Performance & image enhancing drugs

How are PIEDs used?

PIEDs are commonly administered by injection, taken orally in pill form, or applied to the skin.⁶

Effects of PIEDs

Use of any drug can have risks. It’s important to be careful when taking any type of drug.

PIEDs affect everyone differently, based on:

• size, weight and health
• whether the person is used to taking it
• whether other drugs are taken around the same time
• the amount taken
• the strength of the drug (varies from batch to batch)
• method of use (oral vs injection).

Because PIEDs belong to a range of different drug classes, their effects can differ quite a bit. The section below outlines the typical effects of the PIEDs most commonly used in Australia.

Insulin 

Short-term effects:

• low blood sugar which can lead to headaches, tremors, sweatiness, dizziness and blurred vision
• extremely low blood sugar which can eventually lead to seizures, coma and death.^{3, 4, 7}

The long‑term effects of insulin have primarily been studied in people with diabetes. There is currently limited evidence on its long‑term effects when used for performance and image enhancement.

Insulin-like growth factors (IGF-1):

Short term effects:

• low blood sugar which can lead to headaches, tremors, sweatiness, dizziness and blurred vision
• extremely low blood sugar which can eventually lead to seizures, coma and death.

Long term effects:

• temporary facial pain, weakness or paralysis
• joint and nerve damage
• increased risk of certain cancers⁴

Human growth hormone (hGH)

Short-term effects:

• low blood sugar
• high blood pressure
• water retention and bloating.³

Long-term effects:

• joint and nerve damage
• increased risk of diabetes
• increased risk of impotence (low libido or erectile dysfunction)
• osteoporosis (weak bones)
• liver damage
• cardiomyopathy (a weak heart).^{3, 4}

Thyroid hormone

Short-term effects:

• rapid or irregular heartbeat
• feeling nervous, anxious and/or irritable
• enlargement of the thyroid gland in the neck.³

Long-term effects:

• reduced bone density and increased risk of osteoporosis
• vision problems
• cardiovascular issues (e.g. heart failure).^{3, 5}

Clenbuterol 

Short-term effects

• headaches
• tremors (especially hand shakes)
• cramps
• anxiety
• insomnia
• increased heart rate
• high blood pressure.³

Long-term effects

• cardiovascular issues (e.g. enlargement of the heart, sudden cardiac death)
• enlargement of the liver
• high blood sugar.^{3, 4, 8}

Diuretics

Short-term effects

• dehydration
• cramps
• fatigue

Long-term effects

• abnormal heart rhythms.³

Overdose

The use of some PIEDs, like anabolic androgenic steroids and human growth hormones (hGH), doesn’t result in acute toxicity or overdose (when immediate harmful effects happen shortly after taking too much of a drug).

Prolonged non-medical use of these PIEDs – particularly at high doses – can result in serious long-term health consequences and may increase the risk of premature death.

But, you could overdose if you take a large amount of other PIEDs, like insulin or clenbuterol.^{3, 9} Overdose risk, as well as symptoms of an overdose, will depend on the type of PIED used.^{4, 7, 8}

PIEDs like insulin and clenbuterol can cause death.

Call triple zero (000) and request an ambulance if you or someone else has any of the following symptoms (emergency services are there to help and can provide more instructions).

• nausea/vomiting
• blurred vision
• tremors
• fast heart rate
• confusion
• seizures.^{6, 9}

Mixing with other drugs

PIEDs use often involves polypharmacy. This means more than one substance is used at the same time to enhance results, manage side effects, or achieve specific appearance or performance goals.^10-12

This practice is commonly referred to as 'stacking' among people who use PIEDs. While stacking is often believed to improve outcomes, it can greatly increase the risk of health harms.¹⁰

People who use PIEDs are also more likely than the general population to use other illicit drugs, such as amphetamines, cannabis, GHB and cocaine.^{6, 10, 13}

This is concerning because using more than one substance can increase the harms linked to each drug. It can also lead to unexpected and potentially serious interactions.

Using more than one drug or type of drug at the same time is also called polydrug use.¹⁴

Long-term effects

PIEDs and mental health

The use of some PIEDs has been found to have an impact on mental health.

People who use anabolic-androgenic steroids (AAS) are more likely than people who don’t use them to report mood swings, anxiety, depression, body dysmorphia disorder and self-harm/suicidal ideation.^17-22

Recent findings suggest that using trenbolone, a type of AAS, may be linked to increased verbal aggression. But, it also highlights the current lack of research on how individual AAS may affect mental health.²³

There is limited research on whether the use of other PIEDs may affect mental health.

