Michael Evans-Brown

Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study

Objective To describe drug use, sexual risks and the prevalence of blood-borne viral infections among men who inject image and performance enhancing drugs (IPEDs). Design A voluntary unlinked-anonymous cross-sectional biobehavioural survey. Setting 19 needle and syringe programmes across England and Wales. Participants 395 men who had injected IPEDs. Results Of the participants (median age 28 years), 36% had used IPEDs for <5 years. Anabolic steroids (86%), growth hormone (32%) and human chorionic gonadotropin (16%) were most frequently injected, with 88% injecting intramuscularly and 39% subcutaneously. Two-thirds also used IPEDs orally. Recent psychoactive drug use was common (46% cocaine, 12% amphetamine), 5% had ever injected a psychoactive drug and 9% had shared injecting equipment. ‘Viagra/Cialis’ was used by 7%, with 89% reporting anal/vaginal sex in the preceding year (20% had 5+ female-partners, 3% male-partners) and 13% always using condoms. Overall, 1.5% had HIV, 9% had antibodies to the hepatitis B core antigen (anti-HBc) and 5% to hepatitis C (anti-HCV). In multivariate analysis, having HIV was associated with: seeking advice from a sexual health clinic; having had an injection site abscess/wound; and having male partners. After excluding those reporting male partners or injecting psychoactive drugs, 0.8% had HIV, 8% anti-HBc and 5% anti-HCV. Only 23% reported uptake of the hepatitis B vaccine, and diagnostic testing uptake was poor (31% for HIV, 22% for hepatitis C). Conclusions Previous prevalence studies had not found HIV among IPED injectors. HIV prevalence in this, the largest study of blood-borne viruses among IPED injectors, was similar to that among injectors of psychoactive drugs. Findings indicate a need for targeted interventions.

Use of melanotan I and II in the general population

Is unlicensed, unregulated, and potentially harmful

Getting up to speed with the public health and regulatory challenges posed by new psychoactive substances in the information age.

Until about a decade ago, most new psychoactive substances that emerged were typically sold on the illicit market. They were usually produced in clandestine laboratories and called ‘designer drugs’, or were sourced from diverted medicines. This continues to be the case, with some of these drugs simply acting as temporary substitutes—often unknown to users—for established controlled drugs that are in short supply, such as 3,4methylenedioxy-N-methylamphetamine (MDMA). The sale of new drugs on an open market, beginning with 1-benzylpiperazine (BZP) and methylone, followed by mephedrone, marked the start of what is now called the ‘legal highs’ market. We now know that many new drugs that are destined for the ‘legal highs’ market are produced in bulk in China and India and imported into Europe and elsewhere, where they are processed, packaged and sold. The marketing and distribution of these drugs has reached a new level of sophistication, including advertisement and sale on the open market, such as through the internet (with delivery via courier and postal services), as well as ‘head shops’ in towns and cities. They may also sold by streetlevel drug dealers [1]. Addiction has drawn together a collection of papers that have been published over the last few years, as a virtual issue which considers the challenges presented by these new psychoactive substances. Only a few years ago the issue of the ‘legal highs’ market was regarded as an area of limited significance. Things change rapidly, however, and today the question of how to respond to the challenges posed by the emergence of new drugs has become one of major international concern [2]. The papers begin the task of elaborating the policy challenges we now face, particularly in relation to public health and regulatory responses. Before introducing them, however, it is worth taking a brief moment to reflect upon why these things have come to pass, and in so doing ground this virtual issue within the wider social and contextual factors that not only help to shape contemporary patterns of substance consumption but also impact upon almost all other aspects of our modern life. Posting on an internet discussion forum on 26 September 2006, Mexican Seafood noted that some of his, or possibly her, friends had been smoking a herbal mixture called ‘Spice’ that was, by all accounts, surprisingly impressive. The post contained a list of the 14 herbal constitutes it was claimed to contain and sought advice on their provenance. This was swift in coming, with MadScientist claiming early the next day that none of these substances contained CB1 agonists and that laboratory testing had not revealed any cannabinoids to be present. It was further speculated that the product might contain ‘additional active compounds as there were many legal and structurally distinct CB1 agonist available’. This post was followed within hours by claims from Shamantra that ‘Spice’ contained the synthetic cannabinoid HU-210 and speculating that none of the herbal substances claimed on the labelling were likely to be present. It was also noted that the effects were similar to, but longer-lasting than, hashish [3]. While not the first online discussion relating to ‘Spice’, the excerpts above are examples of how modern communication has impacted upon drug use trends [1]. It also serves to highlight the speed at which developments can now occur in the drugs field and by contrast how lumbering remain our efforts to track them.To put these posts into historical perspective, it was only in December 2008 that three synthetic cannabinoids, JWH-018, CP-47 497 and its active homologue, were identified in ‘Spice’ products [4]. Addiction was among the first journals to open the scientific debate on this topic, and by the time the editorial on ‘Spice’ products was published in 2010 nine synthetic cannabinoids had been reported to the European Union Early warning system on new psychoactive substances [4]. By June 2013, more than 80 synthetic cannabinoids

