Risk management strategies of synthetic cannabis users

Introduction

This paper will describe the harm reduction (HR) practices of a sample of synthetic cannabinoid (SC) users in four United States cities (Houston, Galveston, New Orleans and NYC). This was a subsample of a larger study on the use and market of synthetic cathinones and other novel psychoactive substances (NPS). SCs are a type of NPS produced to act on the same brain cell receptors as tetrahydrocannabinol, the main active ingredient in cannabis (CDC, 2017). Commonly referred to as “synthetic marijuana,” news outlets report that much of it is produced in Chinese laboratories (Vandrey et al., 2012) and sold in the US.

Negative reactions are prevalent among SC users. Data from the Drug Abuse Warning Network in the US indicates that emergency department (ED) visits related to SCs more than doubled from 2010 to 2011 - from 11,406 ED visits to 28,531 (Bush and Woodwell, 2014). In NYC in 2018, more than 11,000 SC-related ED visits were recorded since January 2015 (NYCDOHMH, 2018). Adverse effects associated with SC consumption include anxiety (Schneir et al., 2011); psychotic symptoms (Every-Palmer, 2011); memory and mood changes (Castellanos et al., 2011); hallucinations, high heart rate and blood pressure, suicide attempts and substance dependence (Hu et al., 2011). In a nationally representative survey of high school students, only 9.4% reported ever using SCs but this group had a higher prevalence of risks associated with substance use and sexual behavior than students who reported only ever using marijuana (Clayton et al., 2017). Long term use of SCs is also associated with withdrawal symptoms such as agitation, irritability, anxiety, and mood swings (Cohen and Weinstein, 2018). Based on these findings, we define harm as adverse health effects.

Measures have been taken by Congress and individual states to ban and control various types of SCs but their use continues (Sacco and Finklea, 2016; Vandrey et al., 2012; Stogner and Miller, 2014). According to the Drug Enforcement Agency (2017), more than 26 SC substances have been listed in Schedule I under the Controlled Substances Act, meaning they have high abuse potential and no currently accepted medical use. SC retailers attempt to evade bans by frequently changing the chemical compounds in their products (Caviness et al., 2015). More than 130 SCs have been identified (Castellanos and Gralnik, 2016). But methods to detect, identify and confirm new SCs lag behind their appearance on the market (Tait et al., 2016), making government supervision difficult. This gives SC producers time to reformulate their products through the inclusion of legal chemicals as a way to evade enforcement efforts (Bannister et al., 2015). An unintended consequence of administrative bans in the US, UK and Australia seems to be the introduction of more potent SC molecules in the drug market, a contributing factor in negative health outcomes (Lamy et al., 2017). In the US, individuals trafficking in SCs may be prosecuted under the Controlled Substance Analogue Enforcement Act, which allows non-controlled drugs to be treated as Schedule I substances if specified criteria are met (DEA, 2017).

Documented reasons for using SCs include: availability, curiosity, perceived legality and affordability (Barratt et al., 2013; Bonar et al., 2014; Lauritsen and Rosenberg, 2016). There is some evidence that individuals who have been arrested are more likely to use NPS, including SCs (Miller et al., 2017). For instance, circumventing legal sanctions attached to positive drug screens of natural cannabis is an important motivating factor for the use of SCs among men under community supervision (Gunderson et al., 2014; Meshack et al., 2013; Perrone et al., 2013; Richardson et al., 2016). Cannabis users may also use SCs as a substitute when cannabis is unavailable or to alleviate symptoms related to cannabis abstinence (Gunderson et al., 2014). Self-reported rates of SC use were at their highest in 2012 and overall prevalence remains relatively low compared to other drugs (DPA, 2018). Some recent research has recorded a decline in SC use in the US, UK and Australia (Lamy et al., 2017; Tellioglu, 2018).

