The supply of steroids and other performance and image enhancing drugs (PIEDs) in one English city: Fakes, counterfeits, supplier trust, common beliefs and access

Highlights

• ‘Social supply’ defined much of the supply of local steroids and other PIED.

• Forensic analysis of local user-sourced PIED showed them to be nearly all poor-quality fakes or counterfeits.

• PIED users believed substances they sourced were genuine and efficacious, and used largely ineffective and outdated lay ‘methods’ to detect fakes/counterfeits.

• The negative health effects of poor-quality, fake and counterfeit PIED should not be exaggerated or assumed without more evidence.

Abstract

As with other illicit drugs, such as heroin or cocaine, illicit steroids and other performance and image enhancing drugs (PIED) have for some time been assumed to involve an inherent degree of danger and risk. This is due to the unknown and potentially dangerous substances present in them; fakes and counterfeits are of particular concern. Many of these ‘risks’ are unknown and unproven. In addition, a tendency to abstract these risks by reference to forensic data tends to negate the specific risks related to local PIED markets, and this in turn has led to much being missed regarding the broader nature of those markets and how buyers and suppliers interact and are situated within them. This article reports on research that sought to explore each of these issues in one mid-sized city in South West England. A snapshot image is provided of what the steroids and other image or performance enhancing drugs market ‘looked like’ in this particular city in 2013: how it operated; how different users sought out and purchased their PIED; the beliefs they held about the PIED they sourced; and the methods they employed to feel confident in the authenticity of their purchases. A forensic analysis was undertaken of a sample of user-sourced PIED as a complementary approach. The results showed almost all of these drugs to be poor-quality fakes and/or counterfeits. The level of risk cannot be ‘read off’ from forensic findings, and poor-quality fakes/counterfeits cannot simply be considered an attempt to defraud. Users believed they had received genuine PIED that were efficacious, and employed a range of basic approaches to try to ensure genuine purchases. Many, if not most, transactions at the ‘street’ level were akin to ‘social supply’ rather than commercial in nature.

Introduction

As long ago as 1991, Strauss and Yesalis claimed the non-prescription steroid and other PIED market to be increasingly besmirched by fakes and counterfeits and moreover, because these PIED were often being injected, these represented a real danger to those using them. Some years later Lenehan (2003) suggested that the ‘majority’ of PIED purchased by users were likely to be fakes and carried meaningful public health consequences. These concerns, about the public health risks of ‘fake’ or counterfeit PIED, are similar to concerns historically voiced about the ‘dangers’ contained in most illicit street drugs, particularly injectables, regarding dangerous cutting agents or substitutes/fakes. The equation of fake/counterfeit = danger/risk however should not be taken as a simple given.

In Coomber (1997a, 1997b, 1997c, 1997d, 1999, 2006) and later in Cole et al. (2011), it was established that nearly all that is believed about the ‘cutting’ of illicit drugs such as heroin, cocaine, ecstasy and other street drugs is mythical and/or misunderstood. Such substances are not ‘cut’ or ‘stepped on’ (adulterated/diluted) by drug dealers with dangerous substances such as rat-poison, brick-dust, ground-glass, talcum powder or scouring powder, and street drugs such as heroin and crack are not ‘cut’ down through the chain of distribution as is commonly supposed. Nor are they routinely cut at any stage. Adulteration does occur, but this is almost always purposive, mostly happens prior to importation and is usually done with either comparatively benign substances (compared with the main drug) or with substances that mimic or enhance the drug being supplied. So-called ‘fakes’ or substitutes are supplied to unsuspecting customers on occasion, but this is often either a direct attempt to simply defraud – for example, individual wraps sold by street dealers to transient buyers rather than buyers known to them (cf. Coomber & Maher, 2006) who might seek recompense – or, in the case of ‘pills’ (e.g. PMA in place of MDMA), it is either unknown to the seller (most likely) or, if known, is an attempt to supply something close to the desired product during a time of scarcity of the desired drug. For illicit street drugs, trust is a key criterion for users when they are choosing their source, and an attempt to protect against ‘rip-offs’ and ensure (to some extent at least) quality or reasonable potency (Coomber et al., 2015, Jacobs, 2000, Moyle and Coomber, 2015). The health risks assumed to be inherent in non-genuine street drugs, while clearly not an unimportant concern, are none-the-less often unreasonably exaggerated on the basis of assumption rather than evidence, as is the case with so many drug market-related fears (Coomber, 2011).

