Substance Use & Misuse, Early Online:1–7, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.891625
ORIGINAL ARTICLE
Doping in Gymnasiums in Amman: The other side of Prescription and Nonprescription Drug Abuse
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Mayyada Wazaify1 , Ahmad Bdair1 , Kamal Al-Hadidi2 and Jenny Scott3 1
Department of Biopharmaceutics and Clinical Pharmacy, The University of Jordan, Amman, Jordan; Department of Toxicology, The University of Jordan, Amman, Jordan; 3 Department of Pharmacy and Pharmacology, The University of Bath, Bath, United Kingdom 2
Hughes, & McElnay, 2006). Misuse has been defined as the incorrect use of an OTC product for a medical purpose, usually in terms of dosage or duration of use, while OTC drug abuse is the use of an OTC product for a nonmedical purpose (Fleming, McElnay, & Hughes, 2004). Clarifying that, sports-doping can be classified as a form of “OTC drug abuse” (Cooper, 2013). The risks of doping to both athletes and society generally arise from the nature and concentration of the substances used and from the methods adopted (FIP, 2005). The major risks to health include the development of cardiovascular pathologies especially from the use of erythropoietin (EPO) or stimulants like ephedrine (or derivatives), cancers from the use of growth hormone (GH) or anabolic-androgenic steroids (AAS), neurodegenerative symptoms, and behavioral disorders like aggressiveness, mood fluctuations, or suicidal ideation from the use of AAS (National Institute on Drug Abuse, 2006; Thiblin, Runeson, & Rajs, 1999) A new World Anti-Doping Code, created by the World Anti-Doping Agency (WADA), became effective globally in January 2004. The Jordanian Anti-Doping Organization (JADO) was founded in 2007 and in response to the increasing concern about steroid abuse among Jordanian youth, JADO accepted the World Anti-Doping Code late in 2009, committing Jordan to fighting all types of sportsdoping including AAS abuse (Tahtamouni, 2013). To the best of the authors’ knowledge, apart from the prevalence and risk factors of use of AAS in gymnasiums and among collegiate students (Tahtamouni et al., 2008), no studies in Jordan have assessed the use of drugs that can be obtained without a prescription in gymnasiums.
This study investigated the abuse of over-the-counter (OTC) products (e.g. proteins, dietary supplements) and prescription drugs (e.g. hormones) in gymnasiums in Amman by random distribution of a structured questionnaire to 375 gym clients (November 2012–February 2013). Data were analyzed using SPSS for Windows (version 17.0). A total of 31 (8.8%) clients admitted to using 21 products (mentioned 71 times) of anabolic steroids and other hormones (e.g., growth hormone and thyroxine) to increase muscular power at the gym or build muscle mass. Abuse of different prescription and OTC drugs among gymnasium clients is present in Jordan, but current methods for controlling the problem are ineffective. Better methods should be developed. The study’s limitations are noted. Keywords abuse, Amman, anabolic-androgenic steroids, athletes, doping, fitness, gymnasiums, proteins
BACKGROUND
Anecdotal reports in Jordan have shown that people of both genders are consuming increasing amounts of some drugs that can be obtained without prescription (over-thecounter—OTC). One area of particular concern is in relation to the alteration of physique, with drug use often reported in gymnasiums. Such drugs include stimulants which are taken as “fat burners” and some products that are sold as “dietary supplements,” although they may contain some hormones like testosterone. Testosterone may lead to serious adverse health effects including death, especially among athletes (World Anti-Doping Agency (WADA), 2009). When talking about legitimate substances (i.e. OTC and prescription medicines) rather than illicit drugs such as heroin and cocaine, the differentiation between the terms abuse and misuse becomes important (Wazaify,
Aims and Objectives
The aim of this study was to investigate the use of prescription medications and those purchased without prescription (OTC) in terms of prevalence, types, sources of
Address correspondence to: Mayyada Wazaify, Department of Biopharmaceutics and Clinical Pharmacy, The University of Jordan, Amman, Jordan; E-mail: [email protected]
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knowledge, and pattern of use in a sample of clients at gymnasiums in Amman, the capital of Jordan. The study also aimed to detect any significant variables that may have affected such use.
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Methodology
This study took the form of a cross-sectional survey of clients of both genders attending 16 different gymnasiums in Amman, the capital of Jordan. Ethical approval for conducting the study was obtained from the Scientific Research Committee at the Deanship of Academic Research at The University of Jordan (UJ). The data collection was carried out by three research assistants (two males and one female) who we intentionally appointed as pharmacy graduates and regular clients at the gymnasiums. Gymnasiums were visited on different weekdays (including weekends), thereby encountering a wide crosssection of the community. After obtaining the consent of the responsible manager in each gym, all gym clients present at times of data collection were personally approached and invited to complete the questionnaire before or after (never during) their work-out sessions. They were informed that the aim of this study was to survey the number, types, patterns, and reasons for use of substances that they bought without prescription. Participants were assured of anonymity and that data would be kept confidential. Data collection took place between November 2012 and February 2013. Based on the experience of the authors, literature review, and the expected total number of gym members in Amman, a convenient reasonable target sample was calculated to be 200 clients. In order to achieve the target sample, a higher number of questionnaires (n = 375) were distributed. The anonymous questionnaire (available from the authors upon request) consisted of 20 questions (a mix of preformulated and free-text responses) and was piloted on a small sample of gym clients (5% of the target sample size; n = 10); these data were not included in the analysis. The questionnaire was constructed after the conduction of an extensive literature review to ensure content validity. Face validity was also ensured by consulting with experts in the field at UJ and Jordan Food and Drug Administration (JFDA). The questionnaire was written, piloted, and conducted in Arabic, which is the main language in Jordan. Based on the pilot study, a few questions were modified to be clearer, while others were split into multiple questions. The questionnaire was divided into two sections: (a) demographic details, lifestyle, and medical history of the participant and (b) knowledge about and use of anabolic steroids, “fat burners,” dietary supplements, and other prescribed or OTC products. Data were coded and entered into the SPSSC version 17 for analysis. Chi-square test, Fisher exact test, and multivariate analysis were carried out to detect any significant differences between groups (p < .05).
