Injecting human growth hormone as a performance-enhancing drug—perspectives from the United Kingdom

Abstract

Injectable human growth hormone has been used as a performance-enhancing drug in the United Kingdom since at least the mid-1980s. However, because of its prohibitive cost and limited supply it was initially restricted to a relatively small number of people. More recently data suggest that there has been a large increase in the use of the hormone within some sections of the general population. Here the hormone is usually taken as part of a high-dose polydrug regimen (which includes multiple types of anabolic steroids) predominately to enhance physique and/or bodily aesthetics. However, detailed systematic studies of the cultural diffusion of this drug (including the motivations for use, prevalence, patterns of use, and supply network) are lacking. Moreover, questions about growth hormone's efficacy, effectiveness, and safety (including risks from injecting and the use of adulterated products) when used as a performance-enhancing drug remain largely unanswered. This article reviews the data that are available on the self-directed use of growth hormone in the United Kingdom and the associated risks to individual and public health.

Keywords:

• Growth hormone
• performance-enhancing drugs
• drug adulteration/counterfeits
• anabolic steroids
• Needle and Syringe Programmes
• 20^th century history
• United Kingdom
• harm reduction
• body image
• acromegaly
• causality
• observational research

Acknowledgements

The authors wish to thank Dr Pirkko Korkia for providing further details of the methodology used in Korkia & Stimsons' study (1993) for use in Table 1, Martin Chandler for some of the data provided in Table 2, and Andreas Kimergård for his thoughtful comments on the final draft of this paper. We would also like to thank our colleagues in NSPs and outreach programmes who have provided us with some of the information used in this paper.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Notes

¹High levels are also seen in the neonatal period (Giustina & Veldhuis, 1998).

²This indirect signaling pathway is part of the reason why exogenous IGF-1 is used as a performance-enhancing drug by some individuals (Llewellyn, 2009, pp. 544–545; Velloso, 2008).

³Prior to this equivocal data had been presented. Schäfer (1908), Robertson (1916), and Goetsch (1916) all reported accelerated growth of rodents fed on anterior pituitary lobes, while Cushing found that “repeated subcutaneous injections of sterile extracts or emulsions of the whole gland, or of the posterior lobe alone … we apt to lead to emaciation” and “Sandri's experiments in feeding young mice with bovine anterior lobe were quite negative. The feeding of posterior lobe arrested development—an effect attributed to the toxicity of the active principle … More recently Aldrich, and similarly Lewis and Miller, have reported negative results after feeding [anterior pituitary lobes] to young rats” (Goetsch, 1916, p. 32) (our emphasis). See Brown (1984, pp. 369–389) for a discussion of the methodological limitations of these experiments.

⁴Where the pituitary gland was removed experimentally.

⁵This is because of the differences in the structure of the hormone between the two species (Lui & Papkoff, 1956; Peterson & Brooks, 2000).

⁶At the time the NICE guidance was issued growth hormone was not licensed to treat children for this indication, and so the guidance does not cover this indication (National Institute for Clinical Excellence, 2002).

⁷Parenthetically, the use of growth hormone for performance-enhancing reasons have been reported in a number of other countries including the United States (e.g., Cohen, Collins, Darkes, & Gwartney, 2007) and Australia (e.g., Larance, Degenhard, Copeland, & Dillon, 2008).

⁸Furthermore, no data are available on the ‘meaning response’ to growth hormone (Moerman, 2002)—that is, the expectancy and placebo effects that are mediated from the use of the hormone in this way.

⁹But if they were, could we objectively measure the “performance-enhancing” effect of a drug(s) as the difference in time between first, second, and third place on the podium? (or indeed the difference between being on the podium or not?).

¹⁰There are diverse structural and personal factors that serve to drive the use of performance-enhancing drugs (see Evans-Brown & McVeigh, 2009; Grogan, 2008; Mishkind, Rodin, Silberstein, & Striegel-Moore, 1986for a discussion).

¹¹We use the term meme to describe the cultural diffusion of growth hormone practices and trends (and more broadly those of performance-enhancing drugs in general) within the user community (Dawkins, 2006, pp. 189–201; See also Rogers, 2003, pp. 17–18).

¹²Cost of ∼£6.58 was calculated based on the report by Evans (1997) that stated that a “competitive bodybuilder reported using subcutaneous injections of 2 IU (0.66 mg) daily, which costs around £400 per month.” We defined “month” as 30.42 days (365 days/12 months).

¹³Particularly as there are many different Internet sites offering growth hormone products for sale and the size/importance of this supply route has not been systematically examined.

¹⁴This includes substandard (World Health Organization, n.d.(a)) and/or counterfeit (World Health Organization, n.d.(b)) products.

¹⁵Excepting the small amount of met-hGH that was being tested in clinical trials prior to this (e.g., Kaplan et al., 1986).

¹⁶The case report by Young and Anwar (2007) being one of a few notable exceptions to this.

¹⁷Such as the active pharmaceutical ingredient(s) and excipient(s).

¹⁸The use of GHB as a growth hormone secretagogue is also documented in the anti-aging literature (Klatz & Kahn, 1998, p. 213–215).

¹⁹Sharing injecting equipment can also be a route for the transmission of bacterial infections.

²⁰To-date hepatitis C infection has not been examined in PED/anabolic steroid users in the United Kingdom.

²¹‘While at first glance under-strength active ingredients may not appear to be a problem, anecdotally this finding in illicitly-supplied anabolic steroids is believed to have led some users to compensate by using much larger doses. However, given the potential variability in the composition from different products (one may be over-strength, the next maybe under-strength – there is no way of knowing with products derived from the illicit market), the next time the user may get a product that is over-strength leading to an even higher does being inadvertently used.

²²Which could also include undeclared ingredients.

²³Which because it is sourced from the illicit market the quality and safety of these products will be unknown to the user.