Only a few NPS studies have looked beyond prevalence to user experience and motivation (Chatwin et al., 2017). Limited qualitative research has recorded SC user beliefs and consumption norms (Meshack et al., 2013) and the experiences and perceptions of recovering SC-dependent users (Kassai et al., 2017). Qualitative data on user experiences with SCs and other NPS, including HR practices, is largely limited to online self-reports, Internet forums, instant messaging technology and websites, where demographic data are not provided (Boothroyd and Lewis, 2016; Boyer et al., 2007; Corazza et al., 2014; Davey et al., 2012; Kaló et al., 2017; Newman et al., 2016; Soussan and Kjellgren, 2014; Van Hout and Hearne, 2015). While contributing to the qualitative literature on NPS user experiences, these studies may not reflect the diversity of the population, such as those who do not participate in online forums and members of racial/ethnic minority groups.

Survey research has not captured the extent of SC use among non-white populations such as Black/African Americans (B/AA) (a group heavily represented in our sample). Studies in this area are either incomplete (see Gunderson et al., 2014) or inconclusive (see Palamar et al., 2017; Stogner and Miller, 2014). While contributing to our knowledge of SC use among different groups (students, young adults, cannabis users), it is difficult to gauge SC use among B/AA from these studies. Our sample is too small to fill this gap in the literature; data from our study, however, provides in-depth insight into SC use, especially HR practices, among a group of B/AA SC users.

There is a rich literature on the HR practices of a wide range of drug users, including those who consume opiates (Zinberg and Jacobson, 1976; Zinberg, 1984; Blackwell, 1983; Shewan and Dalgarno, 2005), cocaine (Cohen and Sas, 1994; Decorte, 2001; Reinarman et al., 1994; Waldorf et al., 1992) cannabis (Lau et al., 2015) and ecstasy (Allott and Redman, 2006; Jacinto et al., 2008; Panagopoulos and Ricciardelli, 2005). NPS users have developed support structures, cared for their drug using-using peers and shared HR information on darknet cryptomarkets and other online communities (Bancroft, 2017; Masson and Bancroft, 2018; Van Hout and Hearne, 2017 ; Van Schipstal et al., 2016). No study to date has investigated HR strategies among SC users specifically.

Marlatt (1996) posits that HR “emerged primarily as a ‘bottom-up’ approach based on addict advocacy, rather than a ‘top-down’ policy” (786). There are competing definitions of harm reduction in the literature. Lenton and Single (1998), referring to programs, interventions and policies, describe HR as having three components: 1) to reduce drug related harm instead of reducing drug use; 2) strategies are included to decrease harm for individuals who continue to use drugs; and 3) actions are included “to demonstrate whether harm is reduced, or likely to be reduced (217).” Collins et al. (2012) provides a broad definition: an overarching humanitarian attitude that has led to a set of pragmatic and humane approaches that aim to reduce harm deriving from “health-related behaviors that are considered to put the affected individuals and/or their communities at risk for negative consequences (6).” Finally, Harm Reduction International, advocating a social justice and human rights perspective, states that HR “refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws.” These differing definitions highlight a tension between two perspectives of HR: a medical approach to support and minimize harm to individuals vs. a more activist outlook that perceives HR “as a platform for broader and more structural change (Roe 2005: 244).”

For example, Smith (2012) points out the concern among advocates that public health officials’ emphasis on institutionalized HR (i.e. policy, prevention and treatment programs) can potentially disregard the voice of user-driven movements (Collins et al., 2012). The strategies discussed in this paper represent the “bottom up” approach. The SC users we interviewed may not have directly expressed their use practices as HR and were not organizing politically, but they sought to reduce risk to themselves and others through strategies embedded in day-to-day use.

Methods

This paper is based on focus groups that were components of a larger study on the use and market of synthetic cathinones conducted in NYC, New Orleans, Houston and Galveston. Parent study baseline interviews showed that 59% of 60 participants reported current or past use of a SC product. Such prevalence prompted the investigators to initiate focus groups to explore SC use patterns in greater depth. Research staff conducted focus groups instead of interviews and surveys because SCs were not a focus of the parent study and resources were limited.

Individuals were recruited for the focus groups in all four study sites through targeted and referral sampling. Field staff recruited from service agencies, public spaces where drug users are known to congregate and by applying snowball sampling. Potential focus group participants screened eligible if they used SCs within the past 30 days and consumed it at least once a month in the past 12 months. Consumption of synthetic cathinone was not a requirement for these focus groups.

