Pharmacology: Drug Administration

Pharmacology: Drug Administration

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Why is the enteral route seem by far the most common way to administer a drug to the body?

Let's review drug administration routes, and see for yourself:

  • transdermal/ionophoric: expensive, unreliable release concentrations (which makes it expensive because of the extensive research needed for controlled release), noticeable to others ("why do you have that skin patch, mom?" Er… )
  • Sublingual: quite similar to oral route, however absence of first pass hepatic metabolism can result in completely different blood concentrations between the two routes. Impairs speech. Could cause mouth irritation (quite disabling). Requires patient compliance.
  • intravenous: quite unpractical in outpatient settings. Invasive measure.
  • intramuscular/intradermal: hurts. As all things using a needle. Usable, but impractical in the outpatient setting. Can lead to skin lesions (insulin injection in diabetes, for example)
  • rectal: culturally unacceptable to some, unreliable release.
  • vaginal: similar to rectal, but only for women obviously
  • spinal/epidural: very invasive, only in inpatient settings.
  • topical: usually only acts locally, can cause discomfort (eyes)
  • oral/enteral: well known pharmacokinetics, mostly invisible to others, practical in the outpatient setting, requires limited patient compliance, well known excipients. Of course there can be secondary effects, but that is the case for all administration routes. Most common side effects are abdominal discomfort and nausea, but no one can see you in the water closet. Plus people are used to see pills as medication, something which might not be the case for other routes, depending on the cultural background of the patient.

This answer is of course somewhat subjective, however the importance of the patient's perception and his/her view of what the administration route implies socially cannot be overemphasized.

Pill, tablet and time release are great enteral treatments because of their ability to control dosage by the patient at home. Compared with an IV and oil/sublinguals they are less effective at due to the greater risk of causing toxic damage to the liver and kidneys but there is little chance of overdose by reason of mechanical failure. That is the reason that viagra and metformin are first lines of defense; followed by insulin and alprostadil if they so fail. You do not infect yourself typically with a pill but with an injection its possible for a needle to be dirty. Likewise also there is the ever fear of an air bubble.

Pharmacology emerged as its own discipline in the 19th Century, branching off from research done in fields of science such as organic chemistry and physiology. Oswald Schmiedeberg, who was born in what is now Latvia in 1838, is considered the father of pharmacology. His doctoral thesis was on the measurement of chloroform levels in blood, and he went on to become a professor of pharmacology at the University of Strasburg, where he ran an institute of pharmacology. There, he studied chloroform, which was used as an anesthetic, chloral hydrate, a sedative and hypnotic, and muscarine, a compound isolated from the mushroom Amanita muscaria that stimulates the parasympathetic nervous system and has been used to treat various diseases such as glaucoma.

In 1890, John Jacob Abel became the first pharmacology chair in the United States, at the University of Michigan. He later went to Johns Hopkins University in Baltimore. Abel was the first to isolate the hormone epinephrine from the adrenal gland, isolate histamine from the pituitary gland, and make pure crystalline insulin. Animals such as dogs, cats, pigeons, and frogs were used to test pharmacological substances. Humans were even used as test subjects. Sometimes they suffered through severe adverse effects from these substances, such as when the German pharmacist Friedrich Serturner and three of his friends had poisoning for several days from an alkaloid that Serturner had isolated from opium. This alkaloid was later named morphine, after the Ancient Greek god of sleep, Morpheus.

Today, the most common test animal is the mouse, which is convenient to use because it is small, easy to breed, and can produce many generations in a relatively short amount of time. Guinea pigs and rabbits are also sometimes used. Once a compound has undergone enough testing to be considered reasonably safe, it is used in Phase I clinical trials on human volunteers, and eventually it may become a widely available drug.

Curriculum Overview

This program places a great emphasis on undergraduate research. Students have ample opportunity to pursue research projects under the close mentorship of a full-time faculty member in the Department of Chemistry, Department of Biology and the School of Medicine’s Department of Pharmacology and Physiology. Students use a variety of specialized equipment and computers in their laboratories and in their research. Students in upper-level courses enjoy small classes and personalized attention.

