Shared learning database

Lifeline Kirkless
Published date:
March 2014

The project provides Harm Minimisation advice, guidance and support, and referral pathways into structured treatment for those using Performance & Image Enhancing Drugs - specifically steroids (PIED). It also focuses on the Recovery of individuals from other substances commonly associated with Steroid use such as GHB and Ketamine.

The project works both within drug services, through the front of house engagement and needle exchange provision, but also provides in reach support within a number of pro body building and mainstream gyms in the Kirklees area. Our provision clearly follows NICE guidance in regards to Harm Minimisation and Needle Exchange scheme provision distribution, alongside Psychosocial and Pharmacological Interventions guidance aswell.

We also provide training to other professionals such as Gym and sports centre managers and within Gyms personal trainers to bolster the knowledge of PIED and the pathways into treatment.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The use of enhancement drugs is by no means a new phenomenon. However, in recent years, needle and syringe programmes across the United Kingdom have experienced a significant increase in clients reporting the use of these drugs. In Lifeline Kirklees we have sought to have a proactive response to this important Public Health issue.

- To develop and maintain a robust Lifeline Kirklees service response to PIED use within Kirklees
- To highlight the use of image and enhancement drugs as a public health issue in Kirklees
- To prompt local research and response to the issues of PIED use Objectives:
- To broaden access to advice and treatment for steroid users, many of whom can have reservations about accessing drug services
- To proactively engage with steroid users in order to increase understanding of safe practices and the wide range of health risks associated with steroid use
- To increase Lifeline's understanding of the range, sourcing, distribution and types of steroids used in the community
- To develop a greater understanding of user trends and likely demands for steroid support within the community - including the likely health and societal impacts of increased use
- To develop a system for clear communication of information and advice relating to steroid use i.e. safe injecting, harm minimisation, substance awareness and management, health care and risks associated with steroid use - risks which commonly include heart disease, impacts to the immune system, high cholesterol and blood pressure, liver and kidney damage, increased injury, hormonal imbalance, nausea, diahorrea, prostate enlargement, testicular shrinking, growth of breast tissue, mood swings, aggression, increased libido, reduced inhibitions, psychological addiction, water retention, increased hair growth, hair loss, greasy skin etc.
- To bring together key individuals involved in Public Health and the Gym and Fitness Industry to tackle the challenges PIED use can bring to an area.

Reasons for implementing your project

For many Needle Exchange services, the majority of their clients are no longer opiates or stimulant users but injectors of anabolic steroids, growth hormones and other peptide hormones such as melanotan II. The levels of harm caused by enhancement drugs, in particular relating to those new and emerging drugs, remains largely unknown. However, case reports and cross sectional studies indicate a range of chronic adverse conditions associated with this form of drug use. These include liver damage, cardiovascular pathologies, genitourinary disorders, and additionally, the presence of blood borne viruses including HIV, all of which contribute to this public health concern. It is also concerning the cocktail of substances that Steroid users present with such as GHB and Ketamine as examples, but with no understanding of what the consequences of use may be or the reality of why they are being used as part of a regime.

In 2007/08 Lifeline Kirklees needle exchange workers started to see an increase in the number of steroid clients. Staff knowledge around the substance was limited so in 2008 we received formal training around the substance.

In March 2009, Jim McVeigh, Head of Substance Use at John Moores University, reported a 2000% increase in the number of steroid users attending needle exchange (NX) services between 1991-2006; and that from 2006-2009, new clients injecting steroids outnumbered new injectors of all other drugs combined. Mr McVeigh also notes a high level of peer distribution of injecting equipment, suggesting that steroid users attending NX services may only be the 'tip of the iceberg'.

We have continued to see year in year the number of steroid clients increasing from approximately 40% of our total Needle Exchange client base in 2010 to just over 56% in 2013, and a continued increased into 2014.

We also concur with Jim McVeigh that these figures underrepresent as some people do collect for their friends as well as themselves. We are also aware that a lot of steroid/PIED users buy directly from the internet. There is also a network within Gyms whereby some Personal Trainers and other Steroid Users are supplying for money various Paraphernalia. As a result of this we have supported a number of steroid users to understand fully Harm Minimisation messages so that there are good clear peer messages in the Steroid community delivered by peers.

How did you implement the project

In line with NICE PH52 Recommendation 3, in an attempt to increase our outreach presence in Kirklees for steroid users in order that we could make sure each steroid user had a clean needle for one injection, two members of staff outreached all the private gyms in Kirklees offering support for this client group. Unfortunately only a few gyms at the time were receptive, resulting in one gym welcoming our presence in a structured manner. Over the past two years a weekly needle exchange service was introduced, and the gym owner is a strong advocate for the importance of Lifeline's Provision. Provision works in line with PH52 recommendation 10, offering a range of steroid specific paraphernalia, advice guidance and support and referral into mainstream provisions. Due to us securing a partner gym and very influential ex-pro body builder working alongside us, we have managed to overcome initial barriers around accessing gyms. The trust and work they have seen us develop with a specific gym has allowed other owners to welcome rather than be cautious of our presence.