Twenty individuals participated in focus groups (4–5 individuals per group). Perhaps because we recruited in cities where minority populations are overrepresented, two-thirds of our sample identified as Black or Hispanic. Nearly three-quarters were men (see Table 1).

Table 1.

Demographics

	Synthetic Cannabinoid Users
Mean Age	35.7
Race/ Ethnicity
Black	12
White	7
Hispanic	1
Native American	0
Gender
Male	14
Female	6

Most participants reported an annual income below $25,000, had some or completed high school and were employed or received some form of public assistance: (Table 2)

Table 2.

Education and Income

	Synthetic Cannabinoid Users
Education
> High school	4
GED	2
HS diploma	4
Some college	6
College degree	0
Attending Now	0
Vocational/Tech	1
Missing	3
Unemployed	0
Main Source of Income
Employment	5
Public Assistance	2
Disability	4
Unemployment	0
Social Security	0
Drug Sales	2
Other	3
Missing Data	4

Before each session, participants provided written consent after staff explained study goals and confidentiality policies. These include an NIH-issued certificate protecting participants from legal exposure for disclosing most illicit behavior and participant-chosen pseudonyms. Research staff were also prepared to make referrals to drug treatment programs upon request. The focus groups were digitally voice-recorded and all audio files were transcribed, cleaned and entered into our database.

We employed a grounded theory approach, taking multiple passes through the data and using systematic inductive analysis to develop a conceptual framework for understanding risk management among SC users (Charmaz, 2014). During the initial coding stage, the first author closely reviewed focus group transcripts and labeled data fragments that mentioned HR practices (i.e. participants spoke about how they kept themselves safe) or were related to HR strategies (e.g., discussion of product content). During the focused coding stage, the first author established the adequacy and conceptual strength of initial codes (Charmaz, 2014) by using the most frequent and/or significant initial codes to sort, synthesize, and conceptualize data (Charmaz and Belgrave, 2012) . From these codes, the first author developed tentative themes and continued coding occurred until no new properties of these themes materialized. The second author coded transcripts independently and confirmed themes reflecting risk awareness and recurrent HR behaviors.

Results

The majority of focus group members were heavy users of SCs: 60% used 6 to 7 days per week and 20% used 2 to 4 days per week. Half (50%) purchased SCs from general grocery stores or smoke shops. The second most popular method (25%) of acquiring the drug was from friends. This included a friend sharing one’s SCs with the participant or the friend buying it ahead of time and being reimbursed when peers came together to smoke it. One-fifth (20%) bought SCs through dealers. Participants smoked their SC rolled in standard cigarette paper (50%), also known as a joint, or wrapped in tobacco leaves (45%), called blunts. Participants also reported smoking through pipes (10%), hookahs (5%), and bongs (5%). They also reported using other substances: (Table 3)

Table 3.

Substances Used

Drug Used	Number of Focus Group Participants
Marijuana	13
Alcohol	6
MDMA	3
Crack	2
Xanax	2
Methamphetamine	1
Synthetic cathinones	1
Cocaine	1
Tramadol	1
Promethazine with codeine	1
Drank/lean (slang words for combination of prescription cough medicine, soft drinks, hard fruit-flavored candy)	1

Motivations for use varied, but participants most frequently cited substituting for marijuana and circumventing drug testing under community supervision: (Table 4)

Table 4.

Reasons for consuming SCs

Motivation for using SCs	Percentage of focus group participants
Did not describe their motivations	4
Drug testing because of community supervision	5
Drug testing because of work	1
Going along with what peers were doing	1
Likes the feeling	1
Relaxing	1
Substitute for marijuana	5
Substitute for pain pills	1
Substitute for marijuana to encourage partner’s efforts to not smoke marijuana because he was tested for drugs at his workplace	1

Focus group members often referred to SC products as K2, Spice and Mojo, names widely used as generic shorthand for all SCs in the US. Participants in NYC often spoke of K2 and respondents in the southern cities were more likely to mention Spice and Mojo.

