Shifting Awareness among Electronic Dance Music Party Attendees that Drugs May Contain Fentanyl or Other Adulterants

Abstract

Background:

Drugs like ecstasy, cocaine, and counterfeit prescription pills can contain fentanyl. We examined knowledge about potential adulteration/contamination of such drugs among people attending electronic dance music (EDM) parties.

Methods:

Adults in New York City were surveyed entering randomly selected EDM parties during the summers of 2018 (n=1,029) and 2019 (n=559). Surveys assessed perceptions that: 1) ecstasy/Molly can contain adulterants more dangerous than MDMA, 2) cocaine can contain fentanyl, and 3) prescription pills from non-pharmacy sources can contain fentanyl. We compared prevalence of perceptions between 2018 and 2019.

Results:

Prevalence of agreeing that cocaine can contain fentanyl increased from 42.1% to 58.6%, a 39.2% increase (p=.003). Increases in agreement were not significant regarding ecstasy potentially containing adulterants (55.0% vs. 59.0%) and non-pharmacy prescription drugs potentially containing fentanyl (46.8% vs. 52.9%). Those reporting past-year ecstasy use in particular reported increased agreement that ecstasy can be adulterated (from 52.9% to 80.0%, a 51.2% increase; p<.001) and those reporting past-year cocaine use reported increased agreement that cocaine can be adulterated (from 48.2% to 70.7%, a 46.7% increase; p=.016).

Conclusions:

Knowledge of potential adulteration or contamination of commonly used drugs in this high-risk scene is increasing. Continued education about possible drug contents is needed.

Introduction

Electronic dance music (EDM) party attendees are at high risk for synthetic drug use and drug-related adverse effects (Palamar, Acosta, Le, Cleland, & Nelson, 2019). The use of ecstasy (3,4-methylenedioxymethamphetamine [MDMA]), also known as Molly when in powder or crystalline form, is well-documented in this population of festival and nightclub attendees (Krotulski, Mohr, Fogarty, & Logan, 2018; Palamar & Keyes, 2020). While ecstasy and cocaine are known to be associated with a wide range of adverse effects, including poisonings and deaths (Palamar et al., 2019; Parrott, 2013), another potential risk associated with the use is adulteration or contamination with other synthetic drugs. Synthetic cathinones (known as “bath salts” in the US) in particular have been detected as adulterants in ecstasy over the past decade, and may increase the risk of adverse effects associated with use when used unknowingly or in combination with ecstasy (Oliver et al., 2019). Illicitly manufactured fentanyl, which has been found to be the primary driver behind recent increases in drug overdose deaths in the US (O’Donnell, Gladden, Mattson, Hunter, & Davis, 2020), has also been increasingly identified as an adulterant in both powder cocaine and counterfeit pharmaceutical pills (Arens et al., 2016; DiSalvo et al., 2020), which heightens the risk of overdose especially among those who may lack opioid tolerance. Given that EDM party attendees are at high risk for exposure to such adulterants, research is needed to determine whether they are aware of this potential for being exposed.

Nightclub and festival attendees in the eastern US in particular have been shown to be at high risk for unintentional exposure to synthetic drugs as adulterants. A study of attendees at four EDM festivals in Florida and Georgia found that novel stimulants were detected in 12–34% of oral specimens of those reporting recent ecstasy use (Krotulski et al., 2018). Studies of adults attending EDM parties in New York City (NYC) who reported past-year ecstasy use have similarly detected extensive unknown exposure to synthetic cathinones via hair testing (Palamar et al., 2017). Two cases of unintentional exposure to fentanyl were also discovered in this population among participants who did not report heroin use, but who reported use of ecstasy and/or cocaine (Palamar, Salomone, & Keyes, 2020).

