BiDAS are an integrated drug and alcohol service across Bolton enabling and empowering individuals and their families to achieve their full potential, positive outcomes and improved health and wellbeing.
The Steroid Clinic is part of the Harm Reduction Service and is a free and confidential service offering a range of services, delivered in line with recommendations 1, 4, 7 and 10 in NICE guidance PH52 for needle and syringe programmes. The example also demonstrates how recommendation 6 of PH43 for testing for hepatitis B and C can be implemented in drug services. Services offered include:
- Sterile equipment and safer injecting advice to Image and Performance Enhancing Drug (IPED) users.
- Testing and referral for hepatitis C and in-service hepatitis B vaccination.
- Specialist Steroid Worker offering tailored, evidence based advice and information, providing assessment including full steroid cycle history, physical and mental health history and presentation, measurement of blood pressure and blood analysis and the results, site inspection and referral to relevant treatment providers.
- Specialist clinic relevant to presenting issues and addressing a need to encompass the needs of service users who use IPEDs providing assessment, devising client led - person centred action plans and monitoring in an environment that does not (based on feedback) make them feel alienated and are more likely to attend and invest in their short and long-term health needs.
- General healthcare advice, as well as safe sex, blood borne vvirus information, advice transmission routes and providing supporting literature with harm minimisation messages.
- Referral and liaison with relevant health providers and professionals including: GPs, primary and secondary care, BiDAS Wound Care Clinic, accident and emergency units, genito-urinary medicine clinic etc.
Aims & Objectives
The aims and objectives of the BiDAS Steroid Clinic are to raise awareness of the impact steroid use and administration can have on physical health and other public health issues such as blood borne virus (BBV) infection and transmission within the borough. The steroid service aims and objectives are consistent with the BiDAS philosophy and are based on consultation with the target group. Furthermore they have been developed in response to the growing academic literature and guidance from NICE PH52 and Public Health England http://www.nta.nhs.uk/uploads/providing-effective-services-for-people-who-use-image-and-performance-enhancing-drugs.pdf
The primary aim is to engage a reluctant and often misinformed cohort of service users who through consultation have demonstrated the identified need for this IPED specific service and to reduce the harms associated with this form of drug use.
To monitor and record BiDAS Steroid Clinic service users, their presenting issues, develop action plans, review outcomes, onward referral, record relevant information for the collation of statistics to contribute to service delivery and shape service response.
To provide questionnaires and assessments to review service users response to service delivery but also to monitor changes in behaviour and attitudes and their outcomes which will contribute to the measure if objectives are being fulfilled.
The future aim is to provide case studies to support interventions and based on measured outcomes.
- To provide increased knowledge and understanding of the short-term and long-term risks related to this form of drug use
- To promote informed decision-making related to the commencement, continuation or cessation of drug use.
- To raise awareness of the risks and potential harm arising from the misuse of IPEDs.
- To facilitate an understanding of how the effects of steroid use can and does lead to risky sexual practice and other risky behaviour.
- To ensure awareness of HIV, hepatitis B and hepatitis C prevalence and an understanding of the risks of transmission.
- To impart safer injecting advice and information, including appropriate equipment and safe disposal of used ‘works’
- To provide an ‘easy-to-access’ BBV testing service through joint working protocols with relevant treatment providers.
- To encourage peer education and ease of referral.
- To engage with and develop positive trusting relationships with key members of the community such as gym owners/managers, personal trainers, supplement store staff, influential bodybuilders etc.
- To conduct research locally and contribute to national and international research into trends, and service response and to share good practice with other agencies and professionals.
This increasing cohort of service users has presented to BiDAS needle and syringe provision and through consultation, the presenting issues identified have been:
- poor monitoring of steroid cycles,
- lack of knowledge about specific steroids and their effects,
- combinations of steroids with no real understanding of the outcome of their use,
- poor misinformed injecting practice,
- site infections,
- lack of knowledge and understanding and ignorance to their own contribution to the potential of transmission of BBV,
- poor peer education,
- using steroid cycles to address mood or mental health issues and sexual dysfunction, sport acquired injuries,
- self-medicating for sports injuries that exacerbate the injuries reported due to behaviour borne from elevated testosterone levels and a number of other issues.
We researched into the cohort need for a local service which in turn helped shape the design and response of BiDAS Steroid Clinic.
The issues that arose from the 54 IPED service users’ questionnaires were:
- Length of cycles ranging from 6 weeks – 26 weeks.
- 32 clients with no post course therapy or knowledge of how it can help restore hormone levels and symptoms reported – low mood, energy levels low, sexual dysfunction, erratic behaviour, depression.
- Peer intramuscular injecting and lack of awareness of BBV and transmission routes
- 2 clients diagnosed hepatitis C positive, in treatment.
- 38 not tested for hepatitis C
- 18 collecting injecting equipment for friends and associates combined with poor personal knowledge of IPED or BBV
- Inappropriate steroid cycles advised by friends, gym associates, steroid dealers.
- 42 lack of monitoring or recording of progress.
IPED, using presentations in the years since the formulation of BiDAS in 2012 to 2015 has increased 520%.
Bolton Harm Reduction Service (HRS) has had a year on year increase of new service users presenting with steroid use e.g. 2013 = n=78 to 2014 = n=443.
A service level agreement was negotiated by Lifeline Harm Reduction Service Manager and drawn up to ensure clinical guidance and recommendations for blood analysis results by Bolton Hospital and contracts negotiated were supported and agreed by the service manager for blood sciences and supported her team.
