There's no question that nearly every bodybuilder, athlete and gym rat that uses anabolic steroids and other performance-enhancing drugs obtains his supplies (or gear) from black market sources. The black market has been glamorized into being an exclusive members-only club where the best drugs (guns, electronics, tax-free cigarettes, etc.) are moved at the best prices. America has changed its attitude from supporting the law-abiding citizens and marshals of the law, to a pro-crime society. Gone are the days when people honor the police, FBI and DEA. Now, the modern day heroes are gangsters and criminals.

This is not restricted to bodybuilders or even athletes. It's pervasive in our culture. As evidence, I would offer the ratings of the cable drama "The Sopranos;" the popularity of Allen Iverson of the Philadelphia 76ers and the following of rap stars Tu Pac and Snoop Dog. Crime seems to be tolerated and even enjoyed by much of America, until it does one thing- affect the public pocketbook.

    Serostim Scam
A perfect example of this is taking place in New York State. It involves a multi-million dollar Medicaid scam whereby AIDS patients are receiving the growth hormone Serostim, and selling it on the street and in the gyms. The uproar this scam is creating is of such a grand scale that it was the cover story for the New York Daily News.1 As written by Thomas Zambito, the details of the scam are revealed.

An HIV education coordinator by the name of Enrique Rojas would collect the names and identification numbers of AIDS patients, then submit phony prescriptions for Serostim (growth hormone), billing Medicaid for the very expensive drug. Rojas would have the drug delivered to friends or clients of the AIDS clinic, paying these people $50 to $100 for the use of their addresses, and collect the drug. This provided Rojas with a steady and legitimate supply of growth hormone at nearly no cost. Rojas would then sell the drug to bodybuilders and other athletes. It's estimated that Rojas' scam cost the Medicaid system, financed through our tax dollars, over $1.7 million.  

This story is remarkable for several reasons. One is the sheer audacity of Mr. Rojas and the numbers of willing participants who provided their names or addresses for his use. The second is the impact the theft has on a financially strained public health care system. Lastly, is the fact that the media found this story newsworthy- not because AIDS patients suffered from the misappropriation of Medicaid funds, but because the drugs were being sold to the underground subculture of bodybuilding.1,2 It's worth looking into the reason why there's a demand for growth hormone and why Serostim in particular is so prevalent in the black market.

Growth hormone was originally isolated and purified from cadavers (dead people) by extracting the hormone from the pituitary gland (a small part of the brain). Not only was this method expensive and of limited supply, it carried the risk of transmitting a devastating disease to anyone injected with the drug. Growth hormone was originally developed to treat children who failed to grow at a normal rate due to a deficiency in circulating growth hormone.

In 1979, a method for producing growth hormone from genetically engineered bacteria was developed and a more pure and less dangerous source became available. However, it was not until much later that production was increased to the scale in use today. The original growth hormone produced by this bio-engineered method was modified slightly, as children were producing antibodies to the first product.3 The modified, bio-engineered growth hormone now produced is identical to the major form of growth hormone released from the human pituitary. This form of growth hormone is available under many brand names, including Serostim.3,4

A Growing Market
As a better source of growth hormone became available, additional uses beyond treating growth-retarded children were investigated.5-8 It has been found to reverse many of the signs of aging, promote tissue repair and prevent or reverse the severe, catabolic wasting associated with many diseases- AIDS being the most prominent. In 1996, the pharmaceutical company Serono received approval from the FDA for its growth hormone, Serostim, to be used in treating AIDS-related wasting.3

Thus, a greater market was developed for the legitimate use of growth hormone, increasing its availability and production. As in the case of Mr. Rojas, the black market quickly recognized an opportunity to profit from the influx of a high-demand, high-dollar product. Serostim is not a cheap product. A one- month supply of Serostim costs the Medicaid system approximately $6,300. Funds that should be used to treat sick and dying people are instead being used to finance dealers.1

On the black market, that same box of Serostim is sold for hundreds to thousands of dollars to bodybuilders who are only too glad to purchase a legitimate product. Sadly, professional criminals are not the only ones profiting from the demand for Serostim. Pharmacists and pharmaceutical distributors have been caught selling counterfeit Serostim. The problem has been so prevalent, that Serono has had to issue public press releases regarding counterfeit lots of the drug several times and increase the security and tracking of Serostim to retail pharmacists.9-11

The numbers and examples of Serostim trafficking may be astounding until it is realized how large the market is for growth hormone. Growth hormone is in high demand for recreational use, not just among bodybuilders, but also athletes, media celebrities and anyone with a little vanity and a lot of money.1,2,6,7,12,13 Growth hormone has been shown to improve skin tone, energy and vitality for those who depend upon their looks for personal or professional success. More importantly, for the bodybuilder and athlete, it has been proven to reduce body fat, while increasing lean body mass, including muscle.3,14,15 It is important to note that growth hormone does not necessarily increase strength, regardless of any gains in muscle size.

Bodybuilders have been using growth hormone for decades. Originally, its use was restricted to only the most elite in the sport. But, as the drug's availability has increased, its use has spread down to amateur and even non-competitive bodybuilders. This drug, along with another dangerous hormone called insulin, accounts for the change in physique noted during this period from the graceful and symmetrical look of Frank Zane, to the more exaggerated forms that dominate the sport today.