RESULTS
A total of 353 questionnaires (out of 375 distributed) were completed, giving a response rate of 94.1%. The research assistants approached a total of 20 gymnasiums, out of which 16 (80.0%) agreed to participate in the study. The majority of participants were males (n = 267, 75.6%) and between 19 and 32 years of age (n = 248, 70.3%). Tables 1 and 2 summarize the demographic and training details of participants. A total of 29 participants (8.2%) reported regularly using medication bought without prescription (OTC), more than half of which (n = 16, 55.1%, p < .05) were females. On the other hand, 24 participants (6.8%) reported chronically using prescribed medications. Participants with Bachelor of Science or a college or higher TABLE 1. Participant demographic data (n = 353) Characteristic Gender of participants Male Female Agea (years) 12–18 19–25 26–32 33–39 40–46 > 47 Marital status Single Married Other Educational Level BSc. or higher postgraduate degree Diploma High school Less than high school Work nature Full timer Part timer Unemployed Student Monthly Income (JD)a,b No fixed income < 150 151–300 301–500 501—850 851—1000 > 1000 Health problemsa No Yes (hypertension = 12, ligaments and tendons problems = 17, depression = 6, anxiety = 9, dyslipidemia = 8, other 14; kidney, heart, skin problems, or diabetes) a b
Frequency (%) 267 (75.6) 86 (24.4) 32 (9.1) 138 (39.1) 110 (31.2) 42 (11.9) 13 (3.7) 7 (2.0) 286 (81.0) 64 (18.1) 3 (0.9) 288 (81.6) 17 (4.8) 30 (8.5) 16 (4.5) 200 (56.7) 51 (14.4) 28 (7.9) 74 (21.0) 92 (26.1) 4 (1.1) 28 (7.9) 70 (19.8) 66 (18.7) 34 (9.6) 54 (15.3) 283 (80.2) 66 (18.7)
The total does not add up to 353, as some data are missing. 1.00 JOD = 1.41 USD
ABUSE OF OTC AND PRESCRIPTION DRUGS IN GYMNASIUMS IN AMMAN
TABLE 2. Summary of sports practice and training levels among participants
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Characteristic Level of Training Professional and national team member Professional Amateur Last continuous training period < 3 months 3–6 months 6–12 months 1–3 years > 3 years Frequency of weekly training Daily 5–6 days 3–4 days 1–2 days The purpose of training Build up muscles Weight gain Weight loss Fitness Strength and power More than one Main sport Body building Machines, aerobics Swimming Athletics Football Basketball Taekwondo, MMA, Muay thai Other More than one
Frequency (%) 19 (5.4) 78 (21.5) 251 (70.8) 91 (25.8) 62 (17.6) 49 (13.9) 57 (16.1) 94 (26.6) 69 (19.5) 122 (34.6) 128 (36.2) 32 (9.1) 92 (26.1) 12 (3.4) 27 (7.6) 71 (20.1) 26 (7.4) 123 (34.9) 92 (26.1) 51 (14.4) 11 (3.1) 4 (1.1) 4 (1.1) 9 (2.5) 11 (3.1) 7 (2.0) 156 (44.2)
education 10.3% used significantly more medications bought without prescription (OTC) compared with 3.3% for high school and 6.2% for clients with less education than high school (p = .05). There were no statistically significant relationships between the use of OTC drugs and monthly income, work nature, level of training, purpose of training, or main sport (p > .05). With regard to doping products, a total of 130 (36.8%) participants stated that they had used proteins or amino acids as supplements at least once, whereas 75 (21.2%) used other supplements to increase power at the gym, and 42 (11.9%) used fat burners or other weight loss products. Only 31 participants (8.8%) admitted to currently (n = 11, 3.1%) or previously (n = 20, 5.7%) using anabolic steroids. The main method of administration of anabolic steroids was by injection (n = 16, 51.6%), followed by a combined method of oral and parenteral administration (n = 10, 32.3%) and oral consumption (n = 5, 16.1%). The 31 anabolic steroid users mentioned above used a total of 46 doping products (mentioned 150 times), giving an average of 4.8 products per participant (Table 3). A total of 20 clients (64.5%) reported using more than one doping product. These were divided into three categories:
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(a) dietary supplements and vitamins (n = 66, 44.0%), (b) power enhancers/fat burners (n = 13, 8.7%), and (c) anabolic steroids and hormones (n = 71, 47.3%). The most commonly used single product was testosterone (different brand names, Table 3; n = 14, 9.4%) followed by Decadurabolin (Nandrolone decanoate; n = 12, 8.4%). Using a fat burner to lose weight was not statistically correlated with both age and gender. The use of anabolic steroids was not statistically associated with age, marital status, education level, monthly income, purpose of training, or main sport practiced (p > .05). However, the use of anabolic steroids was found to be significantly correlated with level of training, where professional national team members were reported to be more likely to use anabolic steroids previously (22.2% vs. 7.8% professionals nonteam members and 4.2% for amateurs) and currently (6.5% professionals national team members vs. 5.6% for professionals nonteam members and 2.1% for amateurs; p = .02). The main factors that played a statistically significant role in using supplements and amino acids were gender, training level, and frequency in addition to the type of sport, where males (47.7% vs. 3.4% for females), professionals (52.6% vs. 31.3% for amateurs), those who train 5 to 7 days per week (52.5% vs. 9.4% for those who train 1–3 days per week) and Mixed Martial Arts (MMA), body building, and Muay Thai (71%, 66% and 50%), respectively, had statistically significant higher rates of using supplements and amino acids (p = .000). More than a quarter of participants (n = 99, 28.0%) stated that they had never heard of anabolic steroids (or the Arabic equivalent of anabolic steroids; Al-Hormonat Al-Bena’eyah/Al-Steroideyyah). Of the 242 (68.6%) who had heard about anabolic steroids and were asked about their source of knowledge, 30.3% of cases (n = 107), reported more than two sources, most of which were friends (n = 38, 10.2%) followed by the Internet (n = 36, 10.2%) and a coach (n = 23, 6.5%). As expected, significantly more males had heard of anabolic steroids (75.5%) than females (58.3%; p = .003). There was no statistically significant difference with regard to age or educational level (p > .05). The majority of those who knew about anabolic steroids were practicing MMA (100%), Muay Thai (a combat sport from the Muay martial arts of Thailand that uses stand-up striking along with various clinching techniques; World Muaythai Council, 2013) (85.7%), and body building (81.2%), while least likely to know about them were basketball players (12.5%, p = .000). There were no statistically significant differences concerning knowledge of anabolic steroids with either age or educational level (p > .05). The source of information about anabolic steroids was statistically associated with the purpose of training, where a coach was the main source (33%) when the purpose was “strength and power,” the gym (14%) was the source when the purpose was “fitness,” and friends were mainly the source when the purpose was “weight gain” (37%; p = .02). When asked about whether the sought after effects were achieved or not, more than quarter of participants