Commissioners agreed in principal to BiDAS Steroid Clinic and a new specialist practitioner was recruited. Phlebotomy training was provided at Bolton Hospital and I fulfilled my competencies at Bolton Hospital phlebotomy department.
The site for the clinic was identified and all clinic guidance and governance was put in place for a phlebotomy service to be delivered. Clinical consultation for this service is provided by the head of biochemistry and the team at Royal Bolton Hospital.
Consultation with the phlebotomy managers and biochemists resulted in a series of blood analysis codes providing information for blood analysis requests for testing including general testing for hormone levels, lipids, kidney and liver function.
These testing request protocols were formulated to respond to the accepted testing regimes – pre cycle, midway and post cycle. These tests comprised of common analysis requests to monitor the effects on the physiology through the use of AAS (anabolic androgenic steroids) such a Testosterone, LH (luteinising hormone), FSH (folic stimulating hormone), LFT (liver function test) and Lipids (cholesterol) and Renal Profile and additional testing requests on reporting of abnormalities identified in assessment.
BiDAS has understood the need for liaison with the local community and has embraced as part of its working practice and with the guidance from Cheryl Goddard – Lifeline around the need to embrace and build relationships with the gymnasiums and the hurdles to this work.
A volunteer who had specifically expressed an interest at being placed within Harm Reduction Service and is currently employed as a personal trainer at a local franchised gymnasium has been recruited to support the Harm Reduction Service. Her knowledge of the human physiology, nutrition and specifically focused training regimes has enhanced the ability to respond to the needs of the service but also enhances service provision.
Local gymnasiums had been historically difficult to engage in Bolton. The consensus was that these businesses did not want to encourage or be seen to encourage steroid use in their gymnasiums to the local stakeholders and local authorities.
A recent exercise drawing on the local knowledge of Harm Reduction S service volunteer was a success and has been able to build successful relationship and joint working with BiDAS HRS and 4 local gymnasiums. An outline of the service was explained, the offer to provide free training around safe disposal of sharps, IPED education and BBV training to staff and PT’s was accepted. The fact that providing safe sharps disposal training, BBV training and IPED education enhanced their ability as employers to safeguard staff and clients alike, enhance the PDF of their staff and demonstrated to the local authority that proactive steps were taken in a from a health and safety perspective.
Results and evaluation
In my capacity of Specialist Practitioner and Steroid Lead, I have found the need for tools to record and assess IPED use, monitor progress and identify risk to be imperative. I have devised a number of clinical monitoring tools to record historical use of steroid cycles, use of supplements, PCT (post course therapy).
The assessment and monitoring tools have been formulated to be lay person/client friendly and are being used to assess and monitor BiDAS IPED users as records to their progress or lack of, their cycles, identify risks, record recovery outcomes and are helping them record or identify progress rather than a ’take it and see if it works’ perspective or being influenced by peers or their steroid suppliers. BiDAS IPED users have expressed their feeling of empowerment with this process.
The outcome statistics for the service working with service users as Steroids being the presenting substance in the period 01/09/15 – 01/09/16:
General Health Advice
Extended Brief Advice
Overdosse Prevention/Safer Injecting
It has been challenging to measure the outcomes and record statistically.
The service is confidential as are all blood analysis results. Advice and referral to GP and/or specialist services is on the basis of results of blood work and identification of abnormalities are identified by biochemists. These referrals happen only with the permission of the service user and is part of the working practice of the clinic. This has helped the service engage, retain and support this hard to engage cohort to make informed, person centred choices in their own time.
As a Substance Misuse Practitioner for 14 years and working with addiction, I have worked with IPED use as its use as addictive practice, and in regards to Maslow’s Hierarchy of needs and ‘self-actualisation’. IPED use can be consuming and a very difficult to motivate clients to proportionate their needs, especially when it impacts on their how they perceive themselves, their self-worth, their identity, their hobby, their confidence, social circle and can be integral to their life and self.
With this in mind, a slow steady approach, clients leading treatment and armed with relevant factual information and the facts supported by blood analysis results that correlate to presenting issues, I have found the IPED service has made significant changes through empowered decision making and peer pressure, peer led misinformation has less importance and IPED users have an awakened, informed confidence which has impacted beneficially on less risky practice, increased drive for knowledge that has steered proactive changes to steroid use and more confidence to make these changes.
Key learning points
Engagement and liaison with the local fitness industry has raised the profile of the clinic and help de-stigmatise NSP in Bolton to the IPED cohort. We proactively network every six weeks and the free training programmes are/will be live on the BIDAS website for easy access and booking for organisations in the fitness industry but also for any other stakeholders.
NSP is a Tier 2 service but, as a practitioner I have used, recorded and reviewed ‘action plans’ with IPED users to monitor harm reduction interventions with clients. These action plans can involve minimising risks in all domains that can contribute, such as:
- IPED use to address mental health issues and alternative evidence based interventions, relevant medication and strategies being sought and risky practice reduced.
- Risky sexual practice partnered with elevated testosterone use. Strategies devised to find triggers and develop alternative, safer strategies.
- More appropriate steroid cycles on identification of goals, and any benefits recorded and acknowledged.
- Informing on recovery, what it entails and promote the need to identify, correct and minimise short and long-term effects.
These short brief interventions, I have found can have profound effects on IPED use and can contribute significantly to the ‘recovery’ or reduction of a client’s risky practice and contribute to raised awareness, peer education and informed choices contributing to short term and long-term positive health outcomes.
Ongoing research and regularly consulting with fellow practitioners and professionals in the field, nationwide, has helped shape this service and share good practice.