Anabolic-androgenic steroids: procurement and administration practices of doping athletes
Julius Fink, Brad Jon Schoenfeld, Anthony C. Hackney, Masahito Matsumoto, Takahiro Maekawa, Koichi Nakazato & Shigeo Horie
To cite this article: Julius Fink, Brad Jon Schoenfeld, Anthony C. Hackney, Masahito Matsumoto, Takahiro Maekawa, Koichi Nakazato & Shigeo Horie (2018): Anabolic-androgenic steroids: procurement and administration practices of doping athletes, The Physician and Sportsmedicine, DOI: 10.1080/00913847.2018.1526626
To link to this article: https://doi.org/10.1080/00913847.2018.1526626
Accepted author version posted online: 24 Sep 2018.
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Publisher: Taylor & Francis
Journal: The Physician and Sportsmedicine
DOI: 10.1080/00913847.2018.1526626
Authors
Julius Fink1, Brad Jon Schoenfeld2, Anthony C. Hackney3, Masahito Matsumoto4, Takahiro Maekawa5 Koichi Nakazato6 and Shigeo Horie7
Affiliation
1Graduate School of Medicine, Department of Metabolism and Endocrinology, Juntendo University, Tokyo, JAPAN
2Department of Health Sciences, Lehman College, Bronx, NY, USA 3Department of Exercise & Sport Science; Department of Nutrition – School of Public Health, University of North Carolina at Chapel Hill, USA 4Advanced Diabetic Therapeutics, Department of Metabolic Endocrinology, Juntendo University, Japan
5Department of Rehabilitation for the Movement Functions Research Institute, National Rehabilitation Center for Persons with Disabilities 6Graduate Schools of Health and Sport Science, Nippon Sport Science University, Tokyo, JAPAN
7Graduate School of Medicine, Department of Urology, Juntendo University, Tokyo Japan
Corresponding author Name: Julius Fink
Mailing address: 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan Telephone: +81-3-3813-3111
Fax: +81-3-3813-596
E-mail: [email protected]
There is no funding received for this work (from NIH, Wellcome Trust,
HHMI, or any others). There are no professional relationships with companies or manufacturers who will benefit from the results of the present study for each author.
Review
Anabolic-androgenic steroids: procurement and administration practices of doping athletes
Authors
Julius Fink1, Brad Jon Schoenfeld2, Anthony C. Hackney3, Masahito Matsumoto4, Takahiro Maekawa5 Koichi Nakazato6 and Shigeo Horie7
Affiliation
1Graduate School of Medicine, Department of Metabolism and Endocrinology, Juntendo University, Tokyo, JAPAN
2Department of Health Sciences, Lehman College, Bronx, NY, USA 3Department of Exercise & Sport Science; Department of Nutrition – School of Public Health, University of North Carolina at Chapel Hill, USA
4Advanced Diabetic Therapeutics, Department of Metabolic Endocrinology, Juntendo University, Japan
5Department of Rehabilitation for the Movement Functions Research Institute,
National Rehabilitation Center for Persons with Disabilities
6Graduate Schools of Health and Sport Science, Nippon Sport Science University, Tokyo, JAPAN
7Graduate School of Medicine, Department of Urology, Juntendo University, Tokyo Japan
Corresponding author Name: Julius Fink
Mailing address: 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
Telephone: +81-3-3813-3111
Fax: +81-3-3813-596
E-mail: [email protected]
Abstract
Performance enhancing substances are becoming increasingly popular amongst bodybuilders and people who want to enhance their physiques. However, due to the rise of the Internet and laws prohibiting sales of these substances without prescription, the route of procurement and administration practices have become more and more dangerous. Prior to the mid-1970’s, anabolic steroids were not regulated and easily available from physicians and pharmacies in several countries. In 1990, the United States enacted the Anabolic Steroid Control Act, leading to the proliferation of black markets and underground laboratories. The shift from pharmacy to underground online sites for the procurement of anabolic steroids led to an increase of fake products with low purity and the ability to potentially endanger the health of anabolic steroid users. Underground laboratories emerged both locally and in countries with lax legal regulations. “Anabolic steroid tourism” and large networks of online resellers emerged, leading to the banalisation of the illegal procurement of anabolic steroids. Furthermore, the increase of anecdotal information spreading on the internet among anabolic steroid user forums nourishes the rampant misinformation and dangerous practices that currently exist. The dosages and ways of administration recommended on these forums can be false and misleading to those who lack a medical background and cannot go to their physician to seek advice because of the fear of repercussions. This review aims to elucidate and describe current practices of the anabolic-androgenic steroids black market and draw attention to potential dangers for users.
