The Long Tail of a Demon Drug: The ‘Bath Salts’ Risk Environment

Abstract

Using the case of synthetic cathinones (commonly referred to as ‘bath salts’ in the US context), this paper analyzes structural factors surrounding novel psychoactive substances (NPS) as contributing to the unique risk environment surrounding their use. Drawing on interviews with 39 people who use bath salts from four U.S. cities and analysis of the infrastructural, social, economic, and policy contexts, we document the unique harms related to changing contexts for illicit drug regulation, manufacture, and consumption. Findings suggest that NPS and designer drug markets, which are highly reliant upon the internet, share characteristics of the entertainment industry which has come to rely more heavily upon profits derived from the ‘long tail’ of myriad lesser-known products and the diminished centrality of ‘superstars’ and ‘hits’. Findings point toward increased theoretical and policy attention to changing drug market structures, more rigorous evaluations of drug ‘analogues’ legislation and greater involvement with NPS education and testing by harm reduction agencies.

INTRODUCTION/BACKGROUND

Perrone has noted that most so-called novel psychoactive substances (NPS), are ‘neither new nor novel’ (2016, p. 150). Rather, they are substances either first synthesized decades ago and experiencing a resurgence in use or are drug ‘analogues’ representing minor chemical alterations to an existing drug molecule to rebrand a familiar substance or circumvent legal prohibition. Despite their dubious claims to novelty, however, NPS have drawn news media to sensational stories of violence and death, reportedly precipitated by the use of dangerous new synthetic compounds, and have found themselves at the heart of rapidly shifting legislation. ‘Drug analogue’ legislation has emerged across Europe and the U.S. and is designed to equip regulatory and legislative bodies with rapid, emergency-based authority to prohibit emergent substances deemed to hold chemically analogous relationships to other, already-illicit substances (Losoya, 2013; van Amsterdam, Nutt, & van den Brink, 2013). As a number of drug scholars have recently warned (Hammersley, 2010; Losoya, 2013), accelerated legislative enactment of prohibitions on NPS and blanket sanctions contained within various drug analogue acts supply much of the impetus for a ‘chemical arms race’ (Feng, Bridgewater, McIntire, & Enders, 2016) in which contemporary drug labs produce seemingly endless iterations on an illicit molecule—a process most clearly evident in the more than 100 synthetic cannabinoids that have been identified and appear in various grey and black-market smoking blends (Feng et al., 2016; Langer et al., 2016). While this practice has been criticized for preempting pharmacological research into emergent substances, thus preventing assessment of a molecule’s potential for legitimate medical use and for leading to potential legal injustices (Losoya, 2013), the more immediate impact is to create an impetus for grey-market chemists to rapidly develop new substances as substitutes for those lost to expedited prohibition (Feng et al., 2016), resulting in potential confusion and harms for consumers who are poorly informed about the changing formulation of the generically marketed substances, bearing such monikers as Spice or Bath Salts, in the case of synthetic cannabinoid blends and synthetic cathinones, respectively. One public health implication of such rapid proliferation is that the banning of substances that might be harmful leads to the introduction of new analogues that genuinely are (Hammersley, 2010, p. 373).

