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As with other illicit drugs, such as heroin or cocaine, illicit steroids and other performance and image enhancing drugs (PIED) have for some time been assumed to involve an inherent degree of danger and risk. This is due to the unknown and potentially dangerous substances present in them; fakes and counterfeits are of particular concern. Many of these 'risks' are unknown and unproven. In addition, a tendency to abstract these risks by reference to forensic data tends to negate the specific risks related to local PIED markets, and this in turn has led to much being missed regarding the broader nature of those markets and how buyers and suppliers interact and are situated within them. This article reports on research that sought to explore each of these issues in one mid-sized city in South West England. A snapshot image is provided of what the steroids and other image or performance enhancing drugs market 'looked like' in this particular city in 2013: how it operated; how different users sought out and purchased their PIED; the beliefs they held about the PIED they sourced; and the methods they employed to feel confident in the authenticity of their purchases. A forensic analysis was undertaken of a sample of user-sourced PIED as a complementary approach. The results showed almost all of these drugs to be poor-quality fakes and/or counterfeits. The level of risk cannot be 'read off' from forensic findings, and poor-quality fakes/counterfeits cannot simply be considered an attempt to defraud. Users believed they had received genuine PIED that were efficacious, and employed a range of basic approaches to try to ensure genuine purchases. Many, if not most, transactions at the 'street' level were akin to 'social supply' rather than commercial in nature.

This study provides the strongest evidence to date that changes in atmospheric pressure and humidity are associated with symptom exacerbation in MD. Improving our understanding of the role of weather and other environmental triggers in Ménière's may reduce the uncertainty associated with living with this condition, significantly contributing to improved quality of life.