Eight participants (3 females, 5 males) aged 23 to 54 years (Mean = 35.63, SD = 8.6) were interviewed. The remaining participants did not respond to the participation request or follow-ups. All participants had used multiple types of AAS, with the majority reporting current injectable AAS use (6/8) and two participants presently using oral AAS. However, there were differences in the length of use and/or number of ‘cycles’ (periods of use followed by periods of cessation)29 they had engaged in. Overall, there was a diversity of experience present among users. The mean interview duration was 35.25 minutes (SD = 15.8). The reflexive thematic analysis revealed two major themes. Table 1 provides additional participant demographic details, while Table 2 illustrates the coding process.
Table 1
Participant Demographic Details
Participant | Gender | Age (years) | Work/Study Background | Exercise Background | Current AAS Use | Region |
Consumer 1 | Male | 23 | University study | Bodybuilding | Oral | Rural |
Consumer 2 | Male | 31 | Multiple trades | Combat Sports | Injectable | Rural |
Consumer 3 | Female | 42 | Veterinary nurse | Powerlifting | Oral | Urban |
Consumer 4 | Male | 40 | Gym owner | Powerlifting | Injectable | Urban |
Consumer 5 | Male | 33 | Coaches strength athletes | Powerlifting | Injectable | Urban |
Consumer 6 | Female | 32 | Registered Nurse | Powerlifting | Injectable | Urban |
Consumer 7 | Male | 30 | Coaches strength athletes | Powerlifting | Injectable | Urban |
Consumer 8 | Female | 54 | Coaches diverse clients | Powerlifting | Injectable | Urban |
Table 2
Data Extract | Coded For | Potential Theme | Overarching Theme |
“It doesn't matter where you are. You can chuck it (AAS equipment) into the internet, like Google and then man it gives you options out the backside.” | Access, location, motivations, injecting, substance use | External & Personal Factors effecting AAS use | Accessing Equipment and Overcoming Challenges |
“They're always giving me, like if it's brought up, they'll always give me the spiel (steroids are bad spiel).” | Healthcare, provider interaction, attitudes, perceptions | Therapeutic relationships of HCP and AAS consumer | Nurturing Therapeutic Alliances |
Theme 1: “It would be a really good idea for pharmacists to be aware”: Accessing Equipment, Information, and Overcoming Challenges
All participants highlighted the presence of numerous pharmacies in their immediate surroundings, emphasising the ease with which they could access these healthcare destinations. However, there was a disparity in access to AAS injecting equipment between urban and rural areas, with participants in rural areas experiencing more pronounced challenges where there are fewer pharmacies to access. Participants reported instances of limited access to required equipment in specific circumstances, such as being situated in remote rural areas or failing to adequately plan ahead. The contradiction between the participants' proximity to pharmacies and their reported difficulties in accessing equipment suggests a potential discrepancy between availability and actual accessibility.
Consumer 2: It was in the middle of nowhere (ran out of equipment), they (pharmacy) did have an exchange program for the little orange needles for, I guess heroin. So, I know that they had that there, but they didn't have anything in the terms of gauged draw needles for steroids.
Consumer 3: I've always been able to get what I need. I mean, I'm in [population-dense place], right? Like I got a million pharmacies here. There's always plenty of stuff.
When asked about experiences of not having access to appropriate equipment, most participants indicated that they had never encountered such situations. However, among participants who had experienced running out of necessary equipment, a pattern of potentially risky practices emerged, where participants were using far larger needles than required. Alternatively, participants would defer to AAS-using peers to assist them with equipment when possible.
Consumer 2: Yeah, when I was stuck out in the middle of bum steer [‘nowhere’], I didn't really have access to a lot. So, I would have to travel a lot, like a long way, or get a mate to go somewhere and bring it up.
Consumer 7: Yes and no. Like there’s been once or twice where I've probably run out of barrels or 23-gauge needles, and even in like one circumstance I just used the 19-gauge needle to draw it back and shove it in my glutes. Or I just message a friend and be like “hey bro, do you have any like 25 or three mil barrels?” And they're like, “yeah, man”.
Obtaining equipment through NSPs, outside pharmacy settings, was common among this cohort. However, participants also identified certain issues associated with NSPs, particularly related to their locations and the stigma associated to substance use outside of AAS specifically. The participants' perspectives on themselves as AAS consumers and their attitudes towards accessing equipment from NSPs revealed concerns and nuanced perceptions. Some participants expressed apprehension about being associated with "more extreme" drug users when obtaining equipment from NSPs.
Consumer 2: Yeah. No, they (NSPs) usually are not great areas. They're usually in back-alley things. Like, I could say I'm not a junkie. Like, I don't do meth(amphetamines), I don't do heroin and that. And that's the kind of clientele these people (NSPs) are having there and it’s like, I don't like kind of associating myself with them. Well, even people that do steroids, I don't really like associating myself with them either, because it's just like. I feel like there's a certain level of ego and, that type of person that comes with it.