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TABLE 3. The main doping products (n = 46, mentioned 150 times) reported to be used by anabolic steroid users (n = 31) in the study
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Category Dietary supplements and vitamins∗ Aminos, BCAA∗∗ (n = 2) Super mass gainer Promix Optimum nutrition Whey protein Creatine Animal pak Other: Glutamine (n = 3), Jack 3D (n = 3), Omega 3 (n = 2), B 100, Liver Aid, Multi-pro, Multi-vit, muscle tech, Nitrotech, (n = 1 each) Power enhancers/fat burners NO explode Other: Clenbuterol, Ephedrine, Muscle Tech, GAT, Hydroxycut, Hot Blood, HMB (n = 1 each) Anabolic Steroids/Hormones Testosterone (Testa) Winstrol Stanazol Deca-durabolin Primobolan Dianabol Anapolon Androlic Anavar Trenbolone GH T3 Insulin/ILGF IGF1- LR3 MGF Otherα : Animal stak, Testo pump, animal pump, Parbolan, Thaiger pharma, (n = 1 each)
N (%)
Comments
66 (44.0) 12 (7.4) 9 (6.0) 8 (5.3) 7 (4.6) 6 (3.9) 6 (3.9) 3 (2.0) 16 (10.6)
16 products
13 (8.7) 7 (4.6) 8 (6.7)
9 products Nitric oxide
71 (48.2) 14 (9.4) 7 (4.6) 2 (1.3) 12 (8.4) 8 (5.3) 3 (2.0) 2 (1.3) 2 (1.3) 2 (1.3) 1 (0.6) 5 (3.2) 1 (0.6) 4 (2.7) 2 (1.3) 1 (0.6) 5 (3.2)
21 products Different brand names: Andriol, Sustanon, testosterone Stanozolol Stanozolol Nandrolone decanoate Methonolone acetate Methandrostenolone Oxymetholone Oxymetholone Oxandrolone Trenbolone esters Growth hormone Thyroxine ILGF = Insulin like growth Factor Insulin like growth factor - Long R3 Muscle growth factor
∗
Sixteen clients (4.5%) used AAS and proteins/supplements concomitantly, while 12 (3.4%) used the 3 types of drugs concomitantly. BCAA = Branched Chain Amino Acid. α Different steroid boosters as reported by participants. ∗∗
(n = 96, 27.1%) were positive about this as 33 participants (9.3%) reported losing weight, while 63 participants (17.8%) reported gaining weight depending on the product and the training schedule used. Thirty four (9.6%) participants experienced adverse effects, the majority of which were: tachycardia, palpitations, hypertension, priapism, testicular atrophy, renal, and psychological problems. DISCUSSION
This study was the first to comprehensively survey a sample of gymnasium clients in Amman regarding their use/abuse of medications obtained without prescription, even if originally they were classified as prescription only medications. Since the use of these drugs is for a nonmedical use, as per the aforementioned definitions, this use can be obviously classified as Prescription/OTC drug abuse (Fleming et al., 2004; Wazaify et al., 2006). The current research is an important beginning point for future research in increasing the awareness of the
public regarding the misuse/abuse of such medications as well as playing an important role in the classification/reclassification of scheduled drugs by the JFDA. For example, stricter legislations could be enforced on the classification of testosterone or other hormones to become “controlled” not just “prescription-only medications.” Greater focus should be directed towards the vital role of the pharmacist in this regard, as in many cases, these medications are bought from pharmacies without prescription. Pharmacists have an important role to play in promoting the health benefits of exercise. They can also educate their clients as to the benefits and risks associated with sports-doping. Moreover, pharmacists should remain vigilant to differentiate between the justified use of medication and illegitimate practice and to refuse to supply a medicine when it is clearly intended to be used to illegally improve performance (International Pharmaceutical Federation (FIP), 2005). Clients in this study used more than one source for information about AAS. However, the single main source of information was friends (10.8%) followed by internet
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ABUSE OF OTC AND PRESCRIPTION DRUGS IN GYMNASIUMS IN AMMAN
(10.2%) and a coach (6.5%). This is comparable to what has been reported previously (Petroczi et al., 2008; Tahtamouni et al., 2008). Unlike other studies, where only professional athletes were surveyed and thus most percentages of AAS and other performance enhancing drug (PED) use were higher (Petroczi et al., 2008; Tahtamouni et al., 2008), the selection of all clients entering the door at each gymnasium affected the results of this study as the sample consisted of professional athletes in addition to amateur athletes. For example, a study conducted by Tahtamouni et al. (2008), with 154 bodybuilding athletes in Jordan seeking to measure the extent of AAS abuse, found that 26.0% of the bodybuilders used AAS, whereas in our study the level of AAS use was found to be only 8.8%. Moreover, the level of stacking (the use of more than one substance in order to achieve a synergistic doping effect) in this study was reported to be lower (64.5%) than that (77%) reported by Tahtamouni et al., (2008) for the same aforementioned reason. A “supplement” is an overarching name for vitamins, minerals, herbal remedies, and other substances taken orally and regulated as food (Petroczi et al., 2007a). In some countries like the United Kingdom and the United States, supplements are required to exhibit efficacy before marketing only if manufacturers make medical claims and fall outside food regulations (FDA, 1994; Petroczi et al., 2008). Many dietary supplements contain Ma-Huang, a Chinese herb that contains ephedrine, and had been used widely as a dietary supplement, appetite suppressant, and stimulant. However, it has been linked to a number of serious cases of toxicity, including myocardial infarction (Cockings and Brown, 1997) and death (Charatan, 2003; Theorides, 1997). Consequently, Ma-Huang was banned by the U.S. FDA in February 2004 (Charatan, 2002; Mayo Clinic, 2013). Moreover, ephedrine can be used for clandestine synthesis of amphetamine-like illicit drugs such as methcathinone “CAT,” a highly addictive street drug and methylamphetamine (Anonymous, 1995). This has led the Drug Enforcement Administration (DEA) in the United States to ask manufacturers and pharmacists who sell OTC products containing ephedrine to keep transaction records (Anonymous, 1994). In Jordan after the death of a 22-year-old body builder in 2011 (Boulad, 2013), the Jordan Food and Drug Administration (JFDA) issued new directives prohibiting the circulation or importation of any foods classified as dietary or sport performance enhancing without JFDA licensure (JFDA, 2013). Moreover, these directives prohibit the use of such supplements under the age of 14 years and require the package label to be in clear easy to read Arabic language. During data analysis, some incongruences between the given name of the products and the aim of use were noticed, where some AAS or hormones were mistakenly classified by participants as fat burners or “supplements.” Previous research has highlighted incongruences between choices of supplement use among athletes and reasons for use, as many of their choices were divergent from available information based on scientific evidence (Petroczi, Naughton, Mazanov, Holloway, & Bingham, 2007b; Petroczi et al., 2008).
