Piatkowski, T. M., Neumann, D. L., & Dunn, M. Drug and Alcohol Review. 2023;42(6). 
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This qualitative study explores the physical and psychological harms of trenbolone, an anabolic-androgenic steroid (AAS) used in the performance and image enhancing drug (PIED) community. Semi-structured interviews were conducted with 16 Australian strength athletes (bodybuilding, powerlifting, strongman/woman), all of whom reported lifetime use of PIEDs, and 50% of whom had used trenbolone. Participants had a mean age of 31.25 (range = 24-45) and included 9 men and 7 women. The researchers used reflexive thematic analysis to identify and organise themes, and analysis was guided by social constructivism, emphasising the collaborative nature of the learning.

The study found that trenbolone was seen as the most harmful AAS by people who use PIEDs, and it was associated with increased aggression, violent behaviour, insomnia, and impulsivity regulation issues. Participants also identified physical harms including impaired cardiovascular function. The theoretical underpinning for the emotional and behavioural effects of trenbolone, and AAS more broadly, is thought to be decreased serotonin neurotransmission. Trenbolone is significantly more potent than testosterone and has a binding affinity for the androgen receptor three times as high as testosterone, which may account for the increased severity of its adverse effects. 

The authors concluded that people who use PIEDs should be aware of the potential for
significant harms associated with trenbolone, and that healthcare providers could consider focused screening strategies. They also suggest that their findings contribute to an emerging body of evidence that AAS harms are compound-specific, and that policymakers may wish to consider the role trenbolone plays in adverse outcomes for this unique cohort.

I must admit I had never heard of trenbolone, or “tren”, until I read this paper, but its use among people who use PIEDs is apparently widespread. A 2016 survey of 563 people reporting past year use of image and performance enhancing drugs
(IPED) showed 33% of respondents had injected trenbolone acetate in the last year (Begley et al., 2017). As a side note, IPED is often used preferably to PIED as it foregrounds the fact that the majority of people who use these drugs do so for 
aesthetic reasons; indeed, 56% of the 2016 survey respondents reported aesthetic reasons as their main motivation for using IPEDs (Begley et al., 2017).

But back to the Piatkowski study, which raises two really important points. One is that, like other classes of drugs such as amphetamine-type stimulants, the harms (and severity of harms) associated with testosterone and its derivatives may vary
from compound to compound. It is important therefore that clinicians understand the different risk profiles of individual drugs, and obtain clear information from patients when taking a drug history, so that tailored harm reduction interventions can be provided.

The second thing this paper highlights is the voices of people who use drugs. Much of what I have learned over the years about illicit drugs has come from asking patients about their experiences. Of course, exploring an individual’s experience of
using a drug (what they like and don’t like about it) helps to aid motivational interviewing interventions, but over time these conversations have allowed me to acquire a more nuanced picture of the effects of different drugs; gaining an understanding of not only the positives and negatives, but the typical and atypical effects. This knowledge has, in turn, informed my harm reduction interventions. The authors of this paper suggest that, as online forums are a popular form of social media among people who use AAS, lived experience narratives of people who have experienced harms could be disseminated within online communities, alongside input from researchers and clinicians. I think this is a great idea as it acknowledges the vital input of ‘experts by experience’ in developing harm reduction interventions.

Image and Performance Enhancing Drugs: 2016 National Survey Results
Begley, E., McVeigh, J., & Hope, V. 2017. Public Health Institute.
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Written by: Tom Jones, Master of Advanced Nursing Practice Master