56]; re Wines[58] ve n Aminogluthimide Reducingreceptors’attraction Peters[46] Reducingreceptors’attraction Gruber[22];Peters[46] 2 tion tocortisol tocortisol ,a n d Amylnitrate NS Chandler[12] NS Chandler[12] 1 P o Analgesics/opioids† Painrelief Ahlgrim[9];Hegazy[23]; Painrelief Ahlgrim[9];Fudala[17];Gruber[22]; 14 lic y Kanayama[28];Klötz[31]; Hegazy[23]; (2 Kusserow[34];Lundholm[37]; Kanayama[26,28],Klötz[31];Kusserow 0 1 Malone[38];McBride[39]; [34];Malone 5 Pappa[43];Skårberg[53] [38];McBride[39];Pappa[43];Rashid[49]; ) 10 Skårberg :1 2 [53,54] Anti-acnedrugs† – – Combatingacne Skårberg[54] 1 Antibiotics† Combatingacne Peters[46] Combatingacne Korkia[32];Peters[46] 2 Anti-catabolics† NS Skårberg[53] Facilitatingsynthesisofhepatic Skårberg[53,54] 2 proteinandnitrogeneconomy Anti-depressants† Combatingsideeffects Klötz[31] Combatingsideeffects,depression Klötz[31];Skårberg[54] 2 relief,boostinglevelsofserotonin andnoradrenaline Anti-oestrogens† Burningfat,combating Klötz[31];Kusserow[34]; Combatinggynecomastia,burning Gårevik[18];Hope[25];Klötz[31]; 9 gynecomastia, Peters[46];Skårberg[53] fat,reducingeffectsonoestrogen Korkia[32]; reducingeffectsonoestrogen Kusserow[34];Larance[35];Peters[46]; Skårberg [53,54] Aromataseinhibitors† NS Chandler[12] NS Chandler[12] 1 Aspirin® NS Klötz[31];Perry[45];Skårberg NS Klötz[31];Larance[35];Perry[45]; 5 [53];Strauss[55] Skårberg[53]; Strauss[55] P a Ben-Gay® NS Strauss[55] NS Strauss[55] 1 ge 1 0 o f 1 9