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Steady levels of anabolic steroid misuse within the general population can have implications for risk management
infocusIssue No. 62, December 2013
Mortality and morbidity risks associated with substance misuse have long been recognised. UK protection providers attempt to mitigate these risks by identifying lives with a current or former history of substance misuse during the risk selection process. This enables them to apply substandard ratings or decline cover altogether in more serious cases.
The process of identifying at-risk individuals generally begins with a positive disclosure in response to questions about substance use within application forms or question sets of on-line point of sale solutions. Such questions typically focus on recreational drugs, in particular psychoactive drugs, such as cannabis, ecstasy, heroin and cocaine.
One class of drug seldom asked about is anabolic androgenic steroids. This is despite steady levels of use among young-to-middle aged males: precisely the demographic most likely to hold protection insurance, as our current consumer research shows.i
We recommend that anabolic steroids, as they are colloquially known, should be included alongside other drug examples in application forms and online question sets. This practice should assist in identifying more lives who engage in non-prescribed use that don’t necessarily regard themselves as drug misusers.
Legitimate medical applicationAnabolic steroids are a group of substances that includes the male sex hormone testosterone along with numerous synthetic
derivatives. Their primary action is to build muscle or promote androgenic effects (masculine characteristics). They may be administered orally, parenterally (i.e. via intramuscular or subcutaneous injections) or in the form of topical gels or patches.
In the UK their clinical utility has included the treatment of cachexia (wasting syndrome, often associated with chronic disease), delayed puberty, male hypogonadism (diminished functional activity of the testes) and, to a lesser extent, suppression of lactation, loss of libido following pregnancy or menopause, metastatic breast cancer, osteoporosis, endometriosis and hereditary angioedema (an inherited blood disorder), as well as certain anaemias and growth disorders. Therapeutic doses are often designed to replace or mimic normal physiological testosterone levels.
Medically prescribed anabolic steroids, however, account for only a small proportion of use. Far greater use, or misuse, is reported amongst recreational body builders, amateur sportsmen, body-conscious youths and young adults, and within certain occupations.
Changing user profileIn recent years there has been a significant epidemiological shift in the type of individuals using non-prescribed anabolic steroids. Their use is no longer confined to elite professional athletes and people regularly involved in competitive sports. There has been a marked increase in use by those simply
When the Gain is Toxic
2 | Hannover Re UK Life Branch
seeking to enhance their personal appearance. It has been reported that as many as 15-30% of current users do not participate in any regular sport.ii
Such ‘cosmetic doping’ may be linked to media-driven shifts in cultural perceptions of masculine and feminine stereotypes. These may also have contributed to the emergence of a form of body dysmorphia. An obsessive focus on muscular appearance (muscle dysmorphia) can deflect conscious attention from other psychological issues and underlying conflicts.
Anecdotally, it seems anabolic steroid misuse is also more common in occupations that involve exposure to some level of hostility, where an increased physical presence can be advantageous. There is some evidence of anabolic steroid misuse among females, but markedly less so than among males.
Accurate statistics on anabolic steroid use in the UK are difficult to acquire. Those estimates we do have for annual incidence and prevalence are probably on the low side. Anabolic steroids have Class C status under the Misuse of Drugs Act, which means it is illegal to manufacture (without an appropriate licence), supply or source anabolic steroids via certain routes. This would obviously tend to encourage under-reporting.
In 2012 the National Institute for Health and Care Excellence
Contents When the Gain is Toxic ............................................... 1 Getting to the Heart of Consumers............................. 5 Life 2013 Conference and Exhibition ......................... 8
We hope you enjoy infocus and we welcome your feedback, please forward comments to Kirsteen Grant at [email protected].
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(NICE) said it believed that up to 70,000 people aged between 16 and 59 in England and Wales were thought to have injected anabolic steroids. The total number of UK users (once we factor in other means of administering the drug and other parts of the country) is presumably much higher – even without taking account of users’ reluctance to disclose for fear of facing questions about access and supply.
