Variability and dilemmas in harm reduction for anabolic steroid users in the UK

13 Pages·2014·0.28 MB·English

LJMU Research Online
Kimergård, A and McVeigh, J
Variability and dilemmas in harm reduction for anabolic steroid users in the
UK: a multi-area interview study
http://researchonline.ljmu.ac.uk/id/eprint/2113/
Article
Citation (please note it is advisable to refer to the publisher’s version if you
intend to cite from this work)
Kimergård, A and McVeigh, J (2014) Variability and dilemmas in harm
reduction for anabolic steroid users in the UK: a multi-area interview study.
HARM REDUCTION JOURNAL, 11 (19). pp. 1-13. ISSN 1477-7517
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KimergårdandMcVeighHarmReductionJournal2014,11:19
http://www.harmreductionjournal.com/content/11/1/19
RESEARCH Open Access
Variability and dilemmas in harm reduction for
anabolic steroid users in the UK: a multi-area
interview study
Andreas Kimergård1,2* and Jim McVeigh2
Abstract
Background: The UK continues to experience a rise inthenumberof anabolic steroid-using clients attending harm
reduction services such as needle and syringe programmes.
Methods: The present study uses interviews conducted with harm reduction service providersas well as illicit users
ofanabolicsteroids from different areas of England and Wales to explore harm reduction for this group of drug
users, focussing onneedle distribution policies and harm reduction interventions developed specificallyfor this
population of drug users.
Results: The article addresses the complexity of harm reduction service delivery, highlighting different modelsof
needle distribution, such as peer-led distribution networks, as well as interventions available insteroid clinics,
including liver function testing of anabolic steroid users. Aside from providing insights into thefunction of
interventions available to steroid users, along with principles adopted by service providers, thestudy found
significant tensionsand dilemmasin policy implementation due to differing perspectivesbetween service providers
and service users relating to practices,risksand effectiveinterventions.
Conclusion: The overarching finding ofthestudy was thetremendous variabilityacross harm reduction delivery
sites in terms ofavailablemeasuresand mode of operation. Further research into the effectiveness ofdifferent
policies directed towards people who use anabolic steroids is critical to thedevelopment ofharm reduction.
Keywords: Harm reduction,Needle and syringe programmes, Anabolic steroids
Introduction Needle distribution can take place from fixed-sites
Needle and syringe programmes (NSPs)were introduced services,suchasdrug agencies, community-basedphar-
around the mid-1980s in response to the threat of HIV macies, hospitals and vending machines, and mobile
transmission amongst intravenous opioid injectors from sites like outreach vans. Many NSPs combine needle
the sharing of contaminated needles [1]. As a public distribution with other measures including health edu-
health policy, the primary role oftheseprogrammes isto cation, referral, screening for blood-borne viruses, coun-
provide injecting drug users (IDUs) with access to sterile selling, opioid substitution treatment and safe disposal of
needlesand syringestoreducesharingand prevent trans- used injecting equipment [2,5,6]. Broadly, these strategies
mission of blood-borne viruses. After more than two de- fall under the definition of harm reduction, that is, inter-
cades of research, evidence in support of this approach ventions, programmes and policies aiming to minimise
in preventing HIV and hepatitis C infections amongst drugharmsinindividualsandsociety[2].
psychoactivedrugusersisrelativelyrobust[2-4]. Although NSPs were initially established to serve injec-
tors of psychoactive drugs, data from programmes in the
USA[7],Australia[8]andtheUK[9]showanincreasein
*Correspondence:[email protected] thenumberofanabolicsteroid-using clients.Whilelongi-
1AddictionsDepartment,NationalAddictionCentre,InstituteofPsychiatry,
tudinal data on steroid-using client attendance in NSPs is
King'sCollegeLondon,4WindsorWalk,LondonSE58BB,UK
2CentreforPublicHealth,LiverpoolJohnMooresUniversity,HenryCotton unavailable for many areas, in Merseyside, North West
Campus,Level2,15-21WebsterStreet,LiverpoolL32ET,UK
©2014KimergårdandMcVeigh;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublic
DomainDedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthis
article,unlessotherwisestated.
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England, the number of new steroid-injecting clients in- owners and dealers (AK, personal communication). For
creasedsixfold from 1991to2001[9],withthis appearing years, these informal distribution networks were widely
tobeanongoingtrend[10].InmanyareasoftheNorthof used to reach anabolic steroid users, exceeding by far
England, injectors of anabolic steroids and associated needle distribution to steroid users from fixed-sites NSPs.
image and performance enhancing drugs (IPEDs) now As a consequence, opportunities for service providers to
constitute the majority of clients, with data from local engagedirectly withthisuserpopulation werelimited [6].
authorities indicating that in some areas over 80% of Steroid clinicsare programmesdesignedfor steroidusers.
