The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20

Anabolic-androgenic steroids: procurement and

administration practices of doping athletes

Julius Fink, Brad Jon Schoenfeld, Anthony C. Hackney, Masahito Matsumoto,

Takahiro Maekawa, Koichi Nakazato & Shigeo Horie

To cite this article: Julius Fink, Brad Jon Schoenfeld, Anthony C. Hackney, Masahito Matsumoto,
Takahiro Maekawa, Koichi Nakazato & Shigeo Horie (2018): Anabolic-androgenic steroids:
procurement and administration practices of doping athletes, The Physician and Sportsmedicine,
DOI: 10.1080/00913847.2018.1526626

To link to this article: https://doi.org/10.1080/00913847.2018.1526626

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Publisher: Taylor & Francis

Journal: The Physician and Sportsmedicine

DOI: 10.1080/00913847.2018.1526626

Authors

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Julius Fink1, Brad Jon Schoenfeld2, Anthony C. Hackney3, Masahito

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Matsumoto4, Takahiro Maekawa5 Koichi Nakazato6 and Shigeo Horie7

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Affiliation
1Graduate School of Medicine, Department of Metabolism and Endocrinology,

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Juntendo University, Tokyo, JAPAN
2Department of Health Sciences, Lehman College, Bronx, NY, USA
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3Department of Exercise & Sport Science; Department of Nutrition – School
of Public Health, University of North Carolina at Chapel Hill, USA
4Advanced Diabetic Therapeutics, Department of Metabolic Endocrinology,
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Juntendo University, Japan

5Department of Rehabilitation for the Movement Functions Research
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Institute, National Rehabilitation Center for Persons with Disabilities

6Graduate Schools of Health and Sport Science, Nippon Sport Science
University, Tokyo, JAPAN
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7Graduate School of Medicine, Department of Urology, Juntendo University,

Tokyo Japan
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Corresponding author
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Name: Julius Fink

Mailing address: 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
Telephone: +81-3-3813-3111
Fax: +81-3-3813-596
E-mail: j-fink@juntendo.ac.jp

There is no funding received for this work (from NIH, Wellcome Trust,

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HHMI, or any others). There are no professional relationships with
companies or manufacturers who will benefit from the results of the present
study for each author.

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Review

Anabolic-androgenic steroids: procurement and administration practices

of doping athletes

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Authors

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Julius Fink1, Brad Jon Schoenfeld2, Anthony C. Hackney3, Masahito Matsumoto4,

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Takahiro Maekawa5 Koichi Nakazato6 and Shigeo Horie7
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Affiliation
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1
Graduate School of Medicine, Department of Metabolism and Endocrinology,
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Juntendo University, Tokyo, JAPAN

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2
Department of Health Sciences, Lehman College, Bronx, NY, USA
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3
Department of Exercise & Sport Science; Department of Nutrition – School of

Public Health, University of North Carolina at Chapel Hill, USA

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4
Advanced Diabetic Therapeutics, Department of Metabolic Endocrinology,

Juntendo University, Japan

5
Department of Rehabilitation for the Movement Functions Research Institute,

3
National Rehabilitation Center for Persons with Disabilities

6
Graduate Schools of Health and Sport Science, Nippon Sport Science

University, Tokyo, JAPAN

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7

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Graduate School of Medicine, Department of Urology, Juntendo University,

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Tokyo Japan

Corresponding author

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Name: Julius Fink
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Mailing address: 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan

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Telephone: +81-3-3813-3111
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Fax: +81-3-3813-596
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E-mail: j-fink@juntendo.ac.jp
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Abstract

Performance enhancing substances are becoming increasingly popular amongst

bodybuilders and people who want to enhance their physiques. However, due to
the rise of the Internet and laws prohibiting sales of these substances without
prescription, the route of procurement and administration practices have

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become more and more dangerous. Prior to the mid-1970’s, anabolic steroids

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were not regulated and easily available from physicians and pharmacies in
several countries. In 1990, the United States enacted the Anabolic Steroid

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Control Act, leading to the proliferation of black markets and underground
laboratories. The shift from pharmacy to underground online sites for the

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procurement of anabolic steroids led to an increase of fake products with low
purity and the ability to potentially endanger the health of anabolic steroid users.
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Underground laboratories emerged both locally and in countries with lax legal
regulations. “Anabolic steroid tourism” and large networks of online resellers
emerged, leading to the banalisation of the illegal procurement of anabolic
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steroids. Furthermore, the increase of anecdotal information spreading on the

internet among anabolic steroid user forums nourishes the rampant
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misinformation and dangerous practices that currently exist. The dosages and
ways of administration recommended on these forums can be false and
misleading to those who lack a medical background and cannot go to their
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physician to seek advice because of the fear of repercussions. This review aims
to elucidate and describe current practices of the anabolic-androgenic steroids
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black market and draw attention to potential dangers for users.