AdministrationNon-prescribed use often involves increasing doses over a number of weeks or months, known as ‘build-up cycles’, followed by intervals of complete abstinence. These intervals are designed to minimise side-effects and allow some downtime for the receptors to which steroids bind. Cycles may also include ‘stacking’, where more than one steroid is used to avoid acquiring tolerance, and ‘pyramiding’, which involves a regimen of escalating anabolic steroid dosing. Non-prescribed doses can sometimes be 10 to 100 times greater than therapeutic doses.
Adverse effectsNot surprisingly, we have limited data on lives with a history of medically unsupervised anabolic steroid use, and direct evidence linking anabolic steroid misuse to a wide range of complications has yet to be definitively established. However, numerous side effects have been reported. Many of these are dose-related and reversible once drug use has ceased. Unfavourable manifestations reportedly range from acne and male pattern baldness to isolated stroke, myocardial infarction and cardiomyopathy.
Detrimental effects have been noted in, but are not limited to, the following systems; cardiovascular, hepatic, reproductive, urinary, endocrine, musculo-skeletal, mental health and dermatological. Evidence of anabolic steroid related complications or side effects at application, particularly following a period of discontinuance, should be regarded cautiously during the risk assessment process as many complaints should resolve within months.
Risk management considerationsIdentifying lives with a history of previous or current anabolic steroid misuse usually relies on individual disclosure as formerly mentioned. There are, however, certain physical stigmata, signs and laboratory results that may hint at a history
Hannover Re UK Life Branch | 3
of anabolic steroid misuse. Most physical findings, however, are non-specific or can be attributed to a variety of causes. Table 1 illustrates physical findings that may be suggestive of anabolic steroid use when recorded in insurance medical or paramedical reports or in general physician’s statements.
Similarly, abnormal lab results on standard insurance blood tests or abnormal electrocardiograms which could suggest anabolic steroid misuse may also be attributed to other aetiologies.
Blood test results which might indicate anabolic steroid misuse may include elevated muscle enzymes such as ALT, AST, LDH and CK, lipid derangements such as increased LDL values and decreased HDL values, increased liver function tests and increased red blood cell count, haemoglobin, haematocrit on full blood count testing. Ventricular hypertrophy on electrocardiograms could also suggest anabolic steroid use.
Presentation of one or more of these findings, particularly among young males, should give us pause to consider the possibility of anabolic steroid misuse, but can never be more than suggestive.
Individuals who misuse anabolic steroids rarely seek professional medical help for minor associated problems. They may also not regard themselves as drug misusers and frequently assume their doctor will know little about anabolic steroids. This suggests that GP reports obtained during the risk selection process may sometimes offer little or nothing of relevance.
Where the route of administration involves injected anabolic steroids, there are additional risk factors to consider. These include the development of bacterial abscesses, septic arthritis, septicaemia and transmissible infections such as HIV and viral hepatitis. Prudent practice would suggest acquiring HIV and hepatitis B & C serology alongside any history of injected anabolic steroids. Some commentators also see the use of non-prescribed anabolic steroids as a potential gateway to other forms of substance misuse.
A Swedish study by Skarberg and Co. published in 2009 examined the association between anabolic steroid misuse and polysubstance dependence, and reported that many of the subjects interviewed also took other drugs of abuse. Eighty-one percent had used cannabis; 78% had used amphetamines, and 25% heroin. Around 50% also drank alcohol to hazardous or harmful levels.iv The study also found that anabolic steroids were frequently combined with other hormones, pharmaceuticals and dietary supplements.
Despite the small sample size of this study, and an apparent selection bias in the recruitment of subjects, we may conclude that some anabolic steroid misusers also use other drugs of abuse, pharmaceuticals and dietary supplements. Users may take these to consolidate the effects of steroids, to manage unwanted side-effects, to avoid detection via testing or to improve sleep. In some cases their use may simply be symptomatic of increased risk taking behaviour.
Supplementary questions or questionnaires requesting,
Table 1: Physical Findings Suggestive of Anabolic-Androgenic Steroid Misuse
Physical Findings
Vital signs Increased blood pressure (relatively uncommon)
Skin Acne, needle marks in large muscles, male pattern baldness, hirsutism – excess body hair (especially in women), jaundice with liver disease and stretch marks
Head and Neck Jaundice eyes with liver disease; deepening of the voice in women
Chest Gynaecomastia in men; breast tissue atrophy in women
Abdominal Right upper quadrant tenderness and hepatomegaly (enlarged liver) with liver disease
Genitourinary Testicular atrophy in males
Musculoskeletal Generalised muscle hypertrophy with disproportionately large upper body mass (especially neck, shoulders, arms and chest)
Extremities Oedema due to water retention for which diuretics may be used
(Brower, 2002)iii
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among other details, evidence of polysubstance use with any disclosure of anabolic steroid misuse may be useful during the risk selection process.