In partnership with the North Kirklees Gym, and the University of Huddersfield Research Department, we held a Steroid Seminar. Attended by a mix of commissioners and services from across the Yorkshire and Humber region, the seminar gave us an opportunity to raise the importance of seeing steroid use as harmful, and helped attendees understand fully the range of interventions we as a service could provide, and should be offered to clients. On the day we had several individuals from the Body Building communities and gym services speaking to delegates about real issues they had faced and the importance of putting the right interventions in place such as outreach and correct advice. In line with NICE recommendations 6 and 7 we felt there was a real need to raise the importance of this issue, and the associated harms that can prevail such as Hepatitis C. In line with PH52 recommendation 10, we have consolidated a further relationship with Kirklees Active Leisure (KAL), who run and manage 12 gyms. We have put in place a robust training programme starting with all senior managers to raise the awareness of the problem, then with the middle managers to get them on board and see the importance of us being actively in their gyms, to now having a bi-annual programme in place were we train the Personal Trainers who are offering services face to face with potential Steroid users.

Key findings

During 2014 we have worked with Kirklees Gyms and the users within these environments to undertake research into the views of treatment service provision in order to understand the value of service provision and how it impacts on the changes people make within their lives. The main component of this has been qualitative research asking people about their experiences of recovery and engagement with services. There have been lots of positive responses to our provision including quotes such as "without Lifeline I would probably be dead" and "since using the services I have understood better the need for understanding my body, and what I need to put in it to stay healthy but also achieve the look I want?. There is partnership Steering Group incorporating key stakeholders, including Gym managers. This partnership is responsible for auditing the work carried out within the project, and the research undertaken above. We also hold partnership meetings held with our clinical partners Locala in the area. The agenda of PIED use is regularly on the agenda for this meeting to look at cross cutting issues, and clinical support for interventions. There are also other recognised forums such as the Treatment Reference Group, the Recovery Partnership and the Commissioning Manager Contract meetings, where this subject is discussed frequently. We have continued to see year in year the number of steroid clients increasing. The following stats reflect the increase in numbers of steroid clients. These figures are from June to June; 2010 to 2011 = 438 steroid clients out of 1078, 2011 to 2012 = 572 steroid clients out of 1181, 2012 to 2013 = 639 steroid clients out of 1152
The total number of transactions made to steroid clients from June 2012 to June 2013 was = 1426 - The following stats are from 12 pharmacies that provide needle exchange in the Kirklees area. Again these are from June 2012 to June 2013: Total number of new Steroid User registrations = 247. Total number of Steroid related transactions conducted at pharmacies = 9106
We have re-visited the other private Gym's in Kirklees and now have 3 with an interest in replicating the types of services we provide, one of these is also a mixed martial arts centre which will open up a new clientele for us to deliver interventions to. As a result of our seminar we have also been providing direct sessions to clients within Prison settings, and have recently held a session at Wealstun HMP with the inmates.

Key learning points

The above shows the issues that we are facing as service with this client group but it is important to note the benefit of supporting outreach or on-site Needle Exchange for Steroid users from Lifelines provision. The benefits for clients are mainly the quality of the intervention they get, and the range of paraphernalia they receive directly relevant to their injecting behaviours. We also work directly with Steroid Users, and experts within the Body Building Community, therefore making sure our messages are up to date and clear. This is not the service that can be expected via Community Pharmacy provision although we do liaise with community provision to support them also to keep abreast of the issues. It is also interesting the disassociation that Steroid users have from actual "drug use", even though they use the same services as other injectors, and for the main undertake similar ritualistic behaviours associated with dependency, they do not on the whole define them selves as having a problem with dependency. We are however seeing more harmful consequences of steroid use in regards the associated substances individuals are taking such as GHB which is now being used as a fat burner, but concerningly being ingested in the same manner as protein shakes alongside daily exercise. In turn we have found that although steroid users will engage with our onsite provision, they prefer to have the harm minimisation discussions on site in the gyms, therefore outreach is imperative, and it is imperative the gyms own the need for this as much as possible. We have found that raising the issue in several different ways will hopefully get the result we want. We have found that the first time we have approached organisations they have not fully understood the need for their involvement, and PIED use has to be a partnership approach, this is not just one providers agenda to deal with.

Contact details

Chris Lawton
Service Manager
Lifeline Kirkless

Is the example industry-sponsored in any way?

Lifeline Kirklees is commissioned by Kirklees Public Health, through the Head of Health Improvement Commissioning Manager - Tony Cooke.