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Introduction
Anabolic-androgenic steroids (AAS) have existed since the discovery of
synthetic testosterone in the 1930’s. Their potent beneficial effects on sports
performance due to increased neuromuscular performance and muscle fiber
characteristics (1) were soon discovered and became widely used by athletes
until they were banned by the International Olympic Council in 1972.

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Nevertheless, medical research led to the development of several new

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testosterone derivatives triggering a rise in demand among athletes who early
on noticed not only the performance-enhancing properties of these compounds,

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but also their anabolic effects. The use of AAS in competitive bodybuilding
became widespread and was often supervised by physicians who supplied the

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drugs to the athletes, ensuring what they were injecting was pure while
monitoring and minimizing side effects such as infertility, liver toxicity, impaired
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lipid profiles, high blood pressure, acne, hair loss or gynecomastia. During this
time, there was no need for a black market or underground laboratories (UGL)
since these drugs were readily available from heath professionals. However, the
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situation dramatically changed after the introduction of the Anabolic Steroid

Control Act in 1990, and subsequently reinforced by the Anabolic Steroid Control
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Act of 2004. In 2014, the Designer Steroid Control Act was enacted in an attempt
to close loopholes for slightly modified compounds. These events created an
immense demand for black market products, which facilitated the creation of
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UGL products and the importing of drugs produced in countries with lax AAS
legislations.
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Black market products can be categorized into four basic groups; 1)

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counterfeit products of well known pharmaceutical brands, 2) UGL products

labeled as such, 3) pharmaceutical products imported from countries not
prohibiting AAS, 4) local pharmaceutical products coming to the black market via
illegal routes, 5) Selective androgen receptor modulators (SARMs). Each of
these are explained below.

1) Counterfeit products often contain under-dosed, cheaper derivatives of the

intended AAS compound, or worse, inert fillers and binder chemicals. Safety
6
 issues are a major concern with these kinds of products, since they are not
controlled by any institution and may display high rates of contamination, with
the risk being especially high for injectable products.
2) UGL products have gained popularity since the overflow of counterfeit
products. UGL products often do not claim to be affiliated to any
pharmaceutical company and try to gain customer trust via manufacture of

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quality products, even though they are not controlled and the manufacturing

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facilities are often below standard for the production of human grade drugs.
Recently, UGL labs have begun to advertise modern production facilities on

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their websites to reassure potential customers as to product efficacy. UGL
products are often sold under different brand names as compared to

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pharmaceutical grade products or just labeled with the active ingredient
depending on the manufacturer.
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3) AAS produced in countries such as Thailand, India, Pakistan or Mexico are
often illegally imported and sold online. These products are often shipped
directly from the country of origin to the buyer’s house. This category of AAS
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is conceivably safer to use as compared to the categories above; however

the illegal route of procurement might endanger the buyer with regard to
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violating the law in their country.

4) The last category of black market AAS is probably the safest but most
expensive and difficult route of procurement: local legitimate pharmaceutical
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grade AAS. The physician or pharmacist selling these products without

prescription encounters a high legal risk which reflects on the price on the
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black market. The risk of losing their license or getting incarcerated often
makes sellers charge several times the retail price of the products. However,
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due to the increase of fake AAS and the health risks associated with
counterfeits, many AAS users are willing to pay the higher price to ensure the
quality and safety of what they are using.
5) SARMs are not approved by the Food and Drug Administration (FDA).
However, many sellers on the black market use the fact that SARMs are not
yet listed as banned substances and can therefore be sold as research drugs.
However, this is a grey zone and might be soon regulated by the FDA.