  • First year: General Chemistry I and II with labs, Principles of Biology I and II with labs, Calculus I and II
  • Second year: Organic Chemistry I and II with labs, Analytical Chemistry I with lab, Physics I and II with labs
  • Third year: Human Physiology, Biochemistry I and II with labs, Molecular Pharmacology, Physical Chemistry, Undergraduate Research, Chemistry Literature
  • Fourth year: Chemical biology electives (three selected from upper-level chemistry, biology and pharmacology coursework), Undergraduate Research, Medicinal Chemistry

Different Routes of Drug Administrations

There are different type of routes for drug administration. There are mainly two different routes 1. Local Route and 2. Systemic Route.

Oral Routes

Drugs absorption via oral administration can be quite variable. Dosage form design may also be used modify the rate of absorption.

Advantages of Oral Drug Administration

  • Drugs administrated via Oral routes are safe, cheap and easy to take.
  • Drug administration via oral routes are very convenient.
  • Variety of dosage forms are available for oral administration.

Disadvantages of Oral Drug Administration

  • Sometimes inefficient – high dose or low solubility drugs may suffer poor availability, only part of the dose may be absorbed. Griseofulvin was reformulated about 1970 to include the drug as a micronized powder. The recommended dose at that time was decreased by a factor of two because of the improved bioavailability.
  • First-pass effect – drugs absorbed orally are transported to the general circulation via the liver. Thus drugs that are extensively metabolized will be metabolized in the liver during absorption.
  • Food – Food and G-I motility can affect drug absorption. Often patient instructions include a direction to take with food or take on an empty stomach. Absorption is slower with food for tetracyclines and penicillins, etc. However, for propranolol bioavailability is higher after food, and for griseofulvin, absorption is higher after a fatty meal.
  • Local effect – Antibiotics may kill normal gut flora and allow overgrowth of fungal varieties. Thus, antifungal agents may be included with an antibiotic.
  • Unconscious patient – The patient must be able to swallow solid dosage forms. Liquids may be given by tube

Buccal and Sublingual

Some of the drugs are taken as smaller tablets that are held in the mouth or under the tongue. These are buccal or sublingual dosage forms. Buccal tablets are usually harder tablets [4 hour disintegration time], designed to dissolve slowly. Nitroglycerin, as a softer sublingual tablet [2 min disintegration time], may be used for the rapid relief of angina. This Route of Administration is also used for some steroids such as testosterone and oxytocin. Nicotine-containing chewing gum may be used for cigarette smoking replacement.

  • First pass – In this route, the Liver is bypassed so there is no loss of drug by the first-pass effect like the Oral administration route for buccal or sublingual administration. Bioavailability is higher also.
  • Rapid absorption – Because of the good blood supply to the area of absorption is usually quite rapid, especially for drugs with good lipid solubility.
  • Drug stability – pH in mouth relatively neutral (cf. stomach – acidic). Thus the drug may be more stable.


  • Holding the dose in the mouth is somewhat difficult. If any part of the dose is swallowed mistakenly then that portion must be treated as an oral dose and it will be then subject to first pass metabolism.
  • Usually Buccal and Sublingual routes more suitable for drugs with small doses.
  • Drug taste may need to be masked


Drugs are given by the rectal route of drug administration are most commonly given as suppository or enema. Some of the drugs that are given by this route include aspirin, theophylline, chlorpromazine, and some barbiturates.

  • By-pass liver – Some (but not all) of the veins draining the rectum lead directly to the general circulation thus bypassing the liver. Therefore there may be a reduced first-pass effect.
  • Useful – This route may be most useful for patients unable to take drugs orally or with younger children.


  • Erratic absorption – Drug absorption from a suppository is often incomplete and erratic. However, for some drugs, it is quite useful. There is research being conducted to look at methods of improving the extent and variability of rectal administration. Absorption from solutions used as an enema may be more reliable.


Drugs that are given via Intravenous are usually given into a peripheral vein. Rapid injections are used to treat epileptic seizures, acute asthma, or cardiac arrhythmias.