Introduction
Anabolic-androgenic steroids (AAS) have existed since the discovery of synthetic testosterone in the 1930’s. Their potent beneficial effects on sports performance due to increased neuromuscular performance and muscle fiber characteristics (1) were soon discovered and became widely used by athletes until they were banned by the International Olympic Council in 1972. Nevertheless, medical research led to the development of several new testosterone derivatives triggering a rise in demand among athletes who early on noticed not only the performance-enhancing properties of these compounds, but also their anabolic effects. The use of AAS in competitive bodybuilding became widespread and was often supervised by physicians who supplied the drugs to the athletes, ensuring what they were injecting was pure while monitoring and minimizing side effects such as infertility, liver toxicity, impaired lipid profiles, high blood pressure, acne, hair loss or gynecomastia. During this time, there was no need for a black market or underground laboratories (UGL) since these drugs were readily available from heath professionals. However, the situation dramatically changed after the introduction of the Anabolic Steroid Control Act in 1990, and subsequently reinforced by the Anabolic Steroid Control Act of 2004. In 2014, the Designer Steroid Control Act was enacted in an attempt to close loopholes for slightly modified compounds. These events created an immense demand for black market products, which facilitated the creation of UGL products and the importing of drugs produced in countries with lax AAS legislations.
Black market products can be categorized into four basic groups; 1) counterfeit products of well known pharmaceutical brands, 2) UGL products labeled as such, 3) pharmaceutical products imported from countries not prohibiting AAS, 4) local pharmaceutical products coming to the black market via illegal routes, 5) Selective androgen receptor modulators (SARMs). Each of these are explained below.
⦁ Counterfeit products often contain under-dosed, cheaper derivatives of the intended AAS compound, or worse, inert fillers and binder chemicals. Safety
issues are a major concern with these kinds of products, since they are not controlled by any institution and may display high rates of contamination, with the risk being especially high for injectable products.
⦁ UGL products have gained popularity since the overflow of counterfeit products. UGL products often do not claim to be affiliated to any pharmaceutical company and try to gain customer trust via manufacture of quality products, even though they are not controlled and the manufacturing facilities are often below standard for the production of human grade drugs. Recently, UGL labs have begun to advertise modern production facilities on their websites to reassure potential customers as to product efficacy. UGL products are often sold under different brand names as compared to pharmaceutical grade products or just labeled with the active ingredient depending on the manufacturer.
⦁ AAS produced in countries such as Thailand, India, Pakistan or Mexico are often illegally imported and sold online. These products are often shipped directly from the country of origin to the buyer’s house. This category of AAS is conceivably safer to use as compared to the categories above; however the illegal route of procurement might endanger the buyer with regard to violating the law in their country.
⦁ The last category of black market AAS is probably the safest but most expensive and difficult route of procurement: local legitimate pharmaceutical grade AAS. The physician or pharmacist selling these products without prescription encounters a high legal risk which reflects on the price on the black market. The risk of losing their license or getting incarcerated often makes sellers charge several times the retail price of the products. However, due to the increase of fake AAS and the health risks associated with counterfeits, many AAS users are willing to pay the higher price to ensure the quality and safety of what they are using.
⦁ SARMs are not approved by the Food and Drug Administration (FDA). However, many sellers on the black market use the fact that SARMs are not yet listed as banned substances and can therefore be sold as research drugs. However, this is a grey zone and might be soon regulated by the FDA.