Consumer 7: I'm happy to go to the Community Health Centre, because there is very much, less people, less traffic, you don't have to be so sus about it (obtaining equipment). Like when you go to [place name, NSP], you are kind of like, “oh, I feel like a heroin addict”.
One participant had a positive experience, feeling non-judged by NSP workers. However, a lack of questions were asked when picking up equipment at NSPs.
Consumer 6: Not a problem at all. I didn't feel that I was being judged. I didn't feel that I was having to be secretive going there or anything like that, because obviously it's like de-identifying. They don't really ask questions.
When participants were presented with the hypothetical scenario of the provision of comprehensive AAS kits containing necessary equipment and information into community pharmacies, there was mixed support. Some consumers indicated they would opt to purchase kits from the pharmacy while others saw some limitations which needed to be overcome first, specifically privacy and confidentiality.
Consumer 2: I'd just like to go and buy a kit from the pharmacy, instead of going to the needle exchange.
Consumer 6: I think the limitation would be standing in line in the checkout, having those kinds of items in your basket. So, I think that maybe in some ways to have it be de-identified.
Notably, and in contrast, some participants regarded online platforms as a convenient and readily accessible means of acquiring equipment. One participant even advocated for others to procure equipment online. Furthermore, participants expressed concerns regarding the provision of these kits through community pharmacies, particularly regarding the potential costs involved. Although NSPs in Australia provide free, clean needles for injecting substances, community pharmacy ‘sharps kits’ generally incur a cost to the consumer. Participants expressed mixed opinions regarding this aspect, with one consumer highlighting their unwillingness to pay for something that can be obtained for free, whilst another expressed a strong willingness to bear the financial costs associated with their practices, expecting others to do the same:
Consumer 5: I told my (AAS-using) clients about it, “just do it online.” They would rather pay for it (equipment), than get it for free because they don't have to go talk to anyone.
Consumer 7: I don't see a problem with that (access via pharmacies), but again, it just comes down to, like why pay for something when you can get for free?
Consumer 6: I mean people that utilise these drugs are already paying a lot of money for the drugs, if they don't have the spare money to pay for the syringes and the needles, then they shouldn't be doing it.
Interviewer
So, you would prefer to pay money at the pharmacy, than go and get it for free at the NSP?
Consumer 2: Absolutely, I would. 10 times out of 10.
There was mixed support for the availability of AAS-related kits in community pharmacies. One participant specifically emphasized the significance of pharmacists being aware of AAS utilisation and its potential impact on medications being dispensed, reflecting their concern for personal and user group wellbeing. When asked about potential factors that would encourage them to seek AAS-related resources from pharmacies, participants highlighted the importance of increased awareness and information about AAS use.
Consumer 3: I think it would be a really good idea for pharmacists to be aware that people do utilise the substances (PIEDs) and that potentially is going to impact medications that they're dispensing.
Consumer 6: I think for me it would just be awareness, which is obviously currently lacking at this point. Like if there was the regular syringes, needles, sharps disposal boxes, alcohol wipes, all the obvious things available at the pharmacy, I'd happily go and get them from there.
It was observed that participants often sought information about AAS use from peers and coaches. Some AAS consumers faced challenges in discerning between reliable and unreliable advice due to a lack of knowledge regarding credible sources and appropriate criteria for evaluating information. There was also reference to the limited credible evidence-based sources for AAS-related information.
Consumer 5: You know, or take the wrong thing, especially for a chick [female]. It takes one wrong thing. I've seen it, you know, take one wrong injection from one thing. There's one of the girls here, had a horrible coach, and she injected this one thing she wasn't 100% sure what it was, and she was listening to her coach at the time, and she lost her voice and her hair fell out… Being able to distinguish good information from bad information is difficult for people who aren't trained and understand what good and bad information is, and the thing is with steroid use, it is quite limited in its research.
The participants expressed concerns and uncertainties regarding the potential role of community pharmacies in the context of harm reduction frameworks for AAS use. They indicated a lack of awareness or understanding regarding the specific services and resources that pharmacies could provide in relation to AAS use.
Consumer 1: I haven't really looked into it, or had reasons to go there, so I'm not really sure what they even have available in the first place, unfortunately.
Consumer 6: No, I wasn't aware there was any tools [resources] available.
Theme 2: Nurturing Therapeutic Alliances: “I think pharmacies are less confronting”
This theme delves into participants' interactions, affiliations, and perspectives concerning HCPs and how these factors shape their behaviours and trust towards them. The implications of these experiences for fostering effective communication and overcoming the perceived "therapeutic barrier" between HCPs and users of AAS is explored, building on extant literature. Notably, participants' historical backgrounds and relationships with doctors exhibited substantial variation of a therapeutic alliance.
Consumer 5: Once you have a good doctor, who's not willing to judge you for your use, and who knows their stuff. My doctor’s good.