As with other street drugs, it is the controlled or prohibited nature of PIED use that produces a black market. In black markets, supply to users takes place in clandestine contexts, which means that products usually have little or no formal quality control to protect consumers and ensure that what is sold/purchased is authentic. Essentially, ‘the rise of the “black market” sources brings with it a host of risks, from poor quality doping products to a general “hardening” of the market’ (Lenehan, 2003: 239). To date, however, despite the solid body of evidence developing on the black market of illicit drugs, there has been little focus on either the nature of the black market for PIED or supply-side dynamics (Lenehan, 2003, Paoli and Donati, 2013). This is especially true for the market intersection with those non-elite athletes mainly engaged with PIED for body and image enhancing purposes.

A report by the UK Advisory Council on the Misuse of Drugs (ACMD) in 2010 (Advisory Council on the Misuse of Drugs (ACMD), 2010) reviewed data suggesting that the illicit market for PIED has three basic sources: (1) products manufactured ‘legitimately’ in middle-income countries (for example, China and India) where regulatory oversight is weak; (2) products manufactured/packaged in ‘underground’ laboratories where quality and safety is not demonstrable (or guaranteed); and (3) legitimate products manufactured in high-income countries and bought either legally or illegally. The contribution of each source to the overall market is unknown.

The picture is further complicated in the sense that, although PIED are strongly controlled substances in many jurisdictions, they are nonetheless legal in some. Also, the addition of new products – and therefore new laws – complicates the legal standing of some substances (Denham, 2011). This means that the production and distribution of PIED worldwide is in fact a ‘semi-legal’ market (Paoli & Donati, 2014).

Where non-prescribed use and non-licensed distribution of PIED are illegal, however – as in the non-sporting world – common assumptions are made about the drug market that tend to an over-homogenisation of what it looks like (cf. Coomber, 2015). In general, the ‘street drug’ market is stereotypically thought to be controlled from the top down by organised crime and characterised by control through endemic violence and intimidation, the use of predatory tactics and the drive for profits (Lenehan, 2003). This view has now largely been discredited, and drug markets and the people operating within them are increasingly seen as highly diverse (Coomber, 2010, Coomber, 2015), although the traditional view continues to drive much enforcement policy (Erickson, 2001).

Further, in this vein, from research in Belgium and the Netherlands, Fincoeur, Van de Ven, Katinka, and Mulrooney (2014: 240) argue that, despite the widely held belief that ‘mafia type’ organised crime and commercially/profit-driven dealers control the supply of PIED, this is both ‘empirically unsubstantiated’ and contrary to the emerging evidence (see also Paoli & Donati, 2014). This should not be a surprise, as emergent concerns around doping in the sporting world have long mirrored (despite lagging behind and taking a policy lead from) the fears and misconceptions about street drugs from the non-sporting world (Coomber, 2013). Moreover, and as we shall see from the research presented here, Fincoeur et al. (2014) point to a non-elite PIED market that is often closer to that of social supply or minimally commercial supply (Coomber & Moyle, 2014) and a normalised supply (Coomber et al., 2015) than to ‘Mr Bigs’ or a market saturated with commercially orientated dealers.

Rather than understanding ‘the’ drug market as a single entity, it is helpful to understand that there are often multiple drug markets (heroin/cannabis/‘pills’, etc.) within any one geographical area, and that these markets will sometimes overlap and intersect but at other times they will not (Coomber, 2015, Coomber and Turnbull, 2007). Even within a single drug (e.g. heroin and crack) market, there can be numerous types of supplier and the market can operate on different levels, with each of these levels manifesting different market-related activities such as violence and intimidation to different degrees. Some groups will be violent, while others will not. Middle-class suppliers, women suppliers, youth-friend suppliers, club-goers with a ‘designated buyer’ for the next night out, heroin user-dealers, young ‘runners’, female drug ‘mules’ and so on all differ meaningfully from the stereotype of a drug dealer. Overall – especially among those who broker and supply to/for/from friends – these variations from the stereotype of a drug dealer numerically dominate in the current milieu (Coomber, 2010).

As mentioned above, while it is a common assumption that PIED markets are stereotypically ‘top-down’, essentially controlled by drug dealers, this is not borne out by emerging research. Research, including this current study, continues to demonstrate that meaningful levels of social supply are commonly present. Social suppliers, or minimally commercial suppliers (because most supply transactions involve some level of ‘profit’ – such as getting drugs for free) are less motivated by commercial gain (Coomber & Moyle, 2014) than ‘dealers proper’. In a micro social context, where their own drug use is relatively normalised, it is easy for some users to drift into supply and for them to neutralise the idea that they are ‘dealers’ because they supply only/mainly to friends and acquaintances (Denham, 2011), often for altruistic reasons. Many of Fincoeur et al.’s samples of local PIED users (bodybuilders and recreational weight trainers) in Belgium and the Netherlands, for example, didn’t see themselves as ‘real’ dealers and saw their activity simply as part of everyday life. Analogously, in Plymouth, many PIED injectors also collect needles for other peers from needle exchanges and supply those too. Needles are free and legal, but some PIED users prefer not to engage with services and those that don’t mind doing so help out their peers in this way. Doing similar with PIED is an extension of these peer related activities. Fincoeur et al. (2014: 37) also found that, in addition to PIED, many of their suppliers also supplied knowledge and information on how to use PIED and other helpful advice (e.g. nutritional or medical), and received kudos/status in return. The relationship was reciprocal in ways that went beyond simple economic exchange and economic incentives appeared to be a minor motivational factor for supplying PIED for many.