Even though legitimate pharmaceutical grade AAS can be purchased on the black market via several routes, physician supervision of usage is lacking, making a legitimate pharmaceutical product potentially dangerous for uninformed users. Since buying and using AAS (without a medical prescription) is a criminal act in many countries, the AAS user is often reluctant to seek advice from a physician when health issues arise. Indeed, a survey found that AAS users very often have no trust in physicians’ knowledge about AAS and typically do not disclose their AAS use to them (11).
In sum, the AAS market has undergone major changes over the past 20 years, especially caused by shifts in the legal status. The purpose of this review is to elucidate the routes, practice of usage and the context in which athletes procure and use AAS currently, as well as provide information to prevent this population from endangering themselves via the use of illicit doping drugs.
Routes of procurement of black market AAS
A survey of 1,955 AAS users showed that the major route of procurement is the Internet (52.7%), followed by local sources (16.7%), friends or training partners (15%), physician’s prescription (6.6%) and obtaining them from foreign countries (5.8%) (5). Routes of procurement can basically be divided into the following five methods:
⦁ Local dealers: These transactions often take place at gyms. The buyer has to rely 100% on the credibility of the dealer with regard to the products he is buying.
⦁ The Internet: Currently there are numerous online sites selling AAS worldwide.
⦁ Overseas: “Steroid tourism” in countries without prohibitive laws against AAS.
⦁ Local pharmacies or physicians.
⦁ Patients with prescription for drugs.
The quality of products offered by a local dealer can vary widely, ranging from legitimate pharmaceutical grade drugs to counterfeits. This method of procurement is the preferred choice for most newcomers because of its ease as well as the personal advice often provided by the dealer. Moreover, this method of procurement is not traceable and therefore is generally regarded as the safest with regard to avoiding law enforcement. However, buyers cannot track the origin of the products and are frequently given inaccurate advice with regard to dosages and injection practices.
A recent study showed that AAS-selling websites are mainly registered in the United States (46.7%) and Europe (30%) (6). Besides AAS, several other performance/muscle mass enhancing products (clenbuterol: 76.7%; growth hormone/insulin-like growth factor-1; 60%, thyroid hormones: 46.7%; erythropoietin: 30%, and insulin: 20%) and products aimed at reducing AAS-induced side effects (estrogen antagonists: 63.3%; products for erectile dysfunction: 56.7%; 5α-reductase inhibitors: 33.3%, and; anti-acne products: 33.3%) are also sold on those web sites (6). Due to the detailed personal information collected, and the use of credit cards, many potential buyers are reluctant to order online. This has led many online sellers to accept anonymous payment methods such as Bitcoin, thus making the transaction safer for the buyer. Parcels are typically shipped in package size and labeling approaches aimed at avoiding customs inspection (6). The online sellers can be divided into two categories: online sellers offering brand name counterfeit products often targeting newcomers without knowledge and online sellers offering UGL or pharmaceutical grade products from overseas. The former online sites are often scams aiming to make large profits within a short period of time until the scam is exposed in the AAS user community. The latter online sites, often calling themselves “online pharmacies,” attempt to take advantage of the self-regulated aspect of this industry and the lax regulations of several overseas countries, making them immune against the laws of countries in which AAS users are buying from. These sellers typically target more experienced AAS users and develop sophisticated supply systems from a number of different countries. This
type of online site tends to have greater credibility among AAS users, but the risk of seizure at customs can discourage consumers from choosing this method. These types of websites often project the appearance of import services from overseas pharmacies, offering a large variety of drugs in addition to AAS. Sometimes the products offered on these sites include pharmaceutical grade drugs for human consumption and UGL products that are not approved for human consumption; this creates confusion among naïve consumers who believe they are buying legitimate pharmaceutical grade drugs.
Traveling overseas to obtain AAS in countries such as Mexico or Thailand is a popular option. Since such drugs are sold without prescription at pharmacies in these countries, the user is able to isolate the origin of the product. Moreover, AAS are often cheaper in these countries, creating a financial incentive to travel abroad. However, in certain countries, counterfeit products might be sold even in pharmacies. There also is the legal risk of passing through customs with the AAS; if caught, the user may face significant jail time.
