Open Access

Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis

  • Dominic Sagoe1Email author,
  • Jim McVeigh2,
  • Astrid Bjørnebekk3,
  • Marie-Stella Essilfie4,
  • Cecilie Schou Andreassen1, 5 and
  • Ståle Pallesen1
Substance Abuse Treatment, Prevention, and Policy201510:12

https://doi.org/10.1186/s13011-015-0006-5

Received: 19 December 2014

Accepted: 24 February 2015

Published: 15 March 2015

Abstract

Background

As far as we are aware, no previous systematic review and synthesis of the qualitative/descriptive literature on polypharmacy in anabolic-androgenic steroid(s) (AAS) users has been published.

Method

We systematically reviewed and synthesized qualitative/descriptive literature gathered from searches in electronic databases and by inspecting reference lists of relevant literature to investigate AAS users’ polypharmacy. We adhered to the recommendations of the UK Economic and Social Research Council’s qualitative research synthesis manual and the PRISMA guidelines.

Results

A total of 50 studies published between 1985 and 2014 were included in the analysis. Studies originated from 10 countries although most originated from United States (n = 22), followed by Sweden (n = 7), England only (n = 5), and the United Kingdom (n = 4). It was evident that prior to their debut, AAS users often used other licit and illicit substances. The main ancillary/supplementary substances used were alcohol, and cannabis/cannabinoids followed by cocaine, growth hormone, and human chorionic gonadotropin (hCG), amphetamine/meth, clenbuterol, ephedra/ephedrine, insulin, and thyroxine. Other popular substance classes were analgesics/opioids, dietary/nutritional supplements, and diuretics. Our classification of the various substances used by AAS users resulted in 13 main groups. These non-AAS substances were used mainly to enhance the effects of AAS, combat the side effects of AAS, and for recreational or relaxation purposes, as well as sexual enhancement.

Conclusions

Our findings corroborate previous suggestions of associations between AAS use and the use of other licit and illicit substances. Efforts must be intensified to combat the debilitating effects of AAS-associated polypharmacy.

Keywords

Anabolic-androgenic steroids Ergogenic aids Doping Human enhancement drugs IPEDs Polypharmacy Stacking Metasynthesis Qualitative research

Introduction

Anabolic-androgenic steroid(s) (AAS) refer to testosterone and its synthetic derivatives mainly used nonmedically for enhancing muscle growth and strength, boosting physical activity or sports performance, and for aesthetic purposes as well as for enhancing psychological well-being [1]. AAS are typically used in phases referred to as ‘cycles’: ‘on cycles’ referring to specific periods when the users administer AAS and ‘off cycles’ referring to an AAS-free phase intended to prevent tolerance towards AAS, lessen the possibility of side effects, and allow recovery of natural hormonal functioning. During ‘on cycles’ users sometimes combine different injectable and oral AAS. This phenomenon is referred to as ‘steroid stacking’ or simply ‘stacking’ [2].

There is also a trend referred to as ‘blast and cruise’ or ‘bridging’ – a continuous ‘on cycle’ whereby many users never go off AAS but alternate between periods of high dose intake during a ‘blast’ phase, and low dose intake during a ‘cruise’ phase. Another way of administering AAS is called ‘blitz-cycles’ , which implies rapidly changing AAS with the aim of preventing tolerance and androgen receptor down-regulation. Moreover, many users complement AAS use or stacking with the use of other substances. In this respect, AAS use has been found to be associated with the use of both licit and illicit substances in systematic reviews of predominantly quantitative literature [3,4].

It has been noted that one of the major drawbacks to successful AAS interventions is public health officials’ failure to recognize AAS users’ extensive pharmacological regimen [2]. A synthesis of the qualitative or descriptive literature on polypharmacy by AAS users is, both from a clinical and research perspective, important in order to increase the understanding of the polypharmacy often associated with AAS use. Such a literature review and synthesis is also valuable in terms of the development and strengthening of AAS use and harm reduction interventions as such investigation will deepen existing knowledge on the various substances used and the specific function they serve, which in some cases deviates significantly from their formal medical indications. Furthermore, results of such investigation would complement evidence emanating from a systematic review of mostly quantitative evidence [3] in the effort to elucidate the phenomenon of polysubstance use by AAS users. However, as far as we are aware, a systematic review and synthesis of the qualitative or descriptive literature on polypharmacy by AAS users has not been published.

Against this backdrop, we conducted the first systematic review and synthesis of the qualitative or descriptive studies presenting data on the use of other licit and illicit substances among AAS users. The research questions guiding the present study were: (a) what substances do AAS users report consuming prior to their AAS debut? (b) what ancillary or supplementary substances do AAS users report using? and (c) what reasons do AAS users assign for using these substances?

Method

Search strategy and inclusion criteria

We searched in PsycINFO, PubMed, ISI Web of Science, and Google Scholar for literature. For searches in PubMed and ISI Web of Science, ‘anabolic steroid’ , ‘doping’ , and ‘performance enhancing drug’ , were each combined with ‘interview’ , ‘focus group’ , and ‘qualitative’. These combinations were not practical in PsycINFO and Google Scholar as they produced voluminous redundant hits. Thus, ‘anabolic steroid + doping + performance enhancing drug + interview + focus group + qualitative’ was used in searches in PsycINFO and Google Scholar. From a total of 10,106 hits, 7,720 articles were assessed after the removal of duplicates. We also inspected references of relevant studies and searched in online databases and websites.

This search yielded 15 new articles. Based on titles and abstracts, 106 full-text papers were retrieved for screening after initial evaluation of the 7,735 papers. After screening of the 106 full-text papers, 79 papers were deemed relevant for inclusion. Thus, of the 79 papers scrutinized, 50 studies satisfied the following inclusion criteria: (a) studies used qualitative approaches (interviews, focus groups, or case studies) in data collection, (b) studies delineated or described licit and illicit substances used nonmedically by AAS users, and (c) studies were published in English.

We again inspected the characteristics of extracted studies for similarities to curb duplicate extraction and synthesis. The literature search was completed in June 2014. The literature search strategy adhered to Shaw et al.’s [5] recommendations for qualitative literature search as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [6]. Figure 1 presents the literature search process.
Figure 1

Flow diagram of systematic literature search.

Data extraction and synthesis

The first author conducted the study scrutiny and selection. Analysis of the studies was conducted using Smith et al.’s [7] Interpretative Phenomenological Analysis (IPA). Each full-text paper was regarded as a transcript. The first author (DS) read through the full-text papers several times, gaining an overall sense of the themes in the studies through this process. These themes were then highlighted. Using a standardized data extraction form, the first author and another reviewer independently extracted the following data from the included studies: author name and publication year, country, study type, type of AAS users involved in the study, and recruitment site or mode. To assess the quality of the extraction, we calculated inter-reviewer reliability for the two reviewers in SPSS version 20 (IBM Corp.) [8]. DS then independently coded the full-text papers by substance used and reason(s) or motive(s) for use. Study characteristics are presented in Table 1. We have presented all the studies that fall under each substance.
Table 1

Characteristics of qualitative/descriptive studies presenting data on polypharmacy in AAS users

First author, year, reference

Country

Study type

AAS users

Recruitment site/mode

Non-AAS substances ever used

Ahlgrim 2009 [9]

USA

Case study

41-year-old male former bodybuilder

Hospital

Captopril, carvedilol, digoxin, furosemide, growth hormone, hydrochlorothiazide, spironolactone, torsemide,

Angoorani 2009 [10]

Iran

Interview

843 bodybuilders aged 16 to 40 years

Gymnasium

Amphetamine

Bilard 2011 [11]

France

Interview

203 bodybuilders

Voluntary

Beta-2-agonists, cannabinoids, glucocorticosteroids, peptide hormones

Chandler 2014 [12]