Legislative controls help frame the ways in which markets manifest. In the United Kingdom, for example, anabolic steroids are Class C drugs under the 1971 Misuse of Drugs Act. On presentation of a doctor's prescription, they can be sold by pharmacists. While possession for personal use is legal, the manufacture, supply or intent to supply steroids without a license is a crime. This includes the giving or gifting of steroids to friends. These offences carry a maximum penalty of 14 years in prison and/or a fine. In April 2012, it became illegal to import steroids into the United Kingdom via post, courier or other freight services. Steroid users can still travel abroad to purchase steroids for personal use only and bring them into the United Kingdom (Public Health Wales, 2014). These constraints, plus relatively buoyant demand, create the context for illicit supply and clandestine markets.

A large-scale study of EU Member States’ regulatory and legal frameworks with regard to PIED (Backhouse et al., 2014) found that both broader street drug legislation and specific legislation providing criminal sanctions against doping in sport applied in 19 Member States. An even larger international study (Houlihan & García, 2012) of over 50 countries found that legislation and regulatory frameworks were complex, and varied dramatically in their interpretation and adherence. For example, in Denmark, the supply and use of PEID was under PEID-specific legislation, while in Greece it was under general sports legislation (Houlihan & García, 2012). Typically, in countries where general drug legislation covered the use and supply of PEID, penalties were more severe (Houlihan & García, 2012); however, this was not always the case.

Hermansson (2002) has previously noted that PIED at the end of the 1990s and early 2000s could be bought without prescriptions in most countries in Asia, Africa and South America, and that most anabolic steroids seized in Sweden and Finland originated from Spain, Russia, Greece, Turkey, Egypt and Thailand. Somewhat surprisingly, both Sweden and Denmark were considered to be the source of a number of popular black market PIED. An increased prevalence of counterfeit PIED being manufactured illegally in Russia and being smuggled into Finland and Sweden was also reported (Hermansson, 2002).

The situation, therefore, is that there are many authentic and (variously) inauthentic PIED being produced and supplied to PIED markets around the world and that this has been the case for some time. It has also become clear that that, for non-sporting users in countries such as England (Baker, Graham, & Davies, 2006), Australia (Larance, Degenhardt, Dillon, & Copeland, 2005), Germany (Striegel et al., 2006), the United States (Cohen et al., 2007, Parkinson and Evans, 2006), Belgium and the Netherlands (Lenehan, 2003), supply for most is essentially via the black market as opposed to medical prescription or bona fide pharmaceutical sourcing, and as such there is a question mark over exactly what is being supplied.

There are a limited number of studies that have examined the composition of anabolic steroids and other PIED obtained from the illicit market (Melrose, 2013). One of the first studies of this kind was from Walters, Ayers, and Brown (1990). They found that the anabolic steroids tested were either under- or over-strength (to what was listed on the packaging or labels), and thus likely to be counterfeits produced with unreliable methods. Musshoff, Daldrup, and Ritsch (1996) found that 15 of 42 (35%) products from the black market in Germany did not contain the expected ingredients. More recently, Graham et al. (2009) found 42 per cent of 57 tested substances to be counterfeit, with what was stated on the label often being different to what was contained in the substance. Similarly, this time in Germany, Thevis et al. (2008) found that 18 out of 70 (25.7%) (mostly) anabolic steroids contained ingredients different from those listed on the packaging.

A further study from Germany (Kohler et al., 2010) yielded similar results with only four of 11 confiscated black market products containing the substance and amount declared on the label. Showing consistency across borders a recent Italian study (Pellegrini, Rotolo, Di Giovannadrea, Pacifici, & Pichini, 2012) found that only two of 15 pharmaceutical preparations seized by authorities contained the content stated on the labels. In each of the other cases, either no PIED were present at all or steroids different from those listed on the labels or different amounts from those declared were found. In Belgium, Coopman and Cordonnier (2012) found 25 of 74 (34%) black market products used by bodybuilders did not match their labels. Read differently, though, two-thirds did.