clientsreporttheuseofIPEDs(Table1). Theseclinicstypicallyprovidesterileneedlesandsyringes,
Steroid users first accessed NSPs in some parts of the informationmaterialaboutsafeinjectingandblood-borne
UK around the late 1980s [11]. Since then, NSPs for viruses screening. Other interventions may include advice
usersofanabolicsteroidsandotherIPEDshavebecome about weight training and diet to bring about desired
an established element of the service provision for drug improvement of physical appearance to avoid continuing
users in the UK. Alongside conventional NSPs, other drug usage. In some clinics, service providers offer med-
types of harm reduction interventions and programmes icalexaminations,likebloodpressuremonitoringandliver
for steroid users have emerged such as outreach pro- function tests, and advise steroid users to reduce dosage
grammes in gyms where harm reduction service pro- or not to use drugs at all in case of negative results [13].
viders are handing out sterile needles and syringes to Service delivery sites may offer interventions for opioid
steroid users and facilitating access to other types of and stimulant users as well as steroid users in the same
health care. The exact number of outreach programmes facility whereas some have opening hours reserved ex-
in the UK is unknown; however, a 2008 survey by the clusively for steroid users. Other steroid clinics are set
National Treatment Agency for Substance Misusea found upin facilitiesseparatefrom conventionalNSPssuchas
that specific services for steroid users, including mobile the Drugs in Sport Clinic and Users' Support (DISCUS)
needle distribution programmes in gyms and so-called whichopenedin1994[10].
steroid clinics, had been developedor werein the process While the use of IPEDs is by no means a new
of being developed in many parts of England [12]. Still, phenomenon,recentyearshaveseenamarkedincrease
outreach programmes in gyms is not a new phenomenon in the availability and utilisation of these drugs. Devel-
with research suggesting that needle distribution pro- opments in global communication systems (in particu-
grammes in gyms have been in operation since at least lar, the growth of the Internet), cheap mass-produced
the early 1990s [11], such as a programme initiated in pharmaceuticals and weak regulatory and enforcement
1992 in South East England providing peer-led needle practices in many parts of the world have combined to
distribution to steroid users through a network of gym create a lucrative illicit supply of these drugs [14]. Di-
versesectionsofthepopulationareobtainingrelatively
Table1PercentageofNSPclientsusingIPEDsinthe cheap drugs in an attempt to increase their muscle mass,
NorthofEngland-2014 reduce fat, enhance intelligence or beauty or to improve
their mood [15]. Research shows that many steroid users
Area Percentage
takethesesubstancestoenhancetheirphysiqueaswellas
Middlesbrough 67
body satisfaction and that a majority of them are males
Kirklees 60
[14]. By contrast, these drugs appear to have limited ap-
Sheffield 62
peal to women partly because the main effect of these
Newcastle 52 drugs is increased muscularity and partly due to adverse
Sunderland 60 drug reactions including masculinisation. Most steroid
Bradford 41 users take two or more types of anabolic steroids at the
same time, known as ‘stacking’, in 6- to 12-week periods
Halton 86
or longer, referred to as the ‘on’ cycle, which is usually
Liverpool 83 followed by a period of abstinence, called the ‘off’ cycle
Sefton 43
[16].Anabolic steroids are taken both orally and by injec-
St.Helens 34 tion, but unlike many other injectors of illicit drugs, ana-
Warrington 86 bolic steroids must be injected intramuscularly, rather
Wirral 77 than intravenously. Long needles with a wide bore are
needed to inject viscous steroids into large muscles such
Manchester 60
as the gluteus maximus (buttocks) or vastus lateralis
Bolton 52
(thigh). In addition to the possible adverse reactions of
DataprovidedbyNSPserviceproviders/managersviapied-forum@googlegroups.
anabolic steroid use, including acne, gynaecomastia, liver
com.PresentedbyJMatthePublicHealthandEnhancementDrugsConference,
9April2014,Liverpool. damage, harms to the cardiovascular system and impact
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on moodand behaviour [17],sharinginjectingequipment how stigmatisation influenced IDUs in a city in South
canresultinthetransmissionof blood-bornevirusessuch West England, Simmonds and Coomber [29] found that
as HIV, hepatitis B and hepatitis C. Studies with steroid groupsofIDUstendedtostigmatiseothergroupsofIDUs.