UK

Interview

8 persons

Online forums, syringe exchange center

Aromatase inhibitors, clenbuterol, 2,4-dinitrophenol, clomiphene, diuretics, ephedrine, growth hormone releasing peptide, growth hormone, human chorionic gonadotropin (hCG), insulin-like growth factor 1, insulin, mechano growth factor, melanotan, mephedrone, tamoxifen, thyroid hormones, viagra®/cialis®

Cornford 2014 [13]

England

Interview and focus group

30 males aged 20 to 40 years

Syringe exchange center

Heroin

Davies 2011 [14]

England

Interview and questionnaire

9 male bodybuilders

Gymnasium

Creatine, dietary supplements

Dunn 2010 [15]

Australia

Interview and questionnaire

70 persons

Community

Alcohol, cannabis, cocaine, ecstasy, gamma hydroxybutyrate, hallucinogens, inhalants, ketamine, amphetamine

Filiault 2010 [16]

Australia, Canada, USA

Interview and questionnaire

16 gay male athletes aged 18 to 52 years

Gay sporting groups

Creatine, dietary supplements, growth hormone, recovery drinks

Fudala 2003 [17]

USA

Interview

7 males aged 22 to 33 years

Gymnasium and community

Alcohol, analgesics, cannabis, cocaine, stimulants, growth hormone, human chorionic gonadotropin (hCG), insulin-like growth factor 1

Gårevik 2010 [18]

Sweden

Interview

45 offenders; mean age 30 years

Police station

Amphetamine, anti-oestrogens, benzodiazepines, cannabis, clenbuterol, cocaine, diazepam, ephedra, ephedrine, growth hormone, human chorionic gonadotropin (hCG), heroin, insulin, sildenafil

Goldfield 2009 [19]

Canada

Interview and questionnaire

8 female bodybuilders

Gymnasium

Diuretics, laxatives

Gruber 1998 [20]

USA

Interview

19 female weightlifters

Gymnasium

Clenbuterol, ephedrine, narcotics/other drugs

Gruber 1999 [21]

USA

Interview

5 female bodybuilders

Gymnasium

Alcohol, cannabis, cocaine, clenbuterol, dietary supplements, other drugs, other performance-enhancing drugs

Gruber 2000 [22]

USA

Interview

25 female weightlifters; mean age 31 years

Gymnasium

Aminogluthemide, amphetamine, caffeine, clenbuterol, diuretics, ephedrine, hydroxyl butyrate, human chorionic gonadotropin (hCG), growth hormone, laxatives, nalbuphine, other opioids, tamoxifen, thyroid hormones, yohimbine

Hegazy 2013 [23]

USA

Case study

28-year-old male

Clinic

Alcohol, amphetamine, opioids

Hoff 2012 [24]

Sweden

Interview

11 male (10 powerlifters, 1 weightlifter)

Swedish Sports Confederation

Alcohol, amphetamine, cocaine, narcotics, others

Hope 2013 [25]

England and Wales

Interview and questionnaire

340 injecting drug users

Syringe exchange center

2,4-dinitrophenol, alcohol, amphetamine, anti-oestrogens, clenbuterol, cocaine, ephedrine, erythropoietin, growth hormone, human chorionic gonadotropin (hCG), insulin, melanotan II, nalbuphine, thyroid hormones, diuretics, PDE5i, viagra®/cialis®

Kanayama 2003 [26]

USA

Interview and questionnaire

48 male weightlifters; mean age 29 years

Gymnasium and sports supplement store

Alcohol, cannabis, cocaine, opioids, other narcotics/illicit drugs

Kanayama 2003 [27]

USA

Interview

24 male drug users; mean age 32 years

Clinic

Alcohol, cocaine, heroin, nalbuphine, opioids, oxycodone

Kanayama 2009 [28]

USA

Interview

62 male weightlifters

Gymnasium and sports supplement store

Alcohol, cannabis, cocaine, opioids, other performance-enhancing drugs, other drugs

Katz 1990 [29]

USA

Case study

23-year-old male bodybuilder

Gymnasium

Alcohol, cocaine

Kimergård 2014 [30]

England and Wales

Interview

24 males aged 21 to 61 years; mean age 34 years

Gymnasium, prison, steroid clinic and charity, syringe exchange centre

Amphetamine, clenbuterol, growth hormone, ephedrine, human chorionic gonadotropin (hCG), insulin, melanotan II, sildenafil, tamoxifen

Klötz 2010 [31]

Sweden

Interview

33 male prisoners aged 21 to 52 years

Prison

Antidepressants, anti-oestrogen, aspirin®, benzodiazepines, caffeine, cannabis, central stimulating drugs, clenbuterol, creatine, diuretics, ephedrine, Gamma hydroxybutyrate, insulin-like growth factor 1, insulin, genotropine, muscle relaxing drugs, myoblast, opiates, other drugs, potency increasing drugs, somatotropine, testicular function recovering hormones

Korkia 1993 [32]

England, Scotland, and Wales

Interview

110 persons (13 female) aged 16 to 63 years

Clinic, gymnasium, syringe exchange centre

Antibiotics, corticosteroids, dietary supplements, diuretics, esiclene, human chorionic gonadotropin (hCG), oestrogen-antagonist drug, growth hormone, thiomucase, thyroxine

Korkia 1996 [33]

England

Interview and questionnaire

15 females; mean age 28 years

Not specified

Clenbuterol, growth hormone, nolvadex, nubain®, thiomucase, triacana

Kusserow 1990 [34]

USA

Interview

72 (6 female) persons (mostly adolescents); 14 to 25 years; mean age 20 years

Not specified

Alcohol, blood pressure regulators, ‘downers’, estrogen inhibitors, growth hormone, cannabis, Recreational substances/drugs, ‘uppers’

Larance 2008 [35]

Australia

Interview

60 males aged 17 to 59 years

Gymnasium, internet forums, supplement shops

Anti-oestrogenic agents, aspirin®, benzodiazepines, caffeine, cannabis, cocaine, clenbuterol dehydroepiandrosterone (DHEA), diuretics, ecstasy, hallucinogens, heroin, human chorionic gonadotrophin (hCG), ephedrine, growth hormone, inhalants, insulin-like growth factors, insulin, meth/amphetamine, thyroxine

Lenehan 1996 [36]

England

Interview

386 persons aged 17 to 56 years; mean age 28 years

Gymnasium

Clenbuterol, corticosteroids, diuretics, growth hormone, human chorionic gonadotropin (hCG), thyroxine, insulin-like growth factor 1, nubain®, tamoxifen

Lundholm 2010 [37]

Sweden

Interview

924 (20 female) persons

Prison

Benzodiazepines, cannabis, cocaine, meth/amphetamine, opiates

Malone 1995 [38]

USA

Interview

77 (6 female) powerlifters and bodybuilders

Gymnasium

Alcohol, cocaine, hallucinogen, opioids, sedatives, stimulants, tetrahydrocannabinol, tobacco

McBride 1996 [39]

Wales

Case study

3 males: 1 AAS dealer and roofer aged 27 years, 1 bodybuilder aged 22 years, and 1 gym owner aged 26 years)

Not specified

Amphetamine, cannabis, clenbuterol, human chorionic gonadotropin (hCG), nalbuphine, tamoxifen, temazepam

McKillop 1987 [40]

Scotland

Interview

8 male bodybuilders aged 17 to 32 years

Gymnasium

Furosemide, thiazides, thyroxine, human chorionic gonadotropin (hCG)

Moss 1992 [41]

USA

Interview

50 male bodybuilders

Gymnasium

Clomiphene citrate, human chorionic gonadotropin (hCG)

Moss 1993 [42]

USA

Interview

30 male bodybuilders

Gymnasium

Clomiphene citrate, human chorionic gonadotropin (hCG)

Pappa 2012 [43]

Europe

Interview

9 athletes aged 19 to 26 years

Community via snowball sampling

Analgesics, amphetamine, caffeine, cannabis, dietary supplements, diuretics, erythropoietin.

