C Novel Psychoactive Substances h r i s t The unprecedented increase of legally ambiguous and easily available Novel Psycho- o p active Substances (NPS) constitutes a challenge for legislators, public health agencies, h e and researchers alike. Therefore, the aim of the present investigations is to contribute S o to knowledge about the online NPS community, including the users’ experienced ef- u s fects and motivations for use. The findings demonstrate that the community is char- s a acterized by robust group cohesiveness, counter public attitudes, and a focus on harm n reduction. A range of diverse reasons for NPS use were revealed and described in more detail than previous accounts. Several distinct motivation and risk profiles were N identified at the level of drug groups. The results point to the occurrence of at least o v three user orientations including the risk-negligent sensation seeker, the self-medi- e cating pursuer of coping, and the well-informed selfexplorer. It is concluded that l P the diverse field of NPS needs to be approached with more sophistication than the s broad brush approach of drugs in general. A one fits all preventive solution is likely y c to be ineffective at best and counterproductive at worst. We may also benefit from h recognizing most drug use as an adaptive function with instrumental value rather o than something pathologic, which will run the risk of fueling potentially harmful be- a c haviors like self-medicating and drug user stigmatization and alienation. Moreover, t i prohibition not only drives presumably harmful substance displacement but may also v e serve as the key incentive for engagement in risky behaviors. The current investi- gations could be a starting point for science based benefit-risk evaluations, greater S Novel u appreciation of the users’ views, and the development of more effective prevention. b s t a n Psychoactive c e s Substances Experienced effects, attitudes, and motivations among online drug community users Faculty of Arts and Social Sciences Psychology DOCTORAL THESIS | Karlstad University Studies | 2018:2 Christophe Soussan C h r i s t o p h e S o u s s a n | N o v e l Novel Psychoactive Substances P s y c h o a Novel Psychoactive The unprecedented increase of legally ambiguous and easily available Novel Psychoactive c t i v Substances (NPS) constitutes a challenge for legislators, public health agencies, and e S researchers alike. Therefore, the aim of the present investigations is to contribute to u b Substances s knowledge about the online NPS community, including the users’ experienced effects ta n and motivations for use. The findings demonstrate that the community is characterized ce s by robust group cohesiveness, counter public attitudes, and a focus on harm reduction. | Experienced effects, attitudes, and motivations A range of diverse reasons for NPS use were revealed and described in more detail 2 0 1 among online drug community users than previous accounts. Several distinct motivation and risk profiles were identified 8 : 2 at the level of drug groups. The results point to the occurrence of at least three user orientations including the risk-negligent sensation seeker, the self-medicating pursuer of coping, and the well-informed self-explorer. It is concluded that the diverse field of NPS needs to be approached with more sophistication than the broad brush approach Christophe Soussan of drugs in general. A one fits all preventive solution is likely to be ineffective at best and counterproductive at worst. We may also benefit from recognizing most drug use as an adaptive function with instrumental value rather than something pathologic, which will run the risk of fueling potentially harmful behaviors like self-medicating and drug user stigmatization and alienation. Moreover, prohibition not only drives presumably harmful substance displacement but may also serve as the key incentive for engagement in risky behaviors. The current investigations could be a starting point for science based benefit-risk evaluations, greater appreciation of the users’ views, and the development of more effective prevention. ISBN 978-91-7063-828-2 (print) ISBN 978-91-7063-923-4 (pdf) Faculty of Arts and Social Sciences ISSN 1403-8099 Psychology DOCTORAL THESIS | Karlstad University Studies | 2018:2 DOCTORAL THESIS | Karlstad University Studies | 2018:2 Novel Psychoactive Substances Experienced effects, attitudes, and motivations among online drug community users Christophe Soussan DOCTORAL THESIS | Karlstad University Studies | 2018:2 Novel Psychoactive Substances - Experienced effects, attitudes, and motivations among online drug community users Christophe Soussan DOCTORAL THESIS Karlstad University Studies | 2018:2 