Synthetic cathinones

In the past 10 years, claims of drug-related harms for NPS have become commonplace in the U.S., particularly in local news media. Accounts of violence, suicidality, seizures, hallucination and psychosis have been repeatedly linked to use of synthetic cannabinoids and cathinones—chemical analogues of psychoactive components in cannabis and Catha edulis, or Khat, a plant chewed for its stimulating properties throughout the Arabian Peninsula and East Africa (Al-Hebshi & Skaug, 2005; Brenneisen, Fisch, Koelbing, Geisshusler, & Kalix, 1990; Gatherings, 1976), respectively. While the first cathinone analogues were synthesized as early as 1928 (Kau, 2008; Perrone, 2016), they remained relatively unknown to people who use illicit substances and the general public until reintroduced as over-the-counter drugs posing as shoe deodorizers, plant foods, or bath salts—the latter term eventually serving as a catchall for synthetic cathinones (SCs) being sold in U.S. gas stations, tobacconists, and head shops. In 2011, the U.S. Department of Justice issued a report indicating a growing concern with SCs, which had emerged in Europe as popular recreational substances around 2007 according to other sources (Shaller, 2013). Concurrently, reports indicating rising rates of emergency department visits related to SC use began to emerge (Carbone, Carbone, Carstairs, & Luzi, 2013; Prosser & Nelson, 2012; Sivagnanam, Chaudari, Lopez, Sutherland, & Ramu, 2013), as did a growing array of sensational news stories regarding the dangerous consequences of SC use. The U.S. Congress introduced a series of bills in 2011, including the Combating Dangerous Synthetic Stimulants Act of 2011 (H.R. 1571, S. 409); the Synthetic Drug Control Act of 2011 (H.R. 1254) and the Dangerous Synthetic Drug Control Act of 2011 (S. 839), all of which provided more direct access to Schedule 1 of the Controlled Substances Act, a list of illicit substances defined by a stipulated lack of medical value (Sacco & Finklea, 2011). Quickly thereafter, the U.S. Department of Justice moved to schedule three SCs appearing in bath salt products—mephedrone, methylone, and MDPV—later adding another 10 to the list (U.S. Drug Enforcement Administration, 2014).

SC’s path to prohibition are undergirded by Catha edulis’s status as a substance used among Muslim peoples and the rich history of yellow journalism related to drug topics in the U.S., (DeGrandpre, 2006; Denham, 2008; Forsyth, 2012; Glassner, 2010; C. Reinarman & H. G. Levine, 1997). Its demonization is reminiscent of sensational narratives about PCP, cocaine, and even marijuana, all of which were granted a singular power to corrupt and transform their users at various points during the 20^th century. Where PCP and cocaine had been alleged to grant (usually male, ethnic minority) users superhuman strength and marijuana to prompt sexual licentiousness and loose morals (Jenkins, 1999; Musto, 1999; C. Reinarman & H. Levine, 1997), SCs were rapidly hailed by the U.S. news media as drugs causing radical breaks with sanity. High school revelers in Minnesota were discovered in random acts of violence and confusion; a 21-year-old in Louisiana attempted to cut his throat in front of his parents and finally succeeding in taking his life with a low-caliber child’s rifle; and most gruesomely, a homeless man was disfigured by a purportedly bath-salts intoxicated ‘cannibal’ assailant who successfully removed large portions of the man’s face with his teeth before being shot by police (Shaller, 2013). As the number of deaths attributed to SC use grew, so too did skepticism over the claims being made on internet news sites, and a number of the accounts were ultimately debunked or revealed to have involved unverified claims of SC involvement (Forsyth, 2012).

Sensationalizing drug reportage aside, SCs are a clear exemplar of shifting drug marketplaces and dissemination processes. Purchased through ‘dark web’ venues in the mold of the now defunct Silk Road (Barratt, 2012; Van Buskirk, Roxburgh, Farrell, & Burns, 2014; Van Hout & Bingham, 2013a, 2013b), paid for with cryptocurrencies (like Bitcoin), ‘mined’ and transmitted across the internet (Barratt & Aldridge, 2016), and popularized by online drug journalism and education sites (e.g., Erowid and Lycaeum.org), SCs constitute a highly technologically mediated class of drug commodities and, as such, raise important questions about how risk and harm flow (or ‘trickle down’) through online and face-to-face commercial networks. In particular, how, we want to ask, are SCs and their (perhaps overstated) risks encountered and negotiated by their end users—those far more likely to have purchased SCs from street-level dealers in traditional face-to-face transactions.