Anabolic steroids detected in bodybuilding dietary supplements – a significant risk to public health

Twenty-four products suspected of containing anabolic steroids and sold in fitness equipment shops in the United Kingdom (UK) were analyzed for their qualitative and semi-quantitative content using full scan gas chromatography-mass spectrometry (GC-MS), accurate mass liquid chromatography-mass spectrometry (LC-MS), high pressure liquid chromatography with diode array detection (HPLC-DAD), UV-Vis, and nuclear magnetic resonance (NMR) spectroscopy. In addition, X-ray crystallography enabled the identification of one of the compounds, where reference standard was not available. Of the 24 products tested, 23 contained steroids including known anabolic agents; 16 of these contained steroids that were different to those indicated on the packaging and one product contained no steroid at all. Overall, 13 different steroids were identified; 12 of these are controlled in the UK under the Misuse of Drugs Act 1971. Several of the products contained steroids that may be considered to have considerable pharmacological activity, based on their chemical structures and the amounts present. This could unwittingly expose users to a significant risk to their health, which is of particular concern for naïve users.

Identification and characterization by LC-UV-MS/MS of melanotan II skin-tanning products sold illegally on the Internet.

New methods were developed and validated to determine the identity, contents, and purity of samples of melanotan II, a synthetic melanocortin receptor agonist, sold in vials as injectable skin-tanning products that were purchased from three online shops. Methods were based on liquid chromatography with ultra-violet detection (LC-UV) at wavelength 218 nm, and tandem mass spectrometric detection (MS/MS) after collision-induced fragmentation of the double charged [M+2H](2+) precursor ion (m/z 513). Identification of melanotan II was verified by correct chromatographic retention time, and relative abundance ratios of five qualifying fragment ions. LC-UV was used to quantify melanotan II as well as impurities. Method validation was performed with reference to guidelines for assessing active substances in authorized medicinal products to reach acceptable accuracy and precision. Vials from two shops contained unknown impurities ranging from 4.1 to 5.9%; impurities from one shop were below the quantification limit. The total amount of melanotan II in vials ranged between 4.32 and 8.84 mg, although each shop claimed that vials contained 10 mg melanotan II. A broad range of drugs used for enhancement purposes can be obtained from the illicit market. However, users of these drugs may be exposed to a range of potential harms, as shown in this study, given that these products are manufactured, distributed and supplied from an illicit market.

Injecting human growth hormone as a performance-enhancing drug—perspectives from the United Kingdom

Injectable human growth hormone has been used as a performance-enhancing drug in the United Kingdom since at least the mid-1980s. However, because of its prohibitive cost and limited supply it was initially restricted to a relatively small number of people. More recently data suggest that there has been a large increase in the use of the hormone within some sections of the general population. Here the hormone is usually taken as part of a high-dose polydrug regimen (which includes multiple types of anabolic steroids) predominately to enhance physique and/or bodily aesthetics. However, detailed systematic studies of the cultural diffusion of this drug (including the motivations for use, prevalence, patterns of use, and supply network) are lacking. Moreover, questions about growth hormones efficacy, effectiveness, and safety (including risks from injecting and the use of adulterated products) when used as a performance-enhancing drug remain largely unanswered. This article reviews the data that are available on the self-directed use of growth hormone in the United Kingdom and the associated risks to individual and public health.

