826079

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JODXXX10.1177/0022042619826079Journal of Drug IssuesSmith and Stoops

Original Articles
Journal of Drug Issues

Synthetic Cathinone Use Among

1­–18
© The Author(s) 2019
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DOI: 10.1177/0022042619826079
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Taking or Preferred Drug of Abuse?

Kirsten E. Smith1,2 and William W. Stoops1

Abstract
A survey pertaining to synthetic cathinone (SC) use was completed by 499 polysubstance
users enrolled in a residential recovery program in the Southeastern United States. Of the
final sample, 28% reported ever SC use. SC-users, compared with nonusers, were more often
younger (32.7 vs. 36.0, p = .001), White (93.4% vs. 80.8%, p = .001), and on probation/parole
since 2010 (80.9% vs. 70.9%, p = .032). SC-users evidenced extensive drug histories and were
less likely to be enrolled in an urban-based program, compared to a rural, Appalachian-based
program (73.8% vs. 86.6%, p = .001). Use of synthetic cannabinoids (adjusted odds ratio
[AOR] = 1.9, p = .044), kratom (AOR = 1.7, p = .045), and inhalants (AOR = 2.3, p = .001)
were significantly associated with SC use. Approximately 23% of SC-users preferred SCs to
amphetamines or cocaine; however, only 3.6% ranked SC as their most preferred drug. Past-
year SC use declined to 6.6%. Among polysubstance users in this sample, SC use may be a
potential indicator of versatile and indiscriminate drug-taking.

Keywords
synthetic cathinones, bath salts, polysubstance use, novel psychoactive substances

Introduction
A full decade has not yet passed since the emergence of synthetic cathinones (SCs) as drugs of
recreation and abuse in the United States (Sammler et al., 2010; Winstock et al., 2011). Yet, in
this short time, there has transpired first an increase and then peak in SC use, publication of doz-
ens of case reports documenting SC toxicology and SC-related fatalities, widespread media
attention, and passage of broad legislation prohibiting SC and other compounds considered part
of the growing novel psychoactive substances (NPS) taxonomy (Kasick, McKnight, & Klisovic,
2012; Miotto, Striebel, Cho, & Wang, 2013; Sacco & Finklea, 2016; Spiller, Ryan, Weston, &
Jansen, 2011; Stevens, Fortson, Measham, & Sumnall, 2015; Stogner & Miller, 2013; Swalve &
DeFoster, 2016; Wood et al., 2010).
SC are molecularly similar to cathinone, the main psychoactive constituent of the
­botanical Catha edulis (common name “khat”) and to some amphetamines, demonstrating potent

1University of Kentucky, Lexington, USA

2University of Louisville, KY, USA

Corresponding Author:
Kirsten E. Smith, University of Louisville, Kent School of Social Work; Center on Drug and Alcohol Research,
University of Kentucky, Lexington, KY 40508, USA.
Email: kirstenelin.smith@louisville.edu
2 Journal of Drug Issues 00(0)

psychostimulant effects and serious risk for neurotoxicity (Angoa-Pérez, Anneken, & Kuhn,
2016; Baumann, Partilla, & Lehner, 2013; Carroll, Lewin, Mascarella, Seltzman, & Reddy, 2012;
Valente, De Pinho, de Lourdes Bastos, Carvalho, & Carvalho, 2014). Although preclinical mod-
els continue to investigate the pharmacodynamics and pharmacokinetics of first- and second-
generation analogs (e.g., 4-methylmethcathinone, methylone, methylenedioxypyrovalerone,
alpha-PVP) (Baumann, Baumann, Partilla, Lehner, Thorndike, et al., 2013; Bonano, Glennon, De
Felice, Banks, & Negus, 2014; Cameron, Kolanos, Verkariya, De Felice, & Glennon, 2013;
Naylor, Freeman, Blough, Woolverton, & Huskinson, 2015), clinical studies seeking to under-
stand the pharmacology of SC among humans remain limited due to practical and ethical con-
straints (Green & Nutt, 2014; Nutt, King, & Nichols, 2013).
Although rates of SC use in the United States appear lower than other NPS, SCs were the third
most commonly identified NPS type in 2017 after synthetic opioids and synthetic cannabinoid
receptor agonists (SCRAs; U.S. Drug Enforcement Agency, 2017). Globally, new cathinone ana-
logs continue to be identified, despite generic, “catch-all” legislation (Corkery, Guirguis, Papanti,
Orsolini, & Schifano, 2018; Hughes & Winstock, 2012). This abundance of different SC analogs
poses challenges for community-based researchers in that under this broad “SC umbrella” are
dozens of molecularly similar, but nevertheless distinct compounds (Murphy, Dulaney, Beuhler,
& Kacinko, 2013). Although some more knowledgeable or experienced users may be aware of
the specific cathinone analog they are consuming, and demonstrate preference for particular
product brands or analogs, many other may not have this knowledge or discrimination between
SC brands or analogs (Guirguis et al., 2017; Herrmann, Johnson, Johnson, & Vandrey, 2016).
SC use is often reported by younger individuals and males (P. S. Johnson & Johnson, 2014;
Miller & Stogner, 2014; Vardakou, Pistos, & Spiliopoulou, 2011; White, 2016), but it remains
unclear how best to characterize SC-users. For instance, SC and other NPS use has been reported
among people who evidence proclivity for drug experimentation and who participate in online
drug-using communities where the dissemination of experiential knowledge among peers is
common (e.g., “psychonauts,” “e-psychonauts”), although SC use has also been observed among
other substance-using subpopulations, such as men involved in Europe’s night club scene
(Ashrafioun et al., 2016; Corazza et al., 2014; Deluca et al., 2012; Measham, Wood, Dargan, &
Moore, 2011; Orsolini, Papanti, Francesconi, & Schifano, 2015). In addition, SC use has been
found among especially vulnerable populations, such as those who experience homelessness and
criminal justice involvement, with SC-users often appearing as more versatile polysubstance
users compared with polysubstance users not reporting SC use (Daveluy et al., 2017; Santa Maria
et al., 2018; Smith et al., 2017; Wagner et al., 2014). This drug use versatility is evidenced by a
greater number of different drug classes used at higher frequencies. Among younger populations
with less drug use history, SC use positively correlates with other drug use (Loi et al., 2015;
Miller & Stogner, 2014; Palamar, 2015; Sutherland et al., 2016), though not always (Palamar,
Salomone, Vincenti, & Cleland, 2016).
In attempting to characterize individuals who use SC in the United States, one question that
remains unanswered is if there are appreciable differences between polysubstance users who
report SC use and polysubstance users who do not. Although between-group comparisons of
drug users in cross-sectional studies have significant limitations for interpretability, in no small
part due to some degree of sample-wide homogeneity and some degree of (potentially signifi-
cant) within-group heterogeneity, this form of comparison is a useful point for exploration of SC
use among polysubstance users, particularly as other data are lacking (Shaw, Shah, Jolly, &
Wylie, 2008; Terracciano, Löckenhoff, Crum, Bienvenu, & Costa, 2008; Tetrault et al., 2008).
Because the long-term durability of SC popularity is uncertain, but appears to be waning, it is
of additional interest to determine whether polysubstance users prefer SCs compared with other
drugs, including traditional psychostimulants (e.g., amphetamines, cocaine). Users’ perception
of pleasure in association with drugs is a sometimes-overlooked component when attempting to
Smith and Stoops 3