The Risk Environment framework

Rhodes and others have advanced the notion of a ‘risk environment’ (Rhodes et al., 2003; Rhodes & Simic, 2005; Strathdee et al., 2010) as a corrective to the individual-centric focus of much public health work on ‘risk factors’ for drug- and sex-related harms. Drawing on Foucaultian constructs like biopower and governmentality, risk environment analyses have sought to demonstrate the interface between micro and macro-level processes and between individuals and the social and economic structures in and through which they operate. While offering a simple heuristic by which a risk environment can be charted in terms of its component physical, social, economic and policy domains, more recent theorizations have focused on the overlapping and imbricated relationship between different environmental contexts and the complex place of human agency therein (Rhodes, 2009). In bringing the risk environment framework to bear on a qualitative inquiry into the sociocultural practices of people who use SCs, this paper seeks, in particular, to explore the interface between the macro-structure of NPS marketplaces as they have emerged and the microsociology of SC procurement and use. The following literature review elucidates each of the four environmental domains, which will be further explored in parallel in the paper’s Results section.

METHODS

The qualitative analyses presented below represent a hybrid of inductive and deductive approaches to in-depth interview data from a study of the SC marketplace in the U.S. The project was initially guided by a set of deductive, a priori analytic concerns—to identify the market structure surrounding SCs across 4 US cities; to understand the phenomenological dimensions of SC/bath salt use, and to illuminate the public health concerns related to continued use of SCs after they were scheduled, and effectively outlawed, by the U.S. Food and Drug Administration and Drug Enforcement Agency.

To that end, project staff conducted 39 qualitative interviews lasting between 55 and 95 minutes with people using bath salts at time of enrollment in Houston, Galveston, New Orleans and New York City, cities where the study team had strong networks emerging from earlier research. Participants were recruited using a combination of venue-based and peer directed chain referral techniques. More than half of participants (21/39) identified as black/African-American, 8% as Hispanic/Latino, and 36% as white; 26 identified as male, 13 as female. Participants ranged in age from 19 to 57, with a mean age of 36 for the sample. Only 10 of the 39 were employed at the time of enrollment in the study, and the mean educational level for the sample was below that of a high school diploma. Interviews focused on personal experiences with SCs and the contexts for their use as well as issues related to dependence, social stigma, and the markets in which SCs are purchased.

Initially, interview transcripts were reviewed by all authors to generate a set of a posteriori themes of interest. One of the central topics emerging from team discussions concerned the ways in which SC-related harms were understood and articulated by participants and how risk was ‘situated’ in participant narratives—whether within individual factors, such as a predisposition to anxiety or psychosis, or environmental factors, such as the structure and characteristics of the SC street market. Given a shared ecological interest among team researchers in how the larger legislative, commercial, and policy regimes surrounding SCs were embodied and negotiated by individuals, Rhodes’ Risk Environment framework was chosen as a heuristic and employed in largely deductive coding procedures. The full set of interview data was subsequently re-reviewed and subjected to a process in which three project staff members discussed code categories and coded a set of sample interview transcripts. Coders met to discuss codes several times during the iterative process and to refine the codebook. Staff coded the entire range of emergent categories, recording divergent experiences and choosing the most content-rich quotes for inclusion in the manuscript.

Results below are organized around representative quotes illuminating component domains of the SC Risk Environment but are presented as such with the caveat that environmental categories are primarily organizational, or heuristic as per Rhodes (Rhodes, 2009) and often not mutually exclusive. Findings are further limited by the non-representative nature of the sample and its relatively small size.

All procedures were approved by the NDRI, Inc. Institutional Review Board, and all names used are pseudonyms chosen by the participants themselves.

RESULTS

Economic Environment: Marketing Bath Salts Post-Prohibition

All participants in the study were asked how they refer to SCs or ‘bath salts’. Their responses constitute a dizzying array of marketing nomenclature and informal neologisms demonstrating the relative diversity of product appearance across locations and the rapidly changing nature of drug reference. One participant quipped that he guessed bath salts was ‘a square term’ while another explained that the term had become outmoded:

If you go out on the street and ask somebody about bath salt, they won’t know what you’re talking about because that was the first wave… what MDPV and methedrone were (Worm, 33-year-old Caucasian male).

