How the love of muscle can break a heart: Impact of anabolic androgenic steroids on skeletal muscle hypertrophy, metabolic and cardiovascular health.

It is estimated 6.4% of males and 1.6% of females globally use anabolic-androgenic steroids (AAS), mostly for appearance and performance enhancing reasons. In combination with resistance exercise, AAS use increases muscle protein synthesis resulting in skeletal muscle hypertrophy and increased performance. Primarily through binding to the androgen receptor, AAS exert their hypertrophic effects via genomic, non-genomic and anti-catabolic mechanisms. However, chronic AAS use also has a detrimental effect on metabolism ultimately increasing the risk of cardiovascular disease (CVD). Much research has focused on AAS effects on blood lipids and lipoproteins, with abnormal concentrations of these associated with insulin resistance, hypertension and increased visceral adipose tissue (VAT). This clustering of interconnected abnormalities is often referred as metabolic syndrome (MetS). Therefore, the aim of this review is to explore the impact of AAS use on mechanisms of muscle hypertrophy and markers of MetS. AAS use markedly decreases high-density lipoprotein cholesterol (HDL-C) and increases low-density lipoprotein cholesterol (LDL-C). Chronic AAS use also appears to cause higher fasting insulin levels and impaired glucose tolerance and possibly higher levels of VAT; however, research is currently lacking on the effects of AAS use on glucose metabolism. While cessation of AAS use can restore normal lipid levels, it may lead to withdrawal symptoms such as depression and hypogonadism that can increase CVD risk. Research is currently lacking on effective treatments for withdrawal symptoms and further long-term research is warranted on the effects of AAS use on metabolic health in males and females.

Generating evidence on the use of Image and performance enhancing drugs in the UK: results from a scoping review and expert consultation by the Anabolic Steroid UK network.

BACKGROUND: The use of anabolic androgenic steroids (AAS) and associated image and performance enhancing drugs (IPEDs) is now a global phenomenon. There is a need to develop evidence to support the development of interventions to prevent the commencement of use, to minimise the potential harms or to support those in their cessation of use. While the United Kingdom (UK) is no exception to this issue, its public health and legislative response to the phenomenon differs to other countries and requires the examination of research specific to the UK. Therefore, a scoping review has been conducted to examine the recent relevant literature to help inform the development and evaluation of effective interventions to reduce the harmful use of IPEDs. METHODS: A comprehensive search strategy was developed for multiple bibliographic databases, supported by and iterative citation searching process and complimented by expert input from the Anabolic Steroid UK Network. Research conducted by or UK academics or within the UK were eligible, if published in the previous five years. RESULTS: In total 87 eligible outputs were identified, including 26 review articles, 25 qualitative papers and 24 quantitative papers. together with small numbers of clinical studies/case reports (6) and commentaries/correspondence (6). The most common topics of research were public health, treatment and harm reduction (41), followed by studies focusing on epidemiology, sub-groups of people using IPEDs and motivations for use (34). The studies illustrated the diverse populations of people who use a range of enhancement drugs including concomitant psychoactive drug use. A number of papers focused on blood borne viruses and associated issues, while others reported on the uptake of needle and syringe programmes. No effectiveness evaluations related to any aspect of treatment, harm reduction or other intervention were published during study period. CONCLUSION: There is a need for the development of effectiveness evaluations of current interventions and any future service provision for people using image and performance enhancing drugs. While there have been no studies of this nature to date, this review illustrates the rich data that has been gathered through diverse methodologies, that will assist in the development of future effectiveness evaluations.

Treatments for people who use anabolic androgenic steroids: a scoping review.

BACKGROUND: A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a diverse population with varying motivations. Evidence has increased greatly in recent years to support understanding of this form of substance use and the associated health harms, but there remains little evidence regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health problems. METHODS: A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible. RESULTS: In total, 109 eligible studies were identified, which included case reports representing a diverse range of disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings were limited throughout by the case report study designs and limited information was provided. CONCLUSION: This scoping review indicates that while a range of case reports describe treatments provided to AAS users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.

A scoping review of home-produced heroin and amphetamine-type stimulant substitutes: implications for prevention, treatment, and policy.

