Spotlight on… Performance- and image-enhancing drugs

Close up of a needle of a syringe against pile of vials

What are performance- and image-enhancing drugs?

Performance- and image-enhancing drugs (PIEDs) are substances used to improve or change a person’s physical appearance, and/or increase their strength and sporting prowess. PIEDs form part of a wider category of substances, often referred to as human enhancement drugs (HEDs). HEDs also include substances taken to enhance cognitive functioning, mood and social behaviours, as well as sexual behaviour and performance.

What is happening in Europe?

The use of PIEDs is currently predominantly found among professional and amateur athletes, including fitness and bodybuilding enthusiasts and other recreational gym users, but has also been identified among groups of men who have sex with men, and people in prison.

Information on the use of PIEDs is limited and mainly related to the use of anabolic androgenic steroids (AAS). Lifetime prevalence of AAS use has been estimated as 3.8% in Europe, amongst the highest levels globally, and there are some data to suggest the development of dependence in some individuals. AAS are administered via various means, but are predominantly taken orally or via intramuscular injection, with the latter method raising concerns about the spread of blood-borne viruses.

Users of AAS often combine them with other substances to combat their adverse effects. Illicit drug use (particularly cocaine) is also common amongst some populations using AAS. In addition, high levels of AAS use among drug treatment clients have been identified as a significant issue in some countries.

What problems are associated with its use?

In Europe there is a general paucity of information on the use of PIEDs and their potential related harms. Table 1 summarises some of the documented problems associated with their use.

Table 1. Examples of harms associated with the main types of performance- and image-enhancement drugs

Expected benefit

Type of PIED

Harms associated with its use

Enhanced Musculature

Anabolic androgenic steroids (AAS)

Cardiomyopathy, polycythaemia, hypertension, endocrine abnormalities – hypogonadism, gynaecomastia (males), changes in genitalia, deepening of the voice, increased hair (women), depression, dependence, aggression, mania, hepatic abnormalities, cognitive impairment, renal damage, immunosuppression, severe acne.

Human growth hormones

Cardiomyopathy, hypertension, acromegaly - endocrine disorders (diabetes), changes in bone structure, thickening of skin, potential increased risk/acceleration of cancers.

Human chorionic gonadotrophin (HCG)

Harms similar to those associated with AAS; potential increased risk/acceleration of certain types of cancers.

Weight loss


Myocardial infarction or cerebrovascular events (in those with underlying cardiovascular disease).


Cardiovascular effects (hypertrophy, hypertension, tachycardia, atrial fibrillation), anxiety.

Dinotrophenol (DNP)

Metabolic poison, fatalities due to hyperthermia, cataracts.

Changed or improved skin and hair

Melanotan II

Nausea and vomiting, abnormal pigmentation, spontaneous erections, hypertension.

Responding to the use of PIEDs

There is limited data on the available responses to problems associated with PIED use across Europe.

PIEDs are subject to different types of regulation among EU countries, including legal controls, and while several Member States recognise the importance of having effective strategies to prevent PIED use in recreational sport, studies examining the effects of such programmes are rare.

Examples of innovative practice include 100% Pure Hard Training, a Swedish community-based programme aimed at reducing PIED use among recreational gym goers, and the international Erasmus+ Sport project – Doping E-learning Tools (DELTS) – aimed at improving prevention materials and health education in the field of PIEDs. In Norway, to complement the structured drug treatment system and overcome barriers to service engagement, a dedicated telephone support service has been developed together with purposeful marketing through social media.

The role of the primary care physician in the treatment and care of people who use PIEDs has been highlighted, including in terms of the identification, assessment and treatment of AAS use and the management of AAS-related problems. People who use PIEDs may be less likely to present for treatment and harm reduction services because they tend not to identify themselves as drug users. Recent work has called for multi-layered interventions that recognise the variations and complexities of PIED use in multiple settings, targeting relevant age groups and levels and types of risk.

Some countries provide guidance on the provision of needles and syringes for people who inject PIEDs, and there are also numerous case reports of treatment for the adverse physical or psychological effects of PIED use. However, again, there is scant evidence of the effectiveness of these programmes.

Implications for the future

Evidence is urgently required to support the development of effective services for people who use performance- and image-enhancing drugs. Also needed are evidence-based guidance and interventions to respond to users in a range of healthcare settings. Furthermore, policies must be developed on the basis of rigorous scientific analysis in order to tackle the current environment that encourages PIED use.

New drugs continue to (re-)emerge and research is needed to better understand the variety of drugs that are grouped under the umbrella term of PIEDs. People who use PIEDs have been at the forefront of the introduction (or re-introduction) of a number of drugs which have then spread to the wider population, and, as such, PIEDs users may be considered a sentinel population in terms of future drug trends.