A further risk assessment consideration is the potential role of anabolic steroids in masking or concealing undisclosed or occult illnesses. In such cases it can be virtually impossible, even with the benefit of GP’s reports, for an underwriter to recognise when an applicant is going to extraordinary lengths to disguise an underlying illness.
Psychological impacts have also been reported in some of those misusing anabolic steroids, but causal links have yet to be established. Reports of hyperactivity, anger, irritability, anxiety, mania and hypomania are all noted in the literature.
Anabolic Steroids may be used to mask or conceal undisclosed or occult illnesses
The term ‘roid rage’, first coined in the 1980s, describes psychotic-type episodes, often involving violence, allegedly resulting from the influence of anabolic steroid misuse. Homicidal behaviour and, more commonly, depressive syndromes with a risk of suicide have also been documented. Where a history of acute mental health issues is disclosed on application, particularly by young adult males with no identified precipitants, it would certainly not be unreasonable to consider possible anabolic steroid misuse.
SummaryThere are currently no defined treatment protocols for anabolic steroid misuse. Abstinence is the ultimate treatment goal, and we would recommend considering insurance terms following a period of discontinuance to avoid potential user relapse, possible withdrawal syndrome, and resolution of the many associated side effects.
At HR UK, we will consider standard rates for life and critical illness following a minimum period of 18 months abstinence
with no significant adverse side-effects. Standard rates are also possible for disablement benefits after a period of 24 months abstinence, again with no significant adverse side-effects.
Long-term outlook for anabolic steroid users depends on numerous variables including current versus past use, route of administration, prescribed versus non-prescribed use, concomitant polysubstance use, and development of complications or side effects.
UK protection providers may wish to give some thought to including anabolic steroids as an example drug type as part of recreational drug questions in application forms and on-line point of sale solutions.
If you would like to know more about this topic, please contact us at [email protected].
Craig ButlerManager Underwriting& Claims Strategy
Sources:i HR UK Consumer Research 2013ii Quaglio G et al., ‘Anabolic steroids:
dependence and complications of chronic use’, Internal Emergency Medicine, 2009, 4:289-296
iii Brower K. J., ‘Anabolic Steroid Abuse and Dependence’, Current Psychiatry Reports, 2002, 4:377-387
iv Skarberg K et al., ‘Multisubstance Use as a Feature of Addiction to Anabolic-Androgenic Steroids’, European Addiction Research, 2009; 15:99-106
Hannover Re UK Life Branch | 5
Positive consumer engagement lies at the heart of everything our industry does. That’s true of every stage in the process, from initial touch point to claims management. Effective engagement builds trust and loyal relationships. So much so, that consumers are often happy to pay more for the products of a brand they associate with a positive customer experience.
Since we became a founder partner of The Syndicate in 2011, its research has focused on consumers and on how they view financial services. Our surveys have sought to understand how and why consumers make the decisions they do, the issues that concern them, their attitude to risk, and how they feel about insurance and the various products available.
Building on this work, The Syndicate this year looked at issues of trust, value and benefit, loyalty, and communication. We will be sharing some of the key findings from this research at our annual Research Forum on 3 February 2014.
Ahead of the Forum, HR UK has also conducted a survey of its own, aimed at understanding how best to approach consumers and gain their trust. The results of this exercise which is shared in this article, clearly indicate that our industry can ill afford to rest on its laurels. We still have much work to do in persuading consumers of the value of the protection products we offer.
We first asked consumers what approach they would find most persuasive in urging them to consider life and critical illness insurance. Seventy-two per cent of respondents said they needed reassurance about the financial benefits that protection products would provide to their families in times of ill health or death, using case studies based on real life experiences (see Chart 1).