Unnecessary Risks
Pro bodybuilders primarily use growth hormone as an anabolic, and dose the drug at the levels prescribed for GH-deficient children.4,16 This dose is determined by using roughly one IU (international unit) per kilogram of body weight per week, divided into daily doses. There are three IU in a milligram of growth hormone. This translates into roughly 100 IU per week, or approximately 15 IU per day. At this dose, GH will increase muscle bulk, but adverse side effects are very common. These may be temporary effects, such as carpal tunnel syndrome, or they may be more serious and permanent, including diabetes, organ growth (accounting for the distended bellies) and disfiguring overgrowth of facial bones, hands and feet.

This is unfortunate, as GH could provide significant benefits at a much lower dose, with minimal risk of any side effects. Studies and clinical practice have shown that a daily dose of approximately two IU per day will improve fat loss and increase serum IGF-1 (a hormone responsible for many of the positive effects of GH).5,17,18 This effect may be achieved either by using the drug daily at this low dose or injecting six IU every three days. This dosing pattern would allow for benefits at a greatly reduced cost and with less risk.

Growth hormone is a powerful drug, capable of promoting muscle anabolism, reducing fat and improving looks and vitality. It is a drug in high demand from many populations, including actors, models, the aging, athletes and bodybuilders, which has prompted the black market into locating sources for this expensive and tightly regulated drug. With the advent of its approval for treating AIDS-related wasting, criminal entrepreneurs have tapped into the Medicaid system, diverting the funds and drugs targeted to treat the sick and dying, into a highly profitable pipeline. The extent of this diversion of the product Serostim has been estimated to account for as much as 10 percent of the annual $3 billion Medicaid fraud loss. That means as much as $300 million of U.S. tax money is being wasted on funding criminal endeavors rather than providing for medical services or other forms of public welfare.1

There is a demand for black market drugs. That has ever been the case in the history of man. Some may argue that being able to obtain growth hormone and other performance-enhancing drugs should be a matter of the free market, where anyone who can afford the drugs can purchase them legally. That is a matter of debate. What is inarguable is that when the federal government becomes aware that it's losing large sums of money to drug diversion, it will quickly turn its attention to the players involved. Examples such as Mr. Rojas are impossible to ignore and the media attention is likely to make drug trafficking among bodybuilders a popular target for law enforcement, as well as any city or county prosecutor looking for headlines.

Some bodybuilders may have profited from Mr. Rojas' scam in the short term, having a cheap and reliable source of Serostim. But in the long run, this abuse of the Medicaid system is going to bring a lot of negative attention to all bodybuilders.

References  
1.    Zambito T. "Muscle Hustle - Pumped By AIDS Drug." New York Daily News, June 2, 2003.
2.    CNN - Cable News Network. "AIDS Drug Entering Black Market." Aired June 3, 2003.
3.    Package Insert - Serostim®. Serono, Inc.
4.    van Mol P. Human Growth Hormone. Available through http://www.bodybuilding.com/fun/cathuman.htm accessed June 10, 2003.
5.    Carrel AL, Allen DB. Effects of growth hormone on adipose tissue. J Pediatr Endocrinol Metab 2000 Sep;13 Suppl 2;1003-9.
6.    Blackman MR, Sorkin JD, et al. Growth hormone and sex steroid administration in healthy, aged women and men. JAMA 2002 Nov 13;288(18):2282-92.
7.    Rudman D, Feller AG, et al. Effect of human growth in men over 60 years old. N Engl J Med 1990;323:1-6.
8.    Scacchi M, Pincelli AI, et al. Growth hormone in obesity. Int J Obes Relat Disord 1999 Mar;23(3):260-71.
9.    "News Release - Serono, Inc. "Serono Issues Notification of Counterfeit Serostim®" May 16, 2002.
10.    News Release - Serono, Inc. "Serono Issues Information on New Counterfeit Serostim® LOT" May 17, 2001.
11.    News Release - Serono, Inc. "Serono Implements New Serostim® Secured Distribution Program." October 2, 2002.
12.    Urhausen A, Gabriel H, et al. Blood hormones as markers of training stress and overtraining. Sports Med 1995 Oct;20(4):251-76.
13.    Urhausen A, Kindermann W. Diagnosis of overtraining: what tools do we have? Sports Med 2002;32(2):95-102.
14.    Ho KK, O'Sullivan AJ, et al. Metabolic actions of growth hormone in man. Endocr J 1996 Oct;43 Suppl:S57-63.
15.    Kim KR, Nam SY, et al. Low-dose growth hormone treatment with diet restriction accelerates body fat loss, exerts anabolic effect and improves growth hormone secretory dysfunction in obese adults. Horm Res 1999;51(2):78-84.
16.    Llewellyn W. Anabolics 2002. Molecular Nutrition Press, Patchogue, NY, 2002;101-4.
17.    Snyder DK, Underwood LE, et al. Pesistent lipolytic effect of exogenous growth hormone during caloric restriction. Am J Med 1995 Feb;98(2):129-34.
18.    Marcus C, Bolme P, et al. Growth hormone increases the lipolytic sensitivity for catecholamines in adipocytes from healthy adults. Life Sci 1994;54(18):1335-41.