7
Even though legitimate pharmaceutical grade AAS can be purchased on the
black market via several routes, physician supervision of usage is lacking,
making a legitimate pharmaceutical product potentially dangerous for
uninformed users. Since buying and using AAS (without a medical prescription)
is a criminal act in many countries, the AAS user is often reluctant to seek advice
from a physician when health issues arise. Indeed, a survey found that AAS

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users very often have no trust in physicians’ knowledge about AAS and typically

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do not disclose their AAS use to them (11).

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In sum, the AAS market has undergone major changes over the past
20 years, especially caused by shifts in the legal status. The purpose of this

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review is to elucidate the routes, practice of usage and the context in which
athletes procure and use AAS currently, as well as provide information to
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prevent this population from endangering themselves via the use of illicit doping
drugs.
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Routes of procurement of black market AAS

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A survey of 1,955 AAS users showed that the major route of procurement is the
Internet (52.7%), followed by local sources (16.7%), friends or training partners
(15%), physician’s prescription (6.6%) and obtaining them from foreign countries
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(5.8%) (5). Routes of procurement can basically be divided into the following five
methods:
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1) Local dealers: These transactions often take place at gyms. The buyer has to
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rely 100% on the credibility of the dealer with regard to the products he is
buying.
2) The Internet: Currently there are numerous online sites selling AAS
worldwide.
3) Overseas: “Steroid tourism” in countries without prohibitive laws against
AAS.
4) Local pharmacies or physicians.
5) Patients with prescription for drugs.
8
The quality of products offered by a local dealer can vary widely, ranging from
legitimate pharmaceutical grade drugs to counterfeits. This method of
procurement is the preferred choice for most newcomers because of its ease as
well as the personal advice often provided by the dealer. Moreover, this method
of procurement is not traceable and therefore is generally regarded as the safest

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with regard to avoiding law enforcement. However, buyers cannot track the

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origin of the products and are frequently given inaccurate advice with regard to
dosages and injection practices.

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A recent study showed that AAS-selling websites are mainly registered in the

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United States (46.7%) and Europe (30%) (6). Besides AAS, several other
performance/muscle mass enhancing products (clenbuterol: 76.7%; growth
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hormone/insulin-like growth factor-1; 60%, thyroid hormones: 46.7%;
erythropoietin: 30%, and insulin: 20%) and products aimed at reducing
AAS-induced side effects (estrogen antagonists: 63.3%; products for erectile
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dysfunction: 56.7%; 5α-reductase inhibitors: 33.3%, and; anti-acne products:

33.3%) are also sold on those web sites (6). Due to the detailed personal
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information collected, and the use of credit cards, many potential buyers are
reluctant to order online. This has led many online sellers to accept anonymous
payment methods such as Bitcoin, thus making the transaction safer for the
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buyer. Parcels are typically shipped in package size and labeling approaches
aimed at avoiding customs inspection (6). The online sellers can be divided into
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two categories: online sellers offering brand name counterfeit products often
targeting newcomers without knowledge and online sellers offering UGL or
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pharmaceutical grade products from overseas. The former online sites are often
scams aiming to make large profits within a short period of time until the scam is
exposed in the AAS user community. The latter online sites, often calling
themselves “online pharmacies,” attempt to take advantage of the self-regulated
aspect of this industry and the lax regulations of several overseas countries,
making them immune against the laws of countries in which AAS users are
buying from. These sellers typically target more experienced AAS users and
develop sophisticated supply systems from a number of different countries. This
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type of online site tends to have greater credibility among AAS users, but the risk
of seizure at customs can discourage consumers from choosing this method.
These types of websites often project the appearance of import services from
overseas pharmacies, offering a large variety of drugs in addition to AAS.
Sometimes the products offered on these sites include pharmaceutical grade
drugs for human consumption and UGL products that are not approved for

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human consumption; this creates confusion among naïve consumers who

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believe they are buying legitimate pharmaceutical grade drugs.

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Traveling overseas to obtain AAS in countries such as Mexico or Thailand is a
popular option. Since such drugs are sold without prescription at pharmacies in

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these countries, the user is able to isolate the origin of the product. Moreover,
AAS are often cheaper in these countries, creating a financial incentive to travel
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abroad. However, in certain countries, counterfeit products might be sold even in
pharmacies. There also is the legal risk of passing through customs with the
AAS; if caught, the user may face significant jail time.
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Buying AAS from a physician or pharmacist willing to “bend” the laws is perhaps
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the safest method of procurement from a health standpoint. This practice

however is illegal and puts the health professional at risk for prosecution. It
should be noted that users must be able to establish a strong connection with a
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health professional, making this a difficult route to pursue.

