The buff blokes at the needle exchange
The typical picture of someone accessing a needle and syringe program involves illicit drug use, marginalisation, and proximity to the health and criminal justice systems. It is a picture that was accurate enough for long enough that it has become embedded in how these services are designed, funded, and staffed.
That picture is increasingly incomplete.
Walk into a needle exchange in any Australian capital city and you'll find a growing proportion of clients who look nothing like the traditional image: physically large, employed, often working in the trades or construction, injecting testosterone, human growth hormone, peptides, or a stack of anabolic-androgenic steroids. They're not there because they're in crisis. They're there because they need clean needles.
And the AOD field , at the policy level , is quietly in an argument about what to do with them.
What the numbers show
The Kirby Institute's 2024 NSP National Minimum Data Collection report is the most current national picture available. It shows that anabolic agents and selected hormones , predominantly anabolic steroids , accounted for 12% of drugs injected on the snapshot day nationally. That puts PIEDs (performance and image enhancing drugs) in third place behind stimulants (48%) and analgesics including heroin and opioids (29%).
The Australian NSP Survey found that PIEDs were the third most commonly reported drug last injected nationally in 2022, and the rate of injecting PIEDs increased significantly from 4% in 2018 to 7% in 2022. Earlier data shows the trend has been building for longer: between 1995 and 2010, 1–2% of NSP users reported steroids as the last drug they injected. By 2011 this had risen to 5%, and by 2012 to 7%.
This is not a niche phenomenon. One in eight people accessing Australian needle exchanges on a typical day is there for PIED-related injecting equipment. The services were not designed for them, the workers are often not trained for them, and the policy framework that governs these services was written with a different population in mind.
What PIEDs are
The term PIEDs , performance and image enhancing drugs , covers a broad and growing category:
Anabolic-androgenic steroids (AAS): synthetic derivatives of testosterone, used to increase muscle mass and strength. Testosterone itself (in various ester forms , enanthate, cypionate, propionate) is the most commonly used. Others include nandrolone, stanozolol, trenbolone, and boldenone.
Peptide hormones and growth factors: Human growth hormone (HGH), insulin-like growth factor (IGF-1), and a range of peptides (BPC-157, TB-500, CJC-1295, ipamorelin) used to stimulate growth hormone release, accelerate recovery, or promote fat loss.
SARMs (Selective Androgen Receptor Modulators): oral compounds designed to produce anabolic effects with fewer androgenic side effects than traditional steroids. Ostarine, RAD-140, LGD-4033. The long-term health effects are largely unknown.
Other compounds: Clenbuterol (a bronchodilator used for fat loss), melanotan II (a tanning peptide also used for erectile function), diuretics for competition cutting, and various ancillary drugs used to manage side effects of the primary compounds (aromatase inhibitors, SERMs, HCG).
The injecting behaviour varies significantly. Some compounds require intramuscular injection; others are subcutaneous. Frequency ranges from once-weekly testosterone injections to daily peptide administration. The technical knowledge required to do this safely , correct needle gauge and length for oil-based versus water-based compounds, injection site rotation, sterile technique , is substantial and largely self-taught from online communities.
Who is using
A cross-sectional survey of 267 men who use PIEDs in Australia found that most participants sourced injecting equipment from health professionals and PIEDs from their social networks, with AAS information primarily from the internet and media.
The demographic profile differs significantly from the traditional NSP client population. PIED users are predominantly male, typically 20–40 years old, and often employed in physically demanding occupations , construction, mining, agriculture, security , where physical size and strength are professionally and culturally valued. They are also present in gyms, in fitness communities, and increasingly across social demographics that would previously have had no contact with injectable substances.
The dramatic increase in steroids detected at Australia's borders and the number of users accessing needle and syringe programs seem to indicate that population studies showing relatively low prevalence of PIED use may be underestimates.
Critically, most PIED users do not identify as drug users in any meaningful sense. They do not see themselves as part of the population that needle exchanges were created to serve. They're not using in a way that resembles the patterns associated with heroin or methamphetamine. They have jobs. They have mortgages. They're at the gym five mornings a week. The cognitive distance between their self-image and the word "drug user" is significant , and it affects where they go for information, whether they disclose to healthcare providers, and whether they engage with harm reduction services at all.