  • Rapid – A quick response is possible for the drugs that are given via the Intravenous route. Plasma concentration can be precisely controlled using IV infusion administration.
  • Total dose – The whole dose is delivered to the bloodstream that is given via the Intravenous route. That is the bioavailability is generally considered to 100% after IV administration.


  • Finding Suitable vein – It may be difficult to find a suitable vein to give the drug via the Intravenous route. There may be also some tissue damage at the site of injection if it is not given carefully.
  • Maybe toxic – As the drugs administrated via the Intravenous show the rapid response, toxicity can be a problem with rapid drug administrations.
  • Requires trained personnel – Trained personnel are required to give intravenous injections.
  • Expensive – Sterility, pyrogen testing, and larger volume of solvent mean greater cost for preparation, transport, and storage.


By Subcutaneous method the drugs are given under the skin. Insulin Injection is given to the patients via this route of administration.

  • Drugs of this route can be given by the patient.
  • Absorption can be fast from an aqueous solution but slower with depot formulations. Absorption is usually complete. Improved by massage or heat. Vasoconstrictor may be added to reduce the absorption of a local anesthetic agent, thereby prolonging its effect at the site of interest.


  • Can be painful. Finding suitable sites for repeat injection can be a problem.
  • Irritant drugs can cause local tissue damage.
  • Maximum of 2 ml injection thus often small doses limit use.


  • A larger volume than Subcutaneous can be given by Intramuscular. They may be easier to administer than intravenous injections.
  • A depot or sustained release effect is possible with the intramuscular injections, e.g. procaine penicillin


  • Trained personnel required to give injections via Intramuscular routes.
  • Absorption can be rapid from an aqueous solution. Absorption is sometimes erratic, especially for poorly soluble drugs,e.g. diazepam, phenytoin. The solvent may be absorbed faster than the drug causing precipitation of the drug at the site of injection.
  • Sometime this method can be painful


Inhalation may be used for local effects like bronchodilators. Inhalation can also be use for systemic effects like general anesthesia. Drugs taken via Inhalation shows rapid absorption as it by pass the liver.


  • Local effect – ear drops, eye drops or ointment, antiseptic creams and ointments, sunscreens, callous removal products, etc.
  • Systemic effect – e.g., nitroglycerin ointment
  • Generally, absorption is quite slow. Absorption through the skin especially via cuts and abrasions or from sites where the skin is quite thin can be quite marked. This can be a real problem in handling toxic materials in the laboratory or pharmacy. This can also be a serious problem with garden chemicals.

Applicants should have a B.A. or B.S. degree with a major in any of the biological or physical sciences. Entering students are expected to have completed college-level courses in chemistry (inorganic, organic, and physical), calculus, and physics a strong background in biochemistry is particularly desirable. A completed application form, at least three letters of recommendation, undergraduate transcripts, and a statement of interest must be received by December 8th.

Students in the Pharmacology program are able to select a course of studies uniquely suited to their own career goals. It is usually required that students successfully complete the following courses:

  • Macromolecular Structure and Analysis
  • Biochemical and Biophysical Principles
  • Molecular Biology and Genomics
  • Cell Structure and Dynamics
  • Organic Mechanisms in Biology
  • Pathways and Regulation
  • Bioinformatics
  • Primary Source Readings and Analysis
  • Organ Physiology
  • Graduate Pharmacology I & II
  • Essential Grantsmanship: Writing the Research Proposal

Students must also take two advanced elective courses selected from those offered by this or other departments.

During their first year of study, students will complete

10-week research rotations in addition to their coursework. They will initiate dissertation research by the end of their first year and complete elective courses relevant to their developing interests in subsequent years of training.

During the second year of study, students will be required to pass a qualifying examination conducted as prescribed by the Doctor of Philosophy Board of the University. This examination will probe the depth and breadth of the student’s knowledge of the biomedical subjects taught in the core courses.

The candidate is required to present a written dissertation based on original research undertaken while in residence as a graduate student and to present a departmental seminar describing the thesis research.