Participants were well aware of the harms associated with SCs, not only through media but through their own experiences and the experiences of others in their social and drug-use networks. They created strategies for reducing risks to health and safety, in two broad categories: purchasing and consumption.

Purchasing

Far from being naïve users, respondents recognized that there was inconsistency in product quality and composition. They were also aware of possible drug adulteration and substitution by dealers and, consequently, were suspicious of packaging. JB (NYC male, 34) spoke about the constant change in product labels:

JB: You’ll be broke tryna to keep up with all these crazy names and the popularity and the images they put on ‘em just to attract you, to manipulate you.

Angel (Houston female, 46) talked about how packages were labeled with images of non-criminalized plants (such as lettuce) to give a misleading impression:

Angel: What gets me is on the back of ‘em (the packages) they always tell you like what the herbs are that’s in the bag, but they never tell you what’s actually sprayed on it.

Interviewer: So do you think that what’s on the back is really what’s in the bag?

Angel: No, I just think that’s what they put on there to be legal so that they have a legal product to sell.

Participants also observed that the chemical composition of SC was not reliable:

Red (Houston male, 47): And sometimes you buy, you think you’re getting Bubble Gum and you’re getting something mixed and you’re not really happy with that.

Jay (NYC male, 30): You don’t know what you’re gonna get in that batch…the difference is chemically. They always have to switch it because the tests are coming.

JB (NYC): You know, whoever manufactures it or make it, they’re – it’s not the same in every batch. That’s just the way it is.

Some users responded to product instability and adulteration by carefully selecting SC sources and brands and going to some effort to purchase what they believed were safer products:

Steve (NYC male, 69): Like I’m in the Bronx and I have no shame, I go all the way to Brooklyn to get mine…because I know what I’m getting.

Similarly, Ms. NoGood (Galveston female, 40) made sure to carefully select her dealers:

Ms. NoGood: I don’t buy it from everybody. You can’t buy that from everybody, because for one thing, some people mix it all together and be acting like “Oh, I got this-this good stuff,”…but it’s not good, it’s just they mix it all and make you think you got a real high but it’s really messing you up, you know, mixing all that different stuff together.

Others applied a form of brand loyalty while maintaining an awareness of the constant changes in the chemical makeup of SC products:

JB (NYC): Stick to what you know. Stick to the script…if you know, you bought that one brand – even though it changes, eventually that batch itself, it changes all the time, but that one brand, I would stick with that one brand.

Steve (NYC): If I get a batch and if it’s a good – the batch is good, I’ll stay with that until it really falls out of favor with me.

Some individuals chose to have more control over the handling of their SCs:

Weezy (Galveston male, 24): I’mma be right there while they rolling it. Cause you know you got some dirty people around this area. They’ll slip – they’ll slip something up in your square [cigarette] or something. That’s why I roll my own stuff…I don’t let nobody roll nothing for me.

While they may not have been able to list the chemical components of the SCs they were using, participants were aware of product inconsistency and potential chemical substitution and developed various strategies to reduce risk in the purchasing and handling of SCs.

Consumption

Participants also applied HR strategies to SC use, such as limiting how much they consumed in one sitting:

Locs (New Orleans male, 19): I don’t have that much that I smoke to run out. Like I smoke a little bit out of bowls, so I never like get sick.

Weezy (Galveston): It’s different for different people…I see some people just be smoking it back to back…I can’t do it like that. If I smoke one, I’m through.

An alternative strategy was to manage the spacing rather than the quantity of use in one session. Tommy (Houston male, 54), altered his consumption pattern after a bad experience:

Tommy: I don’t really smoke a whole one by myself ‘cause I reflect back on that one time they said I almost had a seizure, so I’m probably, you know, self-consciously try to be aware of that. But now I don’t do like 3 hits. I’ll do one hit and then I’ll wait a few minutes.

Spacing out the smoking of “foints” (a combination of the words fake and joints as some users refer to SCs as fake marijuana) was also practiced in groups. Angel (Houston female, 46) and Red (Houston male, 47) described how this occurred:

Angel: A lot of times like I’ll have a foint and you’ll have a foint and Red’ll have a foint, so you know we’ll smoke mine, an hour later we’ll smoke yours, an hour later we’ll smoke Red’s, you know?