Perry 1990 [44]

USA

Interview and questionnaire

20 male weightlifters aged 18 to 28 years

Gymnasium

Human chorionic gonadotropin (hCG)

Perry 2003 [45]

USA

Interview

10 male weightlifters aged 21 to 40 years

Gymnasium

Aspirin®, caffeine, clomiphene, creatine, dietary supplement, ephedrine, glutamine, liothyronine, protein powder, yohimbine

Peters 1997 [46]

Australia

Interview and questionnaire

100 persons (6 female) aged 18 to 50 years

Advertisements, gymnasium, interviews, radio, sports shops and associations, syringe exchange centre

Alcohol, aminogluthimide, amphetamine, antibiotics, beta blockers, caffeine, cannabis, chromium picolinate, clenbuterol, cocaine, daonil®, dietary supplement, diuretics, ecstasy, ephedrine, growth hormone, human chorionic gonadotropin (hCG), hydroxocobal amin, insulin-like growth factor 1, insulin, oestrogen antagonist, pregnyl®, proviron®, teroxin (T3), thyroxine

Pope 1988 [47]

USA

Interview

41 male bodybuilders and footballers

Gymnasium

Alcohol, cannabis, cigarettes, cocaine, human chorionic gonadotropin (hCG)

Pope 1994 [48]

USA

Interview

88 athletes; mean age 26 years

Gymnasium

Alcohol, cannabis, tobacco

Rashid 2000 [49]

USA

Case study

40-year-old male

Clinic

Cocaine, cannabis, ‘uppers’, ‘downers’, lysergic acid diethylamide (LSD)

Schäfer 2011 [50]

Denmark

Case study

26-year-old male bodybuilder

Clinic

Erythropoietin

Silvester 1995 [51]

USA

Interview

22 former athletes aged 36 to 66 years

Not specified

Growth hormone

Skårberg 2007 [52]

Sweden

Interview and questionnaire

18 male drug users; mean age 35 years

Clinic

Alcohol, narcotics/other drugs

Skårberg 2008 [53]

Sweden

Interview

6 drug users (2 female)

Clinic

Alcohol, amphetamine, analgesics, anti-catabolics, anti-oestrogens, aspirin®, benzodiazepines, bronchodilators, buprenorphine, caffeine, cannabis, cocaine, codeine, conjugated linoleic acid, creatine, dietary supplements, ecstasy, ephedra, ephedrine, growth hormone, Herbal products, insulin growth factor 1, insulin, protein powder, testosterone releasers

Skårberg 2009 [54]

Sweden

Interview and questionnaire

32 male drug users

Clinic

Alcohol, amphetamine, anti-oestrogen (clomid), analgesics, anti-acne drug, anti-catabolics, anti-depressants, anti-hypertensive drugs, anti-oestrogens, benzodiazepines, bronchodilators, cannabis, cocaine, creatine, dietary supplements, diuretics, ephedrine, fat-loss agents, gamma hydroxybutyrate, growth hormone, heroin, insulin, insulin-like growth factor 1, levodopa, muscle oil (synthol), non-steroidal anti-inflammatory drugs, opioid, plant steroid compounds, protein powder, stimulants, testosterone boosters, thyroid hormone

Strauss 1985 [55]

USA

Interview

10 weight-trained female athletes; mean age 33 years

Personal contact

Acetaminophen, aspirin®, benoxaprofen, Ben-Gay®, caffeine, calcium, choline and inositol, dietary supplements, dimethyl sulfoxide, codeine, electrolyte solution, epinephrine, furosemide, growth hormone, levodopa, lidocaine, naproxen, oxycodone hydrochloride, phenylbutazone, piroxicam, potassium, suntan pills, thyroglobulin, vitamins

Tallon 2007 [56]

Scotland

Interview and questionnaire

30 males aged 18 to 43 years; mean age 27 years

Gymnasium

Alcohol, cannabis, cocaine, clenbuterol, dietary supplements, diuretics, ecstasy, growth hormone, insulin, tamoxifen

Wilson-Fearon 1999 [57]

England

Case study

29-year-old bodybuilder

Not specified

Clenbuterol, dietary supplements, diuretics, growth hormone, human chorionic gonadotropin (hCG), thiomucase

Wines 1999 [58]

USA

Interview

11 weightlifters (5 female) aged 19 to 42 years

Gymnasium

Alcohol, buprenorphine, heroin, hydrocodone, nalbuphine, other drugs

We relied on the qualitative results generated from the interview.

Classification of substances

We sought to classify the various non-AAS substances used by AAS users into meaningful groups. First, SP provided a functional categorization of the substances. Acknowledging that some AAS users self-administer these substances for purposes contrary to their conventional use, DS built on SP’s classification by allocating the substances into SP’s groups based on motives for use as presented by users in the literature. For substances for which motive for use was not delineated in the literature, DS grouped them based on Evans-Brown et al.’s [2] classification of human enhancement substances and a classification by the Norwegian Institute of Public Health [59]. JM inspected the grouping and provided further advice. Next, DS allocated substances that at this stage could not be allocated into groups based on the three previous methods by referring to Medscape Drug Reference and Wikipedia [60]. We reached consensus on the classification through further review and discussion.

Results and discussion

Description of studies and inter-reviewer reliability

A total of 50 studies were included in the metasynthesis. Participants’ ages ranged from 14 [34] to 66 years [51]. The year of publication of the studies ranged from 1985 [55] to 2014 [12,13,30]. Studies originated from 10 countries with the highest number from the United States (n = 22), followed by Sweden (n = 7), England only (n = 5), the United Kingdom (n = 4), Australia (n = 3), and Scotland only (n = 2). Additionally, one study originated from Canada, Denmark, France, Iran, and Wales only respectively. One study [16] originated from Australia, Canada, and USA while another described the sample as European [43]. Thirty studies used interviews [10-12,17,19-22,24,27,28,30-32,34-38,40-43,45,47,48,51,53,55,58], seven were case studies [9,23,29,39,49,50,57], one used interviews and focus groups [13], and twelve [14-16,19,25,26,33,44,46,52,54,56] used interviews supported by a questionnaire. For the studies that used both interviews and questionnaires, we relied on the qualitative or descriptive results generated from the interviews. There was very good agreement (Kappa = 0.82, p < 0.001) between the two reviewers [61]. Through further analysis and dialogue agreement was reached on discrepant extractions.

Substances used prior to AAS initiation

Before their AAS use debut, some users had experimented with or were regular users of other substances. This was presented by ten studies [17,21,24,26-29,34,47,53]. The most prominent of these substances were alcohol, amphetamine, cannabis, and cocaine. Others were analgesics/opioids, heroin, stimulants, and dietary/nutritional supplements such as creatine, and protein powder as well as other unspecified licit and illicit substances (see Table 2).
Table 2

Non-AAS substances used before AAS use debut, reason(s)/motive(s) for use, and studies

Substance

Reason(s) for use

Studies (First author, reference)

Alcohol

Better sleep and relaxation

Fudala [17]; Gruber [21]; Hoff [24]; Kanayama [26]; Katz [29]; Kusserow [34]; Perry [47]; Skårberg [53]

Amphetamine

Boosting training, alertness, psychological wellbeing

Hoff [24]; Skårberg [53]

Analgesics/opioids

Pain relief

Kanayama [26]

Cannabis

NS

Fudala [17]; Hoff [24]; Kanayama [26]; Kusserow [34]; Perry [47]

Cocaine

NS

Fudala [17]; Gruber [21]; Kanayama [26]; Katz [29]; Perry [47]

Creatine

Boosting training

Skårberg [53]

Dietary/nutritional supplements

Boosting training, energy

Skårberg [53]

Heroin

NS

Cornford [13]

Protein powder

Boosting training

Skårberg [53]

Stimulants

NS

Kusserow [34]

Other IPEDs, licit and illicit substances

NS

Gruber [21]; Hoff [24]; Kanayama [27,28]; Perry [47]

IPEDs: Image and performance-enhancing drugs.