understand drug use (Holt & Treloar, 2008; Moore, 2008; Ritter, 2014), despite it being among
the more obvious factors that might inform choice and drug-taking, irrespective of the degree to
which options and behaviors are constrained by market availability, cost, and rewarding non-
drug alternatives (Bickel, Jarmolowicz, Mueller, & Gatchalian, 2011; Waldorf, Reinarman, &
Murphy, 1992).
In the Southeastern United States, high rates of methamphetamine use persist, particularly
among individuals in rural and Appalachian regions (Oser et al., 2011; Staton et al., 2018; Stoops
et al., 2007). However, the prevalence of SC use among polysubstance users in these high meth-
amphetamine-use regions is uncertain. This uncertainty is due, in part, to the fact that Southeastern
United States contains heterogeneous drug markets that often differ by geography and urban
proximity. It is also unclear whether polysubstance users in these regions prefer SC to other
drugs, such as methamphetamines or cocaine.

Aims
Currently, there are limited data describing the characteristics of SC-users in the Southeastern
United States, including data that might help determine whether SC-users in this region are
meaningfully distinguished from other polysubstance users or previously identified subgroups of
SC-users. It is also unclear whether SC-users in the southeastern United States evidence more
drug use versatility, indicated by a greater number of drugs used at higher frequencies compared
with nonusers. Finally, because SC use has not continued at rates equal to other NPS, such as
SCRA, it is unclear whether SC is actually preferred relative to other drugs among polysubstance
users in this region. Accordingly, this exploratory study sought to help further an understanding
of SC use among polysubstance users in the Southeastern United States by describing the char-
acteristics of SC-users identified among a clinical sample of polysubstance users, investigating
the prevalence of and motivations for SC use, and determining whether those who reported SC
use prefer SC to other drugs. Ancillary aims included documenting how SC was commonly
obtained and self-administered, and whether certain adverse effects were associated with use.

Method
Sample and Setting
In April 2017, five residential drug recovery programs in Kentucky were purposefully sampled
for study inclusion based upon their geographic location. These included two programs located
in a metro area of ≥1-million population, two programs located in a metro area of 250,000 to
1-million population, and one Appalachian-based program located in a nonmetro area adjacent to
a metro area with an urban population of 2,500 to 19,999 (U.S. Department of Agriculture, 2013).
These recovery programs comprise part of a larger network of state-subsidized programs open to
residents with a self-reported substance use problem. The programs are styled as abstinence-only,
residential therapeutic communities. During the program, clients are subject to random drug
monitoring.

Recruitment and Data Collection

To obtain a convenience sample, a researcher met with clients as a group in person to explain the
study and recruit interested clients. Those expressing interest were informed that study involve-
ment was voluntary, posed minimal risk, and that declining to participate would not impact their
standing in the program. Participants were not compensated. This study was approved by the
University of Louisville Institutional Review Board.
4 Journal of Drug Issues 00(0)

Of the 511 clients recruited, 503 chose to participate. Participants were provided with a
49-question, anonymous paper survey to self-administer. Those who declined study involvement
(n = 8) worked on regularly assigned treatment materials (e.g., reading, writing assignments).
The researcher remained in the room during survey completion. Participants could seek clarifica-
tion about the survey if needed. Approximate survey completion time was 15 min.