Only 28% said they would find it more persuasive to have the risks they and their family would face without protection highlighted to them through advertising. These results suggest that consumers like to review what others think before they feel confident enough to purchase a product.
Getting to the Heart of Consumers
To gain consumer trust we have to show that we have their best interests at heart
6 | Hannover Re UK Life Branch
Chart 1: Which of the following do you think would be the most convincing approach to get people to consider life and critical illness insurance?
Option 1: Reassure you about the financial benefits protection products can provide to your family in times of ill health or death (using case studies of real people)
Option 2: Highlight the risks you and your family face without protection cover through advertising
This preference is only likely to become more pronounced in today’s digital age, in which consumers are generating and circulating opinions faster than ever before. This makes a positive online reputation all the more important. Recommendations from friends and family remain highly influential, so it is vital that we spread good-news stories wherever we can. We need to share more case studies reflecting the value of the benefits we provide to customers. This can play a key role in building consumers’ trust in the protection industry.
Our research has consistently found that consumers prefer to live for the moment rather than dwell on potential future risks. But, at the same time, it is important to understand the things in life that consumers hold dearest and how illness, injury or death could impact their financial security (see Table 1).
It seems clear that consumers understand the general concept of, and the need for, our products. However, we need to communicate our messages more clearly and more openly if we are to persuade consumers to take out cover.
There will always be a proportion of people who have never held a policy, “the mass indifferent”. For them the issue is education and shifting them away from a mentality that is focused on living for the moment. Then there are those who formerly held policies but who no longer do, “the rejectors”. With them, the problem is disenchantment, and the industry’s challenge is how to bring them back.
The age groups that most appreciated the need for our products were those between 25 and 44. More than 50% of these said they thought it would be good to have cover in place to help their family financially if they were seriously injured or became ill. Thirty-one per cent acknowledged that, if their partner died, they would struggle to pay their bills, and 27% said they thought it would be difficult for their family to get by if they suffered a heart attack or stroke.
Only 20% of this age group agreed with none of the statements proposed by our researchers. Here is a group that is open to the need for our products (80%). So we need to ensure we communicate with them in a way they can relate to and understand, and through the channels they prefer.
Our survey also looked at how consumers prefer to receive information on the benefits of life and critical illness insurance. A third wanted information online with easy access to purchase. This was closely followed by 31% who wanted the Government to be clearer about what support it would provide if they or their family became ill, were injured or died. Only 11% wanted to be told about benefits face to face or over the telephone.
Table 1: Which of the following statements do you agree with?
Statement Overall Total
If I was seriously injured in an accident or suffered an illness that resulted in me needing daily care, it would be good to know that there is cover in place to help my family financially
42%
None of the above 32%
I think it is important to have cover in place to cover funeral costs 31%
If my partner died I think I would struggle to pay the bills 22%
If I suffered a heart attack or a stroke, I think it would be very difficult for my family to get by 18%
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critical illness or income protection insurance, 25% selected comparison websites. This was closely followed by independent financial advisers. This highlights consumers’ need for unbiased information in the pre-purchase journey (see Chart 2).
Thirty-one per cent of 45-54 year olds chose comparison websites, compared with 18% for 18-24 year olds. Earlier research has shown that the younger age groups look for guidance from friends and family as their knowledge of our products is low. For those who already hold our products, independent financial advisers were trusted slightly more (27% compared with 25%) than comparison websites.
When we find a brand we like and trust, most of us are happy to recommend it to friends and family and stay loyal to that brand. “The biggest challenge is the so-called fragility of trust,” says Roderick Kramer, a professor of organizational behavior at Stanford University. “Trust is hard won and easily lost.” To continue building trust with consumers, we have to show that we have their best interests at heart. We must be open and honest, and deliver on our promises.
We will be sharing more of our findings, along with insights from the latest Syndicate research, in early 2014. We hope these will provide some food for thought, ideas, and next step suggestions for our industry.
Kirsteen GrantMarketing Manager
Source: HR UK
We still have a large percentage of rejectors, 40% said they preferred not to receive any information on these products.