Buying AAS from a physician or pharmacist willing to “bend” the laws is perhaps the safest method of procurement from a health standpoint. This practice however is illegal and puts the health professional at risk for prosecution. It should be noted that users must be able to establish a strong connection with a health professional, making this a difficult route to pursue.
The final option is to buy AAS from individuals receiving medical treatment for conditions such as HIV, cancer, chronic kidney disease, primary or secondary hypogonadism, severe anemia, wasting syndrome and sarcopenia. These patients are often prescribed large amounts of various drugs, and sometimes engage in selling a portion of their prescription. In this case, buyers are especially looking for growth hormone (GH), since legitimate GH is difficult to obtain. HIV patients are often prescribed large amounts of GH worth up to
$7,000 per month, which they can easily resell on the black market to athletes.
In conclusion, there are several routes to buy AAS on the black market, however
each of these include substantial personal health and/or legal risks.
Underground information about AAS on the Internet
A recent survey showed that the major source of information for AAS users is the internet, while information from health care providers was sought out by less than 50% of respondents (10). The internet, with its underground forums and “information” sites, often spreads misleading or false information to AAS users. Search results for information on the internet about AAS frequently lead to AAS-promoting websites that are linked to black market sites. These sites invariably attempt to promote sales by highlighting the muscle-building and performance-enhancing effects of illicit drugs while downplaying associated health risks.
Since there is strong incrimination of AAS use, athletes are often reluctant to visit a physician to get proper advice and instead turn to the internet to gather information. Online “bodybuilding forums” abound with individuals devoid of any medical background who portray themselves as steroid experts and provide false advice to other users with the potential for serious health complications. Improper advice can range from the type of drug to take to dosages and injection practices. Very often, 3 or more compounds taken in enormous dosages 5 to 29 times greater as compared to those recommended in the medical context (10) are recommended on the internet. For instance, testosterone (T) replacement is recommended at ~75-100 mg per week or 150-200 mg every 2 weeks of the enanthate or cypionate ester administrated via intramuscular injection (3). However, a dosage as low as 250 mg of T enanthate every 4 weeks is also common (15). However, a recent survey of AAS users reported that more than 50% of respondents admitted to using more than 1000 mg of T or other AAS per week (9). UGL products and counterfeits are often under-dosed or do not contain any active compound, leading AAS users to raise the dosages in the belief they are getting the real amount of the drug while they are only getting a fraction of it in many cases. This occurrence has the potential for serious health concerns. For example, an AAS user using an under-dosed compound
containing only 50% of what is claimed on the vial might recommend taking 1000 mg or more on underground forums. Based on this information, another AAS user having legitimate pharmaceutical grade drugs might listen to this advice and administer the same amount of drugs with 100% active compound leading to twofold concentrations with the potential for negative health consequences. A recent study investigating the quality of black market AAS and other bodybuilding-related drugs found that more than 80% of drugs seized at the Swiss customs office did not contain the claimed substance in the respective amount, with 60% being under-concentrated and 8% containing no active drug at all (14). Another study found even more alarming rates (48.6%) of inert products in counterfeit drugs (7). These products may contain steroids or steroid-like substances, potentially leading to serious health risks.
AAS and other performance enhancing drugs on the black market
According to a survey by Weber et al., testosterone, especially the enanthate ester, seems to be the most popular drug on the black market, followed by methandienone, stanozol, nandrolone, oxandrolone, boldenone, mesterolone, trenbolone, oxymetholone and methenolone (14). Another survey showed similar prevalence for certain AAS on the black market: Testosterone (78.2%), methandienone (64.9%), nandrolone decanoate (63.5%), stanozolol (56%),
boldenone undecanoate (53.9%), Trenbolone (51.3%), oxymetholone (37.7%),
oxandrolone (37%), methenolone (28.2%), methyltestosterone (26.1%), drostanolone (20%) and fluoxymesterone (19.4%) (5). In addition to AAS approved for human use, several unapproved forms of AAS intended for animal use are popular amongst athletes (Figure 1). From the data of a recent study investigating the Google search trends with regard to AAS, seasonal fluctuations for several AAS have been observed (13). For instance, “hardening” agents (i.e. AAS thought to decrease body fat while increasing muscle mass without water retention) used by bodybuilders pre-contest such as oxandrolone, trenbolone and stanazolol show peaks during pre-contest/contest season (spring/summer), whereas compounds used year-round such as testosterone do not show such seasonal trends (13).
