Polypharmacy among anabolic-androgenic steroid users: a descriptive metasynthesis

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.

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.

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?

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

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.

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 ]; Pa

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.

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.

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

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.

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.

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.

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 ].

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.

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.