usersinSydney[18]andNorthEastEngland[19]reported For example, steroid users looked down at those they be-
that 5% and 2.1%, respectively, had shared injecting lievedengaged inriskierbehavioursthan themselves. One
equipment. One study conducted in South Wales found potential outcome of this is that steroid users may ignore
that 20% of steroid users reported syringe sharing [20]. their own risky behaviours by comparing their practices
A recent study found that 8.9% of IPED users from withintravenousdruguserswhotheyperceiveasengaging
NSPs in Englandand Wales had shared injectingequip- in far more dangerous activities [29]. The sense of stigma
ment [21]. Of particular concern is the fact that 1.5% surrounding harm reduction service sites can also be
were HIV positive (similar to levels of HIV prevalence far-reaching. Smith [30] explored oppositional strat-
found amongst injectors of psychoactive drugs in the egies in response to the opening of a methadone clinic
UK), 8.8% had been infected with hepatitis B and 5.5% in Toronto and found explicit forms of stigmatisation
with hepatitis C, highlighting that this particular group directed towards clients who accessed the facility. In
ofIDUsisatriskof blood-bornevirusinfection. this process, stigmatisation of IDUs extended from
The extent of harm reduction utilisation by anabolic stigma associated with the methadone clinic perceived
steroid users is increasing, and the potential for harm in asa siteofdisease and disorder[30].Giventhat steroid
this group of drug users, including the transmission of usersdonotgenerallyidentifythemselveswithotherIDUs
blood-borne viruses, is in evidence. However, while a [31], over the years, it is likely that some have kept away
growingbodyofresearchhasfocussedonharmreduction fromNSPs,andsomecontinuetodosotoday,inorderto
forpsychoactivedrugusers[6,22,23],studiesintoharmre- avoid being labelled a ‘drug user’. In response, tailored
duction policies for users of anabolic steroids, including harm reduction programmes emerged to overcome such
outreachprogrammesandsteroidclinics,areseverelylim- barriers; for example, the Steroid Peer Education Project
ited.Thispresentstudywasconductedtoexploreexisting in Victoria, Australia, commenced with one bodybuilding
interventions and the mode of operation in harm reduc- peer worker who visited gyms to deliver sterile needles
tionservicesforanabolicsteroid-usingclients. and syringes to steroid users who rarely came in contact
withfixed-sitesNSPs[32].
Literaturereview:variabilityinharmreductionpolicies Attitude amongst harm reduction service providers
Malins et al. [24] focussed on gender-specific risks in towards the perceived benefits of NSPs and towards
IDUs and found that women would try to avoid being IDUs, along with their harm reduction knowledge, have
placed in the marginalised category of a ‘junkie’, for ex- significant implications for the operation of harm re-
ample, by finding a secluded site when injecting. While duction programmes. Tsai et al. [33] surveyed service
this strategy enabled them to avoid police, other IDUs providers in Taiwan and found that a positive attitude
and the gaze of the general public, it also placed them at towards the benefits of NSPs influenced service imple-
risk of not being found in case of an overdose. Similarly mentation. Service providers who offered needle return
to gender-related risks reported by Malins et al. [24], it services, referral, health education and screening ser-
has been shown that body dissatisfaction, along with the viceshadahigherattitudescoreintermsofthebenefits
desire to enhance muscularity, can trigger the use of ana- of NSPs compared to those who did not provide these
bolic steroids in males [16,25]. This exposes users to po- services.Byconsideringindividualcharacteristicsofser-
tential health harms, including from the use of multiple vice providers, focus is directed at those in charge of
IPEDs [16], hazards relating to needle sharing [21], infec- policyimplementation.AsLipsky[34]notes,‘street-level
tions and injuries at injection sites [26], as well as blood- bureaucrats’—public service providers like teachers, po-
bornevirusexposureassociatedwithpastinjectionofher- licemen, doctors and social workers—have significant
oin and imprisonment [21,27]. In these ways, IDUs form influence on the execution of policies based on their atti-
subgroups with specific risk profiles, not just in relation tudes, moral beliefs, knowledge, interpretation of policy
to their drugs of choice but also their characteristics and routines. This is evident in the work of Spittal et al.
and surrounding environment, highlighting that social [22], exploring needle distribution practice in Vancouver.
context is crucial to understanding drug-related harm Here,itwasfoundthatserviceprovidersusedaninformal
[28]. These subgroups may, in turn, affect the evolution ‘loanersystem’ofinjectingequipmentwhenIDUsdidnot
of harm reduction interventions and programmes. This is haveanyneedlestoreturnandhencewerenotallowedto
the case, for instance, withregards to the implementation obtain new injecting equipment. In contrast to such re-
ofsteroidclinics[13]. strictive needle and syringe distribution policy—one new
Issues relating to the stigmatisation of drug users can needle exchanged for one used that is returned—in other
have wide implications for harm reduction. In a study of cases, service providers will not require that used needles
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are returned before providing sterile ones [35]. Clearly, for steroid users in sites classified as (i) conventional
therearemanylegitimatereasonswhyIDUsdonotalways NSPs set up chiefly for intravenous drug users, (ii) out-
return used injecting equipment, such as having disposed reach programmes for steroid users and (iii) steroid
of their used needles and syringes in other services (in- clinics. Given the differences from area to area in terms
cluding at hospitals). Regardless of the difference be- of availability of harm reduction interventions and pol-
tween local practice, these examples serve to highlight icies, the study included respondents from different parts
that harm reduction polices are carried out through re- ofEnglandandWales(Table2).
