Anabolic steroids expose a blind spot in modern harm reduction

For decades, harm reduction has saved lives by responding to the most immediate dangers of drug use — overdose, blood-borne viruses, and contaminated drug supply.

Initiatives such as needle and syringe programs, naloxone distribution and drug checking have dramatically reduced deaths and infections around the world.

But new research suggests these models have a blind spot.

A recent study published in Addiction argues the frameworks used to reduce harm from drugs like heroin or methamphetamine do not translate neatly to anabolic-androgenic steroids, a class of substances widely used across physical and digital fitness and wellbeing communities.

A different risk profile

The reason is simple: steroid use does not look like other drug use.

Most harm reduction models were built around acute risks such as overdose.

By contrast, steroid-related harms tend to develop slowly through long term damage to organ systems including the heart, liver, and kidneys.

Steroid use is also typically structured and goal-driven. Consumers often follow planned cycles over months or years to build muscle, enhance recovery, or improve appearance.

Many see themselves less as “drug users” and more as people pursuing health, performance, or aesthetic goals.

This mismatch has important implications for how risk is understood, and how services respond.

A system not designed for steroids

Current harm reduction systems largely focus on injecting as the primary source of risk. While this remains important, it does not capture the broader risk environment associated with steroid use.

Anabolic-androgenic steroids — such as testosterone and trenbolone — are illegal to use in Australia without a prescription and are approved only for specific medical conditions. Their use for performance or image enhancement occurs within largely unregulated markets.

These markets add another layer of risk.

For example, in Queensland, findings from the ROIDCheck project show that fewer than one in ten illegal steroid samples analysed contained the expected substance at the expected dose.

Further, oral steroids, often perceived as “safer,” may carry significant risks due to liver toxicity and high rates of mislabelling or contamination.

Rethinking harm reduction 

Harm reduction initiatives must evolve to address these realities.

This could include expanding beyond a narrow focus on injecting to incorporate education around dosing, cycling practices, and long-term health monitoring. It may also involve training health professionals to better recognise and respond to the distinct patterns of steroid use.

Digital environments are also increasingly important. Many individuals now access information about steroids and related substances through social media and online communities, which shape knowledge, practices, and perceptions of risk.

A broader challenge for public health 

Steroids challenge some of our basic assumptions about drug use.

They sit at the intersection of health, performance, and enhancement — rather than intoxication.

If harm reduction is to remain evidence-based, it must adapt to the different ways people use different substances. Recognising this diversity, including drugs used for enhancement rather than intoxication, may represent one of the next major frontiers for public health.

Dr Timothy Piatkowski is from The University of Queensland’s School of Public Health & Centre for Community Health and Wellbeing. He is a globally recognised leader in lived-experience research on substance use, particularly in image and performance enhancing drugs.