Drug use is usually portrayed as a hedonistic pursuit of pleasure, whether being the use of thought-expanding hallucinogens, the excitement of stimulants or the euphoria of opiates. However, there are many drugs that are being primarily used for their functional purposes rather than for any instant gratification. These substances, termed ‘Human Enhancement Drugs”, represent a new challenge to public health and reflect a society that in recent years has shifted from an attitude of “a pill for every ill” to a drive for “better than well”. While this evolution of medicine is a topic which has readily been discussed by ethicists and philosophers (and has been the fertile ground for novelists and film makers) it has been largely ignored by drug professionals and public health in general. The drugs that are (at least in part) an exception to this are the drugs used to enhance the structure and function of skeletal muscle. By far the best known of these are the anabolic steroids (and to lesser extent, growth hormone). These are well known to many drug professionals as they are now the main drugs of use amongst clients of many needle and syringe programmes across the United Kingdom. They are also well known to the legislators, having been brought under the Misuse of Drugs Act in 1996 and subject to several amendments, most recently on the 23rd April 2012.

Anabolic steroid users will usually take a variety of other drugs, some for their anabolic properties and others to prevent or minimise side effects. In recent years, an array of new drugs which are taken to stimulate the secretion of growth hormone (including CJC-1295, GHRP-6 and GHRP-2) have been added to the menu. It is difficult to predict the impact of further drug developments such as the selective androgen receptor modulators (SARMs).

The anabolic steroids (and associated drugs) are just one group amongst a diverse range of substances that will sculpt the body, focus the mind or hold back the ravages of time. For the purposes of evidence review we have separated the human enhancement drugs into six categories of function.

• Structure and function of muscle, such as anabolic steroids to get a ‘six pack’ or ‘bulk up’, or growth hormone to ‘get toned and trim’
• Weight loss, such as rimonabant or sibutramine to suppress the appetite, or DNP to ‘burn fat’
• Cosmetic appearance of the skin and hair, such as mercury–containing creams for ‘healthy, lighter, more radiant skin’, or Melanotan II for that ‘holiday tan’
• Sexual behaviour and function, such as sildenafil to ‘get a better, stronger erection’ and bremelanotide to ‘get in the mood’
• Cognitive function, such as methylphenidate and modafinil to ‘help study’
• Mood and social behaviours, such as paroxetine to be ‘better than well’.

While these drugs have diverse pharmacological effects, they have several things in common with each other and with the wider grouping of illicit drugs:

1. They are easily obtained
2. There is no guarantee as to the quality or safety of the product when purchased on the illicit market

Thanks to technological advances and improved communications these products can be delivered overnight at the mere click of a mouse. This ease of access, without recourse to the traditional illicit drugs market, makes the purchase and use of these much more attractive and accessible to sections of the population. Obviously there are overlaps between groups of drugs, with many being used for different or multiple reasons. Public health has a considerable challenge in responding to an advertising strategy that promotes a drug that can cause weight loss, provide a sun tan and enhance sexual performance. Clearly, a ‘just say no’ approach will have limited impact in deterring many from being attracted to this particular drug.

It is important that drug workers remain aware of new and emerging substances, including the use of enhancement drugs. It is difficult to assess which of the substances will result in individuals presenting to drugs services or health services in general, whether that be at primary care services, accident and emergency, or any other health setting. In 2007/8, needle and syringe programmes first started reporting melanotan use amongst its clients. There was little information about the drug, its risks or relevant advice that could be provided to users of this drug. Despite the relatively recent identification of human enhancement drugs as a public health issue, the toll of health harms is growing and the potential for the future detrimental impact on health becoming clearer. ‘Human enhancement drugs: the emerging challenges to public health’ provides the first systematic and comprehensive exploration of this issue.