Consumer 7: It's just like, “Uh, I’ve got to go to the doctor” and then the doctor will be like, “well, how did it happen?”, and you're like, “oh, injected myself with steroids”, and then they give you the “steroids are bad”, like worst case scenario. You're like, “yeah, cool. Whatever. Just give me the amoxicillin so I can get rid of this infection”, and it's just, more annoying than anything. But I never felt bad.
Stigmatisation and negative experiences with HCPs significantly shaped consumers' perceptions of future interactions with HCPs, influencing their behaviour and decision-making processes. Participants reported instances where they avoided engaging with HCPs due to their anticipation of receiving the repetitive admonition that "steroids are bad." This stigma emerged as the primary deterrent for AAS consumers seeking advice and establishing therapeutic relationships with HCPs. Moreover, participants who expressed a desire to consult doctors regarding their AAS use often encountered difficulties, leading to what one participant referred to as "doctor-shopping."
Consumer 4: “The other big one would be, if you go and chat to a GP because you are even at the least bit curious (about AAS). You get a wall put up where they don't wanna chat or converse with you. And they essentially bundle you out of the surgery. You need to then move on to the next one. And like doctor shop, so to speak.”
Despite the absence of a consistent GP or positive prior experiences with HCPs, all participants expressed a high level of transparency regarding their usage of AAS when engaging with any HCP. However, the main challenge identified was the difficulty in finding HCPs who were receptive to discussing AAS use. Participants expressed a desire to engage in supportive and respectful discussions with HCPs regarding their use, yet they encountered challenges in locating trustworthy HCP contacts who were willing to engage in informed and evidence-based conversations on the topic.
Consumer 4: That's how it kind of works. You gotta know somebody who knows someone, who knows which doctor will be open for conversation as opposed to every doctor.
Community pharmacies emerged as a feasible avenue for accessing professional advice, and participants expressed a preference for services that were convenient and easily accessible. During interviews, participants were prompted to share their past experiences with community pharmacies and pharmacists, yielding responses that encompassed a range of sentiments and perceptions. One perspective highlighted the clinical nature of the pharmacy experience and its effectiveness in facilitating meaningful encounters.
Consumer 2: They’re very like, something I have noticed about pharmacists, they’re very to the point, which I appreciate in person, like they’re very clinical as in, “this is a matter of fact. This is the product you want. See you later.”
Participants were prompted to express their own perceptions of pharmacies and pharmacists. Responses exhibited a range of viewpoints, reflecting their individual perspectives and attitudes towards these healthcare settings and professionals. These perceptions were shaped by the participants' past experiences and interactions, providing valuable insights into the social dynamics and subjective experiences within the community pharmacy context. Overall, pharmacies were noted to be less confronting and a preferrable site of service delivery.
Consumer 3: I think pharmacies are less confronting than a medical practitioner.
Consumer 2: I got a haemorrhoid once from lifting heavy and they’re (the pharmacist) so good about it. It was just easier instead of going to a doctor and the doctor being like, you know, “let's have a look” *puts glove on*. So, like yeah no I much prefer to go to a pharmacist.
One participant identified a potential limitation concerning their ability to confide in pharmacists regarding their AAS use. This limitation was attributed to the high volume of consumers seeking services at community pharmacies. Consequently, the participant expressed reservations about discussing their AAS use in the presence of other consumers, perceiving it as a barrier to receiving appropriate advice from pharmacists. This suggests the lack of privacy within the pharmacy space is a concern for some AAS consumers, hindering their willingness to openly disclose their practices.
Consumer 3: You know it's a public space. They’re kind of being quiet for a reason. They're probably not going to announce it (AAS use) at the counter in front of 10 other old ladies.
Participants were probed about their past encounters at community pharmacies to explore whether negative experiences in the past influenced their perceptions of future interactions. No participants reported having had a negative experience during their previous visits to community pharmacies for general health access or AAS-related access. When asked about their previous interactions with pharmacists regarding AAS-related use and their willingness to consult pharmacists in the future for AAS-related concerns, their responses exhibited positive experiences when seeking pharmacist support within the context of their use.
Consumer 2: Once, I had a sore nipple, and I was a bit worried. And then he (the pharmacist) was like, “ahh”, because he looked at me, and he was like “are you on anything?”. And I was like, “Yeah”. And then he's like, “yeah, it's a common side effect”. And I was just like, “oh, okay”. I was like “Oh, cheers bro”. And he's like, “yeah, just probably slow it down a bit”. I can't remember what it was, but yeah, he recommended something. Anyways, it helped almost immediately.
Subsequently, participants were presented with a hypothetical scenario in which their GP recommended consulting a pharmacist regarding their AAS use, and their inclination towards pursuing this avenue was explored. Participants generally exhibited a willingness to consider this option, underscoring the potential role of HCPs in facilitating access to pharmacist support and enhancing the collaborative healthcare approach for AAS consumers.
Consumer 4: Yes, for me, I'm not too shy around it. So, if the doctor guided me, or wanted me to chat to someone or get some more information around something, then yeah, I'm all for it.