Survey
Survey development was informed by SC literature as well as by professional work with this
population. Prior to use in this study, the survey underwent pilot testing and focus group with a
group of similarly matched polysubstance users (N = 10).
Demographics were operationalized using variables of age, sex, race, relationship status (e.g.,
currently single vs. married/in a partnered relationship), past-year employment (e.g., part/full-
time vs. unemployed), highest level of education achieved (e.g., high school diploma, college
degree), and primary past-year living situation (e.g., living alone/with roommate, homeless).
Because approximately 85% of the sample was referred by the Department of Corrections and
because one potential appeal of NPS includes circumnavigating drug monitoring, criminal justice
involvement was also considered. Criminal justice involvement was measured by asking clients
to report whether they had been incarcerated at any point since 2010. This year was chosen
because it is the approximate time period when most individuals in this sample would have been
likely to have first been exposed to SC (American Association of Poison Control Centers, 2016).
Clients were also asked to indicate number of separate incarceration episodes, total number of
years incarcerated since 2010, past-year arrests, and number of months out of the past 12 spent
in a correctional facility. In addition, clients were asked to report probation/parole involvement
since 2010, number of years spent on probation/parole, number of months out of the past 12 spent
on probation/parole, and current probation/parole status, as these factors indicate that partici-
pants were subject to drug monitoring. Finally, participants were asked whether they had ever
violated the terms of their probation/parole due to a positive drug screen.
Substance use history was examined by asking participants to report ages of alcohol and illicit
drug use initiation, number of prior substance use treatment episodes, and any licit (e.g., alcohol,
inhalants, kratom) and illicit (e.g., marijuana, heroin) drugs used ever and in the year prior to pro-
gram entry. Ever and past-year SC use was measured similarly. The term “bath salts” was used on
the survey instead of potentially confusing jargon (e.g., cathinones). Participants could select items
from a list of drugs, placing a mark next to any drug that they had used for the respective periods.
To measure motivations for use, associated side effects, method of obtainment, and route of
administration, participants were asked to place a mark next to any statement that they believed
reflected their experiences with SCs (e.g., “You used bath salts as a substitute for other drugs”;
see Table 2 for a list of survey items). Preference for and positive attitudes about SC were mea-
sured by asking participants to indicate whether they preferred SC effects to other drugs gener-
ally and to amphetamines or cocaine specifically. Participants were also asked to indicate whether
they agreed with statements such as “You would try bath salts again.” Finally, to understand
common drug preferences among this sample, participants were asked to rank their top 3 pre-
ferred drugs of abuse in the order that they most preferred using them.

Analytic Plan
Chi-square and t-test statics were used to determine significant differences for variables of interest
between those who reported ever SC use and those who reported no use. Descriptive statistics
were used to generate rates of preferred substances for each group and response proportions for
SC statements. Logistic regression was used to understand significant associations between SC
Smith and Stoops 5

use and other drug use. The decision to examine relationships between SC use and only other drug
use significant (p < .05) in bivariate analyses (as opposed to all variables significantly correlated
with SC in a correlation matrix) was made for two reasons. First, because the sample was com-
prised of polysubstance users, these relationships are of interest (i.e., does use of certain stimulants
increase odds of SC use?) and second, to avoid model overfitting due to the relatively small sam-
ple size. Analyses were completed with IBM-SPSS version 25 (IBM Corp., 2017). Collinearity
was not an issue as indicated by variance inflation factors, and model fit statistics indicated accept-
able model fit.

Results
Sample Characteristics
A total of 503 clients completed surveys, however three surveys were discarded due to nonran-
dom missing data and/or illegibility of survey responses, and another was discarded to missing-
ness for the outcome variable. The final sample (N = 499) included men (58.3%) and women
(41.7%) aged 18 to 64 years ( x = 35.1), who had been enrolled in the program approximately
3.5 months. Sample characteristics and significant group differences are provided in Table 1.
Approximately 28% of the sample reported having ever used SC (n = 141); however, rates of
past-year use declined substantially to 6.6% (n = 33). Individuals reporting ever SC use were
more likely to be younger ( x = 32.7 vs. 36.0, p = .001), White (93.4% vs. 80.8%, p = .001),
and to report lower rates of past-year employment (37.0% vs. 51.1%, p = .006). Past-year living
arrangement prior to program entry was variable within and between groups, although significant
differences were observed (p = .026). For instance, SC-users were less likely to report living
independently (25.2% vs. 36.2%), whereas homelessness was similar between groups (5.0% vs.
5.6%). Surprisingly, a smaller proportion of SC-users were enrolled in recovery programs located
in an urban area compared with the rural, Appalachian-based program (73.8% vs. 86.6%, p =
.001).