Several home-produced substances such as krokodil and boltushka are prevalent in many Eastern European countries. Anecdotal reports of its use have been circulating in Germany and Norway; however, this has not been confirmed. Its use has also been reported by the media in the USA, although only one confirmed report of its use exists. Home-produced drugs are associated with high levels of morbidity and a number of complex health issues such as the spread of blood borne viruses, gangrene, and internal organ damage. The high incidence of HIV rates amongst people who inject home-produced substances is a public health concern. The resulting physical health consequences of injecting these crude substances are very severe in comparison to heroin or amphetamine acquired in black markets. Due to this fact and the increased mortality associated with these substances, professionals in the area of prevention, treatment, and policy development need to be cognisant of the presentation, harms, and the dangers associated with home-produced substances globally. This scoping review aimed to examine existing literature on the subject of home-produced heroin and amphetamine-type stimulant substitutes. The review discussed the many implications such research may have in the areas of policy and practice. Data were gathered through the use of qualitative secondary resources such as journal articles, reports, reviews, case studies, and media reports. The home production of these substances relies on the utilisation of precursor drugs such as less potent stimulants, tranquillizers, analgesics, and sedatives or natural plant ingredients. The Internet underpins the facilitation of this practice as recipes, and diverted pharmaceutical sales are available widely online, and currently, ease of access to the Internet is evident worldwide. This review highlights the necessity of prevention, education, and also harm reduction related to home-produced drugs and also recommends consistent monitoring of online drug fora, online drug marketplaces, and unregulated pharmacies.

Variability and dilemmas in harm reduction for anabolic steroid users in the UK: a multi-area interview study.

BACKGROUND: The UK continues to experience a rise in the number of anabolic steroid-using clients attending harm reduction services such as needle and syringe programmes. METHODS: The present study uses interviews conducted with harm reduction service providers as well as illicit users of anabolic steroids from different areas of England and Wales to explore harm reduction for this group of drug users, focussing on needle distribution policies and harm reduction interventions developed specifically for this population of drug users. RESULTS: The article addresses the complexity of harm reduction service delivery, highlighting different models of needle distribution, such as peer-led distribution networks, as well as interventions available in steroid clinics, including liver function testing of anabolic steroid users. Aside from providing insights into the function of interventions available to steroid users, along with principles adopted by service providers, the study found significant tensions and dilemmas in policy implementation due to differing perspectives between service providers and service users relating to practices, risks and effective interventions. CONCLUSION: The overarching finding of the study was the tremendous variability across harm reduction delivery sites in terms of available measures and mode of operation. Further research into the effectiveness of different policies directed towards people who use anabolic steroids is critical to the development of harm reduction.

The Association Between the Nonmedical use of Anabolic-Androgenic Steroids and Interpersonal Violence: A Meta-Analysis.

The nonmedical use of anabolic-androgenic steroids (AAS) by athletes and the general population is a public health concern. One particular concern relates to the link between AAS use and violence. Although there is a growing body of research on the association between AAS and violence, results as to what the relationship is seem to be mixed. The aim of this meta-analysis is to improve our understanding of what the current evidence base indicates regarding the relationship between the use of AAS and interpersonal violence. In total, 14 studies with a total of 16 samples met the inclusion criteria, comprising a total sample size of 137,055 participants. The findings show that there is a significant association between AAS use and interpersonal violence (r = .21 [95% confidence intervals (CI): 0.15, 0.27], p < .00001), although small. It is however unclear what the direction of this relationship is as almost all studies failed to demonstrate whether AAS use occurred prior or subsequent to the violent behavior. Risk of bias for most studies was moderate or high. Three potential moderators, AAS use via self-report or testing, interpersonal violence via self-report or criminal records of violent behavior, and proportion of males, were nonsignificant. Although a meta-analytic relationship between AAS use and interpersonal violence was found, it is unclear to what extent AAS causes violent acts. We need to carefully consider the role of mediating factors, and that the relationship between the two could be part of a broader context as opposed to AAS being the cause of violence.

Off-label use of clomiphene citrate to treat anabolic androgenic steroid induced hypogonadism upon cessation among men (CloTASH) - A pilot study protocol.

Background: Non-prescribed anabolic androgenic steroid (AAS) use is associated with AAS-induced hypogonadism (ASIH), and metabolic, cardiovascular, and mental health risks. Symptoms of ASIH (fatigue, depression, anxiety, sexual dysfunction) are hard to endure following cessation, but there is no consensus on whether endocrine treatment should be used to treat ASIH. This proof-of-concept study aims to explore safety of off-label clomiphene citrate therapy, whether the treatment will reduce the symptoms of androgen deficiency, and to study changes in health risks after cessation. Methods: In this open-labeled non-randomized off-label hormone intervention pilot study, we shall include males with AAS dependence intending to cease use. The 16-week intervention included clomiphene citrate, transdermal testosterone gel for the first four weeks and optional human chorionic gonadotropin (hCG) from week 4 if low treatment response. Measures of physical and mental health will be examined from ongoing AAS use, during the intervention, and at 6- and 12 months post cessation. Change in self-reported symptoms of hypogonadism and other withdrawal symptoms will be compared with data from a group of men who ended AAS use temporarily without the medical intervention. The study may provide valuable clinical insights and may be used to inform the design of future intervention studies.