lationships between service providers and clients where Interviews were conducted with nine service providers
decision-making processes employed by service providers whohadpersonallytakenpartinserviceprovisionforana-
havetremendousinfluenceonpolicy[34]. bolic steroid users. From the review of the literature into
This article extends these insights regarding harm re- the various aspects of harm reduction service provision,
duction service delivery to suggest that multiple factors, three overall interview topics were developed: (i) training
including the risk profile and behaviour of clients, social of harm reduction service providers relevant to steroid
context of harm reduction and drug use, along with the use, (ii) health risks amongst steroid users—personal and
decision-makingofserviceproviders, affect serviceimple- anecdotal accounts and (iii) new and existing interven-
mentation.Asaresult,theorganisationofharmreduction tions specifically aimed at steroid users. Although these
programmes may vary significantly across delivery sites, overall topics guided the interview questions, interviews
for example, in relation to number of hours open, fixed- were semi-structured; for example, all respondents were
sites or mobile service delivery, number of clients, client asked what harm reduction meant to them allowing for
demographics, needle and syringe distribution policies, new perspectives on the content of this policy to be
rangeofinterventionsandavailabilityofspecificinterven- brought up. In this article, emphasis is on the findings
tions for IDU subgroups such as young injectors, sex frominterviewswithserviceproviders.
workers,homelessorIPEDusers[5,6].Animportantissue Twenty-four anabolic steroid users were interviewed.
hereisthatagrowingnumberofstudiesindicatethatim- Most of them used multiple steroids with nine reporting
pactfromavailabilityofinterventionsandoperationalpro- use of synthetic growth hormones. Interviews were semi-
cedures on the effectiveness of harm reduction can be structured exploring attitudes, knowledge and experiences
wide-ranging [22,36-38]. An equally important issue, par- of steroid users while covering the following topics: (i)
ticularly in relation to this study, is that individual, social body (dis)satisfaction; (ii) motivations for use; (iii) patterns
andinstitutionalprocessesmakeharmreductionpolicyin of steroid use, sources of steroid information and health
practice highly complex. Hence, dilemmas, tensions and harmsand(iv)previousandcurrentexperiencewithharm
barriersinpolicyexecutionmaylikelyarise. reduction programmes. These broad topics were based on
areviewofliteraturereportingtheexperiences,viewpoints
Methods andpracticesofthisgroupofdrugusers.Thispresentart-
This article is based upon 6 months of research in 2009 iclefocussespredominantlyonfindingsrelatingtocategory
and 2 months in 2011 as part of a study of drug policy (iv),whereasotherfindingsarereportedelsewhere[39].
aimed towards the illicit use of anabolic steroids. The pri-
mary method of data collection used qualitative interviews Recruitment
with service providers as well as steroid users (conducted Service providers were contacted by e-mail or telephone
byAK).Thestudywasdesignedtoexploreharmreduction and asked to take part in the study. Sampling was done
Table2Overviewofdatacollection
Site Harmreductionprogramme Interviewwithsteroid Interviewwithservice Area
users(yes/no) providers(yes/no)
1 Steroidclinic Yes Yes NorthWestEngland
2 Steroidclinic Yes Yes London
3 Steroidclinic Yes Yes Removedduetoissuesofconfidentiality
4 ConventionalNSP Yes No NorthWestEngland
5 Outreachprogrammeforsteroidusers Yes No Removedduetoissuesofconfidentiality
6 ConventionalNSPsa Yes No SouthWales
7 ConventionalNSP No Yes NorthWestEngland
8 Steroidclinic No Yes NorthWestEngland
9 ConventionalNSPsa No Yes NorthWales
aNSPspresentedtogethertoprotectanonymity.
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to ensure that service providers from different types of asthestudyevolved(Tables3and4).Theanalysiswasled
harm reduction programmes were included. As the study by AK with input from JM to compare and contrast the
developed, service providers told of other delivery sites results.
andthroughthis‘snowball’samplingtechniquefurtherre- The study was approved by Liverpool John Moores
spondents were included. Nine steroid users were re- University Research Ethics Committee. Respondents were
cruited from steroid clinics, seven from NSPs and three givenabriefoutlineofthestudyandguaranteedanonym-
fromanoutreachprogramme.Onewasrecruitedatagym itybeforebeingpresentedwithaconsentform.