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With regard to AAS and hormone use, classification in Jordan exists. However, it is not strictly enforced (AlWazaify & Albsoul-Younes, 2005). This limits the ability of inspectors to trace sales and allows some pharmacist to sell such preparations without a prescription, either directly to end users or to coaches and third parties. Moreover, many of these preparations are counterfeit, expired, or smuggled into Jordan to be sold on the black market, a fact that infers additional health risks to consumers (Boulad, 2013; Sawalha, 2013). Almost 10% of participants in this study reported experiencing adverse effects that have been well documented in the literature (Brower, Blow, Eliopulos, & Bresesford, 1989; Gruber & Pope, 2000; Thiblin, Lindquist, & Rajs, 2000). The majority of such effects are mainly caused by AAS and hormones, especially that such use, in most cases, lacks medical supervision, administration occurs by someone who probably is not trained to do so (e.g. a coach or a colleague), injection occurs in the least hygienic ways, and supraphysiological doses are used to achieve faster results (Bhasin et al., 1996; Tinsley & Watkins, 1998). In addition, such practices may sometimes serve as a gateway to narcotic substance use (Arvary & Pope, 2000; Garevik & Rane, 2010; Kanayama, Gruber, Pope, Borowiecki, & Hudson, 2001). However, this theory has not yet been substantiated clinically or sociologically. The limitations of this study were mainly, as in other surveys, the opportunity for respondents to give false answers in order to either please the interviewer (i.e. social desirability bias) or in fear of consequences. Subjects in this study were approached as they entered the gymnasium’s door, resulting in a lack of rigor in the method of recruitment. Although the study was conducted in the largest urban center in Jordan, our findings may not be generalizable to the remainder of the country. CONCLUSIONS
The results of this study indicate that there is a problem with prescription and OTC drug abuse among clients attending gymnasiums in Amman. The cornerstone to limit the abuse of such drugs is mainly application of the WADA regulations that aim to eliminate performance enhancing drug use among athletes, restricting the sale of prescription drugs to pharmacies only and enforcement of this by Ministry of Health (MOH) inspectors in collaboration with JFDA. Greater efforts should be directed toward raising the awareness of young people and coaches regarding the adverse effects of using such drugs without medical supervision. Future qualitative research into the motivations, attitudes, and experiences of abusers is needed, in addition to studies focusing on methods of identification of abuse and prevention. Declaration of Interest
The authors report no conflicts of interest of any kind related to the work of this research paper.
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THE AUTHORS Ahmad Bdair holds a B.Sc. degree of pharmacy, university of Jordan/Amman-Jordan (2011). He has been working in the field of pharmaceutical sales and marketing since 2011 in the area of thrombosis for one of the famous pharmaceutical companies in the area of anticoagulants. In addition, Ahmad has also been working as a research assistant with Dr.M.Wazaify at the University of Jordan. His research interests are mainly in the field of doping, prevention of abuse and misuse of medications in sports. Dr. Kamal Al-Hadidi is a Professor (Clinical and forensic toxicology of doping in sport) in the Faculty of Medicine, The University of Jordan. He has held various positions including as Member—Health and Medical Research Committee—World Anti-Doping Agency (WADA), President of Jordan and West Asian Anti-Doping Organization, Member—Medical and Anti-Doping Committee—Olympic Council of Asia (OCA), Member—Jordan Sport Medicine Federation, and Chairman—Asian Anti-Doping Fund Committee.
of medicines and the prevention of prescription and OTC drug misuse/abuse. Moreover, she is interested in adopting “Harm Reduction” model in identification and management of OTC and prescription drug misuse and abuse.
GLOSSARY
Abuse: “to make a bad use of.” To use a drug for a nonmedical reason, either to feel “high,” lose/gain weight, or increase muscular power or stamina during exercise (Fleming et al., 2004; Wazaify et al., 2006). Doping: The use of substances or processes which aim either to modify artificially the capabilities of a person exercising and athletic activity, regardless of the discipline or conditions in which the activity is conducted, or to mask the use of substances or processes having this property (WADA, 2009). Misuse: “to use wrongly.” The use of a drug for a legitimate medical reason, yet, misapply it either in terms of dosage or duration of use (Fleming et al., 2004; Wazaify et al., 2006) Over-The-Counter (OTC) drugs: A general term used to describe products that can be bought by the public without a doctor’s prescription, either at pharmacies or other retail outlets (Krinsky et al., 2012). Stacking: The use of more than one substance in order to achieve a synergistic doping effect (Tahtamouni et al., 2008).
REFERENCES Dr. Jenny Scott is Senior Lecturer in Pharmacy Practice, University of Bath since 2007 and was previously Lecturer in Pharmacy Practice University of Bath. She completed her PhD in Pharmacy Practice and Drug Misuse from The Robert Gordon University, Aberdeen, in 2000. She also holds a Certificate in Independent Prescribing (2008), University of Bath. She is also part-time Nonmedical Prescriber since 2010 and Lead Pharmacist since 2013 at Turning Point, England. Dr. Mayyada Wazaify is Associate Professor of Pharmacy Practice at the Faculty of Pharmacy, The University of Jordan since February 2004. She has a PhD in Pharmacy Practice (December 2003) from Queen’s University of Belfast, UK, in the area of “Appropriate Use of Over-The-Counter (OTC) drugs.” She has published more than 27 papers targeting the promotion of appropriate use
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Fleming, G. F., McElnay, J. C., & Hughes, C. M. (2004). Development of a community pharmacy-based model to identify and treat OTC drug abuse/misuse: A pilot study. Pharmacy World and Science, 26, 282–288. Food and Drug Administration. (FDA; 1994). Dietary Supplement Health and Education Act of 1994 (DSHEA). Retrieved July 31, 2013, from website: http://www.fda.gov/Food/ DietarySupplements/. Garevik, N. & Rane, A. (2010). Dual use of anabolic-androgenic steroids and narcotics in Sweden. Drug and Alcohol Dependence, 109, 144–46 Gruber, A. J., Pope, H. G. (2000). Psychiatric and medical effects of anabolic-androgenic steroid use in women. Psychotherapy and Psychosomatics, 69, 19–26 International Pharmaceutical Federation. (FIP; Dec 2005/Jan 2006). The role of the pharmacist in the fight against doping in sport. FIP statement of professional standards. International Pharmacy Journal, 19(2), 7–8. Jordan Food and Drug Administration. (JFDA; 2013). The official Directives of Jordan Food and Drug Administration (JFDA) for licensure of athletes’ dietary supplements [Arabic]. The Jordanian Official Gazette, 5212, 1255–1259. Retrieved July 31, 2013, from Website: http://www.pm.gov.jo/DWWebClient/ IntegrationViewer.aspx?DWSubSession=337 Kanayama, G., Gruber, A. J., Pope, H. G., Jr., Borowiecki, J. J., & Hudson, J. I. (2001). Over-the-counter drug use in gymnasiums: An underrecognized substance abuse problem? Psychotherapy and Psychosomatics, 70, 137–140 Krinsky, D. L., Berardi, R. R., Ferreri, S. P., Hume, A. L., Newton, G. D., Rollins, C. J., . . .Tietze, K. J. (2012). Handbook of nonprescription drugs: An interactive approach to self-care (17th ed.). Washington DC: American Pharmacists Association. R Patient Monograph. (2013). Mayo Clinic, Natural Standard Ephedra (Ephedra sinica)/ma huang. Retrieved December 8, 2013, from website: http://www.mayoclinic.com/health/ ephedra/NS patient-ephedra National Institute on Drug Abuse. (2006). Anabolic steroid abuse: Research series. U.S. Department of Health and Human Services. Retrieved December 6, 2013, from website: http://www. drugabuse.gov/sites/default/files/rrsteroids 0.pdf Petroczi, A., Naughton, D. P., Mazanov, J., Holloway, A., & Bingham, J. (2007a). Limited agreement exists between rationale and practice in athletes’ supplement use for maintenance of health: A retrospective study. Nutritional Journal, 6, 34.