Several UGL have improved their packaging systems in an attempt to assume the appearance of legitimate pharmaceutical companies. Some of them even have websites displaying the line of products and identification code security check systems linked to a number on the vials. This information is provided despite the lack of a corporate address or telephone number information on the website. Other UGL websites even display videos of the production of the AAS and includes a “research” section on the website, making it very difficult for novices to distinguish it from legitimate pharmaceutical company websites.
Besides AAS, peptide hormones like GH and insulin-like growth factor 1 (IGF-1), selective estrogen receptor modulators (SERM), and human chorionic gonadotropin (HCG) are also often offered on these sites. GH is a very expensive and a controlled medical substance, however its anabolic actions and “fat burning” (lipolytic) effects are highly sought by athletes, even though its effects on sport performance are still not clear yet, especially due to its usage often in combination with AAS which makes it difficult to assess the effects of GH (12). This has led to a boom of counterfeit GH flooding the black market. In contrast with AAS, the manufacturing, shipping and storage process of GH is very difficult, making it nearly impossible for many UGL to produce potent GH. Several manufacturers in Asia seem to have the facilities to produce GH, however the potency of such products often deteriorates during the shipping and storage process since GH is a very labile peptide hormone that requires cool storage. Recently, several UGLs have began to offer dangerous drugs such as erythropoietin (EPO), which increases the amount of red blood cells (i.e., hematocrit) and thus the potential for increased endurance performance. AAS are also known to increase the amount of red blood cells, and can be potentially dangerous when used in combination with EPO due to blood viscosity issues and increased myocardial stress. Insulin, another potentially very dangerous anabolic drug, is readily available in many countries, limiting its demand on the black market.
Online sellers also are now offering selective androgen receptor modulators
(SARMs), which are believed to have similar effects as AAS without the same degree of negative side effects due to their discriminating targeting of receptors. However, steroid-like side effects such as liver toxicity, increased potential of heart attack and stroke, infertility and mental health problems may also occur with the usage of SARMs. The term “selective” in SARM means they preferentially bind to androgen receptors in muscle tissue without triggering androgenic effects in other tissues such as the prostate (2, 4, 8). The popularity of SARMs has also increased among athletes seeking anabolic effects while minimizing androgenic side effects. The legal status of SARMs allows many web sites to legally sell these products as “research products not for human consumption”. Popular SARMs include Andarine, Accadine (AC-262536), Cardarine, Endurobol (GW501516), Mk-677 (Ibutamoren), Ligandrol (LGD-4033), Ostarine (Mk-2866), Trestolone (RAD-140), S-23, Stenabolic (SR-9009) and YK-11. Even though not approved by the Food and Drug Administration (FDA), many individuals on the black market take advantage of the fact that SARMs are not yet listed as banned substances and can therefore be sold as research drugs, despite being banned by the World Anti-Doping Agency. Athletes who do not want to procure AAS via illegal routes might buy SARMs without realizing the long-term side effects of these drugs are still under investigation, even though similar side effects to AAS have been observed.