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The final option is to buy AAS from individuals receiving medical treatment for
conditions such as HIV, cancer, chronic kidney disease, primary or secondary
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hypogonadism, severe anemia, wasting syndrome and sarcopenia. These

patients are often prescribed large amounts of various drugs, and sometimes
engage in selling a portion of their prescription. In this case, buyers are
especially looking for growth hormone (GH), since legitimate GH is difficult to
obtain. HIV patients are often prescribed large amounts of GH worth up to
$7,000 per month, which they can easily resell on the black market to athletes.

In conclusion, there are several routes to buy AAS on the black market, however
10
each of these include substantial personal health and/or legal risks.

Underground information about AAS on the Internet

A recent survey showed that the major source of information for AAS users is the
internet, while information from health care providers was sought out by less

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than 50% of respondents (10). The internet, with its underground forums and

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“information” sites, often spreads misleading or false information to AAS users.
Search results for information on the internet about AAS frequently lead to

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AAS-promoting websites that are linked to black market sites. These sites
invariably attempt to promote sales by highlighting the muscle-building and

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performance-enhancing effects of illicit drugs while downplaying associated
health risks.
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Since there is strong incrimination of AAS use, athletes are often reluctant to visit
a physician to get proper advice and instead turn to the internet to gather
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information. Online “bodybuilding forums” abound with individuals devoid of any

medical background who portray themselves as steroid experts and provide
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false advice to other users with the potential for serious health complications.
Improper advice can range from the type of drug to take to dosages and injection
practices. Very often, 3 or more compounds taken in enormous dosages 5 to 29
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times greater as compared to those recommended in the medical context (10)

are recommended on the internet. For instance, testosterone (T) replacement is
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recommended at ~75-100 mg per week or 150-200 mg every 2 weeks of the

enanthate or cypionate ester administrated via intramuscular injection (3).
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However, a dosage as low as 250 mg of T enanthate every 4 weeks is also

common (15). However, a recent survey of AAS users reported that more than
50% of respondents admitted to using more than 1000 mg of T or other AAS per
week (9). UGL products and counterfeits are often under-dosed or do not
contain any active compound, leading AAS users to raise the dosages in the
belief they are getting the real amount of the drug while they are only getting a
fraction of it in many cases. This occurrence has the potential for serious health
concerns. For example, an AAS user using an under-dosed compound
11
containing only 50% of what is claimed on the vial might recommend taking 1000
mg or more on underground forums. Based on this information, another AAS
user having legitimate pharmaceutical grade drugs might listen to this advice
and administer the same amount of drugs with 100% active compound leading
to twofold concentrations with the potential for negative health consequences. A
recent study investigating the quality of black market AAS and other

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bodybuilding-related drugs found that more than 80% of drugs seized at the

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Swiss customs office did not contain the claimed substance in the respective
amount, with 60% being under-concentrated and 8% containing no active drug

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at all (14). Another study found even more alarming rates (48.6%) of inert
products in counterfeit drugs (7). These products may contain steroids or

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steroid-like substances, potentially leading to serious health risks.
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AAS and other performance enhancing drugs on the black market

According to a survey by Weber et al., testosterone, especially the enanthate

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ester, seems to be the most popular drug on the black market, followed by
methandienone, stanozol, nandrolone, oxandrolone, boldenone, mesterolone,
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trenbolone, oxymetholone and methenolone (14). Another survey showed

similar prevalence for certain AAS on the black market: Testosterone (78.2%),
methandienone (64.9%), nandrolone decanoate (63.5%), stanozolol (56%),
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boldenone undecanoate (53.9%), Trenbolone (51.3%), oxymetholone (37.7%),

oxandrolone (37%), methenolone (28.2%), methyltestosterone (26.1%),
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drostanolone (20%) and fluoxymesterone (19.4%) (5). In addition to AAS

approved for human use, several unapproved forms of AAS intended for animal
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use are popular amongst athletes (Figure 1). From the data of a recent study
investigating the Google search trends with regard to AAS, seasonal fluctuations
for several AAS have been observed (13). For instance, “hardening” agents (i.e.
AAS thought to decrease body fat while increasing muscle mass without water
retention) used by bodybuilders pre-contest such as oxandrolone, trenbolone
and stanazolol show peaks during pre-contest/contest season (spring/summer),
whereas compounds used year-round such as testosterone do not show such
seasonal trends (13).
12
Several UGL have improved their packaging systems in an attempt to assume
the appearance of legitimate pharmaceutical companies. Some of them even
have websites displaying the line of products and identification code security
check systems linked to a number on the vials. This information is provided
despite the lack of a corporate address or telephone number information on the

