STEROIDS IN KARACHI, PAKISTAN

Aims: To analyzeawareness regarding the use of steroids in the youth studying health sciences. Materials and Methods: A descriptive, observational study was conducted from September to December 2017. Youth studying health sciences aged 21–25 years in Karachi were recruited for the study, among which (n=179) 50.99% were pharmacy students and (n=172) 49% were studying allied health sciences. Descriptive statistics (SPSS version 16.0) was used to analyze the results. Results: Out of 400 questionnaires, the response rate was 87.75%. Majority students were knowledgeable about steroids and (72.64%) agreed that steroids should be sold as prescription only medicine in Pakistan (p= 0.00).Most of them n=147 (41.88%) had no idea about various modes of steroid abuse (p=0.00).Many participants (n= 109;31.05%) thought that steroids were found in toothpaste & dentifrices, cosmetics and ophthalmic preparations;n= 135 (38.46%) had no idea whether or not the steroids had interactions with opiates & cocaine, alcohol and benzodiazepines. The perception was seen in n= 118 (33.61%) persons that nutritional alternative/supplements could be used to reduce steroid abuse; n= 79 (22.50%) used steroids for grooming upon prescription by medical practitioner. Allergic reactions were thought as the mild side effects of steroid use by n= 100 (28.24%) while n= 166 (47.29%) considered kidney & liver diseases as severe side effects of steroid use (p=0.00). Conclusions: It was noted that comprehensive information about the steroids was required by youth since they were studying health sciences. Some modifications in the curriculum have to be made for providing more information about substances like steroids to the health sciences students as steroids have a great impact not only physically but also psychologically.


Steroids
Steroids area group of endogenous and synthetic hydrophobic substances sharing a common structural skeleton and exhibiting considerably importantvariety of biological activity. Apart from the basic molecular skeleton, these substances exist with different substitutions and functional groups 1 .Endogenously, steroids are synthesised and released into the circulation by the cortical tissue of the adrenal glands and from the gonads, former being regarded as corticosteroids and later as sex steroids 2,3 .Dueto their substantial biological activity, corticosteroids have been used clinically specifically for their anti-inflammatory and immunomodulatory effects, and for the treatment of hypoadrenalism 2,4 .Potential medicinal uses of estrogens and progestins which are female sex hormones includetreatment of estrogen deficiency, hormonal replacement therapy in post menopausal women, contraception, and treatment of a variety of ovarian disorders. Potential medicinal uses of androgenic hormones include treatment of debilitated muscle mass due to surgery or any other cause, anemia, osteoporosis, and delayed puberty in males 5 . AnabolicAndrogenicSteroidsAnd Their AbusePotential Male sex hormone, testosterone aids in muscle building and athletic performance enhancement 6 .Androgenic hormones exhibit notable abuse potential for the sake of building muscle mass and for this reason these substances have been known to be quite popular among individuals who are interested in athletic and body building activities 7 .Several derived forms of male sex hormones are commercially available and are subject to abuse by athletes especially bodybuilders and those who are aiming at weight lifting exercises 8 .Abusers do not only expose themselves to androgens but also to the concentrations of steroids which are significantly higher than those observed in normal physiology 9 .In Pakistan, there have been a lot of conversations about growing trend of steroid abuse among professional and recreational bodybuilders and athletes. A number of reports have surfaced linking steroid abuse with adverse consequences including fatalities 10 . AdverseHealth ImpactOf AnabolicAndrogenicSteroid Abuse Significantly encountered adverse health effects that can be linked with the persistent abuse of anabolic androgenic steroids include atherosclerosis, cardiomyopathies, inhibition of testes and their function, development of certain cancers, depression and dependence 11 . In various reports, myocardial infarction, hypertrophic ventricular diseases, cardiac failure, thrombotic events including atherosclerosis and pulmonary embolism and sudden cardiac has been linked with the anabolic androgenic steroid abuse. Myocardial infarction appears to be the most frequent cardiovascular adversity that can be linked with the anabolic androgenic steroid abuse 12 . Since the abuser is taking supra-physiologic levels of androgenic steroids from exogenous sources, male gonads which were otherwise responsible for physiological synthesis of androgens are taken into an inhibited state by the endocrine negative feedback mechanism. This results in overall reduced function of male gonads eventually leading to impaired quality and quantity of sperm. Overall quality of semen is badly affected. All of these effects may eventually contribute to the development of male infertility 13 . Psychiatric problems experienced with the use of anabolic androgenic steroids are thought to be generally reversible and dependant on the doses used. Such adverse effects include,depressive disorders, mania, psychosis and dependence 14 .Pharmacological uses of anabolic androgenic steroids are not known to cause dependence. However, reports suggest incidence of dependence among bodybuilders and athletes of related nature is not unexpected 8 .