NS: Not specified.

Substance class - not specified

In Kanayama et al.’s study [26]:

[AAS] users displayed much higher rates of other illicit drug use, abuse, or dependence than non-users, with use of other illicit substances almost always preceding first use of AAS (p. 77).

A recent study by Cornford, Kean, and Nash [13] also highlights heroin use as a precursor to AAS use:

A quick way to make yourself look healthy, isn’t it, without being embarrassed about being on heroin [is to use AAS], do you know what I mean. It [heroin] does take a lot of your confidence away don’t it and like I say, especially, I lose weight pretty fast when I’m on heroin, do you know what I mean. It [AAS use] is a quick way to just make yourself look healthy again, isn’t it (p. 2).

Furthermore, it is important to note that our data also suggested that AAS use may precede the use of other substances for some individuals. In Hoff’s study [24]:

Respondent 8 reported using narcotics after he had started using AAS. In this case, alcohol and drug abuse cannot explain why he started doping [using AAS]. However, AAS use seems to have led him into drug use and criminality in order to finance his extensive AAS use and investment in elite powerlifting. This respondent became aggressive and violent when he combined AAS and alcohol. Due to these side effects he changed from alcohol to cocaine as his primary social drug when he was on AAS (p. 63).

Use of supplementary/ancillary substances

AAS users often engaged in stacking and the use of various licit and illicit substances during their ‘on cycles’ as previously shown. For instance, in a study by McBride [39], “…Mr B had initially used nalbuphine in conjunction with anabolic steroids, clenbuterol, ephedrine, and tamoxifen, all to aid bodybuilding” (p. 69). Indeed, in a study [46] of 100 AAS users: “A number of other drugs were used in addition to AAS as part of their training routine by 49% of the sample” (p. 49).

The most popular supplementary/ancillary substances declared by AAS users in multiple studies were: alcohol, amphetamine/meth, aspirin®, caffeine, cannabis/cannabinoids, clenbuterol, clomiphene citrate, cocaine, codeine, creatine, ephedra/ephedrine, erythropoietin, furosemide, gamma hydroxybutyrate (GHB), growth hormone, heroin, human chorionic gonadotropin (hCG), insulin, insulin-like growth factor 1 (IGF-1), melanotan, nalbuphine/nubain®, protein powder, tamoxifen, thyroxine, and tobacco. Other popular classes of substances presented were analgesics/opioids, anti-oestrogens, benzodiazepines, dietary/nutritional supplements, diuretics, hallucinogens, and stimulants (see Table 3).
Table 3

Use of non-AAS substances, reason(s)/motive(s) for use, and studies

 

Current polypharmacy (Combined with AAS)

Lifetime polypharmacy (Ever use)

 

Substance

Reason(s) for use

Studies (First author, reference)

Reason(s) for use

Studies (First author, reference)

Number of studies

2,4-dinitrophenol

NS

Chandler [12]

NS

Chandler [12]; Dunn [15]; Hope [25]; Larance [35]

4

Acetaminophen

NS

Strauss [55]

NS

Strauss [55]

1

Alcohol

Better sleep and relaxation

Chandler [12]; Hegazy [23]; Kanayama [28]; Kusserow [34]; Lundholm [37]; Malone [38]; Peters [46]; Perry [48]; Skårberg [52-54]

Better sleep and relaxation

Chandler [12]; Dunn [15]; Fudala [17]; Gruber [21,22]; Hegazy [23]; Hoff [24]; Hope [25]; Kanayama [26-28]; Katz [29]; Kusserow [34]; Malone [38]; Peters [46]; Perry [48]; Skårberg [52-54]; Tallon [56]; Wines [58]

23

Aminogluthimide

Reducing receptors’ attraction to cortisol

Peters [46]

Reducing receptors’ attraction to cortisol

Gruber [22]; Peters [46]

2

Amyl nitrate

NS

Chandler [12]

NS

Chandler [12]

1

Analgesics/opioids

Pain relief

Ahlgrim [9]; Hegazy [23]; Kanayama [28]; Klötz [31]; Kusserow [34]; Lundholm [37]; Malone [38]; McBride [39]; Pappa [43]; Skårberg [53]

Pain relief

Ahlgrim [9]; Fudala [17]; Gruber [22]; Hegazy [23]; Kanayama [26,28], Klötz [31]; Kusserow [34]; Malone [38]; McBride [39]; Pappa [43]; Rashid [49]; Skårberg [53,54]

14

Anti-acne drugs

Combating acne

Skårberg [54]

1

Antibiotics

Combating acne

Peters [46]

Combating acne

Korkia [32]; Peters [46]

2

Anti-catabolics

NS

Skårberg [53]

Facilitating synthesis of hepatic protein and nitrogen economy

Skårberg [53,54]

2

Anti-depressants

Combating side effects

Klötz [31]

Combating side effects, depression relief, boosting levels of serotonin and noradrenaline

Klötz [31]; Skårberg [54]

2

Anti-oestrogens

Burning fat, combating gynecomastia, reducing effects on oestrogen

Klötz [31]; Kusserow [34]; Peters [46]; Skårberg [53]

Combating gynecomastia, burning fat, reducing effects on oestrogen

Gårevik [18]; Hope [25]; Klötz [31]; Korkia [32]; Kusserow [34]; Larance [35]; Peters [46]; Skårberg [53,54]

9

Aromatase inhibitors

NS

Chandler [12]

NS

Chandler [12]

1

Aspirin®

NS

Klötz [31]; Perry [45]; Skårberg [53]; Strauss [55]

NS

Klötz [31]; Larance [35]; Perry [45]; Skårberg [53]; Strauss [55]

5

Ben-Gay®

NS

Strauss [55]

NS

Strauss [55]

1

Benoxaprofen

NS

Strauss [55]

NS

Strauss [55]

1

Benzodiazepines

Better sleep, combating side effects, relaxation

Klötz [31]; Larance [35]; Lundholm [37]; McBride [39]; Skårberg [53]

Combating side effects, enhancing sleep and relaxation, self-control, sedation

Gårevik [18]; Klötz [31]; Larance [35]; Lundholm [37]; Malone [38]; McBride [39]; Skårberg [53,54]

8

Beta blockers

Burning fat

Peters [46]

Burning fat

Peters [46]

1

Beta-2-agonists

NS

Bilard [11]

1

Blood pressure regulators

NS

Kusserow [34]

Lower blood pressure

Kusserow [34]; Skårberg [54]

2

Bronchodilators

Energy and boosting training

Skårberg [53]

Burning fat, energy and boosting training, increasing strength

Skårberg [53,54]

2

Buprenorphine

NS

Skårberg [53]

NS

Skårberg [53]; Wines [58]

2

Caffeine

Burning fat

Klötz [31]; Pappa [43]; Perry [45]; Peters [46]; Skårberg [53]; Strauss [55]

Burning fat

Gruber [22]; Klötz [31]; Larance [35]; Pappa [43]; Peters [46]; Perry [45]; Skårberg [53]; Strauss [55]

8

Calcium

NS

Strauss [55]

1

Cannabis/cannabinoids

Enhancing sleep, relaxation

Chandler [12]; Kanayama [27,28]; Klötz [31]; Kusserow [34]; Lundholm [37]; Malone [38]; McBride [39]; Pappa [43]; Peters [46]; Perry [48]; Skårberg [53,54]