New psychoactive substances: driving greater complexity into the drug problem

webcitation.org/6MzpzCv3R on 17 July 2013). 4. Wilkins C. The interim regulated legal market for NPS (‘legal high’) products in New Zealand: The impact of new retail restrictions and product licensing. Drug Test Anal 2014; 6: 868–75. 5. Wilkins C. Recent developments with the establishment of a regulated legalmarket for new psychoactive substances (‘legal highs’) in New Zealand [Letter]. Drug Alcohol Rev 2014; 33: 678–80. 6. Rychert M., Wilkins C. The challenge of a ban on animal testing for the development of a regulated legal market for new psychoactive substances (NPS) (‘legal highs’) in New Zealand: Issues and options for resolution. Int J Drug Policy 2015; 26: 1273–8. 7. Food and Drug Administration. Guidance for Industry Assessment of Abuse Potential of Drugs. Center for Drug Evaluation andResearch, Food andDrugAdministration, US Department of Health and Human Services; 2010. Available at: http:// www.fda.gov/downloads/drugs/guidancecomplianceregulatory information/guidances/ucm198650.pdf (accessed 17 March 2015). 8. OPSRA. Draft Psychoactive Substances Product Approval Guidelines: Office of the Psychoactive Substances Regulatory Authority, Ministry of Health, 2014, 3 November 2014. Available at: http://psychoactives.health.govt.nz/system/ files/documents/pages/draft-psychoactives-product-approvalguidelines-nov2014.docx (accessed 15 November 2014) (Archived at http://www.webcitation.org/6VXS0zOqV). 9. Psychoactive Substances Regulatory Authority. Product approvals. 2015 (4 February). Available at: http://psychoactives.health.govt.nz/industry/licensees-approved-products/ product-approvals (accessed 9 June 2016). 10. New Zealand Parliament. Psychoactive Substances Amendment Act 2014. Public Act 2014 No 24; Date of assent 7 May; 2014. Available at: http://www.legislation.govt.nz/ act/public/2014/0024/latest/whole.html#DLM6099308 (accessed 13 January 2015) (Archived at http://www. webcitation.org/6VXRL1EAt). 11. Buchanen J. Whatever Happened to New Zealand’s Lauded Drug Regulation? Volteface; 2016 (26 April). Available at: http://volteface.me/features/what-ever-happened-to-newzealands-much-hailed-drug-regulation/ Archived by webcite at http://www.webcitation.org/6i7suEZy2 (accessed 9 June 2016). 12. Rychert M., Wilkins C.What products are considered psychoactive under New Zealand’s legal market for new psychoactive substances (NPS, ‘legal highs’)? Implications for law enforcement and penalties. Drug Test Anal 2016; DOI: 10.1002/dta.1943.

Injection site infections and injuries in men who inject image- and performance-enhancing drugs: prevalence, risks factors, and healthcare seeking

People who inject drugs are vulnerable to infections and injuries at injection sites, but these have rarely been studied in those injecting image- and performance-enhancing drugs (IPEDs). This study examined the factors associated with reported symptoms of injection site infections and injuries in IPED injectors. Of the 366 male IPED injectors surveyed, 42% reported ever having redness, swelling and tenderness (36% in the preceding year), and 6·8% had ever had an abscess or open wound at an injection site. Having these symptoms was associated with a range of factors related to drug use and healthcare utilization. One sixth (17%) of those reporting redness, tenderness and swelling had ever sought treatment, as had the majority (76%) of those reporting an abscess, sore or open wound. Most common sources of advice were emergency clinics and General Practitioners. Interventions are needed to support access to appropriate injecting equipment and provide targeted harm reduction advice.

Is the breast cancer drug tamoxifen being sold as a bodybuilding dietary supplement

For more than 30 years, bodybuilders have taken tamoxifen to prevent and treat gynaecomastia caused by use of anabolic steroids.1 2 3 Usually, tamoxifen is sourced from the illicit market. However, bodybuilding discussion forums have speculated that a dietary supplement called Esto Suppress contains tamoxifen because the label listed one of its chemical names (figure⇓). Four samples were purchased at different times between late 2011 …

Should “legal highs” be regulated as medicinal products?

In the United Kingdom legislators are using the term “legal highs” as shorthand for emerging psychoactive substances that are not controlled under the Misuse of Drugs Act 1971 but that in their opinion cause similar harm to those that are.1 It assumes defined causal links between the use of such substances and serious harm to individuals and society. This is compounded by anecdotal accounts in the media of widespread use and (suspected) serious adverse drug reactions that are presented as typical experiences. The term is misleading in defining the problem and its solution, to the exclusion of other policy measures that may be more effective and efficient, such as the medicines regulatory framework. In such an environment fear and panic can weaken the ability to collect the valid and precise data needed for risk assessments—it is of limited value if we can’t discriminate between pharmacological effects, nocebo (undesirable placebo) effects, or other causes.2 3 The opportunity for rational debate and effective policy making is also limited.4 Policy measures that reflect such errors may be regarded as disproportionate and illegitimate by the sections of society that are the intended focus, which in turn could bring …