Introduction to Pharmacology Course Overview

  • BIOL 1070 is a three-credit introductory pharmacology course that introduces the basic concepts of pharmacology and drug usage for allied health professions. It introduces students to the fundamentals of pharmacology, examining the effects of drugs on the human body systems and the effects of those biological systems on drugs. It explores disorders associated with various body systems and the drugs used for diagnosis, treatment, and prevention of those disorders. The course topics are presented through readings, instructor-led video lessons, and an assortment of interactive activities including discussion forums. Students will be assessed throughout the course with worksheets, quizzes, and case studies, as well as both a cumulative midterm and final exam.

* This course is considered an upper-level undergraduate course (300 level or above)

Introduction to Pharmacology Course Outcomes

  • Review the fundamentals of pharmacology.
  • Discuss the pharmacokinetic process
  • Explore the effects of drugs on human anatomy and physiology
  • Explain the pharmacological benefits and risks of drug therapy
  • Identify commonly used drugs by trade names, generic names and primary classification
  • Review basic concepts of drug dosing

Introduction to Pharmacology Course Prerequisites

How do exams work?

All exams are taken online. Major exams are required to be proctored online through ProctorU. For instructions on how to take your exams online, visit UNE Online’s ProctorU site. Please note exams must also be proctored with the UNE-approved external webcam.

How do labs work?

BIOL 1070 is a lecture-only course. We do not offer an as the laboratory portion of the course.

BIOL 1070: Lecture

*Total payment is due in full at the time of registration. The cost of the materials is not included in this total.

Required course materials

  • Mandatory External Webcam and Whiteboard for Proctored Exams
    • SPHP courses require the use of the UNE-approved external webcam for all proctored exams. The UNE-approved whiteboard is optional depending on the course. (Webcam & Whiteboard Ordering Information)
    • Brenner, G. M., & Stevens, C. (2018). Brenner and Stevens Pharmacology (5th Ed). Pennsylvania: Elsevier.
    • Stringer, J. L. (20112017). Basic Concepts in Pharmacology: What You Need to Know for Each Drug Class (Fourth5th ed.). New York: McGraw-Hill.
    • BIOL 1070 is a lecture-only course. We do not offer a lab component and therefore no lab materials are needing to be purchased.

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    Pharmacokinetics is the branch of pharmacology that deals with what happens to a drug when it is administered or ingested. The effects of a medicine or drug are influenced by the method that the drug enters the body, and often a given drug may be available in different forms or preparations.

    There are five distinct methods for taking a medicine or drug. These methods are: (1) topical administration, (2) inhalation, (3) oral administration, (4) injection, and (5) rectal administration.

    Topical administration refers to drug that is applied on a surface, such as the skin. For example, Neosporin First Aid ointment is often applied to cuts or breaks in the skin to prevent infection.

    Halothane is an example of a drug that is inhaled. This drug is a general anesthetic and because it is inhaled, it is rapidly distributed to the body and, it is very effective.

    Many over-the-counter (OTC) and prescribed drugs come in a pill or liquid form. These drugs are taken orally, and are often the most convenient ways to administer a drug. Because these drugs enter the stomach, some are given a protective coating to prevent irritation in the lining of the stomach.

    There are three ways to inject a drug: (1) intravenous (drug injected into a blood vessel), (2) intramuscular (drug injected into a muscle), and (3) subcutaneous (drug injected beneath the skin). There are a variety of reasons for using each of these methods, such as how quickly a drug’s effect is required or where a physician may want the drug to act (localized).

    Finally, a drug may be in a form of a suppository and be administered rectally. While absorption of the drug through this method is not as reliable as oral administration, specific OTC drugs, such as Preparation H suppository, are very effective due to their actions at the desired local site.


    Our editors will review what you’ve submitted and determine whether to revise the article.

    Pharmacology, branch of medicine that deals with the interaction of drugs with the systems and processes of living animals, in particular, the mechanisms of drug action as well as the therapeutic and other uses of the drug.