Enhancing sleep, relaxation

Bilard [11]; Chandler [12]; Dunn [15]; Fudala [17]; Gruber [21,22]; Hoff [24]; Kanayama [27,28]; Klötz [31]; Kusserow [34]; Larance [35]; Malone [38]; McBride [39]; Pappa [43]; Peters [46]; Perry [48]; Rashid [49]; Skårberg [53,54]; Tallon [56]

21

Captopril

NS

Ahlgrim [9]

NS

Ahlgrim [9]

1

Carvedilol

NS

Ahlgrim [9]

NS

Ahlgrim [9]

1

Choline and inositol

NS

Strauss [55]

NS

Strauss [55]

1

Chromium picolinate

Reducing body weight

Peters [46]

Reducing body weight

Peters [46]

1

Clenbuterol

Anabolic effects, burning fat, removing skin fluid, weight loss

Chandler [12]; Gruber [21]; Kimergård [30]; Klötz [31]; Lenehan [36]; McBride [39]; Peters [46]; Wilson-Fearon [57]

Anabolic effects, burning fat, removing skin fluid, weight loss

Chandler [12]; Gruber [20-22]; Hope [25]; Kimergård [30]; Klötz [31]; Korkia [33]; Larance [35]; Lenehan [36]; McBride [39]; Peters [46]; Tallon [56]; Wilson-Fearon [57]

14

Clomiphene citrate

NS

Chandler [12]; Moss [41,42]; Perry [45]

NS

Chandler [12]; Moss [41,42]; Perry [45]

4

Cocaine

Boosting training, burning fat, increasing strength

Chandler [12]; Kanayama [28]; Larance [35]; Lundholm [37]; Malone [38]; Peters [46]; Skårberg [53,54]

Boosting training, burning fat, increasing strength

Chandler [12]; Dunn [15]; Fudala [17]; Gårevik [18]; Gruber [21]; Hoff [24]; Hope [25]; Kanayama [26-28]; Katz [29]; Larance [35]; Lundholm [37]; Malone [38]; Peters [46]; Rashid [49]; Skårberg [53,54]; Tallon [56]

19

Codeine

Boosting training

Skårberg [53]; Strauss [55]

Boosting training

Skårberg [53]; Strauss [55]

2

Conjugated linoleic acid

Burning fat

Skårberg [53]

Burning fat

Skårberg [53]

1

Corticosteroids

NS

Lenehan [36]

NS

Bilard [11]; Korkia [32]; Lenehan [36]

3

Creatine

Enhancing the effects of training

Klötz [31]; Skårberg [53]; Perry [45]

Anabolic effects, endurance booster, enhancing the effects of training, recovery aid

Davies [14]; Filiault [16]; Hoff [24]; Klötz [31]; Perry [45]; Skårberg [53,54]

7

Daonil®

Increasing insulin release

Peters [46]

Increasing insulin release

Peters [46]

1

Dehydroepiandrosterone (DHEA)

NS

Larance [35]

1

Diazepam

NS

Gårevik [18]

1

Dietary/nutritional supplements

Energy and boosting training, nutrition

Pappa [43]; Perry [45]; Peters [46]; Skårberg [53,54]; Strauss [55]; Wilson-Fearon [57]

Energy and boosting training, anabolic effects, endurance booster, nutrition, recovery aid

Davies [14]; Filiault [16]; Gruber [21]; Korkia [32]; Pappa [43]; Perry [45]; Peters [46]; Skårberg [53,54]; Strauss [55]; Tallon [56]; Wilson-Fearon [57]

12

Digoxin

NS

Ahlgrim [9]

NS

Ahlgrim [9]

1

Dimethyl sulfoxide

NS

Strauss [55]

NS

Strauss [55]

1

Diuretics

Combating side effects, masking doping drugs, reducing fluid levels

Chandler [12]; Klötz [31]; Lenehan [36]; Pappa [43]; Peters [46]; Wilson-Fearon [57]

Combating side effects, masking doping drugs, reducing fluid levels

Chandler [12]; Goldfield [19]; Hope [25]; Klötz [31]; Korkia [32]; Larance [35]; Lenehan [36]; Pappa [43]; Peters [46]; Skårberg [54]; Tallon [56]; Wilson-Fearon [57]

12

Electrolyte solution

NS

Strauss [55]

NS

Strauss [55]

1

Ephedra/Ephedrine

Energy and boosting training, enhancing weight loss

Chandler [12]; Kimergård [30]; Klötz [31]; McBride [39]; Perry [45]; Peters [46]; Skårberg [53]

Energy and boosting training, burning fat, enhancing weight loss, increasing strength

Chandler [12]; Gårevik [18]; Gruber [20]; Gårevik [18]; Hope [25]; Kimergård [30]; Klötz [31]; Larance [35]; McBride [39]; Perry [45]; Peters [46]; Skårberg [53,54]

14

Epinephrine

NS

Strauss [55]

NS

Strauss [55]

1

Erythropoietin (EPO)

NS

Pappa [43]; Schäfer [50]

NS

Hope [25]; Pappa [43]; Schäfer [50]

3

Esiclene

NS

Korkia [32]

1

Fat-loss agents

Burning fat

Skårberg [54]

1

Furosemide

Weight loss

Ahlgrim [9]; Strauss [55]

Weight loss

Ahlgrim [9]; McKillop [40]; Strauss [55]

3

Gamma hydroxybutyrate (GHB)

Enhancing sleep

Chandler [12]; Klötz [31]; Skårberg [54]

Enhancing sleep

Chandler [12]; Dunn [15]; Gruber [22]; Klötz [31]; Skårberg [54]

5

Genotropine

NS

Klötz [31]

NS

Klötz [31]

1

Glutamine

NS

Perry [45]

NS

Perry [45]

1

Growth hormone

Anabolic effects and strength, burning fat, weight loss

Chandler [12]; Kimergård [30]; Kusserow [34]; Lenehan [36]; Peters [46]; Skårberg [53,54]; Strauss [55]; Wilson-Fearon [57]

Anabolic effects, burning fat, endurance booster, recovery aid, weight loss

Chandler [12]; Filiault [16]; Fudala [17]; Gårevik [18]; Hope [25]; Kimergård [30]; Korkia [32,33]; Kusserow [34]; Larance [35]; Lenehan [36]; Peters [46]; Silvester [51]; Skårberg [53,54]; Strauss [55]; Tallon [56]; Wilson-Fearon [57]

18

Growth hormone releasing peptides

NS

Chandler [12]

NS

Chandler [12]

1

Hallucinogens

NS

Larance [35]; Malone [38]

NS

Dunn [15]; Larance [35]; Malone [38]

3

Herbal products

NS

Skårberg [53]

Increasing strength

Skårberg [53,54]

 

Heroin

Enhancing sleep, pain relief

Cornford [13]; Larance [35]; Skårberg [54]

Enhancing sleep, pain relief

Gårevik [18]; Cornford [13]; Kanayama [27]; Larance [35]; Skårberg [54]; Wines [58]

6

Human chorionic gonadotropin (hCG)

Minimizing depressive symptoms upon AAS cessation/withdrawal, improving testosterone production, preventing weight loss, stopping testicular atrophy, increasing strength

Chandler [12]; Kimergård [30]; Lenehan [36]; McBride [39]; Moss [41,42]; Perry [44]; Peters [46]; Perry [47]; Korkia [32]; Wilson-Fearon [57]

Anabolic effects, increasing testosterone production, minimizing depressive symptoms upon AAS cessation/withdrawal, preventing weight loss, stopping testicular atrophy, increasing strength