and four steroid users were recruited from a prison. In
steroidclinicsandNSPs,serviceprovidersapproachedcli- Results
ents and asked if they would be willing to partake. Very Intalkingtoharmreductionserviceproviders,itbecame
few declined. These interviews typically took place in a clear that they all had experienced an increase in the
privateroomatthefacilities.Inaddition,outreachworkers number ofsteroid users intheirlocalarea:
hadaskedclientsbeforehandiftheywouldtakepart.b
…shouldwegiveoutneedlestosteroidusers?AndI
Samplecharacteristics think:yes,weshould.Becausethereismanypeople
The sample of service providers (four males and five fe- usingit.It'sprobablythenumberonedrugofchoice
males) included five agency-trained respondents, two rightnow.(Femaleserviceprovider,steroidclinic,
nurses and two doctors. Respondents were affiliated site1)
with drug agencies and NHS services, respectively. Ser-
vice providers were relatively experienced as many had In addition, they all reported various risk behaviours
beeninvolvedinharmreductionformorethan10years. of steroid users such as inadequate injection technique
However, knowledge about and experience with harm and needle sharing—although service providers' reports
reduction for steroid users varied significantly. Six re- ofsharing variedsignificantly:
spondentswereinvolvedinsteroidclinicswhereasthree
worked in conventional NSPs. Most of their work in- Theylearntoinjectfromoneanother.Soifyougot
volvedserviceprovisionforotherIDUs. someonewhohasn'tdevelopedagoodtechnique
The mean age of steroid users was 34 years. As noted, thenthatwillbepassedonaswell…sometimesthey
moststeroidusersaremale,whichisreflectedinthesam- willbeusingtooshortaneedleandnotleaving
plethatconsistedof24males.Thesampleofsteroidusers enoughtostickoutincaseitsnapsoff…Thewhole
included those on their first visit as well as individuals sharingofequipment,weknowthatisgoingon.We
who had been accessing services for more than 10 years. stillhearthesetalesaboutwherethegymownerhas
Twelveofthemwerecurrentlyorhadpreviouslyattended pre-filledsyringesunderthecounterandwalksout
conventional NSPs, while three made use of an outreach andinjectsgymmembers.(Femaleserviceprovider,
programme and nine of steroid clinics. The majority of NSP,site9)
the samples were working, with occupations including
doorman, taxi driver, gym owner, self-employed business Aside from these two main findings, four themes
person, construction worker, IT-project manager, fitness emerged from the analysis of the accounts of service
instructor,craneoperatoranduniversitystudent. providersandsteroidusers(dealtwithbelow):
Analysis (i) All steroidusersreportedhavingeasyaccessto
Interviews with service providers were transcribed in full. sterile needlesand syringesfrom harmreduction
Interviews withsteroid users weretranscribedas well,ex- servicesites. However,when steroiduserswere
cept when prison rules prohibited electronic devices and asked abouttheirinjecting practices,they tendedto
when respondents felt uncomfortable about being re- ignoreor atleastmaketheir riskybehaviours seem
cordedwhendiscussingsensitiveissuesofanabolicsteroid lesshazardous thanthey actuallywere, impeding,in
use.Insuchcases,awrittenrecordingwasmadeimmedi- some cases,theuptakeofadviceabout safe
atelyaftertheinterviewwasfinished.Allwritteninterview injections.
records were subjected to thematic content analysis in (ii)Secondarydistribution involves distributionof
order to identify and verify themes relevant to the oper- sterile needlesand syringesthrough socialnetworks
ation of harm reduction services allowing for the frame- ofIDUsandhasbeenshown toimproveneedle
work of analysis to be adapted as the study progressed coverageinhard-to-reachgroupsofopioidusers
[40].c During the analysis, comments relating to needle [6,41]—although caremustbetakenwhen
distribution, health education, harm reduction measures extrapolatingthisfinding tosteroid users.Onthe
and customised harm reduction policies were categorised oneside,secondarydistribution wasattributedwith
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Table3Codingframework(selectedexamples):frominterviewrecordstoinitialcoding
Interviewtranscript Initialcoding
Interviewer:Sowhoinjectsyou?
Steroiduser:Mymatedoesit.Igothimtocomehere[intheservice]withme.SoIgot Users'injectingpracticesAvailableinterventions
himstartedondoingit,sowebothcamehereandgotthem[serviceproviders]toshow
Conflictsinperspectivesandpractices(serviceproviders
howheshoulddoit.
recommendedthatusersinjectthemselves)
Interviewer:Whenyougototheservice,you'rejustaskingforsyringesandneedles?
Steroiduser:Idon'tthinktheyknowthatmuchaboutthesteroidsinthosesortofplaces. Users'viewpointsonharmreductionservices
Youcouldputabitmoreinformationaboutcertainthingsinthemleaflets.Ithinkthey're
Negativeviewpointsaboutconventionalneedleand
limitedinwhattheyactuallywilltellyou.It'sallnegative.
syringeprogrammes
Interviewer:Wheredoesyoursenseofresponsibility[towardsclients]comefrom?
Serviceprovider:Becausepeopleassociateit[steroiduse]withhealth,becausepeopleare Harmsrelatingtosteroiduse
goingtothegymsandtheyworkout.Sopeoplethinkofitasbeinghealthy,wellit'snot.
Perceiveddifferencesbetweensteroidusersandopioid
It'slikeit'sokay,becauseyouarenotinjectingintoaveinandcostingusalotofmoney.
users
Perceivedneedforservices
Interviewer:Whatextraservicesdoyouprovide?
Serviceprovider:Wedosyringeexchange,saferinjectinginformation,thenursewillgive Interventionsinsteroidclinics
themhepatitisBvaccinations,completebloodcount[todetermineinfection],liverfunction
Scopeofharmreduction
tests,cholesteroltests,dietaryadvice,bloodpressuremonitoringandsaferdruguse
messages.Evensmokingcessation,thenursewilllookatthataswell.Wedo,recently,
chlamydiaandgonorrhoeascreening.
Interviewer:Ifyoushouldsumupharmreduction,whatisthedefinitionyouwouldgive?