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Petroczi, A., Naughton, D. P., Mazanov, J., Holloway, A., & Bingham, J. (2007b). Performance enhancement with supplements: Incongruence between rationale and practice. Journal of the International Society of Sports Nutrition, 4, 19. Petroczi, A., Naughton, D. P., Pearce, G., Bailey, R., Bloodworth, A., & McNamee, M. (2008). Nutritional supplement use by elite young UK athletes: Fallacies of advice regarding efficacy. Journal of the International Society of Sports Nutrition, 5, 22–30 Sawalha, K. (2013). Death of 14 Youth by stimulants intake in gymnasiums in 2 years [Arabic]. Addustour Newspaper. Retrieved February 7, 2013, from Website: http://www.addustour.com Tahtamouni, L. H. (2013). Use of anabolic androgenic steroids in Jordan: Mini-review. Jordan Journal of Biological Sciences, 6(1), 1–4 Tahtamouni, L. H., Mustafa, N. H., Alfaouri, A., Hassan, I. M., Abdalla, M. Y., & Tasin, S. R. (2008). Prevalence and risk factors for anabolic-androgenic steroid abuse among Jordanian collegiate students and athletes. European Journal of Public Health, 18(6), 661–665 Theorides, T. C. (1997). Sudden death of a healthy college student related to ephedrine toxicity from a Ma-Huang-containing drink. Journal of Clinical Pharmacology, 17, 437–439. Thiblin, I., Lindquist, O., & Rajs, J. (2000). Cause and manner of death among users of anabolic androgenic steroids. Journal of Forensic Sciences, 45, 16–23 Thiblin, I., Runeson, B., & Rajs, J. (1999). Anabolic androgenic steroids and suicide. Annals of Clinical Psychiatry, 11(4), 223–31. Tinsley, J. A., & Watkins, D. D. (1998). Over-the-counter stimulants: Abuse and addiction. Mayo Clinic Proceedings, 73, 977–982 Wazaify, M., Hughes, C. M., & McElnay, J. C. (2006). The implementation of a harm minimisation model for the identification and treatment of over-the-counter drug misuse and abuse in community pharmacies in Northern Ireland. Patient Education and Counselling, 64, 136–141 World Anti-Doping Agency (WADA). World anti-doping code 2009. Retrieved August 2, 2013, from website: http://www. wada-ama.org/en/World-Anti-Doping-Program/Sports-andAnti-Doping-Organizations/The-Code/. World Muaythai Council website. About Muaythai. Retrieved December 8, 2013, from website: http://www.wmcmuaythai. org.
ORIGINAL ARTICLE
Doping in Gymnasiums in Amman: The other side of Prescription and Nonprescription Drug Abuse
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Mayyada Wazaify1 , Ahmad Bdair1 , Kamal Al-Hadidi2 and Jenny Scott3 1
Department of Biopharmaceutics and Clinical Pharmacy, The University of Jordan, Amman, Jordan; Department of Toxicology, The University of Jordan, Amman, Jordan; 3 Department of Pharmacy and Pharmacology, The University of Bath, Bath, United Kingdom 2
Hughes, & McElnay, 2006). Misuse has been defined as the incorrect use of an OTC product for a medical purpose, usually in terms of dosage or duration of use, while OTC drug abuse is the use of an OTC product for a nonmedical purpose (Fleming, McElnay, & Hughes, 2004). Clarifying that, sports-doping can be classified as a form of “OTC drug abuse” (Cooper, 2013). The risks of doping to both athletes and society generally arise from the nature and concentration of the substances used and from the methods adopted (FIP, 2005). The major risks to health include the development of cardiovascular pathologies especially from the use of erythropoietin (EPO) or stimulants like ephedrine (or derivatives), cancers from the use of growth hormone (GH) or anabolic-androgenic steroids (AAS), neurodegenerative symptoms, and behavioral disorders like aggressiveness, mood fluctuations, or suicidal ideation from the use of AAS (National Institute on Drug Abuse, 2006; Thiblin, Runeson, & Rajs, 1999) A new World Anti-Doping Code, created by the World Anti-Doping Agency (WADA), became effective globally in January 2004. The Jordanian Anti-Doping Organization (JADO) was founded in 2007 and in response to the increasing concern about steroid abuse among Jordanian youth, JADO accepted the World Anti-Doping Code late in 2009, committing Jordan to fighting all types of sportsdoping including AAS abuse (Tahtamouni, 2013). To the best of the authors’ knowledge, apart from the prevalence and risk factors of use of AAS in gymnasiums and among collegiate students (Tahtamouni et al., 2008), no studies in Jordan have assessed the use of drugs that can be obtained without a prescription in gymnasiums.
This study investigated the abuse of over-the-counter (OTC) products (e.g. proteins, dietary supplements) and prescription drugs (e.g. hormones) in gymnasiums in Amman by random distribution of a structured questionnaire to 375 gym clients (November 2012–February 2013). Data were analyzed using SPSS for Windows (version 17.0). A total of 31 (8.8%) clients admitted to using 21 products (mentioned 71 times) of anabolic steroids and other hormones (e.g., growth hormone and thyroxine) to increase muscular power at the gym or build muscle mass. Abuse of different prescription and OTC drugs among gymnasium clients is present in Jordan, but current methods for controlling the problem are ineffective. Better methods should be developed. The study’s limitations are noted. Keywords abuse, Amman, anabolic-androgenic steroids, athletes, doping, fitness, gymnasiums, proteins
BACKGROUND
Anecdotal reports in Jordan have shown that people of both genders are consuming increasing amounts of some drugs that can be obtained without prescription (over-thecounter—OTC). One area of particular concern is in relation to the alteration of physique, with drug use often reported in gymnasiums. Such drugs include stimulants which are taken as “fat burners” and some products that are sold as “dietary supplements,” although they may contain some hormones like testosterone. Testosterone may lead to serious adverse health effects including death, especially among athletes (World Anti-Doping Agency (WADA), 2009). When talking about legitimate substances (i.e. OTC and prescription medicines) rather than illicit drugs such as heroin and cocaine, the differentiation between the terms abuse and misuse becomes important (Wazaify,
Aims and Objectives
The aim of this study was to investigate the use of prescription medications and those purchased without prescription (OTC) in terms of prevalence, types, sources of
Address correspondence to: Mayyada Wazaify, Department of Biopharmaceutics and Clinical Pharmacy, The University of Jordan, Amman, Jordan; E-mail: [email protected]
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knowledge, and pattern of use in a sample of clients at gymnasiums in Amman, the capital of Jordan. The study also aimed to detect any significant variables that may have affected such use.