    The first Western pharmacological treatise, a listing of herbal plants used in classical medicine, was made in the 1st century ad by the Greek physician Dioscorides. The medical discipline of pharmacology derives from the medieval apothecaries, who both prepared and prescribed drugs. In the early 19th century a split developed between apothecaries who treated patients and those whose interest was primarily in the preparation of medicinal compounds the latter formed the basis of the developing specialty of pharmacology. A truly scientific pharmacology developed only after advances in chemistry and biology in the late 18th century enabled drugs to be standardized and purified. By the early 19th century, French and German chemists had isolated many active substances—morphine, strychnine, atropine, quinine, and many others—from their crude plant sources. Pharmacology was firmly established in the later 19th century by the German Oswald Schmeiderberg (1838–1921). He defined its purpose, wrote a textbook of pharmacology, helped to found the first pharmacological journal, and, most importantly, headed a school at Strasbourg that became the nucleus from which independent departments of pharmacology were established in universities throughout the world. In the 20th century, and particularly in the years since World War II, pharmacological research has developed a vast array of new drugs, including antibiotics, such as penicillin, and many hormonal drugs, such as insulin and cortisone. Pharmacology is presently involved in the development of more effective versions of these and a vast array of other drugs through chemical synthesis in the laboratory. Pharmacology also seeks more efficient and effective ways of administering drugs through clinical research on large numbers of patients.

    During the early 20th century, pharmacologists became aware that a relation exists between the chemical structure of a compound and the effects it produces in the body. Since that time, increasing emphasis has been placed on this aspect of pharmacology, and studies routinely describe the changes in drug action resulting from small changes in the chemical structure of the drug. Because most medical compounds are organic chemicals, pharmacologists who engage in such studies must necessarily have an understanding of organic chemistry.

    Important basic pharmacological research is carried out in the research laboratories of pharmaceutical and chemical companies. After 1930 this area of pharmacological research underwent a vast and rapid expansion, particularly in the United States and Europe.

    The work of pharmacologists in industry deals also with the exhaustive tests that must be made before promising new drugs can be introduced into medical use. Detailed observations of a drug’s effects on all systems and organs of laboratory animals are necessary before the physician can accurately predict both the effects of the drug on patients and their potential toxicity to humans in general. The pharmacologist does not himself test the effects of drugs in patients this is done only after exhaustive tests on animals and is usually conducted by physicians to determine the clinical effectiveness of new drugs. Constant testing is also required for the routine control and standardization of drug products and their potency and purity.

    The Editors of Encyclopaedia Britannica This article was most recently revised and updated by Barbara A. Schreiber.

    Advanced Courses

    The goal of the advanced courses is to complement the thesis work with additional formal training outside of the mentor’s laboratory. A key feature of the advanced curriculum is the flexibility to tailor the training plan to align with the career goals of each student. A complete list of current advanced courses can be found in the CWRU Bulletin.

    Cell Signaling

    (PHOL/CLBY466, 3 credits). Cell signaling mechanisms, including gated ion channels, growth factor receptor kinases, cytokine and steroid receptors, GPCRs, G proteins, and Ras family GTPases, second messenger cascades, transcription factor regulation, microtubule- and actin/myosin-based motility, cell cycle and apoptosis regulation.


    Function, Structure, and Signaling (PATH/ CLBY417, 3 credits). Cytokine function, expression, receptors, and intracellular signaling, including regulatory and inflammatory cytokines, colony stimulating factors, chemokine/cytokine receptor families, intracellular signaling through STAT proteins and tyrosine phosphorylation, clinical potential, and genetic defects.

    Nuclear Receptors in Health and Disease

    (PHRM/BIOC415, 3 credits). Hormone-gene interactions mediated by the ligand-inducible transcription factors, including their role as therapeutic targets in cancer, inflammation, and diabetes.

    Cancer Biology and Therapeutics

    (PHRM 520, 3 credits). Basic concepts of cancer biology and therapeutics, providing a broad overview of cancer biology and clinical oncology, including oncogenes, tumor suppressor genes, cell cycle control, cell adhesion, and angiogenesis, tumor cell heterogeneity, metastasis, therapeutic approaches, and clinical oncology of selected malignancies. Additional training in therapeutics occurs in a 1 credit enrichment course linked to PHRM 520, involving CCC seminars and written critical evaluation of primary literature.