Human enhancement drugs and the pursuit of perfection.

The emerging threat to public health posed by the use of human enhancement drugs has remained largely unrecognised. In attempts to become stronger, happier or smarter, or to look thinner, younger or more beautiful, people are turning to a diverse range of pharmaceuticals. The widespread availability of drugs with the potential to improve human attributes, appearance and abilities has generated a new and growing audience of users. Unlike users of drugs such as heroin, cocaine etc, users of human enhancement drugs do not necessarily perceive themselves as 'drug users'. Those attracted to these drugs may have little or no knowledge or understanding of the physical or psychological harm associated with these substances or their potential for addiction. In addition to the potent effects of many human enhancement drugs, there are considerable risks associated to the clandestine nature of the market. The growing number of untested, banned or adulterated drugs and the lack of safeguards and quality assurance in the illicit manufacturing process has resulted in serious harms and fatalities. The ease with which pharmaceuticals can be manufactured and distributed, combined with the significant profits that can be made from the illicit market, has resulted in a growing challenge for policy makers and health systems in many countries. This editorial aims to raise awareness of this emerging drugs situation and provide a brief overview of some of the drugs and their associated risks.

Severity of anabolic steroid dependence, executive function, and personality traits in substance use disorder patients in Norway.

INTRODUCTION: Anabolic androgenic steroids (AAS), including testosterone and synthetic derivatives, are typically used to increase muscle mass. Many users develop a dependence on these substances, contributing to worsened physical and mental health outcomes. Aspects of personality and executive dysfunction may represent underlying vulnerabilities for developing dependence. OBJECTIVE: To identify levels of AAS dependence within substance use disorder (SUD) treatment patients and assess the relationship between dependence severity and personality traits and executive function (EF). METHODS: Data were collected from patients at 38 SUD treatment facilities in Norway. Questionnaires were completed for measures of personality and EF. Measures of symptoms of AAS dependence were used in latent class analysis to identify sub-groups of patients, which were evaluated for association with EF and personality traits, and compared with a group of non-AAS using SUD patients. RESULTS: Three classes were identified; largely reflecting low, moderate, and high symptoms of dependence. Multinomial regression analyses indicated that moderate and high symptoms were associated with several measures of EF and personality traits, particularly self-monitoring, antagonism, disinhibition, and rigid perfectionism while users with low symptoms exhibited higher capacities for emotional control and shift, and lower negative affectivity, relative to non-AAS using SUD patients. Backward stepwise regressions indicated antagonism, and decreased self-monitoring as key personality and cognitive characteristics of SUD patients with severe AAS dependence. CONCLUSION: Our findings indicate that specific executive dysfunctions and personality features, particularly those associated with poor emotional control, reduced empathy, and impulsivity are associated with more severe AAS dependence in the SUD population.

Systems mapping to understand complexity in the association between image and performance enhancing drugs (IPEDs) and harm.

BACKGROUND: Effective harm reduction work is needed to prevent and respond to the harms associated with image and performance enhancing drug (IPED) use and the diverse needs of IPED communities. Methods based around understanding and mapping complex systems have previously been applied to advance thinking on a range of complex health issues. We applied a systems perspective to explore factors that contribute to IPED-related harms in the UK and to identify harm reduction priorities. METHODS: An illustrative systems map was developed based on methods for mapping complex systems with expert stakeholders. Participants in two online workshops debated the important factors contributing to harm amongst people who use IPEDs and helped to refine and clarify the map. Discussions using the map reflected on where in the system intervention is needed and the policy implications. RESULTS: Stakeholders (n=18) identified 51 distinct factors as being important determinants of IPEDs-related harms, and the connections between them. These were grouped under nine domains that formed this system: identity, cognitive processes, beliefs about risk and harm, health and wellbeing, social environment, beliefs about healthcare, healthcare providers, interventions, and IPED markets. Four harm reduction priorities identified through reflexive discussion included providing a wider range of interventions, improving engagement between the IPED communities and healthcare professionals, new approaches to disseminating information in the community, and early intervention. CONCLUSION: Systems mapping methods are a useful approach to engage stakeholders to discuss drug use issues. A comprehensive policy response is required to this complex issue that recognises diversity in IPEDs communities, their decision-making, and their intervention and service needs, as current approaches are failing to adequately address important areas of harm. Engaging with a wide range of stakeholders is critical to generate new insights that can help respond effectively to reduce the risk of health harms.