Due to high potential for both known and unknown synthetic drug use and associated adverse outcomes, EDM party attendees represent an important study population to target regarding prevention and harm reduction. Little is known, however, regarding the extent to which attendees are aware of the risk of drug adulteration/contamination, and even less is known about how this awareness has changed over time. While studies suggest many individuals who use opioids are concerned about fentanyl exposure (Jones, et al., 2018), it is unclear if EDM attendees who are more likely to use party drugs share this concern regarding the potential for exposure through the use of ecstasy, cocaine, or pills from non-pharmacy sources. This is important because the prevalence of use of cocaine and various other drugs among EDM party attendees in NYC significantly increased from 2016 to 2019 (Palamar & Keyes, 2020), suggesting that this group may be at increased risk for exposure to adulterants.

In this report, we examine shifts in agreement among EDM party attendees regarding the potential for adulteration of ecstasy, cocaine, and pills from non-pharmacy sources between 2018 and 2019. Results can help inform prevention and harm reduction among members of this population who are at risk for unintentional exposure to adulterants.

Methods

Procedure

This study utilized time-space sampling to recruit participants. Each week, EDM parties were randomly selected and attendees about to enter selected parties were surveyed. Although party selection was random, we aimed to survey as many eligible individuals as possible, so random selection only occurred at the design stage. Each week, a party list was constructed based on parties listed on a popular EDM ticket website and on nightclubs known to have EDM parties on specific nights. Recruitment was conducted from June through September in 2018 and 2019, and recruitment typically occurred on 1-2 nights per week on Thursday through Sunday. Individuals were also surveyed outside of a large EDM dance festival each year in late summer. To be eligible, individuals must have been age ≥18 and about to enter the selected party. Individuals about to enter parties were approached by recruiters and asked if they were willing to take a survey about drug use. Participants provided informed consent and self-administered the anonymous survey on a tablet. In 2018, 1,029 participants were surveyed over 24 nights with a survey response rate of 74.1%, and in 2019, 559 participants were surveyed over 26 nights with a survey response rate of 76.9%. This study was approved by the New York University Langone Medical Center institutional review board.

Measures

Participants were asked about demographic characteristics and frequency of past-year EDM party attendance. They were also asked about past-year use of a variety of drugs including ecstasy/Molly/MDMA, powder cocaine, and nonmedical use of prescription benzodiazepines and opioids. Nonmedical use was defined for participants as using without a prescription or in a manner in which it was not prescribed (e.g., to get high). We focused on these drugs and drug classes in this analysis as these were the drugs we later asked participants about with regard to knowledge of adulteration.

After being asked about use of various drugs, participants were asked about their level of agreement regarding three statements: 1) “Drugs like ecstasy/Molly can actually contain drugs more dangerous than MDMA”, 2) “Some dealers sell cocaine containing fentanyl”, and 3) “Pills from non-pharmacy sources that look like Xanax or Percocet can contain fentanyl”. Answer options were “strongly disagree”, “disagree”, “neutral”, “agree”, and “strongly agree”, and we recoded responses into a binary variable indicating “agree” (including “strongly agree”) versus all other responses.

Statistical Analysis

We first compared participant characteristics between 2018 and 2019 and tested for potential differences using chi-square. We then estimated differences in agreement with the three statements about drug adulteration between 2018 and 2019. This was done for the full sample and then stratified by demographic and drug use characteristics. Differences in prevalence between years according to participant characteristics were examined using logistic regression with interaction terms to determine whether there were log-linear associations between agreement and time. Relative changes in percentage reporting agreement to each item were also calculated.

In order to ensure that estimates were more generalizable to the NYC EDM party-attending population, we utilized sample weights. These weights were based on the proportion of attendees who completed a survey (out of the number of passersby counted entering the party on the night of survey via a clicker) and each surveyed individual’s self-reported frequency of EDM party attendance. This was done because those attending venues with a higher proportion of attendees surveyed and those attending parties more frequently are believed to have a higher likelihood of being sampled. Parties were accounted for as strata when specifying the complex survey design. Data were analyzed using Stata 13 SE and survey commands were used to generate estimates.

Results

Sample characteristics are presented in Supplemental Table 1. In both 2018 and in 2019, the majority of participants identified as male and heterosexual, and the majority reported having a college degree. The percentage of those reporting past-year cocaine use increased (p=.004). Changes in agreement that drugs can be adulterated (via the full Likert scales) are presented in Supplemental Table 2. Among all levels of all measures, only strong agreement that cocaine can be adulterated significantly shifted across years, from 17.6% in 2018 to 33.4% in 2019—an 89.8% increase (p<.001).