    Protein Biophysics

    (PHRM475, 3 credits). An in-depth understanding of the molecular biophysics of proteins. Structural, thermodynamic and kinetic aspects of protein function and structure-function relationships are considered at an advanced conceptual level.

    Advanced Methods in Structural Biology

    (PHRM/BIOC430, 1-6 credits). This course is divided into 6 specific modules: a) X-ray crystallography, b) nuclear magnetic resonance spectroscopy, c) optical spectroscopy, d) mass spectrometry, e) cryo-electron microscopy, and f) computational and design methods. Modules are scheduled in 5-week sessions and all can be taken in one semester.

    Structural Biology of Proteins, Enzymes and Nucleic Acids

    (BIOC434, 3 credits). Introduction to the basic chemical properties of proteins and the physical forces that determine protein structure. Topics include the elucidation of protein structure by NMR and by X-ray crystallographic methods the acquisition of protein structures from databases and simple modeling experiments based on protein structures.

    Contemporary Approaches to Drug Discovery

    (PHRM 526, 3 credits): Drug discovery and development from lead compounds through clinical trials, including medicinal chemistry, parallel synthesis, drug delivery, and devices, drug administration and pharmacokinetics, and clinical trials. Included are guest lectures by industrial leaders who provide specific examples of drug development. A special emphasis is placed on hands-on experience with sophisticated drug discovery software. Each student conducts a project involving in silico screening and lead optimization against known drug targets, followed by drafting of an invention disclosure.

    Pathways to Research in Translational Therapeutics

    (PHRM 527, 3 credits): Students spend time in a clinical or community setting that most directly relates to their area of research interest. Based on this “bedside” experience and in collaboration with basic science and clinical mentors, students identify a significant therapeutic challenge in the treatment of the related patient population and write a review based on the available literature in this field. The course culminates with the presentation of the reviews at a symposium for the TTT members. Students with outstanding review manuscripts are encouraged to submit them for publication.

    Mechanisms of Drug Resistance

    (PHRM / MBIO 434, 3 credits). Molecular, cellular and physiological mechanisms of resistance to antibiotics, anti-viral (& antiretroviral) and anti-fungal agents as well as cancer therapeutic agents.

    Adverse effects

    The undesirable effects arising from anabolic steroid administration ( Table 3 ) have been extensively reviewed (Haupt and Rovere, 1984 Di Pasquale, 1990 Graham and Kennedy, 1990 Landry and Primos, 1990 Shahidi, 2001 Kicman and Gower, 2003b James and Kicman, 2004). Typically, anabolic steroids are taken in cycles of about 6� weeks (the ‘on period') followed by a variable period off the drugs, from 4 weeks to several months (the ‘off period') in an attempt to reduce the likelihood of undesirable effects but some bodybuilders will take them almost continuously.