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website. Other UGL websites even display videos of the production of the AAS

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and includes a “research” section on the website, making it very difficult for
novices to distinguish it from legitimate pharmaceutical company websites.

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Besides AAS, peptide hormones like GH and insulin-like growth factor 1 (IGF-1),

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selective estrogen receptor modulators (SERM), and human chorionic
gonadotropin (HCG) are also often offered on these sites. GH is a very
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expensive and a controlled medical substance, however its anabolic actions and
“fat burning” (lipolytic) effects are highly sought by athletes, even though its
effects on sport performance are still not clear yet, especially due to its usage
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often in combination with AAS which makes it difficult to assess the effects of GH
(12). This has led to a boom of counterfeit GH flooding the black market. In
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contrast with AAS, the manufacturing, shipping and storage process of GH is

very difficult, making it nearly impossible for many UGL to produce potent GH.
Several manufacturers in Asia seem to have the facilities to produce GH,
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however the potency of such products often deteriorates during the shipping and
storage process since GH is a very labile peptide hormone that requires cool
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storage. Recently, several UGLs have began to offer dangerous drugs such as
erythropoietin (EPO), which increases the amount of red blood cells (i.e.,
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hematocrit) and thus the potential for increased endurance performance. AAS
are also known to increase the amount of red blood cells, and can be potentially
dangerous when used in combination with EPO due to blood viscosity issues
and increased myocardial stress. Insulin, another potentially very dangerous
anabolic drug, is readily available in many countries, limiting its demand on the
black market.

Online sellers also are now offering selective androgen receptor modulators
13
(SARMs), which are believed to have similar effects as AAS without the same
degree of negative side effects due to their discriminating targeting of receptors.
However, steroid-like side effects such as liver toxicity, increased potential of
heart attack and stroke, infertility and mental health problems may also occur
with the usage of SARMs. The term “selective” in SARM means they
preferentially bind to androgen receptors in muscle tissue without triggering

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androgenic effects in other tissues such as the prostate (2, 4, 8). The popularity

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of SARMs has also increased among athletes seeking anabolic effects while
minimizing androgenic side effects. The legal status of SARMs allows many web

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sites to legally sell these products as “research products not for human
consumption”. Popular SARMs include Andarine, Accadine (AC-262536),

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Cardarine, Endurobol (GW501516), Mk-677 (Ibutamoren), Ligandrol
(LGD-4033), Ostarine (Mk-2866), Trestolone (RAD-140), S-23, Stenabolic
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(SR-9009) and YK-11. Even though not approved by the Food and Drug
Administration (FDA), many individuals on the black market take advantage of
the fact that SARMs are not yet listed as banned substances and can therefore
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be sold as research drugs, despite being banned by the World Anti-Doping

Agency. Athletes who do not want to procure AAS via illegal routes might buy
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SARMs without realizing the long-term side effects of these drugs are still under
investigation, even though similar side effects to AAS have been observed.
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14
Table 1. List of most popular AAS sold on the black market
Name of the AAS Form of Approval for human use
administration
Anadrol Oral Yes: treatment of anemia,
(oxymetholone) osteoporosis and muscle wasting in
HIV patients

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Anavar Oral Yes: osteoporosis, weight gain after

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(oxandrolone) surgery or trauma, during chronic
infection, counteract catabolic effects

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of long-term corticosteroid therapy,
recovery from burns, Turner

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syndrome and muscle wasting in
HIV patients
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Deca durabolin Intramuscular Yes: anemia, osteoporosis, recovery
(nandrolone) injection from burns, cancer, HIV
Dianabol Oral Formerly approved for the treatment
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(metandienone) of hypogonadism but discontinued in

most countries
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Equipoise Intramuscular No: only veteran medicine

(boldenone) injection
Halotestin Oral Yes: hypogonadism, delayed
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(fluoxymesterone) puberty, breast cancer

