Push to measure steroid use in general practice

Dr Beng Eu, a GP with a special interest in treating patients who use non-prescribed anabolic steroids, is concerned their true population is largely invisible to GPs and other healthcare workers.
 
‘According to my research into the number of people who use non-prescribed anabolic steroids in Australia, we’re probably looking at 100,000–150,000 people, of which probably only a very small minority seek any sort of healthcare, because of the stigma,’ he told newsGP.
 
‘So it’s actually an often forgotten and stigmatised group of people, but it’s really important they are engaged in healthcare.’
 
Dr Eu has found part of the reason these patients are invisible to healthcare professionals is the silence that comes with associated stigma.
 
‘Very few people who use non-prescribed anabolic steroids will volunteer that fact, because they think it will be seen negatively by doctors and health workers in general,’ he said.
 
Stereotypes regarding people who use steroids also help keep this patient population under the radar.
 
‘People’s perception of who [these patients] are is quite different to the actual fact,’ Dr Eu said.
 
‘Most of the people who come to me aren’t the really big body-builders; they’re not that heavily muscular, they just look like someone who’s fit at the gym.
 
‘I think the really heavy users are the tip of the iceberg – there’s a whole big group of people who are just using, but not in the most severe way.’

This tip of the iceberg is what motivated Dr Eu to focus on general practice as the locus of his research.
 
‘Most of our information about adverse effects of non-prescribed anabolic steroids use is from the other end, someone presents at hospital with terrible side effects and heart problems,’ he said.
 
‘But from a general practice point of view, we’re more likely to see people using non-prescribed anabolic steroids who are actually quite well, and might not be using high doses so have a lower risk of getting the adverse effects.
 
‘So collecting [data on these patients] from general practice probably won’t highlight the really severe side effects, and we’ll have a much fairer view of people who use, not necessarily on the extreme scale.’


People who use non-prescribed steroids often do not necessarily resemble the heavily muscular stereotypes, but rather fit people who regularly visit the gym.

In an effort to more accurately identify, count and monitor such patients, Dr Eu has launched a research project called ‘PUSH! the PIED [performance and image enhancing drugs] users’ health audit’.
 
The project has received approval from the RACGP ethics committee to collect data about these patients, as identified and recruited by GPs.
 
‘It’s a bit of a hybrid, almost like an audit and a cross-sectional survey,’ Dr Eu said.
 
‘The participants are actually the doctors, who consent to do the patient audit from their files.
 
‘We’ve also got consent waivers for patients, so their privacy is protected and there is no issue of them being exposed in any way.’
 
The audit, which will run until 2021, will chart patients’ physical health measures in areas that can indicate side effects of non-prescribed anabolic steroid use, including mental health, levels of haemoglobin and fertility. It also compares these measures against a control group of patients who receive prescribed steroids, such as men who are testosterone-deficient or transgender men given testosterone for gender affirmation, to assess whether both populations experience similar side effects.
 
While Dr Eu hopes the research will help shed more light on the non-prescribed steroid population, he believes participating doctors will also benefit.
 
‘The doctors taking part in the audit will go through the checklist, which becomes educational as well, because they’re highlighting things they haven’t covered in the consultations, giving them a chance to go back and do them next time,’ he said.
 
‘So hopefully it will improve doctors’ knowledge and care of people using non-prescribed anabolic steroids.’
 
Dr Eu wants to encourage doctors to actively engage with patients they feel may be using steroids, and educate them on the best ways to approach the topic.
 
‘For example, with someone who’s quite fit and goes to the gym, you might open a conversation by asking them, “Do you take supplements or anything additional?” and that might open the way for them to talk about anabolic steroids,’ he said.
 
Sexual health screening for diseases like hepatitis C can provide a different pathway into the subject.
 
‘You can start asking about injecting behaviours,’ Dr Eu said.
 
‘People assume injections are all about IV drugs, but you can open it further and ask, do you have any injections at all? And some people when asked that question have volunteered, “Well, actually, I do inject anabolic steroids”.
 
‘So there’s different ways of entering the conversation, but that encouragement will have to come from doctors, as there is often hesitation from the patients themselves who are worried about a negative reception.’
 
Overall, Dr Eu is hopeful his research will help reduce stigma for people who use non-prescribed steroids, while promoting greater engagement between these patients and the healthcare sector in general.
 
‘I can categorically say that no one’s ever ended up using more steroids because of a consultation,’ he said.  ‘If anything, some people use less, or modify their use.
 
‘Some have even stopped when you can show them the reasons behind adverse effects they have experienced.
 
‘So PUSH is a sort of harm-minimisation approach. Hopefully, doctors will get educated about it and patients will have a better quality of healthcare as a result of it.’

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