Participants were asked how they refer to SCs or bath salts, generating a multitude of trade names and local terminologies, including, Blue Sky, Cloud Nine, Silky Smooth, Red Dragon, Red Devil, Purple Wave, Ivory Wave, Blue Wave, Crystal Blue, Vanilla Sky, SpongeBob, Cookie Dough, White Dove, White Horse, White Magic, Green Magic, Fire Ant Killer, Shoe Deodorizer, Dunk, Chocolate Syrup, Ghost, Mermaid, Psycho, Blue Hawaiian, Crump, Clean Blue, Clear Blue, White Lightning, Pink Flamingo, Charlie Sheen, Silver Surfer, Go Fast, Orange Mist, Golden Road, Crystals, Snow, Zoom, Bloom, Bliss, Sofa, Drone, Biggie, Tweak, Heaven, Sal (con limón), and Martha Stewart.

The prevalence of color-related brandings appears to derive from what some participants described as their dealers’ practices of ‘dipping’ the crystals (bought in large parcels from internet-based vendors) into colored fragrance solutions, resulting in more easily recognized product lines and brands. The hazard implicit in this practice, several explained, is a false sense of security in one’s product, based not on the core compounds but on superficial adulterants. In the absence of information about the nature of any given sample, however, names and colors are, as a number of participants stated, all that one has to work with:

You know sometimes I’d be kind of leery, they’re coming up with different names for it now, and sometimes I’ll be kind of leery about this shit but, you know if I can find the one that I know by name, then I usually get it. (Soup, 57-year-old Black/African-American male)

Our guess is when you get the different colors it’s just different kinds. I really don’t know a whole lot about the chemicals and all that in it. I guess I should read up on stuff like that. I just know that the different color is a different brand. (Sally, 35-year-old Caucasian female)

Policy Environment & Product Stability

Several participants conceptualized changing drug effects over time as the product of repeat use, not the potential for different compounds with different potencies to be sold under the same umbrella category, as Sally’s experience illustrates:

When we first started doing it, it didn’t make you do all these mean things, but the more you do it the more I don’t know it just triggers something inside of you…It actually makes you want to just eat somebody’s face off.

Similarly, J.J. (30-year-old Caucasian female) explained how, after pleasurable early experiences with bath salts, things had changed dramatically:

It’s [SC] gotten me to the point where I don’t trust people…when I’m on it. I don’t trust my family; I don’t trust people. It’s like constantly feeling like somebody is out to get you, something is coming.

Without evidence to support the theory that changing experiences of SCs should be attributed to changing chemical agents, the varying roles of tolerance, acclimation, and shifting chemical compounds remain pure conjecture, although it is noteworthy that participants like Sally attribute changing effects to variables unrelated to the chemical composition of the drugs themselves.

As Zee (27-year-old Caucasian male), who possessed far more knowledge about the chemical constituents of bath salts than most of the sample, makes clear in the following segment, however, SCs can vary widely in the character and duration of their effects:

For a while there, they were making tons of different chemicals…so that you didn’t have to break the law. And that’s the reason why … you never quite know what you’re getting because it’s all kind of like offshoots of the one type that it was, you know? Because you know, every time I did methedrone, it was great. It was like ecstasy, it was great, like it was so good. But every time I did the bath salts, it was just -- I felt like I was on meth or like crack or PCP. And you know, I just couldn’t help from keep doing it because the comedown was far worse. When I was on methedrone, I felt amazing. But when I was on the other stuff, like I was out of my mind.