urn:nbn:se:kau:diva-65430 ISSN 1403-8099 ISBN 978-91-7063-828-2 (print) ISBN 978-91-7063-923-4 (pdf) © The author Distribution: Karlstad University Faculty of Arts and Social Sciences Department of Social and Psychological Studies SE-651 88 Karlstad, Sweden +46 54 700 10 00 Print: Universitetstryckeriet, Karlstad 2018 WWW.KAU.SE Abstract Background The availability of legally ambivalent Novel Psychoactive Substances (NPS) with mostly undocumented effects and risks has progressively increased during the last decade. The knowledge gap pertaining to the field of NPS and its community of online users constitutes a challenge for legislators, prevention strategists, and researchers. Little knowledge exists about the users and their experienced effects, attitudes, and motivations for use, which is troublesome from a public health perspective. Therefore, the aim of the present research is to contribute to the bridging of the knowledge gap pertaining to the field of NPS by 1) investigating the “leading edge” online communities and their users, 2) characterizing the experienced effects of a novel stimulant, 3a and 3b) sur- veying the users’ attitudes and motivations for use, and 4) exploring their self- reported reasons for NPS use inductively. Methods Online user generated data were collected and analyzed systematically through the protocol of thematic analysis. A comprehensive user survey was promoted at the “leading edge” communities in order to gather data on the user character- istics, including their motivations for use, which were analyzed statistically. Results The findings demonstrate that the studied NPS community was characterized by robust group cohesiveness and social identity. A strong counter attitude to and mistrust in public institutions were detected. The forum discussions func- tioned as an extensive and cumulative exchange of peer to peer generated knowledge and a social support system in service of the shared purpose appear- ing as harm reduction. A sense of drug community belongingness and related- ness was a sought after experience and prominent motivation for NPS use. The users were highly experienced drug users and appeared to be driven by a desire for recreation, pleasure, novelty, and a range of instrumental values. They were also knowledgeable and presented good degree of emotional well-being. Three user orientations are outlined; 1) the risk-negligent sensation seeker with inter- est in stimulating drugs and enhancement, 2) the self-medicating pursuer of 1 coping with mistrust in public health and proneness for sedative drugs, and 3) the well-informed self-explorer advocating harm reduction and hallucinogenic drugs. In addition, a diverse set of effects and motivations for use were identi- fied. For instance, the novel stimulant ethylphenidate appeared as a two-sided, insidious, and potent novel stimulant with imminent harm potential and effects in line with traditional counterpart stimulants like amphetamine. The survey data revealed a similar pattern where the stimulants, opioids and GABA activat- ing substances were perceived as having significantly greater abuse potential than the hallucinogens. The reason for NPS use in general was pleasure and enjoyment although several distinct motivation profiles were found at the level of drug groups. For example, the hallucinogens were used mainly for self- exploration and spiritual attainment while the stimulants to a larger degree were used for enhancement of performance, and opioids used primarily for coping. The use of synthetic cannabinoids was mainly motivated by external circum- stances such as price, availability and legality, and they appeared as less valued substitutes to herbal cannabis. A study into the users’ own and self-reported reasons for NPS use resulted in a multitude of richer and more comprehensive- ly described reasons than previous accounts. Some of the more conspicuous incentives included the seeking of novel and exciting adventures, and the use of NPS for safer drug use circumstances compared with established street drugs, which is noteworthy considering the public’s growing concern of NPS as harm- ful endeavors. Also, it emerged that the use of NPS was driven by a guinea-pig- like service to the community and harm reduction. Conclusions The results provide more nuanced knowledge about NPS and its community of users which could be of importance to all parties involved in the prevention of NPS related harm. On the whole, we need to approach the diverse field of NPS with more sophistication than the broad brush approach of drugs in general in order to minimize the potential for drug related harm and drug user alienation and stigmatization. A one-fits-all preventive solution to such a diverse