Serviceprovider:Whatthetendencyis:‘WhatwasthemistakeImade?Imustnothave Dosageinformation
takenenough[amountofanabolicsteroids],sonexttimeI'lldoit.I'llincreasethedosage’,
Offerinformation/interventionstolimitusage
andtheygothroughthesameprocess,getmoresideeffects.Wetrytoeducatepeople
aboutthewholething,thewholepackage,sothattheyareabletomaximisetheeffects.If Developmentofspecialisedinterventions
theyaregoingtodoit,thentheyshouldgettheresult[inphysique]andmaintainthose
Notionsofsteroidclinics
results.Theideabeingthatiftheyarehappywiththeresultstheyget,theyarelesslikely
tothengoontohigherdosesormorecycles.
Table4Codingframework(selectedexamples):fromreducedcategoriestofinalcodingframework
Refinedandreducedcategories Finalcodingframework
Injectioninjuries Perceptionsofharm(insteroidusers)
Adverseeffects
Notionsofharminintravenous/psychoactivedrugusers
Advicefromserviceproviders Disparitybetweenusingpractices(serviceproviderscontrasteroidusers)
Preferencesandviewpointsamongstusers
Negativepeerinfluence
Perceptionsofsyringedistributionlimitation Needleandsyringedistributionmodels
Experienceswithoutreach-baseddistributionthroughusers
Notionsofkeyusersasdistributors Boundariesofharmreduction
Steroidregimeninformation
Positiveoutcomeofsteroidregimeninformation
Negativeviewsonsteroidregimenadvice Steroidclinicfunction
Steroidclinicsversusconventionalneedleandsyringeprogrammes
Positivenotionsofspecialisedinterventions
Negativeoutcomeofspecialisedinterventions
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greateraccesstosterile injectingequipment in [29] found in their study of needle distribution policies
hard-to-reach groupsofsteroidusersand onthe and IDUs in South West England. Although steroid
other sideserviceproviders expressed concern userstendedtoviewthepotentialhazardsofsteroiduse
because thisapproachlimitedengagement with as minimal, thisdid not mean that theydidnotpractice
vulnerablegroupsofyoung steroidusers.Itbecame risky behaviour. For instance, two steroid users admit-
obviousthat serviceproviders faced atrade-off ted to having reused their injecting equipment. Several
betweenhighneedleavailabilityand personal had suffered ‘lumps’ or abscesses at the injection site
contactwith users. which may have been caused by incorrect injecting
(iii)Whentalking toserviceproviders,disagreements technique or from the use of non-sterile products. Fur-
abouttheboundaries of harm reductionforsteroid thermore, a service provider noted complications of
injectorsarose. Afew serviceproviders provided injectingintothebuttock:
steroiduserswith informationabouttheuseof
specifictypesofanabolic steroids whereasa Iaskedif his[client's]injectingtechniquewasokay
majorityrejectedthispolicy. Thedilemmahereis andhesaid:‘Yes,I’vebeeninjectingforanumberof
that serviceprovidersmayofferthisinformationin years.’Isaid:‘Justhumourmeandshowmewhere
the hopethat steroidusers willcometothem for youhavebeeninjecting’.Sohesaid:‘Rightinthe
adviceorthey maychoose nottoandthereby middleofmybuttock.’Isaid:‘Wellyoudorealise
leavinguserswithpotentiallyuncertaininformation thesciaticnerverunsveryclosetowhereyouare
frompeerusers ingyms. puttingyourfinger?Hesaid:‘Oh,yes.IthinkI
(iv)Availabilityofinterventionsdesignedparticularly mightactuallyhavehititacoupleoftimes.’(Male
forsteroidusersvaried acrossservices.However,in serviceprovider,steroidclinic,site2)
steroidclinics,theuseofmedical examinationsof
steroiduserswaswellestablished. Theaim of Other service providers expressed concern with the
medicalexaminationswastomake usersawareof useofsmallneedlesthatmightbreakinside themuscle:
adversereactionstotheir useofanabolic steroids.
Yetit wasclearthatusers whounderwentperiodic Thatneedle istoobendytogointo amuscleandit's
examinations alsofeltlessatriskfromtheuseof designedforintravenous use.So Iratheradvise them
thesedrugs. not touseitincaseit ‘snaps’.(Female service
provider,steroid clinic,site 1)
‘Weofferadvicearoundinjectiontechnique’
Itwasclearthatsteroidusersinthisstudysawthemselves However, while service providers in this study gener-
as different from other IDUs. In their opinion, steroid ally encouraged clients to use a large needle for steroid
users do not share used needles with other users whereas injections, steroid users had many reasons for why they
this was believed to be the case with users of opioids and preferred to use a smaller one instead, such as being
stimulants: worried that a large one would cause them pain: ‘there
is no way I'm putting that [needle] up my arse’ (Steroid
NobodybuildersthatIknowshare.Imean youhear user, steroid clinic, site 1). In other cases, the decision
ofwhat are calleddruggies,people who useother to use small needles was based on advice on injecting
stuff.Idon'tmixinthose circles tobehonest. techniquefromotherusers.