Criminal Justice Involvement

Rates of past 7-year incarceration were higher for those who reported SC use (96.5% vs. 84.8%,
p = .001). This group also reported more separate incarceration instances ( x = 6.9 vs. 5.1).
However, the total number of years incarcerated was equivalent between groups ( x = 1.8).
SC-users also had higher past-year arrest rates (81.9% vs. 66.0%, p = .001). Current probation/
parole rates (86.5% vs. 84.6%, p = .693) and number of months on probation/parole out of the
past 12 ( x = 7.4 vs. 6.6, p = .139) were similar between groups. However, a greater proportion
of SC-users were on probation/parole between 2010 and 2017 than nonusers (80.9% vs. 70.9%,
p = .032), and for a slightly greater average number of years (3.1 vs. 2.7). Finally, nearly 64% of
SC-users reported violating probation/parole conditions due to a positive drug test, compared
with 52.1% of nonusers (p = .033).

Substance Use
SC-users were significantly younger for age of first illicit drug use ( x = 13.3 vs. 14.6, p = .003),
but not age of first alcohol use ( x = 12.2 vs. 12.6, p = .256). Rates of prior substance use treat-
ment and number of prior treatment episodes did not differ. Overall, SC-users indicated extensive
substance use histories for both ever and past-year use, significantly surpassing rates of those
reporting no SC use. This includes higher lifetime rates of use for less commonly used drugs such
as club drugs/hallucinogens (76.6% vs. 64.4%, p = .001), barbiturates (58.2% vs. 28.2%,
6 Journal of Drug Issues 00(0)

Table 1.  Sample Characteristics and Significant Differences Between Those Reporting Synthetic
Cathinone Use and Those Reporting No Use.

Ever synthetic No synthetic

cathinone use cathinone use
All n = 141 n = 358
N = 499 (28.3%) (71.7%) p value
Age, x 35.1 32.7 36.0 .001
Male 58.3 63.8 56.1 .117
White 84.3 93.4 80.8 .001
Single 56.3 54.4 57.1 .669
Education .445
  No HSD or equivalent 8.3 5.9 9.3  
 HSD/equivalent 51.4 50.0 52.0  
  Some college 26.0 30.1 24.4  
  College graduate (AA, BS, MA) 14.2 14.0 14.3  
Past-year full-time/part-time employment 47.1 37.0 51.1 .006
Past-year primary living situation prior to  
program
  Living alone or with partner/roommate 33.2 25.2 36.2 .026
  Staying with friends/family 22.3 19.4 23.4  
  Halfway house/treatment center 13.0 18.0 11.0  
 Incarcerated 26.2 32.4 23.7  
 Homeless 5.5 5.0 5.6  
Enrolled in drug program in an urban 83.0 73.8 86.6 .001
location (vs. rural, Appalachian)
Incarcerated since 2010 88.0 96.5 84.8 .001
  Separate incarceration instances since 5.7 6.9 5.1 .002
2010, x
  Years incarcerated, x 1.8 1.8 1.8 .763
Past-year arrests 70.4 81.9 66.0 .001
  Months incarcerated out of past 12, x 3.7 4.4 3.4 .011
Currently on probation/parole 85.2 86.5 84.6 .693
Probation/parole months, x 6.8 7.4 6.6 .139
Probation/parole since 2010 73.7 80.9 70.9 .032
Probation/parole number of years, x 2.8 3.1 2.7 .058
Has violated probation/parole for positive 55.6 63.6 52.1 .033
drug test
Age of alcohol use initiation 12.5 12.2 12.6 .256
Age of illicit drug use initiation 14.2 13.3 14.6 .003
Prior substance use treatment 67.8 67.5 68.4 .857
Number of prior substance use 2.4 2.5 2.3 .513
interventions, x
Number of months enrolled in current 3.5 3.6 3.5 .563
treatment program
Past-year number of months enrolled in 1.32 1.42 1.10 .173
another treatment program, x
Lifetime substance use
 Alcohol 99.0 100.0 98.6 .362
 Marijuana 98.6 100.0 98.0 .211
  Synthetic cannabinoid receptor agonists 68.5 87.9 60.9 .001
  Non-prescribed opioids 86.8 99.3 81.8 .001
Smith and Stoops 7

Table 1. (Continued)
Ever synthetic No synthetic
cathinone use cathinone use
All n = 141 n = 358
N = 499 (28.3%) (71.7%) p value
  Non-prescribed buprenorphine 78.2 94.3 71.8 .001
 Heroin 73.5 90.8 66.8 .001
 Cocaine 92.6 99.3 89.9 .001
 Crack 79.6 91.5 74.9 .001
 Amphetamines 86.2 99.3 81.0 .001
 Sedatives 88.2 97.2 84.6 .001
 Barbiturates 63.3 58.2 28.2 .001
 Inhalants 33.3 56.7 24.0 .001
  Club drugs/hallucinogens 60.7 76.6 64.4 .001
 Kratom 21.0 35.5 15.4 .001
Past-year substance use
 Alcohol 75.4 79.0 74.0 .301
 Marijuana 65.3 72.5 62.6 .049
  Synthetic cannabinoid receptor agonists 23.6 36.9 18.4 .001
  Non-prescribed opioids 62.5 73.8 58.1 .002
  Non-prescribed buprenorphine 51.6 73.2 43.3 .001
 Heroin 55.5 67.4 50.8 .001
 Cocaine 44.2 54.3 40.2 .006
 Crack 34.7 34.9 31.3 .014
 Amphetamines 65.7 83.3 58.8 .001
 Sedatives 45.6 55.1 41.9 .011
 Barbiturates 8.9 16.7 5.9 .001
 Inhalants 5.0 8.0 3.9 .105
  Club drugs/hallucinogens 19.6 27.5 16.5 .008
 Kratom 10.2 22.0 5.6 .001
  Synthetic cathinones 6.6 22.7 — —