    Table 3

    Adverse effects from anabolic steroid administration

    TargetAdverse effectComment
    BonePremature closure of the epiphysis in childrenStunting of linear growth
    BreastAtrophy in women
    Gynaecomastia and enlarged nipples in men
    Gynaecomastia can be pronounced and painful corrective surgery may be necessary. As some anabolics are known to be resistant to aromatization, other mechanisms need to be considered, such altered hepatic function causing an imbalance between androgens and estrogens
    CardiovascularIncreases risk of thrombotic events such as myocardial infarction or stroke (raised LDL, lowered HDL and apolipoprotein-1, raised haematocrit (due to polycythaemia) and lowered plasma fibrinogen
    Cardiac damage (left ventricular hypertrophy, fibrosis and heart failure)
    Sudden cardiac death
    The link between long-term anabolic steroid use and cardiovascular events remains to be clearly established but the evidence gathered is fairly compelling. This effect is probably underreported
    Heart disease may be potentiated by concomitant use of growth hormone or insulin (also misused for anabolic purposes)
    CNSIncreased libido in men and women, which may be difficult to control
    Hypomania (less severe form of mania)
    Heightened irritability
    Increased aggression and hostility
    Destructive Impulses
    Self-destructive impulses
    Withdrawal symptoms can include severe depression
    Psychological effects are unpredictable. Anabolic steroids are implicated in cases of violent behaviour (‘roid rage') including, manslaughter and murder
    Polypharmacy can increase the risk of violent criminality (Klotz et al., 2007)
    HairHirsutism in women (conversion of vellus to terminal hair and male-body pattern of growth)
    Acceleration of baldness in men male-pattern baldness in women.
    Hirsutism is at very best only partially reversible on cessation of administration.
    LiverImpaired function
    Hepatic cholestasis (bile canal obstruction) causing jaundice
    Peliosis hepatitis (blood-filled sacs in the liver)
    Liver tumours (increased risk)
    Hepatoxicity is associated with 17α-alkylated steroids (orally active)
    For the liver function test, it is important to include GGT and CK, as ALT and AST can be raised naturally due to exercise
    ReproductiveSuppression of gonadal steroidogenesis
    Clitoral hypertrophy
    Testicular atrophy
    Disproportionate growth of the inner prostate
    Masculanization of female foetus
    Recovery of fertility can take from months up to approximately 1 year after cessation of administration, depending on the extent of abuse
    Growth of the clitoris is irreversible
    SkinCystic acneThis can be very severe on the chest, back and face
    Vocal chordsLengthened in womenIrreversible deepening of the voice can result in considerable distress
    OtherSerious infection associated with injected drugs
    Toxicity from unlicensed products?
    Needle-exchange programmes are helping to address this problem
    Extent is unknown

    For clinical purposes, the administration of these drugs can be of therapeutic benefit and reasonably safe, with the physician making objective decisions based on the benefit/risk ratio in relation to a patient's condition. By contrast, for the purposes of enhancing performance in sport or for cosmetic purposes, usually because it is a clandestine activity, the athletes and bodybuilders are making subjective decisions regarding the effect these steroids are having on their health. Many probably have an attitude of personal invulnerability because they regard themselves as smart steroid users (Perry et al., 1990), their knowledge being based on reconnaissance of the considerable amount of popular literature (also in electronic form) written by steroid ‘gurus', consultation of colleagues who are steroid users in the gym and their own personal experiences from experimentation. Furthermore, it may be perceived that athletes who fail a test show no obvious signs of ill-health, such as blatant gynaecomastia, severe steroid acne or hirsutism, and this may imply to others that the adverse effects of anabolic steroid use are exaggerated. These athletes could be exercising moderation in the doses they were administering, which should help to keep adverse effects to a minimum (Millar, 1994). Of note, however, is that many of the adverse effects can be difficult to recognize without a thorough medical examination (and patient𠄽octor confidentiality would have to be maintained) and other damaging effects are insidious where the athletes themselves will be unaware, such as the potential harmful changes to the cardiovascular system. Even so, it is important not to overstate the medical risks associated with anabolic steroid use (Hoffman and Ratamess, 2006) but to emphasize that the hazards to health are dependent on the sex, the dose, the duration of administration, whether hepatoxic 17α-alkylated steroids are being administered and the susceptibility of the individuals themselves to androgen exposure (likely to be dependent on genetic factors, age and lifestyle). The axiom, particularly among bodybuilders who can use excessively large amounts of steroids, that the ‘more you take, the more you grow' should be accompanied with ‘the more you may damage your health'. It is difficult to gauge the prevalence of severe adverse effects of what is an underground activity, and, moreover, it would be unethical to mimic the large dose regimens in controlled studies over prolonged periods of time to evaluate the risks to health. Notwithstanding, from the records of the doping programme in the former German Democratic Republic, nowhere did the GDR doctors record a damaging effect that was not described in the ‘western' literature. These effects included the irreversible effects of virilization (masculanizing effects) in women and female adolescents, and life-threatening liver damage associated with 17α-alkylated steroids (oral-turinabol was commonly administered), which sadly led to the death of the hammer thrower, Mr Detlef Gertsenberg, following postoperative complications.