Anabolic-androgenic steroid administration increases self-reported aggression in healthy males: a systematic review and meta-analysis of experimental studies.

RATIONALE: Aggression and irritability are notable psychiatric side effects of anabolic-androgenic steroid (AAS) use. However, no previous study has systematically reviewed and quantitatively synthesized effects reported by experimental studies on this topic. OBJECTIVE: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effect of AAS administration on self-reported and observer-reported aggression. METHODS: Twelve RCTs comprising a total of 562 healthy males were identified through systematic searches of MEDLINE, PsycInfo, ISI Web of Science, ProQuest, Google Scholar, and the Cochrane Library. RESULTS: After excluding one outlier, AAS administration was associated with an increase in self-reported aggression under a random-effects model, albeit small (Hedges' g = 0.171, 95% CI: 0.029-0.312, k = 11, p = .018), and when restricting the analysis to the effect of acute AAS administration on self-reported aggression under a fixed-effect model (g = 0.291, 95% CI: 0.014-0.524, p = .014). However, the above effects were neither replicated in the analysis of observer-reported aggression nor after restricting the analysis to the effects of the administration of higher (over 500 mg) and long-term (3 days to 14 weeks) doses. CONCLUSIONS: The present meta-analysis provides evidence of an increase, although small, in self-reported aggression in healthy males following AAS administration in RCTs. Ecologically rational RCTs are warranted to better explore the effect of AAS administration on aggression in humans.

Harm reduction strategies for androgen users: providing appropriate support and improving engagement with healthcare.

PURPOSE OF REVIEW: As evidence continues to emerge of the harms associated with nonmedical androgen use, this review explores the implications from recent studies for designing strategies to reduce harm and support good health amongst androgen users. RECENT FINDINGS: Studies have predominantly come from researchers in the UK and Australia. Major themes include questioning the scope and content of harm reduction strategies and identifying approaches to improve engagement between the androgen using community and healthcare providers. Findings suggest that a broader range of interventions and forms of advice are needed than are commonly provided. This must be supported by efforts to increase opportunities to deliver harm reduction through new engagement approaches, better relationships with health professionals and more guidance on identifying and managing associated adverse health impacts. SUMMARY: A fully developed harm reduction-based response to nonmedical androgen use will be one that not only seeks to reduce risk of bloodborne virus transmission and injecting-related harms, but that considers the range of needs amongst the diverse community of androgen users and respects their decisions and rights. Co-producing interventions with members of this community will help develop effective and engaging approaches. Rigorous studies are needed to evaluate new harm reduction interventions as well as those already delivered.

A sentinel population: The public health benefits of monitoring enhanced body builders.

There is heightened recognition of the public health implications of anabolic androgenic steroids (AAS) for the use of image and performance enhancement; with increasing evidence of their long-term negative health impacts, the hazards associated with their administration (often via injection), and the variability and unpredictability of their contents. In order to optimise the effects of these drugs, together with strict dietary and training regimes, AAS users typically supplement their use with an expansive and continually evolving range of ancillary drugs. The discovery and subsequent adoption of these drugs by the broader AAS user population is largely dependent upon a minority of social influencers within the bodybuilding community. Pioneering enhanced bodybuilders who self-experiment with a diverse range of image and performance enhancing drugs (IPEDs) and ancillary drugs have been the forerunners in the development of an underground user-led literature, online discussion forums, and were early adopters of internet-facilitated drug markets. Yet the impact of their self-experimentations extends well beyond the enhanced bodybuilding community, particularly in their use of ancillary drugs. Most significantly has been their role in the diffusion of various enhancement and psychoactive drugs to the wider population. Using the theoretical framework of the 'diffusion of innovation' we consider the role that pioneering enhanced bodybuilders have played in the diffusion of various enhancement and psychoactive drugs to the wider population through a focus on three substances: dinitrophenol (DNP), melanotan II and gamma-hydroxybtyrate (GHB). With an increasing range of drugs used by bodybuilders, coupled with an expansion in the use of online forums and online platforms to purchase pharmacological and new psychoactive drugs, we anticipate this trend of diffusion amongst the wider population will continue to flourish. Therefore, we highlight the need for policy makers to monitor emergent trends, not only in the general AAS population but particularly amongst enhanced bodybuilders.