Chandler [12]; Fudala [17]; Gruber [22]; Gårevik [18]; Hope [25]; Kimergård [30]; Korkia [32]; Larance [35]; Lenehan [36]; McBride [39]; McKillop [40]; Moss [41,42]; Perry [44]; Peters [46]; Perry [47]; Wilson-Fearon [57]

17

Hydrochlorothiazide

Weight loss

Ahlgrim [9]

Weight loss

Ahlgrim [62]

1

Hydrocodone

NS

Wines [58]

1

Hydroxocobal amin

Weight gain

Peters [46]

Weight gain

Peters [46]

1

Inhalants

NS

Larance [35]

NS

Dunn [15]; Larance [35]

2

Insulin

Anabolic effects and strength, burning fat, weight loss

Chandler [12]; Kimergård [30]; Klötz [31]; Peters [46]; Skårberg [53,54]

Anabolic effects and strength, burning fat, weight loss

Chandler [12]; Gårevik [18]; Hope [25]; Kimergård [30]; Klötz [31]; Larance [35]; Peters [46]; Skårberg [53,54]; Tallon [56]

10

Insulin-like growth factor 1 (IGF-1)

Anabolic effects and strength, burning fat

Chandler [12]; Klötz [31]; Lenehan [36]; Peters [46]; Skårberg [53,54]

Anabolic effects and strength, burning fat

Chandler [12]; Fudala [17]; Klötz [31]; Larance [35]; Lenehan [36]; Peters [46]; Skårberg [53,54]

8

Ketamine

NS

Chandler [12]

NS

Chandler [12]; Dunn [15]

2

Laxative

NS

Goldfield [19]

2

Levodopa

NS

Strauss [55]

Increasing growth hormone

Strauss [55]; Skårberg [54]

2

Lidocaine

NS

Strauss [55]

NS

Strauss [55]

2

Liothyronine

NS

Perry [45]

NS

Perry [45]

1

Lysergic acid diethylamide (LSD)

NS

Skårberg [54]

NS

Rashid [49]; Skårberg [54]

2

Mechano growth factor

NS

Chandler [12]

NS

Chandler [12]

1

Melanotan

Boosting training, skin tanning

Chandler [12]; Kimergård [30]

Boosting training, skin tanning

Chandler [12]; Hope [25]; Kimergård [30]

3

Mephedrone

NS

Chandler [12]

NS

Chandler [12]

1

Meth/amphetamine

Alertness, boosting training, burning fat, increasing aggression during exercise, increasing strength, psychological wellbeing

Chandler [12]; Hegazy [23]; Kimergård [30]; Larance [35]; Lundholm [37]; McBride [39]; Pappa [43]; Peters [46]; Skårberg [53,54]

Alertness, boosting training, burning fat, increasing aggression during exercise, increasing strength, psychological wellbeing

Angoorani [10]; Chandler [12]; Gårevik [18]; Hegazy [23]; Hoff [24]; Hope [25]; Kimergård [30]; Larance [35]; Lundholm [37]; McBride [39]; Pappa [43]; Peters [46]; Skårberg [53,54]; Tallon [56]

15

Muscle oil (synthol)

Anabolic effect

Skårberg [54]

1

Muscle relaxing drugs

Combating side effects

Klötz [31]

Combating side effects

Klötz [31]

1

Myoblast

NS

Klötz [31]

NS

Klötz [31]

1

Nalbuphine/nubain®

NS

Strauss [55]; Lenehan [36]; McBride [39]

Treating pain from weightlifting injuries, “anti-catabolic”, mental high

Gruber [22]; Hope [25]; Kanayama [27]; Korkia [33]; Lenehan [36]; McBride [39]; Strauss [55]; Wines [58]

8

Naproxen

NS

Strauss [55]

NS

Strauss [55]

1

Non-steroidal anti-inflammatory drugs (NSAIDs)

Inflammation, pain, and fever relief

Skårberg [54]

1

Oxycodone

NS

Strauss [55]

NS

Kanayama [27]; Strauss [55]

2

Peptide hormones

NS

Bilard [11]

1

Phenylbutazone

NS

Strauss [55]

NS

Strauss [55]

1

Phosphodiesterase-5 inhibitors (PDE5i)

NS

Hope [25]

1

Piroxicam

NS

Strauss [55]

NS

Strauss [55]

1

Potassium

NS

Strauss [55]

NS

Strauss [55]

1

Potency/testicular increasing drugs

Combating side effects

Klötz [31]

Combating side effects

Klötz [31]

1

Pregnyl®

Improved testosterone production

Peters [46]

Improved testosterone production

Peters [46]

1

Protein powder

Enhancing effects of training, increasing protein synthesis

Perry [45]; Skårberg [53,54]

Enhancing effects of training, increasing protein synthesis

Perry [45]; Skårberg [53,54]

3

Proviron®

Hardiness, improved testosterone production

Peters [46]

Hardiness, improved testosterone production

Peters [46]

1

Recovery drinks

Endurance booster, recovery aid

Filiault [16]

1

Sedatives

NS

Malone [38]

NS

Malone [38]

1

Sildenafil/viagra®/cialis

Enhanced sexual functioning

Chandler [12]; Kimergård [30]

Enhanced sexual functioning

Chandler [12]; Gårevik [18]; Hope [25]; Kimergård [30]

4

Somatotropine

NS

Klötz [31]

NS

Klötz [31]

1

Spironolactone

Weight loss

Ahlgrim [9]

Weight loss

Ahlgrim [9]

1

Stimulants

NS

Klötz [31]; Kusserow [34]; Malone [38]

Increasing strength, burning fat

Fudala [17]; Klötz [31]; Kusserow [34]; Malone [38]; Rashid [49]; Skårberg [54]

6

Suntan pills

NS

Strauss [55]

NS

Strauss [55]

1

Tamoxifen

Combating side effects

Chandler [12]; Kimergård [30]; Lenehan [36]; McBride [39]

Combating side effects

Chandler [12]; Gruber [22]; Kimergård [30]; Korkia [33]; Lenehan [36]; McBride [39]; Tallon [56]

7

Teroxin (T3)

Preventing weight gain

Peters [46]

Preventing weight gain

Peters [46]

1

Testosterone releasers/boosters

Combating side effects, increasing hormone production

Skårberg [53]

Combating side effects, increasing blood serum levels of testosterone or hormone production

Skårberg [53,54]

2

Thiazides

NS

McKillop [40]

1

Thiomucase

NS

Wilson-Fearon [57]

Burning fat

Korkia [32,33]; Wilson-Fearon [57]

3

Thyroxine

Burning fat, increasing metabolism

Chandler [12]; Lenehan [36]; Peters [46]; Skårberg [54]; Strauss [55]

Burning fat, increasing metabolism

Chandler [12]; Gruber [22]; Hope [25]; Korkia [32]; Larance [35]; Lenehan [36]; McKillop [40]; Peters [46]; Skårberg [54]; Strauss [55]

10

Tobacco

NS

Malone [38]; Perry [48]; Pope [47]

NS

Malone [38]; Perry [48]; Pope [47]

3

Torsemide

NS

Ahlgrim [9]

NS

Ahlgrim [9]

1

Triacana

NS

Korkia [33]

1

Yohimbine

NS

Perry [45]

NS

Gruber [22]; Perry [45]

3

Other IPEDs, licit and illicit substances

NS

Kanayama [28]; Klötz [31]; Kusserow [34]; Perry [48]; Skårberg [52]

NS

Gruber [20,21]; Hoff [24]; Hope [25]; Kanayama [26,28]; Klötz [31]; Kusserow [34]; Perry [48]; Skårberg [52,54]; Wines [58]

 

IPEDs: Image and performance-enhancing drugs.

NS: Not specified.

Substance class - not specified.