Red: We could stay stoned that whole time when it’s spreaded out. We smoke 3 joints (back to back), we smoked way too much…we’re gonna have a seizure or something. Somebody’s naked running the street.

Some users managed risk by temporarily stopping use:

Locs (New Orleans): I be trying to clean up Sunday because I be going hard throughout the week…I be smoking a lot of bongs.

Participants also employed strategies related to the setting of use. For instance, Weezy (Galveston) smoked in groups as a way to use less of his preferred SC product:

Weezy: I ain’t fittina [going to] just sit up there and smoke no whole Serenity [an SC product] square by myself. No, I can’t do that. If it’s 4 or 3 of us we could pass it and I hit one time and pass and he hit it about 5 or 6 times or she hit it about 7 and 8 times and I hit once and keep passing it.

Using with others also provided protection against adverse effects, as Peter (NYC male, 43) reported:

[W]e watch each other. So if someone is looking like they are not -- they are not having fun anymore, we will call them out and say, “Hey, are you okay? Are you fine? Are you okay with this?” If they’re saying, “Okay,” we’ll just keep it going but if they keep on well we’re just – you can tell, you can see…if they are going off the deep end or something with K2 then we’ll stop and we’ll stop them and say, “That’s enough for you.”

However, using SCs in groups was not considered protective if the other members were strangers, as JB (NYC) explained:

With K2, because the familiarity of using different types of K2 with different people that you’re not familiar with has dangerous effects. Major dangerous effects that I’ve witnessed.

In other words, using SCs in a group of strangers may increase the risk of consuming an unknown product. JB smoked only with people he knew and who were aware of his choice of product.

More broadly, strangers are to be avoided whether in groups or not:

Angel (Houston): If I don’t know you I’m not gonna buy with you…Like these people, I’ve known Red 20 years, you know? If I just met you I wouldn’t smoke with you cause that stuff you never know, it’s a hit and miss.

For one participant, smoking alone reduces risk for others:

Jay (NYC male, 30): I usually smoke it by myself. I really don’t like to smoke it around other people. I wouldn’t wanna be the influence or be the reason why that person smoke with me because I’mma tell them to smoke and then something happens to them.

Another way to reduce risk is to refrain from combining SCs with other substances:

Ryse (New Orleans male, 27): I found out that if you use more with it, any other type of drug, it can like send a shock to your body and cause you to go into a seizure and stuff like that. So you know, when I’m using Mojo, I pretty much kind of keep it isolated from any other drugs.

Ryse learned this from a friend’s experience.

One of my friends, he was into heroin, and he mixed it, and after he did the heroin, he wanted to smoke marijuana, but he couldn’t smoke marijuana, so he substituted with Mojo, and that caused his body to go into shock, and he went into a seizure, and died. But they had to bring him back to life. So when he went to the hospital, that’s what the doctor told him, that you know, it was the Mojo mixed with the heroin that triggered you know, his body to shut down on him.

NeeNee (Galveston female, 28) believed that avoiding use of SCs with other substances had protected her from seizures, despite having a chronic disease.

No, I don’t mix it…People was doing other drugs on top of that, that’s what was making them trigger and trip. Like the whole time I smoked it I never had no kind of episodes. And I have diabetes on top of – So people was saying they was passing out, I’m like well I was smoking it for five years and I never had none of those episodes. Come to find out they was mixing drugs; you can’t mix that with other stuff.

Participants were aware that interpersonal conflict and perhaps violence pose additional risks while consuming SCs. For example, Angel (Houston) described sharing norms:

I’ve seen a lot of arguments and fights if like I had rolled the last foint and...didn’t smoke it with Red. Red’d be all pissed off about it...We’d be arguing about well, you know, damn you knew it was the last one, why didn’t you wait for me? Inconsideration, you know?