Physical/Pharmacological Environment: Cuts and replacements

Figures related to the presence of SCs in amphetamine and cocaine samples in the US and abroad are scant, but a number of participants spoke to the frequency with which methamphetamine and cocaine might be adulterated with SCs. Worm (33-year-old Caucasian male) was the sole participant who spoke as a former dealer for whom SCs had allowed greater profits from methamphetamine sales:

[SC’s] are a lot cheaper [than amphetamine] so we started cutting our Crystal Meth with Bath Salt to make our money bigger. Oh man, the high was awesome

For others, SCs had resulted in problems with accurate identification of cocaine and amphetamine preparations, resulting in unwitting consumption of SCs:

Like I said [Bath Salts] are not my preference, it’s not even really a chosen thing anymore, it just ends up in your hands and you think it’s speed. (Steve, 48-year-old Native American male)

When I was about 20 years old somebody gave it to me. They told me it was cocaine. (Missy, 28-year-old Caucasian female)

Participants recounting initiation stories with SCs often described the claims made by vendors which served to reinforce the connection between widely variant chemical classes:

It’s synthetic cocaine. That it was presented to me like it can’t be detected during a urine test.(Brii, 39-year-old Black/African-American male)

And he was like you all should try this, its legal methamphetamine because it’s what he said. And we were like okay, and so we tried and we liked it. (Sally, 35-year-old Caucasian female)

[Bath salts are] a molecule off meth(amphetamine). And the way I found them was I live close to a Indian Reservation, and they always had that K-2 for sale. Like that fake weed stuff. I asked, you know, you got some meth, like some fake cocaine or something? He said well actually we have this stuff, it’s like a mixture between meth and coke. And I got that and after that I just kept using it every day. (Paul, 28-year-old Caucasian male)

Social Environment: Stigma

Inaccurate product descriptions are clearly linked to economic imperatives in many of our participants’ accounts, but they are also linked to issues of social status and stigma in others. Although the argument has been made that the ‘wily’ packaging for NPS sold in tobacconists, gas stations, and smart shops served to reduce the stigma associated with SCs (Madras, 2016), our participants had either initiated use or continued to use SCs after their legal prohibition, and commentary on the ‘dirty,’ ‘cheap,’ and ‘unpopular’ social valence ascribed to SCs were common. Stories of psychosis, highlighted by the yellow journalism surrounding bath salts served as the backdrop for some of this commentary. As a result of the media and popular conceptions of SCs that were in circulation at the time of data collection, several participants, including Sally above, spoke of the popular conception that SC’s ‘make you eat people’s faces’ (Zee) or ‘put babies in microwaves’ (J.J.) and their concomitant efforts to hide their SC use, even from people who use other substances. William Green (32-year-old Black/African-American male) noted succinctly that ‘Everyone is not fond of it, so I think it’s kind of embarrassing, while Company (48-year-old Black/African-American male) explained that ‘people are really afraid of bath salts because they hear this and they hear that, but they don’t know.’

The stigma surrounding SCs also figures in stories of unwitting SC use initiation, which, as J.J. further explained, sometimes involves deception about the nature of the substance proffered:

Because I was sick off of heroin one day and a friend of mine had actually told me that [he had]…and I did a line of that, I snorted it, I didn’t know what it was. He told me after the fact [that it was SCs] when I had actually started seeing shit.

As with people who use heroin and may choose to inject alone to protect their anonymity, despite the increased risk of overdose mortality when no peers or bystanders are present, people who use SCs can face a dilemma involving the conflicting interests of social status and safety. While the tendency is to hide SC use from others, even those with whom our participants share in illicit drug use, the risks of using alone are clearly described here by one participant::

I prefer to be with somebody [when I use bath salts]. Yeah, I let my limit be on somebody. If I go overboard I want somebody to be there to help me, like the time that I injected it. If my partner wouldn’t have been there he wouldn’t have been there to call 911 for me. (Black, 43-year-old Black/African-American male)

A secondary form of social disapprobation also exists related to individuals’ concerns about their own behavior and fears that they will damage important social relationships. Red (51-year-old Black/African-American male) explained his preference for avoiding others when using bath salts:

I get bad, like just pretty much doing things that get on people’s nerves. You know, acting delirious, acting strange. That’s the way I make some people very uncomfortable.

