1. The changing nature of performance- enhancing drug use … What are the implications for public health? Michael Evans-Brown & Jim McVeigh

2. Once upon a time … “I have recently been approached by a person who is interested in body building and weightlifting and who has asked me if I would consider giving him anabolic steroids. He alleges that a very large percentage indeed of the top flight of both body-builders and weight-lifters take these drugs … He also says that there is a ready availability of these drugs on the ‘black market’” (BMJ, 1967) “The amateur organizations with which I am associated have heard of many cases of young weight-lifters and bodybuilders being prescribed anabolic steroids more or less on request from their general practitioners” (BMJ, 1967)

3. Then came the 80s … “a quantity of an anabolic steroid had disappeared from a hospital pharmacy” (BMJ, 1985) “The black market is thriving in the buying and selling of anabolic steroids … they included injectable testosterone, a generous supply of needles, and an advanced hormone.” (Times, 1987) ACMD asked to look at the issue … insufficient evidence that steroid use constituted a ‘social problem’ Pharmacist struck off for supply of Anapolon & Growth Hormone (Times, 1988)

4. Then the 90s … National study in 21 gyms (1992). 6% of males currently using, 1.4% of females. Most not involved in elite sport ACMD reviews issue again (1992–93). Recommends control of steroids under the Misuse of Drugs Act 1971 but simple possession to remain lawful Further studies in England & Wales. Some harm reduction services based around providing injecting equipment The Government accepts ACMD recommendations, law changed (1996)

5. Thereafter … A few more studies looked at use in gyms in Wales & England Is more growth hormone use being reported? Are more using for ‘body image’ reasons? Is use starting at a younger age? In the past few years, alongside the ‘classic’ drugs, a large number of products have become widely available on the illicit market, particularly on the Internet. Will these diffuse to broader groups?

9. “I was VERY pleased with the results from melanotan II last year. This year my Mum and Dad are going to try it too.” (how common is this?)

12. We don’t know much about: how many people are using & how long they use for which types of people are using and their ages why they are using, why they started using, and at what age they started using how these drugs are being used (different drugs used, doses taken, duration of use and injecting practices)

13. We don’t know much about: the illicit market (manufacture, distribution and supply) the quality, safety and efficacy of products: most are unlicensed many are either in pre-clinical or in phase I/II trials some licensed products containing the same drug have been withdrawn from the market many believed to be manufactured in China with some ‘assembly’ in the UK

14. We do know: On the Internet the drugs are relatively inexpensive; often offered at “discounted” prices or as part of other offers. Internet sites offer a “one-stop-shop” approach Websites are designed to appeal to desires and insecurities Some products may lower threshold for use (e.g. nasal spray or oral); although injectable products are not necessarily a barrier

15. What this group uses today, others may use tomorrow GHB — used started in the late 1980s to increase Growth Hormone secretion Noted in study from Clwyd (1996) Use diffused to wider group as a ‘legal high’ 2003 controlled under the Misuse of Drugs Act 1971 Stimulants?

16. What about harms? We never had a good evidence base on the harms the ‘classic’ drugs posed, but … A key concern for injectable products is sterility and injecting practices (yet, overall we have poor data) What do we know about the emerging drugs?

17. What should we do? ACMD recommends ‘focus on public health’ rather than criminalisation (2010) So, let’s focus on that It starts with research, but requires support and guidance from policy makers, practitioners and users.