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Methodology
This study took the form of a cross-sectional survey of clients of both genders attending 16 different gymnasiums in Amman, the capital of Jordan. Ethical approval for conducting the study was obtained from the Scientific Research Committee at the Deanship of Academic Research at The University of Jordan (UJ). The data collection was carried out by three research assistants (two males and one female) who we intentionally appointed as pharmacy graduates and regular clients at the gymnasiums. Gymnasiums were visited on different weekdays (including weekends), thereby encountering a wide crosssection of the community. After obtaining the consent of the responsible manager in each gym, all gym clients present at times of data collection were personally approached and invited to complete the questionnaire before or after (never during) their work-out sessions. They were informed that the aim of this study was to survey the number, types, patterns, and reasons for use of substances that they bought without prescription. Participants were assured of anonymity and that data would be kept confidential. Data collection took place between November 2012 and February 2013. Based on the experience of the authors, literature review, and the expected total number of gym members in Amman, a convenient reasonable target sample was calculated to be 200 clients. In order to achieve the target sample, a higher number of questionnaires (n = 375) were distributed. The anonymous questionnaire (available from the authors upon request) consisted of 20 questions (a mix of preformulated and free-text responses) and was piloted on a small sample of gym clients (5% of the target sample size; n = 10); these data were not included in the analysis. The questionnaire was constructed after the conduction of an extensive literature review to ensure content validity. Face validity was also ensured by consulting with experts in the field at UJ and Jordan Food and Drug Administration (JFDA). The questionnaire was written, piloted, and conducted in Arabic, which is the main language in Jordan. Based on the pilot study, a few questions were modified to be clearer, while others were split into multiple questions. The questionnaire was divided into two sections: (a) demographic details, lifestyle, and medical history of the participant and (b) knowledge about and use of anabolic steroids, “fat burners,” dietary supplements, and other prescribed or OTC products. Data were coded and entered into the SPSSC version 17 for analysis. Chi-square test, Fisher exact test, and multivariate analysis were carried out to detect any significant differences between groups (p < .05).
RESULTS
A total of 353 questionnaires (out of 375 distributed) were completed, giving a response rate of 94.1%. The research assistants approached a total of 20 gymnasiums, out of which 16 (80.0%) agreed to participate in the study. The majority of participants were males (n = 267, 75.6%) and between 19 and 32 years of age (n = 248, 70.3%). Tables 1 and 2 summarize the demographic and training details of participants. A total of 29 participants (8.2%) reported regularly using medication bought without prescription (OTC), more than half of which (n = 16, 55.1%, p < .05) were females. On the other hand, 24 participants (6.8%) reported chronically using prescribed medications. Participants with Bachelor of Science or a college or higher TABLE 1. Participant demographic data (n = 353) Characteristic Gender of participants Male Female Agea (years) 12–18 19–25 26–32 33–39 40–46 > 47 Marital status Single Married Other Educational Level BSc. or higher postgraduate degree Diploma High school Less than high school Work nature Full timer Part timer Unemployed Student Monthly Income (JD)a,b No fixed income < 150 151–300 301–500 501—850 851—1000 > 1000 Health problemsa No Yes (hypertension = 12, ligaments and tendons problems = 17, depression = 6, anxiety = 9, dyslipidemia = 8, other 14; kidney, heart, skin problems, or diabetes) a b
Frequency (%) 267 (75.6) 86 (24.4) 32 (9.1) 138 (39.1) 110 (31.2) 42 (11.9) 13 (3.7) 7 (2.0) 286 (81.0) 64 (18.1) 3 (0.9) 288 (81.6) 17 (4.8) 30 (8.5) 16 (4.5) 200 (56.7) 51 (14.4) 28 (7.9) 74 (21.0) 92 (26.1) 4 (1.1) 28 (7.9) 70 (19.8) 66 (18.7) 34 (9.6) 54 (15.3) 283 (80.2) 66 (18.7)
The total does not add up to 353, as some data are missing. 1.00 JOD = 1.41 USD
ABUSE OF OTC AND PRESCRIPTION DRUGS IN GYMNASIUMS IN AMMAN
TABLE 2. Summary of sports practice and training levels among participants
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Characteristic Level of Training Professional and national team member Professional Amateur Last continuous training period < 3 months 3–6 months 6–12 months 1–3 years > 3 years Frequency of weekly training Daily 5–6 days 3–4 days 1–2 days The purpose of training Build up muscles Weight gain Weight loss Fitness Strength and power More than one Main sport Body building Machines, aerobics Swimming Athletics Football Basketball Taekwondo, MMA, Muay thai Other More than one
Frequency (%) 19 (5.4) 78 (21.5) 251 (70.8) 91 (25.8) 62 (17.6) 49 (13.9) 57 (16.1) 94 (26.6) 69 (19.5) 122 (34.6) 128 (36.2) 32 (9.1) 92 (26.1) 12 (3.4) 27 (7.6) 71 (20.1) 26 (7.4) 123 (34.9) 92 (26.1) 51 (14.4) 11 (3.1) 4 (1.1) 4 (1.1) 9 (2.5) 11 (3.1) 7 (2.0) 156 (44.2)
education 10.3% used significantly more medications bought without prescription (OTC) compared with 3.3% for high school and 6.2% for clients with less education than high school (p = .05). There were no statistically significant relationships between the use of OTC drugs and monthly income, work nature, level of training, purpose of training, or main sport (p > .05). With regard to doping products, a total of 130 (36.8%) participants stated that they had used proteins or amino acids as supplements at least once, whereas 75 (21.2%) used other supplements to increase power at the gym, and 42 (11.9%) used fat burners or other weight loss products. Only 31 participants (8.8%) admitted to currently (n = 11, 3.1%) or previously (n = 20, 5.7%) using anabolic steroids. The main method of administration of anabolic steroids was by injection (n = 16, 51.6%), followed by a combined method of oral and parenteral administration (n = 10, 32.3%) and oral consumption (n = 5, 16.1%). The 31 anabolic steroid users mentioned above used a total of 46 doping products (mentioned 150 times), giving an average of 4.8 products per participant (Table 3). A total of 20 clients (64.5%) reported using more than one doping product. These were divided into three categories:
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(a) dietary supplements and vitamins (n = 66, 44.0%), (b) power enhancers/fat burners (n = 13, 8.7%), and (c) anabolic steroids and hormones (n = 71, 47.3%). The most commonly used single product was testosterone (different brand names, Table 3; n = 14, 9.4%) followed by Decadurabolin (Nandrolone decanoate; n = 12, 8.4%). Using a fat burner to lose weight was not statistically correlated with both age and gender. The use of anabolic steroids was not statistically associated with age, marital status, education level, monthly income, purpose of training, or main sport practiced (p > .05). However, the use of anabolic steroids was found to be significantly correlated with level of training, where professional national team members were reported to be more likely to use anabolic steroids previously (22.2% vs. 7.8% professionals nonteam members and 4.2% for amateurs) and currently (6.5% professionals national team members vs. 5.6% for professionals nonteam members and 2.1% for amateurs; p = .02). The main factors that played a statistically significant role in using supplements and amino acids were gender, training level, and frequency in addition to the type of sport, where males (47.7% vs. 3.4% for females), professionals (52.6% vs. 31.3% for amateurs), those who train 5 to 7 days per week (52.5% vs. 9.4% for those who train 1–3 days per week) and Mixed Martial Arts (MMA), body building, and Muay Thai (71%, 66% and 50%), respectively, had statistically significant higher rates of using supplements and amino acids (p = .000). More than a quarter of participants (n = 99, 28.0%) stated that they had never heard of anabolic steroids (or the Arabic equivalent of anabolic steroids; Al-Hormonat Al-Bena’eyah/Al-Steroideyyah). Of the 242 (68.6%) who had heard about anabolic steroids and were asked about their source of knowledge, 