Sharing the last foint demonstrated respect and reduced tension. In a related vein, Peter (NYC) described how users try to protect each other by disseminating information about “good” and “bad” SC:

We watch each other and we have other people that do smoke K2, not with us directly but my -- maybe neighbors or other friends and live in other communities that also smoke or say, “Hey try this one’s good. We had a good time with this one and --” Even if it’s not just with them but within my own circle, my home or my community, we watch each other, we – we inform each other about, “Don’t touch this, don’t touch that or buy this one.”

Networks were therefore important for avoiding potentially dangerous products and network members did not have to smoke together to share information.

The HR strategies described in this section ranged from moderating quantity and pace of SC use to having as much control as possible over the setting of one’s SC consumption. Participants also applied other HR practices such as refraining from polysubstance use, sharing SCs to prevent conflict among group members and disseminating information on SC products. These approaches represent “bottom-up” HR because they were created and implemented by SC users.

Key Findings

A key finding of this qualitative study is that SC users actively create and practice HR strategies in two general categories: purchase and use. Highly aware of inaccurate packaging and manipulation, they were selective of their retail sources, used one brand consistently and handled their own SCs. They managed how much they consumed in one sitting, regulating the pace of consumption and using in a group or alone. They also refrained from combining SCs with other substances. Finally, they strove to reduce interpersonal conflict and circulate messages about potentially harmful versions of SCs. Future research could include larger HR studies with diverse samples in order to expand our findings. In addition, studies that explore the SC market would augment our focus on users and provide insight into how suppliers may or may not contribute to HR activities.

Discussion

Although overall prevalence of SC use has been declining in the US, media outlets have reported recent spikes in SC-related overdose and other serious harm in several cities (Cooney and van Dorn, 2018: Medrano, 2017; Penaloza, 2018). These overdoses may be related to the chemical reformulation of SCs by producers as a way to stay ahead of government surveillance. Qualitative research on NPS user experiences and motivations remains limited (Chatwin et al., 2017) and, to a great extent, based on online data. This paper fills a gap in the literature by documenting HR strategies among a subset that has largely been left out of recent NPS research: low-income, non-white users of SCs. Our use of focus groups complements existing qualitative NPS literature that draws from online sources.

The safeguards described in this paper are similar to protective techniques, including informal mechanisms of quality control, employed by other drug users. Interviewees communicated safety strategies with one another, including which SC products to avoid because they were either too strong or too dangerous, not unlike the support infrastructures NPS users have created in cryptomarkets (Bancroft, 2017; Van Hout and Hearne, 2017; Masson and Bancroft, 2018). In group settings, SC users collectively looked after one another during use and monitored for evidence of danger to group members, similar to shared decision-making documented among ecstasy users (Panagopoulos and Ricciardelli, 2005). SC users in this paper developed and applied HR practices in their everyday SC consumption. While not describing themselves as HR activists, they were informed users who exemplify the bottom-up conceptualization of HR through their creation of practical strategies to address immediate concerns about risks to health.

Other HR strategies can contribute to tailoring effective prevention/risk reduction messages and/or interventions specifically for NPS users. In the face of product inconsistency and contamination risk within the NPS market, focus group members reported developing risk-reduction efforts such as disseminating data on SC products, including descriptions of particular brands and risks to health that result from their use. The use behaviors and experiences described by participants can aid in the construction of ‘best practices’ informational materials that can be shared with other SC users; service providers and drug researchers should learn from them in order to build effective interventions and explore new areas of research.

The small sample size is a limitation of this study, although the in-depth qualitative data that results from relatively small samples is appropriate for exploratory analysis. Most of our participants were B/AA and low-income, which may limit relevance to a broader population. Typical interactive aspects of focus groups such as dominant participants and reproduction of normative discourses may have narrowed the scope of data collected.

The constantly changing composition of SCs (and other NPS) is directly related to rapidly evolving prohibitions on whatever new formulas emerge as NPS chemists attempt to replace banned substances. This creates confusion and potential harms for consumers (Elliott et al. 2018), making HR messaging even more vital. Prohibitionist approaches to SCs also drive users “underground” which may limit HR education outreach by peers and service organizations. Policy makers should consider the experiences and practices of SC users (including those constructed to keep themselves safe) when addressing SC consumption.