Tolerance

There is limited research on whether people can develop a tolerance to PIEDs.

Over time, the effects of PIEDs may begin to level off. This is often due to the body’s natural limits on muscle growth, fat loss and hormone regulation.

Even with higher doses, the effect of PIEDs may slow down or become less noticeable. Rather than the body developing tolerance in the usual sense, people may experience diminishing returns, where increasing the dose may only lead to smaller effects.^{24, 25}

Dependence

While PIEDs use does not cause physical dependence, individuals may develop a psychological reliance on them, often due to the confidence and self-esteem boost they can provide.^26-28 This reliance can make it difficult to stop using PIEDs, especially when there's a fear of losing physique or performance levels.²⁹

For those who become dependent, PIEDs use can begin to dominate thoughts, emotions, and daily activities.

Reducing harm

PIEDs should be used with a valid prescription for a specific medical condition and under the supervision of a healthcare professional.

Some substances commonly used as PIEDs, such as testosterone, insulin, and human growth hormone (hGH), can be appropriately prescribed for legitimate medical use.

For people considering using PIEDs, discussing options with a healthcare professional and accessing prescribed, pharmaceutical‑grade products may help reduce potential health risks.

If you choose to use PIEDs for non-medical purposes, it’s very important to take steps to minimise potential harm:

• If injecting:
  • Always use new, sterile equipment and in a clean environment to reduce the risk of infections and transmission of blood-borne viruses. You can access free, sterile injecting equipment from local Needle and Syringe Programs (NSP).
  • Avoid spot injecting into small muscles (e.g. biceps, calves, pectorals). This does not enhance local muscle growth and instead significantly increases the risk of complications.
  • Rotate injection sites regularly to prevent tissue damage and reduce the risk of abscesses or scarring.
• Monitor your health: schedule regular health check-ups, including blood tests (e.g. liver and kidney function, lipid profile, hormone levels) and cardiovascular screening (e.g., echocardiogram) to detect any issues early.
• Take regular breaks: avoid continuous use of PIEDs. Taking regular breaks can help reduce long-term health risks and allow your body to recover.
• Avoid polydrug use: where possible, avoid using multiple PIEDs simultaneously, and do not mix them with illicit or pharmaceutical drugs. These combinations can lead to unpredictable effects and significantly increase the risk of harm.
• Be cautious with purchasing PIEDs from unregulated markets: PIEDs from unregulated sources may be counterfeit or contaminated.^{15, 16} The Steroid Checking Project highlights the widespread presence of substandard steroids in Australia and offers valuable information for safer use. The technical report provides further detail on the analysis of samples collected as part of this project between 2024 and 2025.
• Rely on trusted sources for information: Peer networks and online forums may provide inconsistent or inaccurate advice. Hi-ground offers reliable resources, including A Practical Primer on Safer Use of Anabolic Steroids and Other Performance Enhancing Drugs - a comprehensive harm reduction guide designed to support informed and safer use practices.

Withdrawal

Withdrawal refers to the symptoms that can occur when someone who is dependent on a drug, or who has used a drug regularly over time, stops or reduces their use.³⁰

Withdrawal can include physical symptoms (such as headaches, or nausea) and psychological symptoms (such as anxiety, or depressed mood).³⁰

PIEDs do not typically cause dependence in the same way as other psychoactive substances. However, after a period of regular use, reducing or stopping PIEDs can lead to withdrawal symptoms as the body adjusts to functioning without them.

Symptoms may include:

• fatigue and low energy
• reduced physical strength
• low mood.²⁸

Symptoms will vary depending on the type of PIEDs and a person’s history of use - including how strong they are and how long they last.³⁰

Withdrawal symptoms and times vary depending on PIED type, but often should settle down after a few days and mostly disappear after a few weeks.³

Pregnancy, breastfeeding and PIEDs

Some PIEDs can interfere with natural hormonal balance, which may lead to fertility problems in both males and females, and pose risk to foetal development.

To minimise harm, PIEDs use should be stopped before trying to conceive and avoided completely during pregnancy and breastfeeding.^{31, 32}

Getting help

If your use of PIEDs is affecting your health, family, relationships, work, school, financial or other life situations, or you’re concerned about someone else, you can find help and support.

Call the National Alcohol and Other Drug Hotline on 1800 250 015 for free and confidential advice, information and counselling about alcohol and other drugs

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