Steroid Harms and Presenting problems Aye naw and

Steroid Harms and Presenting problems Aye, naw and mibbes John Campbell

Overview • The Glasgow IPED Clinic • What the media says about steroids • What harms are a possibility • What harms are a probability • Reducing the harm • Resources

Glasgow IPED Clinic • Introduced 2010 • IEP • Injecting advice and demos • Consultations • Product advice • Help with side effects • Blood testing

Breakdown of visits 2016 -2017 • 491 Clients • 486 advice and discussion • 150 for IEP • 163 for blood tests • 121 for results and discussion

B I N G O Violence Addiction Paranoia Injecting Junkie Young people HIV Depression Crazed Thug Aggression

Pumped full of steroids, sword-wielding club bouncer Moat thought he was irresistible Daily Mail 2010 • The 6 ft-plus ex-nightclub bouncer, who is addicted to steroids and anti-depressants, is so paranoid that he wired his house up with CCTV cameras and microphones.

Steroid-crazed bodybuilder knocked out drunk teen Sydney Morning herald 2004 • A steroid-crazed bodybuilder knocked a man unconscious outside a bar after a bouncer told him to "smack him” • The court heard Passakos, a computer progammer who weighed 130 kg, was drunk and on steroids when he hit Mr Gilligan at the request of his friend, bouncer Michael Rovithis.

Steroid rage driver bit pub goer and girlfriend, punched motorist and threw puppy Northern Echo Feb 2017 • A ROID-RAGE driver who mowed down his girlfriend after deliberately mounting a pavement is starting a prison sentence of nearly three years. • Bolton's barrister, Laurie Scott, said the 22 -year-old - who regularly went to the gym - knew he should not have been drinking while taking steroids to build himself up for a beach holiday. • Bolton got involved in a row about a game of pool and bit a man three times - on the chest, the left upper arm and on his neck. • After fleeing the scene, Bolton turned up in his car at the home of his girlfriend's aunt. • He the punched his girlfriend's cousin in the face when she protested about his throwing a puppy around the inside of the Renault Clio.

Syria’s ‘Ghost’ killers: Steroid-mad thugs who keep tyrant al-Assad’s murderous regime in power are terrorizing civilians Daily Mirror • Dressed in their unofficial uniform of combat trousers and black T-shirts the muscle-bound thugs are the butchers of Assad's regime. • "They were very tall and frightening and took steroids to pump up their bodies. ”

Rise of steroid junkies Daily Star 2012 • They have become obsessed with looking like muscular Arnold Scwharzenegger, 64, rather than weedy junkie Pete Doherty, 33 • But they can have horrible side effects including liver damage, heart problems, shrinking testicles and mental instability.

Spiralling anabolic steroid use leaves UK facing health time-bomb, experts warn The Guardian June 2015 • Image-obsessed young males use drug to build muscle but growing health toll includes HIV infection rate equal to that of heroin users • Steroid users are also increasingly young, with one adviser seeing a 15 -year-old who had injected the drug into his chest to try to bulk up, and anecdotal reports of boys as young as 13 using it.

Health websites • People get 'roid rage' where they are violent and sexually abusive - BBC Health website • Manic behaviour, hallucinations and delusions - NHS Choices • Users feel paranoid, irritable, aggressive or violent - Frank

Harms do occur - calculating the risk • Particular steroid used • Cycle length • Type of steroid • Time off • Method of administration • PCT • Dose (mg) • Gender • Stack • Age

Likely Harms? Potential – Cardiovascular, BBV’s Possible - Liver, kidneys, high blood pressure, prostate, baldness Common - Injecting complications, acne, fluid retention, Gynecomastia, impotence Expect - Hormone imbalance, loss of libido, erectile dysfunction, low mood, shrunken testicles, insomnia

Cardiovascular • Evidence remains limited, however. . . . • Changes in lipids • Increase blood pressure • Left ventricle hypertrophy or dysfunction • Changes to heart tissue • Changes to veins and arteries

Kidneys • Evidence remains limited, however. . . . • Blood pressure • Extreme muscle mass • Formation of scar tissue Are creatine, diuretics, pre workout significant?