The policy dilemma
The number of people who inject PIEDs attending Australian NSPs has increased, posing public policy dilemmas for NSP service provision similar to those seen elsewhere , with a six-fold increase in new PIED clients in British NSPs noted between 1991 and 2001.
The argument at the policy level has several dimensions.
The harm reduction case for inclusion is straightforward. PIED injecting carries real blood-borne virus transmission risk. Needle sharing, reuse, and poor sterile technique are documented in the PIED-using population, particularly among newer and younger users. HIV and hepatitis C transmission through PIED injecting, while less prevalent than in opioid-using populations, is not zero. The purpose of NSPs , to prevent blood-borne virus transmission through provision of sterile equipment , applies directly.
The resource and access argument is more contested. NSPs are funded to serve people who inject illicit drugs. PIED users represent a different kind of need: they are not typically in crisis, not typically marginalised, and not typically in need of the wraparound support services that NSPs provide alongside needle provision. Whether resources designed for one population should be redirected to serve another , particularly a population that is often more financially capable of accessing alternatives , is a genuine resource allocation question.
The workforce issue is real. Research into the experiences of NSP workers found that workers do not feel well informed about the substances PIED users are injecting, were unsure what equipment PIED users required, and perceived PIED users to differ from other client groups in ways that impacted rapport. An NSP worker trained in heroin and methamphetamine harm reduction is not automatically equipped to advise on intramuscular injection technique for oil-based testosterone preparations, or on the cardiovascular risks of trenbolone stacking.
The health risks that aren't being addressed
The blood-borne virus risk is the focus of the NSP debate, but it's not the only health concern.
Cardiovascular. Anabolic steroids have well-documented adverse effects on lipid profiles , HDL (good cholesterol) is suppressed, LDL elevated , and on left ventricular hypertrophy. Long-term users show higher rates of cardiomyopathy. These risks are dose-dependent and cumulative. They are also largely invisible until they're not , the user who feels physically excellent at 28 may have cardiovascular consequences that manifest at 45.
Endocrine disruption. Exogenous testosterone suppresses the body's own testosterone production via the hypothalamic-pituitary-gonadal axis. Testosterone levels may remain suppressed for months to years after stopping, depending on duration and dose of use. Many long-term users experience significant hypogonadism if they attempt to stop. This is not widely understood when people begin using.
Psychological effects. The relationship between anabolic steroids and mood is complex. Aggression during use, mood disturbance during cessation, and a subset of users who develop what has been described as muscle dysmorphia , a form of body dysmorphic disorder characterised by the perception that one is insufficiently muscular , are documented in the literature. Dependence on the physical and psychological effects of PIEDs is increasingly recognised.
Unknown compounds. SARMs and many peptides being used in Australia are research chemicals that have never completed clinical trials in humans. The long-term effects are genuinely unknown. The unregulated market means compound identity, purity, and dose are not guaranteed.
What this means practically
For the person using PIEDs, the practical implication of all of this is that they're navigating a significant health picture largely without clinical support. Most GPs are not trained in PIED pharmacology. Most AOD services weren't designed for this population. The information environment is predominantly online communities with commercial incentives and variable accuracy.
There is an urgent need to reconsider steroid use as a public health issue rather than a criminal justice concern , and to improve prevention and harm reduction strategies rather than merely further criminalising users.
The same principle that underpins needle exchange access applies to self-monitoring: people who are injecting substances, whatever those substances are, benefit from accurate information about what they're doing and what it costs them. The PIED-using population is, if anything, more receptive to data-driven self-knowledge than the traditional AOD client , they are already, in many cases, tracking macros, monitoring blood tests, and optimising variables in their use. The framework of systematic self-monitoring is familiar to them; it just hasn't been applied to the full picture of their health and substance use.
ayodee now includes a dedicated section for PIEDs , steroids, testosterone, peptides, SARMs, and related compounds , alongside mood, sleep, and wellbeing tracking. Anonymous, no email required. Free to start.