Note. HSD = high school degree.

p = .001), inhalants (76.7% vs. 24.0%, p = .001), kratom (35.5% vs. 15.4%, p = .001), and
SCRA (87.9% vs. 60.9%, p = .001), although rates of use for the later were remarkably high
sample-wide (68.5%). Drugs which remained significantly associated with SC use in the regres-
sion model included SCRA (adjusted odds ratio [AOR] = 1.9, p = .044), kratom (AOR = 1.7,
p = .045), and inhalants (AOR = 2.3, p = .001), as shown in Table 4. Use of other stimulants,
such as amphetamines, powder cocaine, and crack cocaine, was not significantly associated with
an increased likelihood of SC use.

SC Use and Drug Preferences

Table 2 displays the proportions of SC-users who affirmed particular statements about SC use.
Among those who had ever used SCs, the two most frequently endorsed reasons for use included
trying SCs because of their friends (42.2%) and using SCs as a substitute for other drugs (36.3%).
In addition, 26.7% agreed with the statement that SCs were easier to obtain than other drugs and
23.7% reported that they used SCs to avoid failing a drug test. Approximately 23% of users
reported that they preferred SC effects to those of amphetamines or cocaine and 15.6% reported
8 Journal of Drug Issues 00(0)

Table 2.  Response Proportions for Synthetic Cathinone Use Survey Items for Individuals Reporting
Ever Use of Synthetic Cathinones (n = 141).

(%)
Bath salts were easier to obtain than other drugs. 26.7
Used bath salts as a substitute for other drugs. 36.3
Tried bath salts because your friends were using them. 42.2
Bath salts were less expensive than other drugs 31.1
Used bath salts to avoid failing a drug test. 23.7
Preferred the effects of bath salt to those of amphetamines or cocaine. 22.5
Preferred bath salt “highs” to other drugs. 15.6
Think bath salts are a helpful drug. 5.2
Would try bath salts again. 17.8
There were fewer unpleasant side effects from bath salts than from other drugs. 5.9
Felt “hungover” after using bath salts. 14.8
Bath salts gave you unpleasant side effects, such as mental or physical 39.6
discomfort.
Often felt jittery or anxious when using bath salts. 46.8
Often felt paranoid when using bath salts. 52.0
Sought medical care because of the effects of bath salts. 6.7
Method of obtainment
 Friend 64.4
  Family member 9.9
  Gas station/convenience store 35.9
 Internet 16.8
 Stranger 9.9
  “Head shop” or smoke shop 29.0
  Drug dealer 30.8
Route of administration
 Insufflated 75.6
 Smoked 32.6
 Swallowed 13.4
 Injected 42.1

preferring SC effects to any other drug effects. Although nearly 18% reported that they would use
SCs again, only 5.2% indicated that they believed SCs were helpful.
Table 3 displays frequencies for the three most preferred drugs as ranked by SC-users and
nonusers. SC-users overwhelmingly preferred amphetamines (73.6%) and showed greater pref-
erence for amphetamines compared with nonusers (51.0%), even as nonusers also indicated pref-
erence for amphetamines. Powder and crack cocaine were not as preferred as amphetamines
among SC-users but were still listed at higher rates compared with nonusers (19.6% vs. 6.1% and
13.9% vs. 7.1%, respectively). Heroin and non-prescribed opioids were favored among both
groups (57.5% vs. 48.0% and 38.9% vs. 38.4%, respectively). Apart from amphetamines, alcohol
showed the most remarkable difference between groups, with rates of preference for nonusers
nearly twice that of SC-users (42.9% vs. 24.4%). SCs was preferred by only 3.6% of all SC-users.

Side Effects Associated With SC Use

Approximately 6% of SC-users agreed with the statement that there were fewer side effects from
SCs than from other drugs. While only 14.8% of users reported “hangover” effects from using
Smith and Stoops 9

Table 3.  Most Preferred Substances Ranked According to Group.

Synthetic cathinone users (n = 141) Nonusers (n = 358)

Second Third Second Third

Most most most Most most most
preferred preferred preferred preferred preferred preferred
  drug drug drug Total drug drug drug Total
Cigarettes 0.7 0.0 2.2 2.9 2.3 2.6 2.3 7.2
Alcohol 5.1 5.8 13.3 24.2 19.5 10.9 12.5 42.9
Marijuana 5.1 8.0 11.9 25.0 6.5 12.0 15.1 33.6
Synthetic marijuana 0.7 0.0 0.7 1.4 0.6 1.5 2.3 4.4
Prescription opioids 10.9 9.5 18.5 38.9 9.3 18.2 10.9 38.4
Diverted 2.2 5.8 6.7 14.7 3.7 3.2 4.8 11.7
buprenorphine
Heroin 36.2 16.1 5.2 57.5 32.8 9.7 5.5 48.0
Powder cocaine 2.9 8.0 6.7 19.6 3.1 6.7 6.1 15.9
Crack cocaine 1.4 4.4 8.1 13.9 5.4 6.7 7.1 19.2
Amphetamines 30.4 32.8 10.4 73.6 15.0 19.6 16.4 51.0
Non-prescribed 0.7 7.3 11.9 19.9 1.7 6.7 13.5 21.9
sedatives
Non-prescribed 0.0 0.0 0.7 0.7 0.0 0.0 0.3 0.3
barbiturates
Inhalants 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Club drugs/ 0.0 2.2 1.5 3.7 0.0 1.2 2.5 3.7
hallucinogens
Kratom 0.0 0.0 0.7 0.7 0.0 0.0 0.6 0.6
Synthetic 3.6 0.0 0.0 3.6 - - - -
cathinones