Lifetime polypharmacy

We also investigated lifetime use of other substances by AAS users. The most popular substances (declared in multiple studies) were: 2,4-dinitrophenol (DNP), alcohol, aminogluthimide, amphetamine/meth, aspirin®, buprenorphine, caffeine, cannabis/cannabinoids, clenbuterol, clomiphene citrate, cocaine, codeine, creatine, ephedra/ephedrine, erythropoietin (EPO), furosemide, gamma hydroxybutyrate (GHB), growth hormone, heroin, human chorionic gonadotropin (hCG), insulin, insulin-like growth factor 1 (IGF-1), ketamine, levodopa, lysergic acid diethylamide (LSD), melanotan, nalbuphine/nubain®, oxycodone, protein powder, sildenafil/viagra®/cialis®, tamoxifen, thiomucase, thyroxine, and yohimbine. Other popular classes of substances presented were analgesics/opioids, antibiotics, anti-catabolics, anti-oestrogens, benzodiazepines, blood pressure regulators, bronchodilators, dietary/nutritional supplements, diuretics, hallucinogens, inhalants, stimulants, and testosterone releasers/boosters.

Of the above substances, the most commonly identified in studies include alcohol, cannabis/cannabinoids, cocaine, growth hormone, human chorionic gonadotropin (hCG), amphetamine/meth, clenbuterol, ephedra/ephedrine, insulin, and thyroxine. Commonly identified classes of substances include analgesics/opioids, dietary/nutritional supplements, diuretics, and anti-oestrogens (see Table 3).

Groups of non-AAS substances used by AAS users

Our classification of the various substances used by AAS users resulted in 13 main groups: analgesics/non-steroidal anti-inflammatory drugs/opioids, anti-oestrogens, cardiovascular drugs, central nervous system depressants, central nervous system stimulants, cosmetic drugs, dietary/nutritional supplements, diuretics, fat burning/weight loss drugs, muscle/strength-enhancement hormones, non-hormone muscle/strength-enhancement drugs, recreational substances/drugs, and sexual enhancement drugs (see Table 4). These groups of substances are briefly discussed below.
Table 4

Groups of non-AAS substances used by AAS users

Group

Examples

Purpose(s)

Analgesics/non-steroidal anti-inflammatory drugs/opioids

Acetaminophen, aspirin®, Ben-Gay®, benoxaprofen, buprenorphine, codeine, corticosteroids, heroin, hydrocodone, lidocaine, muscle oil (synthol) and muscle relaxing drugs, nalbuphine/nubain®, naproxen, oxycodone, phenylbutazone, piroxicam

Relieving inflammation, pain, and fever

Anti-oestrogens

Aminogluthimide, aromatase inhibitors, clomiphene/clomid, proviron®, tamoxifen

Improved testosterone production, burning body fat, reducing the effects of AAS on oestrogens, and dealing with gynecomastia

Cardiovascular drugs

Beta-2-agonists, beta-blockers, captopril, carvedilol, digoxin, thiazides

Lowering blood pressure, reducing risk of infarction, and burning body fat

CNS depressants

Alcohol, benzodiazepines, buprenorphine, cannabis/cannabinoids, diazepam, gamma hydroxybutyrate (GHB), heroin, hydrocodone, ketamine, oxycodone

Improving sleep, relaxation, and dealing with side effects of AAS use such as gynecomastia

CNS stimulants

Amyl nitrate, caffeine, cocaine, ephedrine, epinephrine, mephedrone, meth/amphetamine, yohimbine

Alertness, boosting training, burning body fat, increased aggression and strength, and psychological wellbeing

Cosmetic drugs

Anti-acne drugs, esiclene, melanotan I, suntan pills, thiomucase

Curing acne, skin tanning, and enhancing physical appearance

Dietary/nutritional supplements

Calcium, choline and inositol, chromium picolinate, conjugated linoleic acid, creatine, electrolyte solution, glutamine, hydroxocobal amin, piroxicam, potassium, protein powder

For essential nutrients to supplement the diet and combat the risk of illness

Diuretics

Furosemide, hydrochlorothiazide, spironolactone, torsemide

Increasing strength, masking AAS and other doping drugs, burning body fat, and reducing levels of body fluid

Fat burning/weight loss drugs

2,4-dinitrophenol (DNP), anti-oestrogens, beta blockers, bronchodilators, caffeine, chromium picolinate, clenbuterol, cocaine, conjugated linoleic acid, ephedrine, hydrochlorothiazide, insulin**, laxatives††, liothyronine, melanotan II, meth/amphetamine, spironolactone, teroxin (T3), thiomucase, thyroxine, triacana, yohimbine

Suppression of appetite, increased metabolism, and reduced absorption of body fat

Muscle/strength-enhancement drugs (non-hormone)

Amphetamine/meth, anti-catabolics, glutamine, bronchodilators, chromium picolinate, clenbuterol, creatine, ephedrine, herbal products††, hydroxocobal amin (B12), myoblast, muscle oil (synthol), protein powder, recovery drinks

Enhancing the size and structure of muscles as well as boosting strength

Muscle/strength-enhancement hormones††

Dehydroepiandrosterone (DHEA), erythropoietin (EPO), genotropine, growth hormone, growth hormone releasing peptide (GHRP), human chorionic gonadotropin (hCG), insulin-like growth factor 1 (IGF-1), insulin, levodopa, mechano growth factor, pregnyl®, prohormones, proviron®, somatotropine

Enhancing the size and structure of muscles as well as boosting strength

Recreational substances/drugs

Alcohol, buprenorphine, cannabis/cannabinoids, cigarettes/tobacco methamphetamine, blood pressure regulators, caffeine, cocaine, ecstasy, hallucinogens, heroin, hydrocodone, ketamine, lysergic acid diethylamide (LSD), sedatives, tetrahydrocannabinol

Enhancing sleep, relaxation, and psychological wellbeing

Sexual enhancement drugs

Anti-oestrogens, human chorionic gonadotropin (hCG), melanotan II, phosphodiesterase-5 inhibitors (PDE5i), sildenafil/cialis®, yohimbine

Dealing with testicular atrophy, improved sexual desire or arousal and boosting erectile functioning

CNS: Central nervous system.

Substance class - not specified.

††Some are used for direct muscle enhancing properties and others for counteracting shut-down of endogenous testosterone production.

**Skårberg [54].

There may be overlap between classes (e.g. CNS depressants may be used for promoting sleep and for analgesic properties).

Some of the drugs do not have well documented efficacy for their alleged motives for use.

Analgesics/non-steroidal anti-inflammatory drugs/opioids

These drugs include aspirin®, codeine, and oxycodone. This group of drugs was used for relieving inflammation, pain, and fever emanating from exercise, sports participation or the recreational and occupational activities of AAS users.

Anti-oestrogens

Anti-oestrogens include aminogluthimide, clomiphene, and tamoxifen. These drugs were used for reducing the oestrogen-like side effects of AAS use such as preventing gynecomastia. They were also used for endurance, improved testosterone production, and burning body fat.

Cardiovascular drugs

These drugs such as captopril, carvedilol, and digoxin were used for improved functioning of the cardiovascular system such as lowering blood pressure and reducing the risk of myocardial infarction, as well as burning body fat.

Central nervous system depressants

Examples of depressants are buprenorphine, hydrocodone, and oxycodone. The purposes for which these drugs were used were improved sleep, relaxation, and elevation of mood.

Central nervous system stimulants

Stimulants including epinephrine, amphetamine/methamphetamine, and yohimbine were used for alertness, boosting training, burning body fat, increased aggression and strength (including sexual), and psychological wellbeing.

Cosmetic drugs

Cosmetic or aesthetic drugs such as esiclene, melanotan II, and thiomucase were used in order to deal with acne, and for: inflammatory effects on smaller muscles, skin tanning, and a leaner physique thus enhancing physical appearance.