A Scoping Review of Non-Medical and Extra-Medical Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used medications worldwide and have analgesic, antipyretic and anti-inflammatory properties. Although NSAIDs are recognised as generally safe and effective, non-medical and extra-medical use of these products can occur. Unlike the use of illegal and many prescription drugs, which are subject to extensive research attention, inappropriate use of NSAIDs has been less well investigated. This scoping review collates and describes what is known regarding non-medical and extra-medical use of NSAIDs. In total, 72 studies were included in this scoping review. Three themes emerged from the review: (1) indicative profile of people who engage in non-medical or extra-medical use of NSAIDs; (2) antecedents for non-medical or extra-medical use; and (3) adverse health effects of non-medical and extra-medical use of NSAIDs. The review concluded that there is a need for enhanced patient education, including among sports people; pharmacovigilance in terms of clinician recognition of aberrance; and prescriber and pharmacist awareness of the potential for extra-medical and non-medical use and the related health harms.

The Anabolic Androgenic Steroid Treatment Gap: A National Study of Substance Use Disorder Treatment.

BACKGROUND: Anabolic androgenic steroid (AAS) use is associated with serious mental and physical health problems. Evidence indicates that AAS use among people who use psychoactive substances is higher than in the general population. This study aims to estimate lifetime AAS use among patients in substance use disorder (SUD) treatment, compare characteristics of AAS and non-AAS users and identify whether AAS use was addressed during treatment. METHODS: This cross-sectional survey included 563 (142 women, 24.2%) patients in 38 SUD treatment facilities in Norway. Respondents reported on AAS and substance use, and treatment experiences. RESULTS: Lifetime AAS use was reported by 156 (28.3%) SUD patients, thereof 35.6% of the men and 8.0% of the women. Lifetime AAS use was highest among men with stimulants (55.8%) as preferred substance, and lowest among men who preferred alcohol (14.6%). Initiation of AAS use due to getting thinner following substance use was reported by 44.5% of the AAS using men. AAS users reported more severe substance use than non-AAS users. More than half (58%) of all patients had not been asked about AAS use, and 42.4% of those who were asked, experienced that treatment providers lacked expertise about AAS. CONCLUSION: Lifetime AAS use in this sample of SUD patients is common practice and comprise an underrecognized problem in SUD treatment. Given the deleterious implications to the individual and society that concomitant use of AAS may cause, it would be essential to raise the awareness about AAS use among SUD patients, and the level of competence among health professionals.

A systematic review investigating the behaviour change strategies in interventions to prevent misuse of anabolic steroids.

We examined intervention effectiveness of strategies to prevent image- and performance-enhancing drug use. Comprehensive searches identified 14 interventions that met review inclusion criteria. Interventions were predominantly educational and delivered within school sport settings, but targeted a wide range of mediating factors. Identification of effective components was limited across studies by brief or imprecise descriptions of intervention content, lack of behavioural outcome measures and short-term follow-up times. However, studies with components in addition to information provision may be more promising. Interventions outside of sport settings are required to reflect the transition of this form of substance use to the general population.

The involvement of drugs and alcohol in drug-facilitated sexual assault: a systematic review of the evidence.

The rate of drug-facilitated sexual assault (DFSA; when an incapacitating drug is administered surreptitiously to facilitate sexual assault) is perceived to be increasing in the United Kingdom and elsewhere, causing international concern. This article examines evidence that quantifies the contribution of drugs in instances of alleged DFSA, identifies the substances involved, and discusses the implications of these findings. Of 389 studies examined, 11 were included in this review. The only study to consider covert drugging reported that 2% of alleged DFSA cases were attributable to surreptitious drug administration. Other studies failed to remove voluntary drug consumption from their cohort, biasing results. A study by the United Kingdom's National Forensic Services found no evidence to suggest that flunitrazepam (Rohypnol) had been used for DFSA during its 3-year investigation. In the United States, flunitrazepam is used recreationally, providing a likely explanation for its presence in samples of some alleged DFSA victims.

Identifying a typology of men who use anabolic androgenic steroids (AAS).