SCs, approximately 40% attributed “general mental or physical discomfort” to SCs. Nearly half
of users reported that they often felt “jittery or anxious” when using SCs, and a majority (52%)
reported often feeling paranoid. Despite this, only 6.7% of SC-users reporting seeking medical
care.

Methods of Obtainment and Routes of Administration

Most SC-users reported obtaining SCs from their friends (64.4%), though an additional 9.9%
also reported obtaining them from family. Gas station/convenience stores, drug paraphernalia
shops, and drug dealers each served as sources for approximately one third of SC-users. Finally,
16.8% reported web-based purchasing and 10% reported obtaining the drug from a stranger.
Common routes of administration included insufflation (75.6%) and intravenous injection (IV;
42.1%). Approximately one third reported smoking the drug.

Discussion
Similar to other studies, SC-users here were more likely to be male, White, and younger
(Ashrafioun et al., 2016; P. S. Johnson & Johnson, 2014; Palamar, Martins, Su, & Ompad, 2015;
Smith et al., 2017). Findings also raised the possibility that SC use may differ regionally, as the
proportion of SC-users was greater among the recovery program based in rural Appalachia.
Finally, findings suggest the possibility that SC use may be associated with versatile, more
10 Journal of Drug Issues 00(0)

Table 4.  Regression Model Examining Associations Between Ever Synthetic Cathinone Use and Other
Drugs Ever Used for Which Relationships Were Significant (p < .05) in Bivariate Analysis.

Standardized Adjusted
coefficient odds ratio 95% CI p value
Synthetic cannabinoids .636 1.9 [1.01, 3.50] .044
Non-prescribed opioids 1.54 4.7 [0.537, 39.7] .162
Non-prescribed buprenorphine .249 1.3 [0.493, 3.33] .610
Kratom .509 1.7 [1.01, 2.73] .045
Heroin .212 1.2 [0.577, 2.65] .586
Cocaine 1.00 2.7 [0.330, 22.4] .352
Crack .282 1.3 [0.637, 2.70] .450
Amphetamines 1.5 4.6 [0.552, 38.5] .158
Sedatives −.198 0.8 [0.244, 2.76] .749
Non-prescribed barbiturates .462 1.6 [0.999, 2.52] .051
Club drugs/hallucinogens .319 1.4 [0.665, 2.85] .389
Inhalants .835 2.3 [1.45, 3.56] .001
Chi-square = 113.094  
Pseudo R2 = .203-.291  

Note. CI = confidence interval.

indiscriminate drug use and that, compared with other drugs, SCs are not overwhelmingly pre-
ferred among polysubstance users in this sample.

Regional Differences
That there was a higher proportion of SC-users enrolled in the rural, Appalachian-based recovery
program was an unanticipated finding, though elsewhere NPS use among drug treatment clients
has evidenced regional splits (Campbell, Neill, & Higgins, 2017). Accordingly, response patterns
for SC survey items were further scrutinized by group. Comparing SC-users enrolled in the rural,
Appalachian-based program with SC-users enrolled in the metro-based, non-Appalachian pro-
grams showed that groups were comparable, differing significantly only by rates of SC injection
(60.0% vs. 36.8%, p = .030), web-based SC purchases (30.6% vs. 11.6%, p = .026), price esti-
mates (e.g., SCs are less expensive; 47.2% vs. 26.0%, p = .020), and willingness to use SC again
(36.1% vs. 11.5%, p = .003). The potential combined effects of lower cost, greater likelihood of
IV administration, and willingness to continue using SCs among individuals in rural regions is
concerning not only because of the life-threatening effects associated with SCs, but also due to
the potentially greater reluctance among rural Appalachian drug users to seek medical help, geo-
graphic challenges to providing emergency service response, and fewer treatment avenues (Bush
et al., 2015; Douthit, Kiv, Dwolatzky, & Biswas, 2015; Kesha et al., 2013; Murray, Murphy, &
Beuhler, 2012; Starcher, Geurin, Shannon, & Whitley, 2017). Rural Appalachian areas may also
be more sensitive to supply issues due to less population density, lack of public transportation,
and the more insular nature of the region (Eller, 2008). This may partially explain the higher rates
of web-based purchases among SC-users in the rural recovery program. Here, some SC pur-
chases may have been made prior to prohibitions, with others purchased on the “deep web” after
prohibitions (Dittus, Wright, & Graham, 2018; Orsolini et al., 2015; Vardakou et al., 2011).
Although amphetamines are widely used in Appalachia, decreased availability/increased cost
may temporarily force amphetamine consumption down or incline users to seek substitutions via
peer drug-using networks (Cunningham & Finlay, 2016; Jonas, Young, Oser, Leukefeld, &
Smith and Stoops 11

Havens, 2012; Sutherland et al., 2017). This latter point is emphasized in that nearly 37% of
SC-users reported using SC as a drug substitute and three quarters reported that they obtained SC
from friends/family.