MATERIALS AND METHODS:
Design: A descriptive, survey based study was conducted from September to December 2017. Out of 400 questionnaires, n= 351 were completely filled and returned by the students (response rate = 87.75%). Participants: Youth studying health sciences aged 21-25 years in Karachi were recruited for the study, among which (n=179) 50.99% were pharmacy students and (n=172) 49% were studying allied health sciences. Measurements: Descriptive statistics (SPSS version 16.0) was used to analyze the results.

RESULTS:
For the study, 400 proforma were distributed among various health sciences students and the response rate was 87.75% (n=351). The age group of respondents was 21-25 years among which there were (n=179) 50.99% pharmacy students and (n=172) 49% allied health sciences students. From Table 1 it can be seen that majority of the students replied in affirmative regarding the questions of knowledge about steroids. Most of them (72.64%) agreed that steroids should be sold as prescription only medicine in Pakistan (p= 0.00).  i.e. most of them n=147 (41.88%) had no idea (n=54 pharmacy students, n=93 allied health sciences students) about various modes of steroids abuse while n=91 (25.92%) replied (n=63 pharmacy students, n=28 allied health sciences students) that all the modes were associated with steroid abuse. Total respondents who used oral or topical steroids were n=111 (31.62%) among which n=49 (44.14%) were pharmacy students and n=62 (55.85%) were allied health sciences students; n= 54 had 'No idea' about whether they had used steroids or not (p=0.02). Table 2 shows significant responses among Group A and Group B regarding the perception about steroids. Where p* value = <0.05 is significant Group A= pharmacy students; Group B= allied health sciences students It can be seen from Table 3 that medical practitioner were the main prescribers of steroids to the respondents which was mainly used as anti inflammatory and for grooming purpose; length of treatment for most respondents was from few days to few weeks; mostly no side effects were observed by respondents and even if they occurred, they had no idea about their severity. Where p* value = <0.05 is significant Group A= pharmacy students Group B= allied health sciences students

DISCUSSION:
Results express that most of the study participants were aware about the abuse potential of steroids and they (72.64%) affirm that steroids should only be sold with avalid prescription (see table 1). Furthermore, all participants reported to be aware of potential adverse effects of anabolic steroids like adverse effects related to addiction (68.7%), behaviour (61.45%) and growth (83.79%). Though reported adverse effects of steroids include, impairment of insulin activity leading to glucose intolerance, higher risk of cardiovascular diseases, cerbro-vascular disease, disorders of musculoskeletal system, prostate cancer and psychological disturbances 15 .This outcome can be attributed to the fact that all study participants were associated with health science. A significant proportion (31.62%) of respondents reported using oral or topical steroids. It has been documented that topical steroids have been used for the purpose of brightening skin complexion nevertheless, even topical steroids may cause local and even systemic adversities including severe dependence 16 .Among participants who have used steroids, most (61% of pharmacy students and 62% of allied health sciences students) were prescribed by the medical practitioners.For this reason it can be assumed that medical practitioners can play their role to assist safe use of steroids.It has been reported by a study conducted in Islamabad, Pakistan that rheumatologist irrationally prescribe steroids to a large number of patients suffering from arthritis and other related inflammatory conditions 17 . However, situation varies with the different set of audiences; Baker et al. reported that around 70% of the participants of their study who went to health club used anabolic androgenic steroids 18 . It is pertinent to mention here that even long after the discontinuation of anabolic steroids, cardiac remodeling is not completely reversed 19 .Opinions of pharmacy student regarding potential strategies to minimize steroid abuse significantly differed from the students of allied health sciences (p =0.03). When asked about safety of the steroids with respect to route of administration, opinion of pharmacy students did not significantly vary from the students of allied health sciences (p = 0.06); ubiquitous opinion in case of pharmacy students (97%) and students of allied health sciences (78%) was that oral steroids are safer as compared to the parenteral.

CONCLUSION:
It was observed that the youth studying health sciences had some very basic knowledge about the steroids but were lacking about comprehensive information which should be worked upon by the institutions so that when the youth is ready to serve the community, they serve it well.

ACKNOWLEDGEMENT:
The efforts of Miss WajeehaLatif, Dow College of Pharmacy, Dow University of Health Sciences, in the completion of survey are highly acknowledged.