When looking at how we can better engage with consumers, we know that they require:
• a good overall experience
• easy to access information online
• an easy route to purchase
• jargon-free messages in a language they can relate to
• case studies illustrating the experiences of ‘people like them’
To create trust, we must provide consumers with open, honest, and unbiased information, so that they can make informed purchase decisions. Our products are perceived as complex, so we need to make information more easily accessible. Providing consumers with comprehensive product options, including impartial comparisons with other providers, will earn trust. This creates more loyal customers in the long term.
Asked which source they would trust most when buying life,
Chart 2: Which of the below would you trust the most when buying a life, critical illness or income protection insurance from them?
0 5 10 15 20 25 30
ComparisonWebsite
IFA
Bank/BuildingSociety
InsuranceCompany
Other
YourEmployer
Supermarket
8 | Hannover Re UK Life Branch
Hannover Re UK Life Branch (HR UK) supported, and exhibited at, the UK Life Conference and Exhibition once again. The event took place at the Edinburgh International Conference Centre between 10 and 12 November.
David Hare, President of the Institute and Faculty of Actuaries, opened the conference with a presentation that looked at how the role of the actuary has evolved in response to factors such as technological advances, economic circumstances and political policy.
The programme he introduced offered a wide range of workshops and plenary sessions, from Paul Moore’s presentation on professional responsibility to Alistair Darling’s thoughts both on being Chancellor of the Exchequer and on the current economy. The programme focused on current issues directly relevant to the work of actuaries today.
HR UK’s challenge to delegatesHR UK was delighted to support and attend another successful event, attracting over 900 delegates. During the exhibition as well as attending as delegates we also took an exhibition stand where delegates had a chance to test their hand and eye co-ordination skills with our Loopz Challenge. Delegates were challenged to correctly swipe their hands through each light combination as many times as possible within a sequence. Each player was required to reach a minimum number of accurate swipes to progress through three levels. It’s even trickier than it sounds.
The final proved to be a very close contest, with Matt Cann of The Phoenix Group winning by a single point. Matt was delighted to receive an iPad for his efforts. Will Swales of KPMG, took second prize, winning an iPod Shuffle, while third place went to Niall Clifford of Mercer. Each of our winners went home with a Loopz game of their own to enjoy with family and friends.
Reassuringly differentAt HR UK we fully understand the challenges facing our industry. We work closely with our partners, listening carefully
and responding imaginatively and flexibly to deliver the solutions on which our mutual success depends.
Openness, transparency and accessibility are central to our partnership approach. Our clients trust us to provide them with the information, ideas and insights on which to base new products that can open up new revenue streams.
As one of the leading reassurers, we have access to a global pool of knowledge and experience, from which we continually source new ideas that can help our clients.
Looking beyondThe future success of our industry depends on creating innovative new products that provide clear value to the broadest possible cross-section of society. Recognising this, we have never been afraid to challenge conventional wisdom in the quest for new and better solutions.
We achieve this by working closely together with our clients, considering things from their point of view and from that
Life 2013 Conference and Exhibition
Stuart Hill and Matt Cann
Stuart Hill and Will Swales Stuart Hill and Niall Clifford
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today’s actuaries, and shaping the future of protection, please contact our Business Development team on 01344 845282 or at [email protected].
We look forward to seeing everyone at next year’s conference, which takes place at Birmingham’s International Convention Centre (ICC) on 9-11 November 2014.
Wishing you a Merry Christmas and Happy New Year from all at Hannover Re UK Life Branch
of their customers. Inclusiveness has long been one of our key priorities. We continually seek new ways of extending protection to untapped market segments through products that truly deliver on the promises they make.
If you didn’t have time to visit our stand during the exhibition and would like to know more about how we are supporting
Monday 23rd December 2013 9am-5pmTuesday 24th December 2013 9am-2.00pmWednesday 25th December 2013 ClosedThursday 26th December 2013 ClosedFriday 27th December 2013 ClosedMonday 30th December 2013 9.00am-5.00pmTuesday 31st December 2013 9.00am-5.00pmWednesday 1st January 2014 ClosedThursday 2nd January 2014 9.00am-5.00pm
Wishing you a Merry Christmas
Victorian postmen used to wear a uniform of a red tunic which were nicknamed after the birds ‘Robin Redbreast’. This association earned the Robin a place on early Christmas cards