Preference, Pleasure, and Risk

Overall, SC-users preferred methamphetamines, powder cocaine, and crack cocaine at higher
rates than SCs. Decreases from ever to past-year SC use were far steeper for SCs compared
with SCRAs even though both were prohibited at approximately the same time in the state
(Kentucky Legislature, 2011, 2012). This indicates that while NPS prohibitions may have
impacted accessibility or willingness to use SCs, other factors, such as enjoyability, may be
more relevant (Matthews et al., 2017). This decrease may be partially attributable to the adverse
side effects reported by 40% to 50% of SC-users (Carhart-Harris, King, & Nutt, 2011).
Although it is impossible to causally link SCs to effects reported here—particularly in light of
polysubstance use—these data provide oblique support to previous preclinical, case report, and
cross-sectional findings (Ashrafioun et al., 2016; Kim, Aftab, Shah, & Nayar, 2010; Miotto
et al., 2013; Prosser & Nelson, 2012), including evidence which suggests that concomitant use
of SCs with other drugs may have deleterious health consequences (Shortall, Green, Fone, &
King, 2016; Winder, Stern, & Hosanagar, 2013). For criminal justice–involved users, the dif-
ficulty in detecting SCs coupled with motivations to not disclose use to medical professionals
may make this group particularly vulnerable to SC-related health consequences (Blackman &
Bradley, 2017).
Survey format is also relevant to consider when interpreting drug preference findings. Clients
were asked to list their top 3 preferred drugs before completing SC-specific questions. Only 3.6%
reported SCs as a preferred drug type. When examining findings from the SC portion of the sur-
vey, approximately 16% of SC-users reported that they preferred the effects (i.e., “highs”) of SCs
to all other drugs and 23% reported preferring SCs to amphetamines/cocaine. This discrepancy
indicates two possibilities. The first is that the majority of this 16% to 23% subgroup do enjoy,
or receive some pleasure, from the effects of SCs, but not enough to register SCs as among their
most preferred drugs unless otherwise primed. SC enjoyment by this small subgroup is supported
in that 17.8% reported that they would try SCs again. Considered in full, this first possibility
implies the second, which is that SC use was a highly salient and pleasurable experience, but only
for a small minority. That approximately 40% to 50% of SC-users reported adverse side effects
suggests that SC use may have been a salient experience for others, but not due to pleasure. That
a quarter of SC-users reported that SC were easier to obtain than other drugs and one third
reported that SC were less expensive suggests that convenience, price, and availability are rele-
vant, but not necessarily uniquely deciding factors in SC selection (Ashrafioun et al., 2016;
Carhart-Harris et al., 2011; Sutherland et al., 2017).

Polysubstance Use
Other surveys have found that SC-users evidence polysubstance use and SC use that meets
Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric
Association, 2013) diagnostic criteria for substance use disorder (SUD; P. S. Johnson & Johnson,
2014). However, SUD for SCs and other drugs was not assessed in this study. Accordingly,
SC-users in this sample cannot necessarily be conceptualized as disordered in their drug use, nor
can the severity of use for any particular drug be considered. Yet, it may still be appropriate to
understand SC-users in this sample as versatile in their drug use and, potentially, more indis-
criminate in terms of what drugs they consume. This is evidenced by the high rates of ever and
12 Journal of Drug Issues 00(0)

past-year drug use across drug classes, including the use of infrequently used, less popular drugs,
such as inhalants.
However, the degree to which “polysubstance use” is separable or concurrent among this sample
is uncertain (Boeri, Sterk, Bahora, & Elifson, 2008). It may be that particular drugs, including SC,
were used at particular times, either in isolation or concomitantly, and for a variety of reasons rang-
ing from preference to availability to perceived utility (e.g., circumnavigating drug screens). For
instance, high rates of both being on probation/parole and violating probation/parole due to a posi-
tive drug screen among SC-users suggest that while SC-users may have been using SCs to circum-
navigate drug monitoring, they were also using detectable drugs, as reflected by violations for a
positive drug screen. It is perhaps of interest that all drugs significantly associated with SC are not
readily detectable. With the exception of inhalants, these drugs are also relatively new in the United
States, though kratom, unlike SCRA, is organic (Kruegel & Grundmann, 2018).
Ultimately, these equivocal findings leave unanswered the broader question of how best to
conceptualize polysubstance users who have also ever used SCs, or other NPS. This ambiguity
suggests that perhaps the question itself is predicated on a faulty premise: Namely, that individu-
als with established polydrug histories should be conceptualized differently once they adopt
occasional or regular NPS use. Indeed, NPS have been approached as though, due to their nov-
elty, they are somehow unique beyond inherent chemical differences (Potter & Chatwin, 2018).
To some extent, this consideration ignores the heterogeneity of NPS users (Elliott, Benoit,
Campos, & Dunlap, 2018), along with the potential banality of drug use for some polysubstance
users (Parker, Aldridge, & Measham, 1998; Waldorf et al., 1992). Whether due to greater impul-
siveness, stress, or drug use normalization, polysubstance users with extensive drug use histories
often differ from the general population of recreational users and may therefore simultaneously
be less discriminating while also perceiving NPS as merely additional drug options on an ever-
expanding pharmacological menu (Bechara, 2005; Bickel & Marsch, 2001; Preston et al., 2017;
Sinha, 2008). Accordingly, SC use may not distinguish itself as meaningfully unique from other
drug use. This may be particularly true for younger users. That NPS use is more likely to be
observed among younger individuals makes intuitive and empirical sense given that impulsive-
ness is more common among this population, regardless of other traits predictive of substance
misuse (e.g., novelty- and sensation-seeking; Foulds et al., 2017; Viner et al., 2012). For particu-
larly young users, novice users, and/or those not physiologically dependent, SC-related habits
and responses to SC-related cues may be less rigidly instantiated both neurobiologically and
behaviorally, leaving drug use a more flexible exercise, as pathological drug ‘wanting’ as not yet
come to dominate (Berridge & Robinson, 1995; Koob et al., 2004; Mayo & De Wit, 2015). The
age correlation also suggests that, holding price and accessibility constant, we might expect to
see higher rates of SC and other NPS use among some older polysubstance users within a decade.
Should next-generation SC formulas produce enjoyable drug experiences with fewer undesired
effects, then rates would likely grow irrespective of age. Should a demand for SCs increase, it is
likely that a black market would develop proportionally because or in spite of prohibitions
(Perrone, Helgeson, & Fischer, 2013; Taylor, 2015).