(Steroiduser,NSP,site6) These last few accounts provide a sense of self-
assuranceamongststeroidusersregardingtheirabilities
It came across that the drugs steroid users were taking to conduct safe injections. The important issue here is
seemed to create these differences. One steroid user that self-assurance in steroid users appeared to displace
expressed that ‘steroids aren't addictive, it's a hormone’ acknowledgement of their risky behaviour—a finding
(Steroid user, NSP, site 6). From his perspective, steroid which shares some similarities with those of other stud-
users would not therefore use these drugs compulsively ies indicating that theharmsofsteroids areoftentrivia-
and would not therefore borrow needles from other lised or ignored by steroid users [43]. In addition, this
users—even though weight training, motivations to im- also appeared to act as a barrier to the dissemination
prove body image satisfaction and IPED usage appear to of safer injecting advice. In situations of disagreements
be characterised by obsessive and compulsive behaviour between service providers and steroid users, service
in some anabolic steroid users [42]. In these ways, it providers tended to fulfil the requirements of steroid
seemed that steroid users attempted to distance them- usersbyhandingoutsmallneedlestomaintainrapport
selves from risk behaviours practiced by intravenous with steroid users and ensure access to sterile injecting
drug users, similarly to what Simmonds and Coomber equipment.
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‘Needleexchangeisacoreprovisionforus’ losingtheopportunitytogetinvolvedwith them.So
Most service providers reported no restrictions on the you havetoworkwith themslightlydifferent tothe
number of syringes that could be provided per visit free oldersteroid usergroup who canbeabitmore
of charge, reflecting an emphasis on high utilisation of responsibleinterms oftheirinjecting. (Female service
sterile needles and syringes to prevent disease from be- provider,Steroidclinic,site8)
ing spread. Alongside traditional needle distribution, in-
terviews showed that secondary distribution of needles Constrained by limited funding, service providers in
and syringes wasaccepted practice toimprovethe use of one NSP had started to ask for an economic contribution
sterile injecting equipment. For instance, in a number of from steroid users to offset costs.e While this financial
harm reduction service sites, established steroid users, contribution was voluntary, and users would supposedly
such as competing bodybuilders and gym owners, were beprovidedregardless,itwasmeanttooffsetcostsofster-
allowed to collect large amounts of injecting equipment oiduserscollectinglargeamountsofneedlesandsyringes
for themselves and for others. Furthermore, interviews for themselves and for secondary distribution. Whereas
with steroid users/gym owners gave insights regarding this might be seen as an obstacle to widespread needle
outreach-based needle distribution revealing that out- availability amongst some groups of IDUs this did not
reachworkersprovidedthemneedlesandsyringeswhich seemtobethecaseforthisuser,reflectingthatmostster-
were distributed to steroid users in these gyms. In some oid users in this study were employed and were able to
cases, outreach work had the added advantage of acting payforagymmembership,foodsupplementsanddrugs:
as a bridge to other harm reduction interventions as ser-
viceproviderswouldpersuadeuserstovisitconventional …steroidusersseeitasgreat thattheydon'thaveto
NSPs. In one NSP, peer-based needle distribution was paybecause thatismore money forprotein[food
based upon informal agreements between service pro- supplement].ButImustbehonest,when she[service
viders and a client. Here, service providers provided a provider]toldabout a[financial] contribution [to
local steroid user and gym owner with needles and sy- offsetthe cost], Ihaven'tgotaproblem with that,
ringes. In turn, he had set up a ‘syringe exchange’ in his because otherwise we'dbeforced tobuyallthese
gym including placing sharp bins in the locker room. He thingsacrosstheInternet.(Steroiduser,NSP,site6)
would statehis reasons:
It was clear that these different needle distribution pol-
…because mostofthe membersaretooembarrassed iciesweretheresultoflocalarrangementsinservicedeliv-
togototheexchange[NSP] themselves,andIwas ery sites. Many of them appeared to have been developed
tired ofseeingusedsyringes inthelockerroom. onanadhocbasiswhichresonateswithfindingsofSpittal
(Steroiduser,NSP,site4) etal.[22]ontheevolvementofaninformal‘loanersystem’
from the formal ‘one-for-one’approach (one clean needle
Thesevariousmodelsofneedledistributionwereclearly for one used returned). It is also in keeping with Lipsky's
ways for service providers to improve sterile needle usage [34] views on the wide manoeuvre room of service
amongst IPED injectors through customised policies. providers in their interpretation of policy.
What these policies share is that in the view of service
providers, the credibility of key steroid users in the gym ‘Giveinformationaboutsteroids'effects’
using population (gym owners/competing bodybuilders) A substantial theme was where the line should be drawn
enabledthemtoengagewithsteroiduserswhodidnotac- in terms of which types of harm reduction interventions
cess conventional NSPs. This resonates with the positive should be provided. As shown below, these different
experiences from the Steroid Peer Education Project, an perspectivesontheboundariesof harmreductionwere
outreach-based needleandsyringedistributionserviceled widely dependent on service providers' knowledge of
byabodybuildingpeerworker[32]. issuesrelatingtoanabolicsteroids.