30.3% of cases (n = 107), reported more than two sources, most of which were friends (n = 38, 10.2%) followed by the Internet (n = 36, 10.2%) and a coach (n = 23, 6.5%). As expected, significantly more males had heard of anabolic steroids (75.5%) than females (58.3%; p = .003). There was no statistically significant difference with regard to age or educational level (p > .05). The majority of those who knew about anabolic steroids were practicing MMA (100%), Muay Thai (a combat sport from the Muay martial arts of Thailand that uses stand-up striking along with various clinching techniques; World Muaythai Council, 2013) (85.7%), and body building (81.2%), while least likely to know about them were basketball players (12.5%, p = .000). There were no statistically significant differences concerning knowledge of anabolic steroids with either age or educational level (p > .05). The source of information about anabolic steroids was statistically associated with the purpose of training, where a coach was the main source (33%) when the purpose was “strength and power,” the gym (14%) was the source when the purpose was “fitness,” and friends were mainly the source when the purpose was “weight gain” (37%; p = .02). When asked about whether the sought after effects were achieved or not, more than quarter of participants
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TABLE 3. The main doping products (n = 46, mentioned 150 times) reported to be used by anabolic steroid users (n = 31) in the study
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Category Dietary supplements and vitamins∗ Aminos, BCAA∗∗ (n = 2) Super mass gainer Promix Optimum nutrition Whey protein Creatine Animal pak Other: Glutamine (n = 3), Jack 3D (n = 3), Omega 3 (n = 2), B 100, Liver Aid, Multi-pro, Multi-vit, muscle tech, Nitrotech, (n = 1 each) Power enhancers/fat burners NO explode Other: Clenbuterol, Ephedrine, Muscle Tech, GAT, Hydroxycut, Hot Blood, HMB (n = 1 each) Anabolic Steroids/Hormones Testosterone (Testa) Winstrol Stanazol Deca-durabolin Primobolan Dianabol Anapolon Androlic Anavar Trenbolone GH T3 Insulin/ILGF IGF1- LR3 MGF Otherα : Animal stak, Testo pump, animal pump, Parbolan, Thaiger pharma, (n = 1 each)
N (%)
Comments
66 (44.0) 12 (7.4) 9 (6.0) 8 (5.3) 7 (4.6) 6 (3.9) 6 (3.9) 3 (2.0) 16 (10.6)
16 products
13 (8.7) 7 (4.6) 8 (6.7)
9 products Nitric oxide
71 (48.2) 14 (9.4) 7 (4.6) 2 (1.3) 12 (8.4) 8 (5.3) 3 (2.0) 2 (1.3) 2 (1.3) 2 (1.3) 1 (0.6) 5 (3.2) 1 (0.6) 4 (2.7) 2 (1.3) 1 (0.6) 5 (3.2)
21 products Different brand names: Andriol, Sustanon, testosterone Stanozolol Stanozolol Nandrolone decanoate Methonolone acetate Methandrostenolone Oxymetholone Oxymetholone Oxandrolone Trenbolone esters Growth hormone Thyroxine ILGF = Insulin like growth Factor Insulin like growth factor - Long R3 Muscle growth factor
∗
Sixteen clients (4.5%) used AAS and proteins/supplements concomitantly, while 12 (3.4%) used the 3 types of drugs concomitantly. BCAA = Branched Chain Amino Acid. α Different steroid boosters as reported by participants. ∗∗
(n = 96, 27.1%) were positive about this as 33 participants (9.3%) reported losing weight, while 63 participants (17.8%) reported gaining weight depending on the product and the training schedule used. Thirty four (9.6%) participants experienced adverse effects, the majority of which were: tachycardia, palpitations, hypertension, priapism, testicular atrophy, renal, and psychological problems. DISCUSSION
This study was the first to comprehensively survey a sample of gymnasium clients in Amman regarding their use/abuse of medications obtained without prescription, even if originally they were classified as prescription only medications. Since the use of these drugs is for a nonmedical use, as per the aforementioned definitions, this use can be obviously classified as Prescription/OTC drug abuse (Fleming et al., 2004; Wazaify et al., 2006). The current research is an important beginning point for future research in increasing the awareness of the
public regarding the misuse/abuse of such medications as well as playing an important role in the classification/reclassification of scheduled drugs by the JFDA. For example, stricter legislations could be enforced on the classification of testosterone or other hormones to become “controlled” not just “prescription-only medications.” Greater focus should be directed towards the vital role of the pharmacist in this regard, as in many cases, these medications are bought from pharmacies without prescription. Pharmacists have an important role to play in promoting the health benefits of exercise. They can also educate their clients as to the benefits and risks associated with sports-doping. Moreover, pharmacists should remain vigilant to differentiate between the justified use of medication and illegitimate practice and to refuse to supply a medicine when it is clearly intended to be used to illegally improve performance (International Pharmaceutical Federation (FIP), 2005). Clients in this study used more than one source for information about AAS. However, the single main source of information was friends (10.8%) followed by internet
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ABUSE OF OTC AND PRESCRIPTION DRUGS IN GYMNASIUMS IN AMMAN
(10.2%) and a coach (6.5%). This is comparable to what has been reported previously (Petroczi et al., 2008; Tahtamouni et al., 2008). Unlike other studies, where only professional athletes were surveyed and thus most percentages of AAS and other performance enhancing drug (PED) use were higher (Petroczi et al., 2008; Tahtamouni et al., 2008), the selection of all clients entering the door at each gymnasium affected the results of this study as the sample consisted of professional athletes in addition to amateur athletes. For example, a study conducted by Tahtamouni et al. (2008), with 154 bodybuilding athletes in Jordan seeking to measure the extent of AAS abuse, found that 26.0% of the bodybuilders used AAS, whereas in our study the level of AAS use was found to be only 8.8%. Moreover, the level of stacking (the use of more than one substance in order to achieve a synergistic doping effect) in this study was reported to be lower (64.5%) than that (77%) reported by Tahtamouni et al., (2008) for the same aforementioned reason. A “supplement” is an overarching name for vitamins, minerals, herbal remedies, and other substances taken orally and regulated as food (Petroczi et al., 2007a). In some countries like the United Kingdom and the United States, supplements are required to exhibit efficacy before marketing only if manufacturers make medical claims and fall outside food regulations (FDA, 1994; Petroczi et al., 2008). Many dietary supplements contain Ma-Huang, a Chinese herb that contains ephedrine, and had been used widely as a dietary supplement, appetite suppressant, and stimulant. However, it has been linked to a number of serious cases of toxicity, including myocardial infarction (Cockings and Brown, 1997) and death (Charatan, 2003; Theorides, 1997). Consequently, Ma-Huang was banned by the U.S. FDA in February 2004 (Charatan, 2002; Mayo Clinic, 2013). Moreover, ephedrine can be used for clandestine synthesis of amphetamine-like illicit drugs such as methcathinone “CAT,” a highly addictive street drug and methylamphetamine (Anonymous, 1995). This has led the Drug Enforcement Administration (DEA) in the United States to ask manufacturers and pharmacists who sell OTC products containing ephedrine to keep transaction records (Anonymous, 1994). In Jordan after the death of a 22-year-old body builder in 2011 (Boulad, 2013), the Jordan Food and Drug Administration (JFDA) issued new directives prohibiting the circulation or importation of any foods classified as dietary or sport performance enhancing without JFDA licensure (JFDA, 2013). Moreover, these directives prohibit the use of such supplements under the age of 14 years and require the package label to be in clear easy to read Arabic language. During data analysis, some incongruences between the given name of the products and the aim of use were noticed, where some AAS or hormones were mistakenly classified by participants as fat burners or “supplements.” Previous research has highlighted incongruences between choices of supplement use among athletes and reasons for use, as many of their choices were divergent from available information based on scientific evidence (Petroczi, Naughton, Mazanov, Holloway, & Bingham, 2007b; Petroczi et al., 2008).