Limitations
This cross-sectional study has several limitations including the fact that SC use was explored
broadly. “Bath salts” likely captures dozens of cathinone analogs and added properties, such as
caffeine (Collins et al., 2016; Schneir et al., 2014). The specific chemical compounds for “bath
salt” products were likely unknown to most SC-users and, in some cases, it is possible that SC
was consumed unwittingly (Ashrafioun et al., 2016; Palamar et al., 2016). Furthermore, product
names were not identified, making even crude approximations of whether individuals were using
first-, second-, or third-generation SCs impossible. Temporal order of drug use was not captured
Smith and Stoops 13

such that it is possible that SC use pre-dated stimulant or other drug use. In addition, SC doses
and dosing frequency were not quantified. For example, ever and past-year SC use could reflect
one dose or significantly more. That past-year SC dosing was unquantified makes it impossible
to determine the regularity with which individuals used SC, thus limiting the ability to conceptu-
alize this group as a true “SC users.” Biological specimens could not be collected to confirm
self-report and, because the survey was anonymous, responses could not be matched to other
potential data sources (e.g., clinical records) which might haved helped to establish whether
SC-users qualified for any SUD. Self-report as a method for obtaining information is subject to
error, such as poor recall and mendacity, though this method has been found to be reliable among
substance-using samples (Darke, 1998; Harrison, 1995). Criminal justice involvement, geo-
graphic location, and program type (i.e., abstinence-only) limits generalizability. Finally, while
the socioeconomic status (SES) of many participants in this sample is likely not high, as indi-
cated by low past-year unemployment rates, criminal justice involvement, and low rates of hav-
ing obtained a college degree, it was also not sufficiently established, meaning that important
differences in SC-use by SES could not be scrutinized.

Conclusion
In documenting SC use among a clinical sample of polysubstance users in the Southeastern
United States, this study found support for the idea that SC use may be an indicator of versatile,
more indiscriminate drug use and that SC use may appear at higher rates among people in geo-
graphic regions with less diverse drug markets. Because of the variety of SCs, future studies
should seek to identify differences in use across SC analogs and products, as well as determine
temporal order of SC use relative to other factors, such as symptom expression (e.g., anxiety,
paranoia) and other drug use (Palamar et al., 2015). In addition, SUD specific to a person’s pre-
ferred drug of abuse, and to SCs, should be assessed using standardized instruments or diagnostic
tools. Structured interviews and cohort studies may be useful in helping discern SC-user knowl-
edge and motives for use. A minority in this sample preferred SC, however, because many stated
that they would try SC again suggests that SC use may persist among some subset of polysub-
stance users, regardless of their drug use history or ecological context. Absent consensus regard-
ing any clear demarcation between the “novel” and the “traditional,” researchers may need to
reconsider the value of bifurcating drug experiences into “old” and “new” and instead focus on
understanding users’ perceptions of drug utility and drug effects according to class or pharmaco-
kinetic characteristics (Calinski, Kisor, & Sprague, 2018; Measham & Newcombe, 2016; Potter
& Chatwin, 2018). It may be that the primary reasons for using traditional drugs and the primary
reasons for using novel ones differ little.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Kirsten Elin Smith is a doctoral candidate at the University of Louisville, Kent School of Social Work and
associate at the University of Kentucky Center on Drug and Alcohol Research. Her research focuses on
polydrug use, with an emphasis on understanding opioid and novel psychoactive drug use among socioeco-
nomically disadvantaged and criminal justice-involved populations who experience barriers to accessing
comprehensive, scientifically-informed treatment for opioid and other use disorders.
William W. Stoops, PhD is a professor in the Department of Behavioral Science, Psychiatry, and
Psychology at the University of Kentucky. His research focuses on the behavioral pharmacology of stimu-
lants in humans, as well as treatment development for stimulant use disorder.