However, in other harm reduction service sites, service Syringe distribution, along with advice on safer inject-
providers were limiting the number of syringes per visit.d ing practices, was viewed as essential, with a number of
Below, a service provider reflected on restrictions on service providers providing additional information about
needle distribution for young and inexperienced steroid the potential harms of anabolic steroids—although it was
users due to concern of the loss of opportunity for apparent that service providers in steroid clinics knew
healtheducation: considerably more about steroid-related harm than those
in conventional NSPs. In five harm reduction delivery
Ifyou aregiving ahundredneedles andsyringes toa sites,steroiduserswereprovidedwithdietaryservicesand
young,uneducatedsteroid user,andifthey aretaking advice about weight training as service providers believed
themtogiveouttoothersimilarpeople,you are that this could help bring about the desired effect on
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steroid users' physique. This approach was based upon a [methandienone],thenyoumightbesayingtothem:
viewthatatbest,improvementof bodysatisfactionwould ‘Youneed toverycareful about gynaecomastia’,
persuadeclientsnottousesteroidsatall: because it'sarealpotentialissuefor youwith that
one.(Maleserviceprovider,steroidclinic,site2)
…quite alotofthetimepeople willtakeonboardthat
whattheyaredoing inthegym isnotcorrect,ortheir Again, interviews with service providers revealed con-
diet,andthattheycan actually make somereally flicting perspectives on this policy. In fact, information
positive changeswithout even goingonsteroids.So about anabolic steroids was limited to one steroid clinic
whatwe tendtosayis,‘Okay,you arethinkingabout whereas a majority of service providers did not provide
usingthem,but yourdietsandtrainingaren'tcorrect. such advice. A concern amongst these service providers
Go away, change allofthose andcomebacktosee was the unknown effects from long-term use of high
meinsixmonthstimeandifyouarenot happywith doses ofanabolic steroids:
the wayyou haveprogressedletuslookat itagain.’
(Male serviceprovider,steroidclinic,site2) We wouldn't givethemspecific advice onthe drugs
theyaretaking,how totakethem,whentotake them
However, the effectiveness ofthis strategyin prolonging allthat sortofstuff because it's suchanunknown
thetimebeforetheuseofsteroidsisdifficulttodetermine, quantity andgenerally theyhavethatguidance from
as it is possible that some people will turn instead to otherusers.Whetheritisaccurateornot Idon't
established steroid users for advice. In this study, as with knowbut they seem toknowmore than wedo.Our
others [43], peer influence was high with steroid users advicewillbespecificallyhealth related. (Female
relying heavily upon information about these drugs from serviceprovider,NSP,site9)
each other, rather than from harm reduction service
providers: Arguably, the uncontrollable nature of the illicit market
makes it difficult to know exactly the active substance in
Yougotothe gym,you getinvolvedwithpeople,they drugs obtained from the illicit market which is reducing
giveyou advice, youcantell themwhatyour own the relevance of information about specific types of
feelingsare. I'veneverhadany information offdrug steroids[44].
services,allmyinformationhasbeenfrom theguyI
boughtthesteroidsfrom. (Steroid user,NSP,site6)
‘Thissteroidclinictomeisvital’
…thedrug serviceisjustahandyplace togetyour Service providers explained that steroid clinics had been
needles,literally thatisall. (Steroid user,NSP,site6) set up as a result of an increase in the number of steroid
users accessing conventional NSPs. In addition, providing
In response to peer-driven information networks in efficient harm reduction in this group of clients required
gyms, a service provider in one steroid clinic argued that tailoredhealthinterventionsasdepictedinthisaccountof
clients should be advised about the use of anabolic ste- a service provider who is reflecting on the opening of a
roids as an alternative to the ‘hokum and misinformation’ steroidclinicaroundthemid-2000s:
from other steroid users (Male service provider, steroid
clinic, site 2). In this clinic, steroid users were provided Therewereallthese steroid userscomingin,andthey
sheets containing information about specifictypes of ana- werejust getting needles,andweweretelling them
bolic steroids including dosage, pharmacological effects, how toinject safely…thatwaswhenwestarted
‘stacking’, period of usage as well as potential side effects. talking,‘Look,these people needtohavetheirown
For this service provider, this information was seen as an clinicandspecialservicesandcome inandget
essentialcomponentofharmreduction: [medically] checkedout.’So that'swhywebroughtit
up. Thenwe justtookittoourline-manager,who
It'saharmreductionmessagethatyouneedtobe tookitfurther up[inthe organisation],andwegot
makingpeople awarethatiftheytake nandrolone theokay.(Femaleserviceprovider,steroidclinic,site1)
[decanoate]onitsown they arenotgoing tohavea
sexdrivefor thenexttwelveweeks.If someone is Itseemedthatinmanycasessteroidclinicswerecreated
usingaparticulartoxic oralsteroidyou might wanna with input from anabolic steroid users. In one clinic, for
makethemawarethatiftheycombineditwith instance, service providers conducted an informal survey
anothersteroid they canactuallyreducethedosage of amongststeroidusingdoormenaswellasmembersofthe
the moretoxic one…ifyou gota steroid thatreadily localgymtodeterminewhichdayandatwhattimesteroid
convertstooestrogen,for example Dianabol users might prefer to come in. In the view of service