Table 1 presents estimates of agreement that ecstasy, cocaine, and pills from non-pharmacy sources can contain fentanyl or other more dangerous drugs. With respect to ecstasy, overall agreement was 55.0% in 2018 and 59.0% in 2019, which was not a significant shift (p=.479). Between 2018 and 2019, prevalence of agreement increased among young adults (a 37.5% increase, p=.019), Asian participants (a 77.6% increase, p=.003), those with some college (a 49.7% increase, p=.007), those identifying as bisexual or other sexual identity (a 69.7% increase, p=.003), and those reporting past-year ecstasy use (a 51.2% increase, p<.001). Prevalence of agreement decreased among Hispanic participants (a 39.7% decrease, p=.045).

Table 1.

Agreement that ecstasy, cocaine, and non-pharmacy-sourced prescription pills can be adulterated with fentanyl or more dangerous drugs, 2018-2019

	Ecstasy can contain drugs more dangerous than MDMA			Some dealers sell cocaine containing fentanyl			Pills from non-pharmacy sources can contain fentanyl
	2018 Weighted %	2019 Weighted %	Relative Change %	2018 Weighted %	2019 Weighted %	Relative Change %	2018 Weighted %	2019 Weighted %	Relative Change %
	Full Sample	55.0	59.0	7.3	42.1	58.6	39.2**	46.8	52.9	13.0
Sex
Male	57.8	59.8	3.5	41.9	58.7	40.1*	47.3	54.8	15.9
Female	50.6	57.5	13.6	42.3	58.3	37.8	46.0	49.6	7.8
Age
18-23 years	50.7	69.7	37.5*	46.8	67.3	43.8*	43.0	66.2	54.0**
24-27 years	48.2	53.9	11.8	37.8	52.1	37.8	48.3	45.0	−6.8
≥28 years	67.4	54.0	−19.9	40.7	56.5	38.8	49.8	48.0	−3.6
Race/Ethnicity
White	55.8	64.2	15.1	46.7	61.1	30.8	51.2	60.2	17.6
Black	67.3	54.3	−19.3	46.9	43.3	−7.7	59.6	51.4	−13.8
Hispanic	60.2	36.3	−39.7*	37.6	61.7	64.1	41.3	44.0	6.5
Asian	43.3	76.9	77.6**	33.4	59.1	76.9*	35.1	52.1	48.4
Other/Mixed	43.5	55.7	28.0	39.9	58.8	47.4	44.7	46.9	4.9
Education
College Degree	56.2	51.9	−7.7	41.3	53.7	30.0	46.3	45.8	−1.1
Some College	53.5	80.1	49.7**	42.6	70.5	65.5*	50.1	72.3	44.3*
High School or Less	53.2	64.2	20.7	43.8	65.3	49.1	44.3	60.3	36.1
Sexual Orientation
Heterosexual	53.5	58.0	8.4	43.2	59.5	37.7**	48.3	53.0	9.7
Gay/Lesbian	67.6	53.5	−20.9	20.4	37.7	84.8	36.8	35.4	−3.8
Bisexual/Other	50.5	85.7	69.7**	66.9	85.0	27.1	46.8	86.0	83.8**
Past-Year Drug Use
Ecstasy	52.9	80.0	51.2***	35.4	52.0	46.9	41.2	55.3	34.2
Powder Cocaine	64.9	70.0	7.9	48.2	70.7	46.7*	52.9	65.7	24.2
Benzodiazepines	79.1	94.4	19.3	42.8	65.1	52.1	63.6	65.7	3.3
Opioids	61.9	62.0	0.2	45.9	61.5	34.0	58.9	65.0	10.4

Note. Opioids refers to prescription opioids. Benzodiazepines and prescription opioids refer to nonmedical use. Differences in prevalence between years according to participant characteristics were examined using logistic regression with interaction terms to determine whether there were log-linear associations between agreement and time. Asterisks reflect significant changes in prevalence between 2018 and 2019.

