Doesn’t stack up

It now affects a broad segment of the public, especially younger men, and is an increasing public health concern.

New research by Oxford Online Pharmacy has found 61% of male gym-goers (of all ages) have or may consider taking anabolic steroids for muscle growth and enhanced athletic performance. This figure increases to 75% of men aged 25–34 years old.

Many commentators believe social media is fuelling this trend, with fitness influencers on platforms like Instagram and TikTok promoting steroid use as a fast-track way to build muscle.

Steroid use is surging alongside the popularity of weight loss medications. The combination of the two – known as ‘stacking’ – has become a significant new risk, as users try to amplify both fat loss and muscle gain at the same time.

The common bulking-shredding concept in the fitness industry means people aim to cut body fat or build muscle in cycles; the idea being that it’s impossible to do both at the same time. Or so it was.

‘Stacking’ is a fitness trend that could prove damaging to public health. The term ‘stacking’ comes from established bodybuilding and performance-enhancing drug (PED) communities, where it refers to the practice of combining multiple substances to amplify results.

Traditionally, this meant combining different types of anabolic steroids, but in more recent years, especially in online forums and underground communities, it’s evolved to include mixing anabolic steroids (testosterone) with other compounds like fat-burning drugs, insulin, growth hormones or even weight loss medications (semaglutide) like Ozempic, Mounjaro and Wegovy.

While the side effects of anabolic steroids are widely recognised and differ between men and women, less is known about the less common side effects of semaglutide, which is a relatively new medication.

This combination increases potential health risks, adding complications from weight loss drugs to those already linked to steroid use.

Behaviours like steroid overuse have uncovered an evolutionary paradox – the Mossman–Pacey paradox.

This is when men damage their ability to have children during efforts to make themselves look more attractive. Research suggests men are trying to get a buff physique, to look like the ‘pinnacles’ of evolution.

Many take steroids to achieve this, but their behaviour is actually having the opposite effect. Studies have shown steroid overuse can lower sperm count considerably.

Follicle-stimulating hormone (FSH) and luteinising hormone (LH) are important hormones in sperm production. These drugs affect FSH and LH and in some men will completely diminish sperm to the point where there are no sperm in the ejaculate.

Another lesser-known side effect is that excessive steroid use can cause permanent hair loss. But our research shows a third of UK men are unaware of steroid-triggered hair loss, and 42% who are aware of the risks would take the chance, falsely believing that it can be reversed with hair growth medication.

Misusing anabolic steroids can also cause psychological or emotional effects, from the minor to increased aggressive behaviour – known as ‘roid rage’ – and mood swings, to the more serious like mania, hallucinations and delusions.

Weight loss medications are intended to be taken weekly, in a controlled manner for the long term, not in a cyclical manner because they are not a ‘quick fix’.

If you stop after an initial weight drop, you’ll likely see the weight come back.

The same goes for anabolic steroids – as soon as testosterone levels drop down to natural levels, muscle mass will reduce. This could lead to users being trapped in a cycle of dependency, fearful of stopping and losing the results.

Experts have long warned about the dangers of extreme and rapid weight loss, with renewed concerns given the rising misuse of GLP-1 medications from unlicensed sources.

Losing weight too quickly can lead to side effects including pancreatitis, gallstones, loss of muscle mass and weakened bones. To gain muscle at speed in parallel to losing fat can place extreme pressure on the musculoskeletal system and someone’s metabolic health.

Anabolic steroids are considered a class C drug in the UK, which can only be issued by a pharmacist with a prescription. They can be injected into the muscle or taken orally as tablets.

Many users of anabolic steroids are taking them illegally, without a prescription.  And those ‘stacking’ steroids with weight loss medication are most likely buying them on the black market too, as they would not meet the criteria to qualify for a prescription.

Taking two black market medications in combination without the oversight of a medical professional is incredibly dangerous.

There is no guarantee what ingredients they contain, where the products have come from with no traceable supply chain, and what the safe dosages would be – if any.

A recent study has shown those struggling with steroid addiction have expressed a preference for community pharmacies when wanting to access support, perceiving them as less confronting and intimidating.

This could mean that many pharmacists often see people who do not currently access other substance misuse services, as well as supporting those who are already on their road to recovery.

Unlike other recreational drugs, steroid use does not lead to an immediate ‘high’. But the satisfaction derived from enhanced physical appearance or performance can create a ‘psychological hook’.

Pharmacists may be able to recognise signs of addiction by asking some of the following questions of patients:

• Are the patients using steroids in larger amounts or for longer than intended?
• Do they have a persistent desire or have they made unsuccessful attempts to cut down?
• Have they continued using steroids despite knowledge of physical or psychological harm?
• Have they developed a tolerance, needing more steroids to get the same effect?

Pharmacies are at the interface of health and social care and can signpost people towards a range of treatment and other support according to where they are on their recovery journey.

Pharmacists who receive proper steroid misuse training can provide essential services like offering accurate information on dosage, health monitoring and potential side effects – all of which could lead to promoting safer usage practices.

Specialist training also means they can refer people struggling with addiction directly into services like the local GP or drug service group.

By integrating blood pressure checks and ongoing health assessments into their services, pharmacists could also prevent many of the adverse effects associated with improper steroid use.

Additionally, pharmacists can support people by providing education on safer injection techniques and sterile equipment, similar to needle exchange programmes.

Expanding the pharmacist’s role offers an effective path to reduce harm from anabolic steroid and weight loss drug misuse.

Medical guidance and supervision are essential to shift away from illicit markets and protect public health.

Kiran Jones is Clinical Pharmacist at Oxford Online Pharmacy