BBV’s • Evidence of route of transmission remains limited, however. . . . • Prison, lack of provision, sexual transmission, previous drug use?

Unwanted effects are common after a steroid cycle finishes • After the cycle comes the crash • The body enters a ‘catabolic’ state • Testes become de-sensitised • FSH and LH are not produced/released • Oestrogen levels can rise • Lethargy and low mood can set in 18

8 Week Cycle 50 Steroid crash -low Test 45 40 35 T e s t 30 L e v e l 20 natural test 25 Steroid Test Estrogen 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 19

No one wants a steroid crash (Post Cycle Therapy) • Idea is to accelerate and restore the body’s endogenous test production • There are many different views on how this can be achieved • However, most involve the same drugs………. . 20

Post Cycle Therapy – Rationale Clomid Reduces oestrogen & stimulates the hypothalamus Nolvadex blocks negative feedback from too much oestrogen HYPOTHALAMUS Gn. RH PITUITARY LH FSH HCG shocks the testicles into action - increasing testicular mass TESTES Testosterone 21

Common Presentations Possible Trigger/Reason On or off cycle Solution Alternative solution often used by clients Loss of libido Low natural testosterone post cycle steroids used i. e. Nandrolone Off On time, pct cessation Viagra Erectile dysfunction Low natural testosterone post cycle steroids used i. e. Nandrolone Off On time, pct cessation Viagra Acne Steroid used i. e. Oxymetholone Post cycle hormone imbalance On Off cessation time, pct Acne medication Low mood Hormone imbalance post cycle Off time, pct Restart testosterone Gynecomastia High dose exogenous testosterone Post cycle hormone imbalance On Off Depends on stage of development Aromatase inhibitor PCT Surgery Fluid Retention Steroid used i. e. Dianabol On cessation or change of steroid Aromatase inhibitor, SERM or diuretic Injecting complication Unsterile preparation injecting technique contaminated substance On On On improve sterility improve technique cessation Seek help

Analysis of 301 ‘post cycle’ bloods (2016) • • 43% showed abnormal liver function 43% showed abnormal Kidney function 41% showed abnormal LH & FSH 39% showed abnormal testosterone • 68% who followed ‘recognised’ PCT recovered • 39% of those who used a bespoke PCT recovered • 37% of those who chose not to use a PCT recovered • 120 BBV tests were taken with 1 HEP C positive

Client 1 – poor PCT after long heavy use

Client 1 – HPTA poor recovery

Client 1 –abnormal kidney function

Client 1 -pre workout or creatine the culprit?

Client 2 – heavy long term user

Client 2 – shutdown HPTA

Client 2 – abnormal liver function

Client 3 – poor recovery (no PCT)

Client 4 (test only cycle)

Client 4 – good recovery

Evidence of poor quality h. GH?

Help – something's not right • Problem related visits are common • Similar issues • Usually the reason is clear • Usually the solution is clear but its not always what they want to hear The best time to discuss ‘sides’ is before the cycle starts

Client images removed to respect privacy 36

People do go their GP for help • They present on-cycle and admit using Steroids • They present on-cycle and deny using steroids • Most common - They present after cessation and do not relate problems to previous use • GP responses vary

Anabolic Steroid Induced Hypogonadism- Dr Scally • “An unproven and unfounded assumption has been made in the medical establishment that the treatment for an individual suffering from ASIH is to do nothing which is coined ‘watchful waiting’ and in time HPTA functioning will return to normal” • “Doctors are treating the symptoms of low test, not the cause” 38

Harm Reduction Advice Avoid counterfeit and underground Learn to prepare and inject properly Avoid toxic oral steroids Take regular breaks Use testosterone as a first choice? Get regular blood tests Use reasonable dosages and stacks Always consider risk and reward 39

Resources for frontline workers

If Barbie developed at the same rate as Jims action men?