For Black Boy (53-year-old Black/African-American male) using bath salts with others involved a struggle to “control [his] behavior,” for fear that he might “do something that [he] didn’t want to do…maybe hurting someone”. Concern with one’s treatment of others while using also constituted a major theme running through Sally’s detailed narrative about her changing relationship with SCs and her partner:

It makes me mean and hateful. And I like say a lot of mean and hurtful things. And Bill has got to love me because it just turns me into a monster. It does. I hit him. I throw things at him. Call him names. I mean I do all kinds of things to him.

DISCUSSION

Ample empirical evidence now exists to establish some of the immediate harms related to SC, or bath salt, use. This analysis has sought to explore the environmental underpinnings of those potential harms among a sample of people who use bath salts across four US cities. Findings indicate that market dynamics, federal drug policy, and social stigma represent a confluence of structural factors heightening the risks associated with use of these drugs.

At the level of the SC economy, there appears a stark divide between those whose experiences with SCs are limited to interpersonal transactions and those with histories of accessing online drug markets. Only two of the 39 participants interviewed (see: above quotations from Worm and Zee) demonstrated any understanding of the shifting array of compounds which have been sold in the US, prior to legal prohibition, as ‘bath salts,’ ‘shoe deodorizer,’ or ‘plant fertilizer.’ For the majority of people who use SCs in our sample, confidence in the consistency of products they were consuming were grounded in the names, colors, and (sometimes) aromas by which dealers sought to establish their brands. As several noted, however, these features constituted little proof of a drug’s chemical composition or the varying SC substances available through online vendors, primarily accessed via the internet—through which SCs move, whether as grey-market or fully illicit drugs.

Given the widely differing effects and dosages reported for different cathinone analogues, this instability constitutes grave risk of adverse experiences. A number of participants described episodes of rage, violence or extreme paranoia, while others expressed fears about their own capacity for violence, several making reference to salacious news coverage of a ‘cannibalism’ event in Florida that became national tabloid news. Despite these widely publicized risks, SCs were, for many, described as viable replacements for (crack) cocaine, methamphetamine and even heroin. As a result of personal experiences and familiarity with popular news media coverage of bath salt psychosis, however, participants spoke of SCs as unpopular, even among people who use cocaine, opioids, and amphetamines and discussed the difficult balancing of privacy and safety required. Where solitary use represents a protection of one’s privacy and, potentially, one’s social status, the dangers of solitary use were highlighted, making the stigma surrounding SCs an important dimension of the broader risk environment.

In that sense, for at least some people who use SCs, the combined constraints of a policy environment precluding the establishment of harm minimizing social norms for any given cathinone analogue and a media environment predicated upon sensational violence has resulted in a form of self-monitoring governmentality (Foucault, 1995; Rhodes, 2009). While the concern to undertake solitary use (thus avoiding the potential for violent or otherwise unwanted interactions with others) may ultimately mitigate against some forms of social disorder related to substance use, it does so at the expense of individual safety. As one participant cited above discussing an emergency department visit related to injecting SCs reminded, having others present—particularly when using drugs with a potential for overdose—can mean the difference between life and death in the aftermath of a cardiac event (Carbone et al., 2013; Prosser & Nelson, 2012; Sivagnanam et al., 2013).

As has been noted for MDMA/Ecstasy pills as well (Duterte, Jacinto, Sales, & Murphy, 2009), SCs have been intensely branded post-prohibition, at least in the four cities from which our participants were drawn. And as with MDMA, the appearance and names (as well as the fragrances, in the case of some SC preparations) are often taken to confer some certainty about the nature of the substance being purchased. As those more experienced with drug marketing reminded, however, there is no certainty in branding of this variety, as formulations change rapidly, while branding may remain consistent. Add to this the potential health impacts of smoking, insufflating, or injecting the colorings and fragrances adulterating SCs, and the risks inherent in the SC physical environment become clearer.

While online forums dedicated to discussing the identification and safe use of NPS do exist, our particular sample of people who use SCs was marked by relatively low levels of drug education. Educational capital and access to the internet both likely figured as important background variables, making the social risk environment for SCs a stratified one wherein low-income individuals with lower degrees of education and computer/internet familiarity are more likely to experience harms related to differing dosage-sensitive SCs with potentially widely varying phenomenological effects.

