For decades, harm reduction has saved lives by responding to the most immediate dangers of drug use - overdose, blood-borne viruses, and contaminated drug supply.
Initiatives such as needle and syringe programs, naloxone distribution and drug checking have dramatically reduced deaths and infections around the world.
But new research suggests these models have a blind spot.
A new study published in Addiction argues the frameworks used to reduce harm from drugs like heroin or methamphetamine do not translate neatly to anabolic-androgenic steroids - the variety of illegal substances widely used in physical and digital fitness and wellbeing communities.
The reason is simple: steroid use doesn't look like other drug use.
Most harm reduction was built around acute risks like overdose.
But with steroids, the harms tend to develop slowly - through long-term organ system damage to the heart, liver, and kidneys, to name a few.
Steroid use is typically structured and goal-driven, with consumers often following planned cycles of drugs over months or years to build muscle, enhance recovery, or improve appearance.
Many consumers see themselves less as "drug users" and more as people pursuing health, performance, or aesthetic goals.
This mismatch means existing health services often miss the real risks.
Current harm reduction systems largely focus on injecting as the primary danger.
Illegal use of anabolic-androgenic steroids is a rising public health threat.
Anabolic-androgenic steroids such as testosterone and trenbolone are illegal to use in Australia without a medical prescription and are approved only for specific health conditions - not performance or image enhancement.
These illegal markets add a further layer of danger.
For example: in Queensland, my research project ROIDCheck found nearly less than 1 in 10 illegal steroids tested from 212 samples contained the right steroid at the right dose.
Further, ROIDCheck has shown that oral steroids - often perceived as "safer" - may actually carry greater risks due to liver toxicity and high rates of mislabelling or contamination in illicit markets.
Harm reduction initiatives must evolve to address all of these realities.
That could include digital education tools for safer injecting, dosing, and health monitoring, and training health workers to recognise the distinct patterns of steroid use.
Steroids challenge some of our basic assumptions about drug harm.
If harm reduction is going to remain evidence-based, it needs to adapt to the different ways people use different substances.
Our study suggests that recognising the diversity of drug use, including drugs used for enhancement rather than intoxication, may be one of the next major frontiers for public health.
The research is published in Addiction.
Dr Timothy Piatkowski is from The University of Queensland's School of Public Health and Centre for Community Health and Wellbeing. He is a globally recognised leader in lived-experience research on substance use, particularly in image and performance enhancing drugs.
