Harm reduction and performance and image enhancing drugs

Performance and image-enhancing drugs (PIEDs) are substances typically used to increase the size and definition of muscles, reduce body fat and build strength and endurance.¹ PIEDs can include anabolic steroids.

This article provides suggestions on harm reduction measures that healthcare service providers can employ to reduce the risk of harm for people who use PIEDs.

The changing demographics of PIED use

Research has found that the Australians who use PIEDs are very diverse in both their backgrounds and in their motivations for use.²

Although previously associated with professional bodybuilders and athletes, research is now finding much more diversity amongst those who use PIEDs.² Australians who are using PIEDs also report being:

• amateur athletes
• fitness trainers
• aging men
• police
• security personnel.²

Each person’s motivations for using PIEDs will be different, and the patterns of use, health risk and health-seeking behaviour will also differ significantly between these groups.²

This means that it may be especially important for harm reduction programs and services that support people who use PIEDs to target programs specifically to reach these diverse groups and the particular risks they might be vulnerable to.²

The risks of injecting PIEDs

Because PIEDs are injected intramuscularly (into muscles) instead of intravenously (into veins), the harm minimisation information that people who inject PIEDs need is different to the information needs of people who inject other drugs.

Safer injecting practices are important to follow because people who inject PIEDs are at risk of:

• developing abscesses
• accidentally hitting bones, nerves or veins
• soreness or redness at the injection site
• blood borne viruses, if injecting equipment is shared.³

Some safer injecting guides have a section specifically on injecting into the muscle, which is one way to help reduce the harms from PIEDs.

Reducing harms from PIEDs

Overall, people who use PIEDs report lower levels of risky injecting practices compared to people who inject other drugs.⁴ They also tend to have lower rates of blood-borne viruses than other cohorts of people who inject drugs – although as a whole, they typically get tested less frequently.³

As the number of Australians who use PIEDs appears to be increasing, it’s important that there are harm reduction measures in place to help keep people safer.

Access to accurate information

All people who use drugs should have access to good information, including harm reduction strategies.

Many people who use PIEDs engage with online options – such as forums and message boards - for peer-to-peer information, which have the advantage of annonymity.⁵ Although that can be problematic if people are given inaccurate or misleading information, it also highlights how engagement with health professionals online may be a successful harm reduction strategy for the PIEDs community.⁵

More than half of the surveyed Australians who use PIEDs also sought information from medical professionals and medical literature, and would like physicians to be better educated about PIEDs.⁴

Other strategies suggested include targeted distribution of information about PIEDs-related harm reduction at locations such as:

• gyms
• nutritional and supplement stores
• schools
• online
• needle and syringe programs.⁴

Needle and syringe programs

While initially developed to support people injecting other drugs, such as heroin, the number of needle and syringe program (NSP) clients who are injecting PIEDs appears to be increasing.

Approximately 4% of people who access needle and syringe programs said the substance they last injected was a PIED, according to an Australian Needle and Syringe Program annual report.6 Among people who have been injecting drugs for less than three years, this number was higher at 18%.⁶

This suggests that NSPs could be a good location to provide harm reduction advice as well as ensure they have the correct equipment for PIEDs injection available.⁴ Frontline staff at NSPs could also benefit from specific training on PIEDs so they can engage effectively with those clients.⁷

Some NSPs in Australia have offered ‘steroid education programs’, providing specific harm reduction information for people using steroids, as well as required injecting equipment and referral to other health services. It may be helpful to expand the provision of these programs.⁸

Further supporting people who use PIEDs

In an Australian survey, people who use PIEDs suggest that support services should be available for people who are struggling with body image problems or who are trying to stop using PIEDs.⁴

Since the demographics have changed to include non-athletes who are using PIEDs to enhance their physical appearance, there is an opportunity for men’s health organisations or other health services to investigate why this shift has occurred, and what can be done to support people who use PIEDs.