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With regard to AAS and hormone use, classification in Jordan exists. However, it is not strictly enforced (AlWazaify & Albsoul-Younes, 2005). This limits the ability of inspectors to trace sales and allows some pharmacist to sell such preparations without a prescription, either directly to end users or to coaches and third parties. Moreover, many of these preparations are counterfeit, expired, or smuggled into Jordan to be sold on the black market, a fact that infers additional health risks to consumers (Boulad, 2013; Sawalha, 2013). Almost 10% of participants in this study reported experiencing adverse effects that have been well documented in the literature (Brower, Blow, Eliopulos, & Bresesford, 1989; Gruber & Pope, 2000; Thiblin, Lindquist, & Rajs, 2000). The majority of such effects are mainly caused by AAS and hormones, especially that such use, in most cases, lacks medical supervision, administration occurs by someone who probably is not trained to do so (e.g. a coach or a colleague), injection occurs in the least hygienic ways, and supraphysiological doses are used to achieve faster results (Bhasin et al., 1996; Tinsley & Watkins, 1998). In addition, such practices may sometimes serve as a gateway to narcotic substance use (Arvary & Pope, 2000; Garevik & Rane, 2010; Kanayama, Gruber, Pope, Borowiecki, & Hudson, 2001). However, this theory has not yet been substantiated clinically or sociologically. The limitations of this study were mainly, as in other surveys, the opportunity for respondents to give false answers in order to either please the interviewer (i.e. social desirability bias) or in fear of consequences. Subjects in this study were approached as they entered the gymnasium’s door, resulting in a lack of rigor in the method of recruitment. Although the study was conducted in the largest urban center in Jordan, our findings may not be generalizable to the remainder of the country. CONCLUSIONS
The results of this study indicate that there is a problem with prescription and OTC drug abuse among clients attending gymnasiums in Amman. The cornerstone to limit the abuse of such drugs is mainly application of the WADA regulations that aim to eliminate performance enhancing drug use among athletes, restricting the sale of prescription drugs to pharmacies only and enforcement of this by Ministry of Health (MOH) inspectors in collaboration with JFDA. Greater efforts should be directed toward raising the awareness of young people and coaches regarding the adverse effects of using such drugs without medical supervision. Future qualitative research into the motivations, attitudes, and experiences of abusers is needed, in addition to studies focusing on methods of identification of abuse and prevention. Declaration of Interest
The authors report no conflicts of interest of any kind related to the work of this research paper.
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THE AUTHORS Ahmad Bdair holds a B.Sc. degree of pharmacy, university of Jordan/Amman-Jordan (2011). He has been working in the field of pharmaceutical sales and marketing since 2011 in the area of thrombosis for one of the famous pharmaceutical companies in the area of anticoagulants. In addition, Ahmad has also been working as a research assistant with Dr.M.Wazaify at the University of Jordan. His research interests are mainly in the field of doping, prevention of abuse and misuse of medications in sports. Dr. Kamal Al-Hadidi is a Professor (Clinical and forensic toxicology of doping in sport) in the Faculty of Medicine, The University of Jordan. He has held various positions including as Member—Health and Medical Research Committee—World Anti-Doping Agency (WADA), President of Jordan and West Asian Anti-Doping Organization, Member—Medical and Anti-Doping Committee—Olympic Council of Asia (OCA), Member—Jordan Sport Medicine Federation, and Chairman—Asian Anti-Doping Fund Committee.
of medicines and the prevention of prescription and OTC drug misuse/abuse. Moreover, she is interested in adopting “Harm Reduction” model in identification and management of OTC and prescription drug misuse and abuse.
GLOSSARY
Abuse: “to make a bad use of.” To use a drug for a nonmedical reason, either to feel “high,” lose/gain weight, or increase muscular power or stamina during exercise (Fleming et al., 2004; Wazaify et al., 2006). Doping: The use of substances or processes which aim either to modify artificially the capabilities of a person exercising and athletic activity, regardless of the discipline or conditions in which the activity is conducted, or to mask the use of substances or processes having this property (WADA, 2009). Misuse: “to use wrongly.” The use of a drug for a legitimate medical reason, yet, misapply it either in terms of dosage or duration of use (Fleming et al., 2004; Wazaify et al., 2006) Over-The-Counter (OTC) drugs: A general term used to describe products that can be bought by the public without a doctor’s prescription, either at pharmacies or other retail outlets (Krinsky et al., 2012). Stacking: The use of more than one substance in order to achieve a synergistic doping effect (Tahtamouni et al., 2008).
REFERENCES Dr. Jenny Scott is Senior Lecturer in Pharmacy Practice, University of Bath since 2007 and was previously Lecturer in Pharmacy Practice University of Bath. She completed her PhD in Pharmacy Practice and Drug Misuse from The Robert Gordon University, Aberdeen, in 2000. She also holds a Certificate in Independent Prescribing (2008), University of Bath. She is also part-time Nonmedical Prescriber since 2010 and Lead Pharmacist since 2013 at Turning Point, England. Dr. Mayyada Wazaify is Associate Professor of Pharmacy Practice at the Faculty of Pharmacy, The University of Jordan since February 2004. She has a PhD in Pharmacy Practice (December 2003) from Queen’s University of Belfast, UK, in the area of “Appropriate Use of Over-The-Counter (OTC) drugs.” She has published more than 27 papers targeting the promotion of appropriate use
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