More comprehensively, in Brazil, of 2818 anabolic products seized by the Brazilian Federal Police Department (da Justa Neves, Marcheti, & Caldas, 2013), 32 per cent were found to be counterfeit, with only half of those containing the listed substances. Interestingly, and demonstrating the levels of variance, approximately 99 per cent of the clenbuterol tested were genuine.

Overall then, the forensic picture is one that has long suggested huge variations in what can be found in the PIED black market internationally. In many respects, the variations greatly exceed those found in the illicit street marketplace, where potency or purity, rather than fakes/counterfeits, is the primary issue.² The variation suggested by these studies is such that, for many users, unless their source is somehow direct or diverted from bona fide medical supplies, they cannot know whether the PIED they use is under- or over-strength, whether it is the product they expected, or whether it even contains any PIED at all.

That the composition of anabolic steroids from the illicit market is largely unknown is only just beginning to be understood by those in the health and medical fields (Melrose, 2013, Kimergård et al., 2014), and the evidence base in this area is still limited. Counterfeit or sub-standard PIED and/or PIED produced in substandard conditions could affect health in a number of ways. Substandard production methods or conditions can lead to over- or under-strength preparations, the use of products that themselves may have been produced in substandard conditions, the use of unreliable product to make a further unreliable product, the risk of contamination with foreign matter that poses health risks and so on. Hence, further knowledge is required in this area but purposeful investigation is currently largely lacking.

Previous general research on PIED has shown that the use of anabolic steroids can have a range of adverse effects (Petróczia, Dodgeb, Backhoused, & Adesanwoa, 2014), such as growth-suppressing effects on young adults (Buckley, Yesalis, & Bennell, 1993), and that high and multi-doses can lead to serious organ damage, reduced fertility and gynecomastia in males and masculinisation in women and children. There is also a range of other effects that can result, including hypertension and atherosclerosis, blood clotting, jaundice, hepatic neoplasms and carcinoma, tendon damage, psychiatric and behavioural disorders (Maravelias, Dona, Stefanidou, & Spiliopoulou, 2005). The use of anabolic steroids can also increase the risk of sudden cardiac death (SCD), myocardial infarction, altered serum lipoproteins and cardiac hypertrophy (Frati, Busardo, Cipolloni, De Dominicis, & Fineschi, 2015).

None of the above health risks is inevitable, and they are, for the most part, dose and administration dependent; however, huge (unintentional) variation in what and how much is being used due to the vagaries of the PIED market is not a framework for a considered and reliable approach to safe PIED use. While of genuine public health concern, it is also important however not to unreasonably exaggerate the risks from impure and inauthentic substances without a genuine evidence base, as was long the case in the world of street drugs (Coomber, 2006).

To date, the evidence relating to authenticity in the PIED market has been considered primarily from a forensic science perspective, as was the case with street drugs for many years (cf. Coomber, 1997a). In this way, the findings of ‘difference’ (less/more than stated on label, different compounds, sometimes stated ingredients substituted for others) are represented as essentially fake and, by extension, ‘dangerous’. This perspective tends to fetishise forensic views of what inauthentic means and thus tends to reproduce the ‘problem’ as proving the dangers of not knowing what you are buying, as previously happened with drugs such as heroin and ecstasy without critical evaluation. More reflective reasoning engaging sociological and cultural understanding of the process of drug production and supply can situate the problem somewhat differently and re-evaluate the risks in this light. The evidence from Thevis et al. (2008), for example, shows that genuine PIED are often bought but that these are not quite what was being ordered. The market is mixed in what is actually supplied and inauthentic substances will present different risks and many of these will not be necessarily high risk nor the product of cynical acts. In terms of what the ‘problem’ really is, there is currently too narrow an approach to both situating forensic evidence and extrapolating health risks from it and this represents a problem in terms of how research addresses PIED markets going forward in this regard.

In addition to the relatively scanty knowledge about what supplied PIED really contain, little is also known about how specific local PIED markets work, how users navigate their way through PIED markets, how local markets compare with local markets in the minds of buyers, and how buyers believe they can discern between authentic and fake or inauthentic PIED, and as a consequence ensure they receive the PIED they desire. This article reports on research that sought to explore all of these issues in one mid-sized city in the south-west of England – Plymouth. What is provided here is a snapshot image of what the PIED market ‘looked like’ in this particular city in 2013: how it operated; how different users sought out and purchased their PIED; the beliefs they held about the PIED they sourced; and the methods they employed to [try to] ensure genuine purchases; and finally, what a sample of PIED sourced from local users/suppliers actually contained.