Taken together, these dimensions of the risk environment surrounding street-level SC commerce and use point toward a commercial shift that, in many ways, resembles that of licit markets in the age of the internet. For roughly a decade, market commentators have been discussing Anderson’s theorization of the ‘long tail,’ a term used to describe entertainment media commerce and the increased importance of a larger number of products with greater ‘shelf life’ and a diminished emphasis on ‘hits’ and ‘superstars’ as the sole sources of profit (Anderson, 2006). While most NPS may not be pharmacologically novel (Perrone, 2016), what does appear new about the emergent SC (and synthetic cannabinoid) markets is the enormous diversity of product types and the relative lack of any stable drug commodity of the sort that has conventionally defined drug ‘epidemics’ and subcultures in the U.S. and Europe. Reading online forums at reddit.com devoted to NPS and ‘research chemicals,’ this diversification appears a cause for celebration—and opportunity for greater neoliberal consumer choice and experiential control. Without access to the diverse marketplace for NPS and the online forums for discussing everything from modes of administration and contraindicated drug mixes to dosage and ideal settings for use, however, people who buy SCs in traditional street-level venues appear at far greater hazard of being harmed by the long tail than riding it to greater heights of pleasure and self-exploration.

CONCLUSIONS

Scientific literature and first-hand reports alike confirm the mental and physical health risks associated with use of SCs. These risks are exacerbated, we find, by the social, economic and legislative conditions surrounding the substances. In particular, the current state of blanket scheduling and prohibition practices in the US and Europe compels market transformation and the diversification of drug commodity types, leaving many without the means to verify the nature of the substances being purchased and consumed. In that sense, current drug enforcement policy contributes to what in other industries has been designated the long-tail marketplace—that is, one in which myriad lesser-known commodity forms come to represent a growing share of the market in aggregate. The proliferation of novel SCs could, following numerous anecdotes about the replacement/substitution value of these substances for people who use stimulants, be seen as the grounds for pharmacological research into new maintenance medications or lower-harm alternatives to crack cocaine and methamphetamine, in particular. By effectively designating substances as without any potential medical value in advance of research, current drug ‘analogue’ policies effectively preclude the formation of a traditional illicit drug wherein effects and risk (as well as benefits) can be studied over significant periods of time (Hammersley, 2010; Kau, 2008).

Addressing the need for a new approach to NPS policymaking, one drugs researcher, at least, has argued for a monitoring and forecasting effort to replace the current emergency-based scheduling system in place in both the U.S. and the Europe (Stogner, 2015). Currently, only New Zealand has attempted to implement policies consonant with the critiques of researchers by establishing a regulatory environment in which NPS are studied by a panel of experts and, when deemed relatively unthreatening to public health, regulated, sold, and taxed in carefully controlled economic development zones (Wilkins, 2014a, 2014b). After an interim period during which numerous concerns over the labeling, safety, and advertised potency of synthetic cannabinoids being sold in the regulated marketplace were raised, however, the new policy regime in New Zealand was abandoned (Rychert, Wilkins, & Witten, 2017).

Major policy transformations of this nature may be politically anathema, at least in the U.S. and therefore slow to emerge, and our findings indicate that considerable outreach and educational efforts are needed among communities of stimulant and NPS use to explain issues related to SC’s unique characteristics and the differences between different SC substance types. An innovative intervention targeting dealers might seek to establish the commercial viability of shifting to chemical drug names (e.g., MDPV, Pyrovalerone, Pentelone, Methylone, Mexedrone) to allow individuals to better research effects, dosage, and contraindications online, perhaps by merely explaining the reduced risks to consumers in stable product lines. Finally, harm reduction agencies might explore destigmatizing approaches to SCs that address the very real risks and harms related to their (uninformed) use, while also debunking some of the sensational mythology of violence and death and presenting best practices for testing new SC samples and establishing safe dosages to minimize the risks of adverse physiological and psychological events.