In 2014, Sagoe and colleagues estimated, in a systematic review, that the global lifetime prevalence of AAS use was as high as 3.3% in the general population, but may be as high as 6.4% for males and 1.6% for females . We demonstrate that foreign shipments of fake AAS over the past years may have increased significantly, thus the negative consequences on public health may be substantial. In addition, recreational drugs are also commonly consumed. This is especially concerning when those substances are injected into the muscle as it poses a risk of forming abscesses in the muscle and skin necrosis 36, 61. Products from clandestine laboratories do not go through microbiological quality control, which can lead to sterility issues and microbiological contamination of injectables. This can, taken unknowingly, lead to substantial drug-related side effects. To further determine the proportions of fake AAS found on the black market, we conducted a systematic literature review and meta-analysis of analytical test results for those substances within the published literature. The very wide range in proportions of counterfeit or substandard black market AAS puts the user in a situation of unpredictable uncertainty. This also may have led either to over or under estimation of certain proportions of the estimates of "substandard" or "counterfeit" anabolic androgenic steroids and their subclassifications and sub-analyses. We provide evidence that AAS are more likely to be under-concentrated than over-concentrated if they are of substandard quality. In the case of mislabeled AAS acquired on the black market, it is currently not exactly known what is consumed by the user. In this systematic review we demonstrate that the real composition, the type of production, concentration, quantity, quality, and purity are often not declared on the label, and labels are even misleading. Different anabolic steroids come with compound or class-specific and unspecific adverse events. We further show a limited geographical scope of included studies, with all studies being from countries in Europe or Brazil. Underground laboratories emerged both locally and in countries with lax legal regulations and it is described that an 'anabolic steroid tourism' and large networks of online resellers emerged, simplifying the illegal acquisition of anabolic steroids . Injectable testosterone, synthetic AAS, other hormones and adjunctive therapies can easily be purchased over the internet and are delivered to a consumer’s home without prescription 4, 6, 8. Due to lack of reporting, precise prevalence and demographic information on the use of these substances is challenging . Historically, the majority of AAS users were professional or competitive athletes, but nowadays survey data has revealed that over 75% of AAS users are non-competitive bodybuilders or athletes, who are mostly motivated by cosmetic benefits over performance enhancement from AAS use 4, 6, 8–13. AAS belong to the broader group of image and performance enhancing drugs (IPEDs) and are widely used as a convenient and easy method to improve body image and sport performance goals . The shift from pharmacies to deregulated underground online sites and clandestine underground laboratories occurred after the United States enacted the Anabolic Steroid Control Act in the 1990s. AAS were the most dominant group within all analyzed products, and they were almost exclusively analyzed within the WADA class S1. Some authors assessed visual inspection of packaging and detection of counterfeiting rate with contradicting results. Funnel plot for counterfeit AAS (left), funnel plot for substandard AAS (right). In some studies, the contained active ingredients in "under-concentrated" preparations was much lower than 50% of that indicated (e.g. 0.5–1.5% , 9% or 16% ) if quantitative data was available. Firstly, defined ranges of declared labels could vary massively between articles, had a quantitative analysis been performed, with defined ranges between 50–200% , 80–130% , 80–120% or 90–110% . For most original substances, we were able to extract qualitatively analyzed data (accurately labeled) and only for 37% were we able to extract qualitatively and quantitatively analyzed data (accurately labeled and concentration within range as declared on the label). The full extraction form can be found in Supplementary file 2; the summary form used for data analysis can be found in Supplementary file 3. Importantly, whenever anabolic agents were analyzed with other classes of substances, anabolic agents made the highest proportion of analyzed classes. In addition, other countries from this region (Switzerland, France, Italy, United Kingdom, Czech Republic and Slovakia, Austria, and Belgium) are represented in our list of included studies. The country with the highest number of included studies in this region is Germany with a total of three studies. The geographic scope of the included studies is limited to two world regions, where 37% and 63% respectively were conducted, and these studies reported findings from the Americas (AMR) and Europe (EUR). The detailed data extraction and data analysis plan have been published elsewhere . Ever since, recreational drug testing is being conducted in a growing number of countries. Recreational drug testing services became available in the 1990s . Another strategy could entail the introduction of specialized drug checking services for this user community. Therefore, it is of great importance that clinicians, politicians and law-makers are aware of this considerable individual and public health threat, given the significant negative long-term health impact of AAS misuse and exposure to fake AAS. Furthermore, due to punitive laws, stigma, and inexperience of health care professionals, this user population is widely unaccessed. Furthermore, first time use of anabolic agents has already been described in high-school age adolescents . Updated numbers are urgently needed, as the popularity of these substances is described to have increased, i.e. in the UK it is estimated that AAS popularity has doubled within the 10 years to 2018 . This is amplified by unintentional intake of over-concentrated AAS, which can come with several severe health risks. Unknowingly taking the wrong formulation can lead to unexpected side effects, especially when taken over a longer period than intended or in combination with other substances. Different non-scientific and anecdotal patterns and duration of use are described in literature with the goal of minimizing side effects or maximizing the drug effects of AAS 1, 15.
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