Dietary/nutritional supplements

These supplements such as calcium, glutamine, and potassium were consumed to provide essential nutrients to supplement the diet and combat the risk of illness.

Diuretics

Diuretics such as furosemide, hydrochlorothiazide, and spironolactone were used for combating side effects of AAS use such as water retention, together with masking the use of AAS and other doping agents.

Fat burning/weight loss drugs

These drugs include 2,4-dinitrophenol (DNP), conjugated linoleic acid, and teroxin (T3) and were used for suppression of appetite, increased metabolism, and reduced absorption of body fat as a means to burning body fat and losing weight.

Muscle/strength-enhancement substances

Two types of muscle/strength-enhancement substances were presented in the literature: hormones and non-hormones. Examples of muscle/strength-enhancement hormones are growth hormones, growth hormone releasing peptide (GHRP), and insulin. Non-hormone muscle/strength-enhancement drugs include clenbuterol used by some in an attempt to enhance the size and structure of muscles, as well as boosting strength.

Recreational substances/drugs

Recreational substances/drugs such as cannabis/cannabinoids, cocaine, and lysergic acid diethylamide (LSD) were used to alter experiences, elevate mood, and create psychological wellbeing as well as for relaxation.

Sexual enhancement drugs

These drugs such as phosphodiesterase-5 inhibitors (PDE5i), melanotan II, and sildenafil were used for dealing with testicular atrophy, improved sexual desire or arousal as well as erectile functioning.

In sum, the above groups of substances were used to enhance the effects of AAS, combat the side effects of AAS, and for recreational or relaxation purposes, as well as sexual enhancement. It is important to note that there is overlap between some of the groups. For instance, some central nervous system depressants may be misused for promoting sleep as well as their analgesic properties. Again, some muscle/strength-enhancement hormones are used for direct muscle enhancing properties and others for counteracting shutdown of endogenous testosterone production. Additionally, some of the substances are used for multiple purposes. For instance, melanotan II is used for tanning the skin and also as self–treatment for erectile dysfunction resulting from long-term AAS use. Others may use melanotan II to self-treat specific conditions such as rosacea or fibromyalgia and others may use melanotan for the self-reported weight loss effects due to appetite suppression. It is also important to note that some of the alleged properties or uses are not scientifically well documented such as the use of insulin for burning body fat [54]. Furthermore, the quality, safety, and efficacy of substances obtained from the illicit market cannot be known, with adulteration usually commonplace [2,63].

Implications for policy and practice

The present study has highlighted various licit and illicit substances used by AAS users. Evidence abounds that some of the substances identified in our study, especially dietary and nutritional supplements, may be contaminated with AAS and other pharmacological elements thus, potentially, playing a role in the decision to initiate AAS use [2,64-67]. Preventive efforts should therefore highlight the potential role licit and illicit substance use, especially dietary and nutritional supplement use, may play in the initiation of AAS use as well as the role AAS use may potentially play in the use of other substances, together with the potential negative consequences individuals who engage in such behavior may encounter.

AAS-associated polypharmacy is dangerous for several reasons. First, it has been associated with violent and criminal behavior as well as various forms of pathology and mortality [68-70]. Second, chemical interactions from AAS-related polypharmacy may have adverse psychophysical effects on individuals engaged in such behavior. Thus, the main and combined effects of the use of these substances must attract the attention of clinicians, policymakers and public health officials. Indeed, physicians may inadvertently administer medication to AAS-using polydrug users thereby triggering unintended adverse chemical interactions that may be harmful to AAS-using patients. Accordingly, gathering correct and comprehensive substance use histories of AAS users is important in the effective pharmacological and psychological treatment of AAS users [67,71] as such information may guide clinicians in the diagnosis and prescription of ‘safe’ drugs during treatment.

Additionally, most AAS users obtain the substances identified in the present study from the illicit market [1,2]. Because many of these substances are controlled or illegal [2], they may be produced in unsterile ‘underground laboratories’ leading to inadvertent and sometimes deliberate incorrect dosing, substitution of ingredients and contamination with additional pharmaceuticals, toxic chemicals and pathogens. Furthermore, some users resort to unsterile injection equipment for the administration of these products, resulting in injecting site injuries as well as bacterial and fungal infection [72] and the potential transmission of blood borne viruses such as hepatitis B/C and HIV [25]. Stakeholders must take our findings into consideration in the development of preventive and therapeutic interventions for AAS users. There is also the need for the strengthening of harm reduction interventions to combat the harmful consequences of AAS-related polydrug use.

Implications for research

There is the need for further investigations to elucidate better the pathway to AAS-associated polysubstance use. Further studies are also necessary to examine the main and complementary enervating consequences of the use of different dosages of these varied substances, plus their addictive potential and trajectories. Moreover, there is a dearth of knowledge regarding the spread of these substances due to the fact that most of these substances are relatively new. So far most focus has been directed toward AAS in particular. Thus, the use of ancillary and associated substances has mainly escaped the attention of clinicians, public health officials, policymakers, and researchers [2]. There is therefore the need for studies examining the emergence of these substances in the pharmacopoeia of substance users as well as their diffusion into other substance-using populations.

There is the need for the collection and analysis or testing of these substances, to ascertain their content and potential contaminants. Additionally, apart from the Iranian study [10], all studies were conducted in Western countries. Nonmedical AAS use is a global public health problem [4] and researchers are encouraged to extend their investigations to non-Western nations. Finally, investigations of AAS-associated polypharmacy must be a continuous process requiring updates as evidence accumulates.

Strengths and limitations

As far as we are aware, the present study is the pioneering international systematic review and synthesis of qualitative studies on AAS use and polypharmacy. The inclusion of both peer-reviewed and grey literature, as well as literature published before 1995 and after 2009, also distinguishes this review from a previous review [3]. The present study also has some limitations that ought to be taken into consideration when interpreting our findings. First, due to the nature of the present study, it was not statistically possible to establish ‘gateway’ or causal associations between AAS use and use of the other substances. In addition, we were unable to establish the prevalence of the use of these substances by AAS users. Third, some of the studies included in the present study did not specifically investigate AAS users’ intake of other licit and illicit substances. Although these studies present very useful data in respect of the present study, it is plausible that these studies do not present a comprehensive picture of the variety of substances ingested by AAS users. Similarly, the case reports included in the present study may have been published because they are ‘extraordinary’ and may therefore not be representative of the ‘typical’ AAS user. With the relative paucity of literature in this field [73], the inclusion of these studies is in our view still defendable. Finally, there is the possibility that our exclusion of non-English language literature may have biased our results. It should be noted however that this very common practice in terms of reviews and meta-analyses might not necessarily affect findings [62].

Conclusions

Our findings corroborate previous suggestions of associations between AAS use and the use of a wide range of other licit and illicit substances. AAS-related polypharmacy has potential serious harmful effects for persons who engage in such behavior, which should be of serious public health concern. Clinicians, policymakers, researchers, and public health workers dealing with AAS users must be educated about these issues. Importantly, efforts must be intensified to combat the debilitating effects of AAS-concomitant polypharmacy. Furthermore, there needs to be ongoing research to investigate trends in AAS use and polypharmacy.

Declarations

Acknowledgements

We are grateful to Philomena Antwi for reviewing studies included in the metasynthesis.

Authors’ Affiliations

(1)
Department of Psychosocial Science, University of Bergen
(2)
Centre for Public Health, Liverpool John Moores University
(3)
Department of Physical Medicine and Rehabilitation, Unit of Neuropsychology, Oslo University Hospital
(4)
Departments of Surgery and Paediatrics, La General Hospital
(5)
The Competence Centre, Bergen Clinics Foundation

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This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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