^*p < .05,

^**p < .01,

^***p < .001

With regard to cocaine (Table 1 continued), overall prevalence of agreement significantly increased from 42.1% in 2018 to 58.6% in 2019, a 39.2% increase (p=.003). Significant increases were detected among males (a 40.1% increase, p=.021), young adults (a 43.8% increase, p=.015), Asian participants (a 76.9% increase, p=.040), those with some college (a 65.5% increase, p=.023), those identifying as heterosexual (a 37.7% increase, p=.009), and those reporting past-year cocaine use (a 46.7% increase, p=.016). Finally, with respect to prescription pills, overall agreement was 46.8% in 2018 and 52.9% in 2019, which was not a significant shift (p=.276). Within subgroups, between 2018 and 2019, agreement significantly increased among young adults (a 54.0% increase, p=.006), those with some college (a 44.3% increase, p=.045) and among those identifying as bisexual or other sexuality (an 83.8% increase, p=.001).

Discussion

We examined agreement among EDM party attendees regarding the potential for ecstasy, cocaine, and pills from non-pharmacy sources to be adulterated or contaminated with fentanyl or other drugs. We focused on this population because they are at high risk not only for use of various synthetic drugs, but also for unintentional exposure to adulterated or contaminated party drugs. We estimate that currently, about half of EDM party attendees (42-59%) are aware that ecstasy, cocaine, and/or prescription drugs from non-pharmacy sources can contain more dangerous drugs.

Although agreement remained stable with respect to ecstasy and prescription drugs from non-pharmacy sources containing adulterants, agreement that cocaine can contain fentanyl significantly increased between 2018 and 2019. Participants who used cocaine in particular increased agreement over time, similar to how participants who used ecstasy were more likely to agree that ecstasy can be adulterated across time. Multiple scientific reports have warned about cocaine containing fentanyl (e.g., DiSalvo et al., 2020), but most were published after this study was conducted. However, in June 2017, the NYC Department of Health and Mental Hygiene (DOHMH) issued alerts to bar-goers in NYC that cocaine may contain fentanyl, and in May/June 2018, it piloted an awareness program in bars (Allen et al., 2020; NYC DOHMH, 2017, 2018). Dissemination of this information directly targeting those at highest risk for recreational cocaine use might have helped better educate people who use in NYC, although dissemination began prior to 2018 recruitment for this study.

This study also determined that knowledge of potential adulteration increased across various demographic subgroups. Participants in the youngest age group (age 18-23) and those reporting having attended some college in particular tended to increase agreement that each drug class can be adulterated. It is unclear whether some college education was directly related to increased agreement, but this shift may be driven, in part, by a sizeable portion of those with only some college being younger.

Limitations

Results of this study are limited to adults entering EDM parties in NYC so results may not be generalizable to individuals outside of such scenes. Likewise, NYC is somewhat unique in that the NYC DOHMH has specifically targeted nightlife populations with warnings that cocaine can contain fentanyl and thus may further limit generalizability to other cities. Past-year cocaine use significantly increased between 2018 and 2019, and this increase could have contributed to increased agreement that cocaine (or other drugs) can be adulterated.

Conclusion

This was among the first studies to examine knowledge about potential adulteration or contamination of drugs in a high-risk scene. Knowledge among this high-risk population that drugs can be adulterated is increasing, particularly among select subgroups, but relatively large portions of individuals appear unaware that the drugs they may be using can contain adulterants more harmful than the drugs they believe they are using. Better prevention education about possible drug contents is needed, and this needs to be targeted towards those at risk for use in particular. Such drug education within nightclubs in the US, however, is often hampered due to fear of prosecution under the Illicit Drug Anti-Proliferation Act of 2003 (a.k.a.: the “RAVE Act”) (Palamar, Acosta, Sutherland, Shedlin, & Barratt, 2019). Leniency regarding promotion of drug education and harm reduction services such as drug checking inside high-risk venues could likely further increase awareness that various drugs used in such scenes can be adulterated or contaminated with dangerous drugs.