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Methyltestosterone Oral Yes: hypogonadism, delayed

puberty, menopausal hormone
therapy, osteoporosis and breast
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cancer
Primobolan Oral (acetate) Yes (Japan and Moldova only):
(metenolone) or recovery after surgery or burns,
intramuscular osteoporosis
injection
(enanthate)
Trenbolone Intramuscular No: only veteran medicine

15
 injection
Winstrol (stanozol) Oral or No: Was approved by the FDA in
intramuscular 1962 but discountinued for human
injection use in most countries

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Nontransparent AAS market

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Several pharmaceutical companies produce AAS via subsidiaries in different

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countries and under different names, creating confusion among users and
making it an attractive business for counterfeit dealers. For a variety of reasons,

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it is often difficult to search for a given drug on the official website of the
pharmaceutical company for non-medical personnel. First, the website might be
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accessible only for licensed medical personnel. Second, the products might be
sold in certain countries only or not be marketed by the company directly but
rather by third parties with different names, which makes it nearly impossible for
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a potential AAS buyer to confirm the legitimacy of the products sold on black
market online stores. Counterfeit producers can therefore easily dupe
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consumers by simply labeling their products with well known pharmaceutical

brands. Despite anti-counterfeit measures such as holographic devices or
colour-shift inks, consumers might not be aware of these measures nor able to
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distinguish between real and counterfeit products since the average AAS user
does not acquire his drugs from a physician or pharmacy.
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Cost-comparison between black market and prescription AAS

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Table 2 indicates that price fluctuations strongly depend on the compound being
sought by the athlete. Black market prices often reflect the offer and demand
situation and the difficulty to manufacture the given product. With regard to AAS,
legitimate product prices do not substantially differ from black market prices,
except legitimate drugs sold on the black market by physicians. However, huge
differences can be observed with regard to GH. This gap in the GH price might

16
be mainly explained by the price regulation of each country. Indeed, depending
on different regulations, the price of GH can be nearly twice as much in countries
with similar cost of living. For instance, 10mg GH costs about $600 in the United
States and Germany as compared to about $350 in Japan. The same 10mg of
GH might even be sold for under $100 in the Eastern world. However, in most
Western countries, legitimate AAS can only be purchased with a prescription

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and are very hard to obtain, leading to higher retail prices on the black market.

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Table 2. Comparison of AAS and other hormone prices produced by Japanese

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pharmaceutical companies with black market products in 2018.
Name of the Official Overseas Overseas UGL price Counterfeit

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hormone retail price pharma retail price price
grade
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products
sold on the
local black
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market
price
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Testosterone $10/250mg $6/250mg $1.5/200mg $6/250mg $5/250mg

enanthate
Methenolone $7/100mg $25/100mg - $14/100mg $4.5/100mg
pt

enanthate
Methenolone $2/100mg - - $12/100mg $3.5/100mg
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acetate
Growth $350/10mg $150/10mg $40/10mg $130/10mg $40/10mg
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hormone

17
Conclusion

The legislation of many countries with regard to AAS and other performance
enhancing drugs has seen dramatic shifts towards incrimination in the past
decades, leading to the rise of inferior quality drugs flooding black markets
worldwide. The lack of official supervision of facilities and manufacturing

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processes of underground laboratories endangers the health of AAS users.

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Even though legislation bans more and more substances, the desire to enhance
performance and appearance does not fade, driving athletes and bodybuilders

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to seek illegal ways of procurement and thus incurring the associated health and
legal risks. The internet enabled the rise of such a black market, not only

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providing a platform for selling illegal drugs, but also for propagating misleading
information to athletes. Besides the well-recognized anabolic and performance
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enhancing effects of AAS and other performance-enhancing drugs, severe side
effects may occur with their use, especially when the products come from
uncontrolled environments such as many AAS sold on the internet.
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Declaration of funding
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This manuscript was not funded.

Declaration of financial/other relationships

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The authors have no relevant affiliations or financial involvement with any

organization or entity with a financial interest in or financial conflict with the
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subject matter or materials discussed in the manuscript. This includes

employment, consultancies, honoraria, stock ownership or options, expert
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testimony, grants or patents received or pending, or royalties. Peer reviewers on

this manuscript have no relevant financial relationships to disclose.

18
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