BACKGROUND: Despite recognition that the Anabolic Androgenic Steroid (AAS) using population is diverse, empirical studies to develop theories to conceptualise this variance in use have been limited. METHODS: In this study, using cluster analysis and multinomial logistic regression, we identify typologies of people who use AAS and examine variations in motivations for AAS use across types in a sample of 611 men who use AAS. RESULTS: The cluster analysis identified four groups in the data with different risk profiles. These groups largely reflect the ideal types of people who use AAS proposed by Christiansen et al. (2016): Cluster 1 (You Only Live Once (YOLO) type, n = 68, 11.1%) were younger and motivated by fat loss; Cluster 2 (Well-being type, n = 236, 38.6%) were concerned with getting fit; Cluster 3 (Athlete type, n = 155, 25.4%) were motivated by muscle and strength gains; Cluster 4 (Expert type, n = 152, 24.9%) were focused on specific goals (i.e. not 'getting fit'). CONCLUSION: The results of this study demonstrate the need to make information about AAS accessible to the general population and to inform health service providers about variations in motivations and associated risk behaviours. Attention should also be given to ensuring existing harm minimisation services are equipped to disseminate information about safe intra-muscular injecting and ensuring needle disposal sites are accessible to the different types.

The impact of citrate introduction at UK syringe exchange programmes: a retrospective cohort study in Cheshire and Merseyside, UK.

BACKGROUND: In 2003, it became legal in the UK for syringe exchange programmes (SEPs) to provide citrate to injecting drug users to solubilise heroin. Little work has been undertaken on the effect of policy change on SEP function. Here, we examine whether the introduction of citrate in Cheshire and Merseyside SEPs has altered the number of heroin/crack injectors accessing SEPs, the frequency at which heroin/crack injectors visited SEPs and the number of syringes dispensed. METHODS: Eleven SEPs in Cheshire and Merseyside commenced citrate provision in 2003. SEP-specific data for the six months before and six months after citrate was introduced were extracted from routine monitoring systems relating to heroin and crack injectors. Analyses compared all individuals attending pre and post citrate and matched analyses only those individuals attending in both periods (defined as 'longitudinal attenders'). Non-parametric tests were used throughout. RESULTS: Neither new (first seen in either six months period) nor established clients visited SEPs more frequently post citrate. New clients collected significantly less syringes per visit post citrate, than pre citrate (14.5,10.0; z = 1.992, P < 0.05). Matched pair analysis showed that the median number of visits for 'longitudinal attenders' (i.e. those who attended in both pre and post citrate periods) increased from four pre citrate to five post citrate (z = 2.187, P < 0.05) but the number of syringes collected remained unchanged. These changes were not due to seasonal variation or other changes in service configuration. CONCLUSION: The introduction of citrate did not negatively affect SEP attendance. 'Longitudinal attenders' visited SEPs more frequently post citrate, providing staff with greater opportunity for intervention and referral. As the number of syringes they collected each visit remained unchanged the total number of clean syringes made available to this group of injectors increased very slightly between the pre and post citrate periods. However, new clients collected significantly less syringes post citrate than pre citrate, possibly due to staff concerns regarding the amount of citrate (and thus syringes) to dispense safely to new clients. These concerns should not be allowed to negatively impact on the number of syringes dispensed.

Community pharmacist experiences of providing needle and syringe programmes in Ireland.

BACKGROUND: Community pharmacists are increasingly acknowledged as under-utilized, important and accessible health providers in providing harm reduction support to drug users via needle and syringe programmes (NSP), provision of advice, HIV/Hepatitis testing and as referral mechanism to social, medical and treatment services. We report here on qualitative findings as part of the evaluation of the pilot Pharmacy Needle Exchange (PNEX) programme in Ireland. OBJECTIVES: The aim was to understand and illustrate pharmacist experiences of providing NSP. METHODS: Of the 107 eligible pharmacies, a total of 70 participated in the national evaluation. Telephone interviews (n = 17) and one-to-one interviews (n = 13) using a semi-structured guide were conducted with 30 pharmacists. Analysis of data was conducted using the Empirical Phenomenological Psychological (EPP) five step protocol. RESULTS: Pharmacist experiences illustrated the largely positive nature of providing NSP, and highlighted needs to develop harm reduction training for pharmacists and appropriate strategies to raise awareness, provide exchange packs to meet the specific needs of the diverse populations of people who inject drugs and ensure the development of trusting relationships and opportunities to engage within a confidential service. CONCLUSIONS: Further enhancement of NSP coverage and targeted service delivery within national care pathways for drug and alcohol services is warranted.