Challenges within the Patient Cohort
My experience of working with service users in IPED and harm-reduction is that being able to use a few key phrases and understanding the somewhat unique language and phrasing to be very helpful. Additionally the ability to appear unphased when users disclose their use to you is also paramount in commencing and developing the therapeutic relationship.
You may not be the first clinician they are disclosing their IPED use to, and many have had poor prior “first experiences” with clinicians.
Your interaction may be the first opportunity to change the user from a state of pre-contemplation into contemplation on the “model for change”. This is exceptionally valuable.
Simply stating “well you shouldn’t be doing that. I recommend you stop” is often totally unhelpful and often limits the therapeutic relationship going forward. The motivations for the use need to be explored. Many who attend our clinic have complex motivations for undertaking their use, and aesthetic appearance may be the driving force behind it, but other social factors augment that desire. For example, users who work in the security industry, prison service, armed forces, police face an occupational pressure to appear “muscular” or “tough”.
Simply advising the patient that “IPEDs are bad” is unlikely to result in any behaviour change. The individual is likely to be aware of some of the risks and feels they have made a balanced decision.
That being said, when we engage in some health monitoring, an opportunity may present itself to demonstrate to the patient some lab results that show their liver is struggling, or kidneys are demonstrating a decline. This may well be a turning point in helping them to make plans to reduce and stop their use.
I very much enjoy my work. The overarching majority of IPED users at our clinic are unfailingly polite, enthusiastically interested in their own wellbeing and healthcare and willing to engage with a suitably trained clinician about their usage.
However, the cohort is not without its challenges, some unique to the IPEDs, but not exclusively so:
Adjusted Health beliefs
Users often will often understand the potential risks of the IPEDs that they are taking, most having done at least some research before commencing. However, some feel that the risk is offset by their careful nutritional intake and significant exercise levels. Indeed some cite that peers who are engaging in regular alcohol intake and recreational drug use as a bad practice and comparatively IPEDs are a more beneficial or healthy alternative to this.
High DNA rate
Our clinic averages a 50% “did not attend (DNA)” rate. Despite an appointment booking service and an informal clinic, with a reduction in a standard medical interface. The response from users who do later engage with the service, often cite fear over their test results as a primary reason for non-attendance.
“Broscience is the predominant brand of reasoning in bodybuilding circles where the anecdotal reports of jacked dudes are considered more credible than scientific research” (taken from muscleandstrength.com)
This is certainly a challenge within our clinic. Confronting deeply held dogma in the bodybuilding/sporting community is exceptionally difficult. There are few quality studies which demonstrate harms in IPED usage over the longer term, we often rely on extrapolation from first principles giving an insight into potential harms. Do we have robust evidence to show us that structural changes occur within the heart over longer term abuse? No. However, cardiac muscle has androgen receptors, so we can extrapolate what can occur to heart muscle in the presence of excess of angrogens. So we can draw conclusions. However, long held dogma is hard to challenge without the support of evidence. As mentioned above, very little evidence serves to support the concept of post-cycle therapy, despite evidenced harms of Tamoxifen on the liver. Support for traditional post cycle therapy remains high in the IPED using population.
Many IPED online forums contain a vast array, of sometimes conflicting advice for users and our service users will often appoint credibility to those who appear to be the biggest, fittest and/or strongest.
Adjusted perception of drug use
Some IPED users see IPEDs an extension of the protein powder and creatinine monohydrate they can purchase in a supermarket. They fail to acknowledge the risks in the use, seeing it as an extension of a sports supplement only.
One in five users commenced on the use of IPED’s prior to the age of 20. Traditional harm reduction models may be inappropriate or ineffective in teenage patients. Indeed this population group are more likely to be covert in their usage and encounter barriers to engaging with healthcare and accessing suitable clean-needle services.
IPED cycles are not cheap. Some cycles can run into hundreds of pounds per month. Some users who develop dependency can have problems with debt.
Testosterone and Risk
Studies have demonstrated increased risk-taking behaviour in those with a higher serum testosterone level(41). Higher testosterone levels appear to correlate with risk taking behaviour, such as gambling(53). Therefore, the perception of risk may be altered once IPED users commence a supraphysiological dose of anabolic steroids.