Table 1. List of most popular AAS sold on the black market
Name of the AAS Form of
administration Approval for human use
Anadrol (oxymetholone) Oral Yes: treatment of anemia,
osteoporosis and muscle wasting in HIV patients
Anavar (oxandrolone) Oral Yes: osteoporosis, weight gain after surgery or trauma, during chronic infection, counteract catabolic effects of long-term corticosteroid therapy, recovery from burns, Turner syndrome and muscle wasting in
HIV patients
Deca durabolin
(nandrolone) Intramuscular
injection Yes: anemia, osteoporosis, recovery
from burns, cancer, HIV
Dianabol (metandienone) Oral Formerly approved for the treatment
of hypogonadism but discontinued in most countries
Equipoise
(boldenone) Intramuscular
injection No: only veteran medicine
Halotestin
(fluoxymesterone) Oral Yes: hypogonadism, delayed
puberty, breast cancer
Methyltestosterone Oral Yes: hypogonadism, delayed puberty, menopausal hormone therapy, osteoporosis and breast
cancer
Primobolan (metenolone) Oral (acetate) or intramuscular injection
(enanthate) Yes (Japan and Moldova only): recovery after surgery or burns, osteoporosis
Trenbolone Intramuscular No: only veteran medicine
injection
Winstrol (stanozol) Oral or
intramuscular injection No: Was approved by the FDA in
1962 but discountinued for human use in most countries
Nontransparent AAS market
Several pharmaceutical companies produce AAS via subsidiaries in different countries and under different names, creating confusion among users and making it an attractive business for counterfeit dealers. For a variety of reasons, it is often difficult to search for a given drug on the official website of the pharmaceutical company for non-medical personnel. First, the website might be accessible only for licensed medical personnel. Second, the products might be sold in certain countries only or not be marketed by the company directly but rather by third parties with different names, which makes it nearly impossible for a potential AAS buyer to confirm the legitimacy of the products sold on black market online stores. Counterfeit producers can therefore easily dupe consumers by simply labeling their products with well known pharmaceutical brands. Despite anti-counterfeit measures such as holographic devices or colour-shift inks, consumers might not be aware of these measures nor able to distinguish between real and counterfeit products since the average AAS user does not acquire his drugs from a physician or pharmacy.
Cost-comparison between black market and prescription AAS
Table 2 indicates that price fluctuations strongly depend on the compound being sought by the athlete. Black market prices often reflect the offer and demand situation and the difficulty to manufacture the given product. With regard to AAS, legitimate product prices do not substantially differ from black market prices, except legitimate drugs sold on the black market by physicians. However, huge differences can be observed with regard to GH. This gap in the GH price might
be mainly explained by the price regulation of each country. Indeed, depending on different regulations, the price of GH can be nearly twice as much in countries with similar cost of living. For instance, 10mg GH costs about $600 in the United States and Germany as compared to about $350 in Japan. The same 10mg of GH might even be sold for under $100 in the Eastern world. However, in most Western countries, legitimate AAS can only be purchased with a prescription and are very hard to obtain, leading to higher retail prices on the black market.
Name of the hormone Official retail price Overseas pharma grade products sold on the local black market
price Overseas retail price UGL price Counterfeit price
Testosterone
enanthate $10/250mg $6/250mg $1.5/200mg $6/250mg $5/250mg
Methenolone
enanthate $7/100mg $25/100mg - $14/100mg $4.5/100mg
Methenolone
acetate $2/100mg - - $12/100mg $3.5/100mg
Growth
hormone $350/10mg $150/10mg $40/10mg $130/10mg $40/10mg
Table 2. Comparison of AAS and other hormone prices produced by Japanese pharmaceutical companies with black market products in 2018.
Conclusion
The legislation of many countries with regard to AAS and other performance enhancing drugs has seen dramatic shifts towards incrimination in the past decades, leading to the rise of inferior quality drugs flooding black markets worldwide. The lack of official supervision of facilities and manufacturing processes of underground laboratories endangers the health of AAS users. Even though legislation bans more and more substances, the desire to enhance performance and appearance does not fade, driving athletes and bodybuilders to seek illegal ways of procurement and thus incurring the associated health and legal risks. The internet enabled the rise of such a black market, not only providing a platform for selling illegal drugs, but also for propagating misleading information to athletes. Besides the well-recognized anabolic and performance enhancing effects of AAS and other performance-enhancing drugs, severe side effects may occur with their use, especially when the products come from uncontrolled environments such as many AAS sold on the internet.
Declaration of funding
This manuscript was not funded.
Declaration of financial/other relationships
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial relationships to disclose.
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