area of drug groups, user types, effects, and motivations for use is likely to be ineffec- tive at best and counterproductive at worst. The findings highlight the much debated issue of whether prevention should focus on a reduction in overall use or a reduction in overall harm. The risk-oriented and dominantly prohibitive prevention strategy may benefit from recognizing most drug use as an adaptive 2 function with instrumental value. Otherwise, the existing pathologising views of drug users will run the risk of fueling potentially harmful behaviors like novel sensation seeking, self-medicating and avoidance of public health and emergen- cy care. Moreover, prohibition appears not only to drive the development of and displacement to substituted NPS with yet more harmful effects, but also serves as the key incentive for engagement in risky behavior by users with sen- sation seeking qualities. Exaggerated amounts of external control could also lead to a worsening of the already occurring alienation and stigmatization of drug users with rejected social values. The results of the current investigations could be a starting point for science based benefit-risk evaluations and the de- velopment of more appropriate prevention messages, including not only the risks but also the benefits in order to better resonate with the users. Further- more, identifying not only the explicit reasons for NPS use but also the types of motivation could improve prevention efforts. Finally, the users’ perspectives should be acknowledged and worked with instead of against. Keywords Novel psychoactive substances, drugs, legal highs, Internet, forum, ethylpheni- date, discussions, motivation, substance displacement, harm reduction 3 Sammanfattning Bakgrund Tillgången på legalt tvetydiga Nya Psykoaktiva Substanser (NPS) med mestadels odokumenterade effekter och risker har ökat kraftigt under det senaste decen- niet. Bristen på kunskap om NPS och den internetbaserade brukarkulturen ut- gör en utmaning för lagstiftare, preventionsstrateger och forskare. Ur ett hälso- perspektiv är det bekymmersamt att kunskapen om brukarna och deras upp- levda effekter, attityder och motivation är bristfällig. Syftet med föreliggande forskningen var att bidra till ökad kunskap inom NPS-fältet genom att 1) un- dersöka de mest inflytelserika drogforumen och deras användare, 2) karaktäri- sera de upplevda effekterna av en ny stimulerande drog, 3a och 3b) kartlägga användarnas attityder och motivation för bruk, samt att 4) induktivt analysera deras självrapporterade anledningar för att konsumera NPS. Metod Användargenererad data från Internet samlades in och bearbetades systematiskt genom tematisk analys. Statistiskt analyserad data om brukarnas karaktärsdrag, så som deras motivation, samlades in med en omfattande enkät som marknads- fördes på de mest inflytelserika drogforumen på Internet. Resultat Resultaten visar att den internetbaserade brukarkulturen kännetecknas av en stark grupptillhörighet och social identitet. Brukarna uppvisade även påtaglig misstro till och missaktning mot institutioner och den allmänna drogdiskursen. Forumdiskussionerna karaktäriserades av ett omfattande och kumulativt utbyte av peer-to-peer-genererad kunskap, samt av att fungera som ett socialt stödsy- stem i syfte att främja den övergripande avsikten att minimera drogrelaterade skadeverkningar. Tillhörighet och gemenskap var eftertraktade upplevelser och framstående drivkrafter för användandet av NPS. Brukarna var till stor del er- farna droganvändare som drevs av ett behov för rekreation, nöje, nya upplevel- ser och en rad andra instrumentella avsikter. Trots detta framstod brukarna som påtagligt kunniga, och uppvisade även en hög grad av emotionellt välbefin- nande. Tre brukarmentaliteter beskrevs; 1) den riskförsummande sensationssö- karen med intresse för stimulerande droger och förstärkning av egna förmågor, 2) den självmedicinerande coping-strategen med misstro mot vården och en 4 benägenhet för dämpande droger, och 3) den välinformerade självutforskaren som förespråkar skademinimering och hallucinogena preparat. En mängd olika effekter och motivationer identifierades. Den nya drogen etylfenidat framstod exempelvis som en motstridig, förrädisk och kraftfullt stimulerande substans med överhängande skadepotential och effekter i linje med traditionella stimu- lanter som amfetamin. Med hjälp av en enkätstudie synliggjordes ett liknande mönster där stimulanter, opioider och GABA-aktiverande substanser uppfatta- des ha signifikant större missbrukspotential än hallucinogenerna. Den vanligast förekommande anledningen för att använda NPS (generellt sett) var nöje och njutning. På substansgruppsnivå hittades dock flera specifika motivationsprofi- ler. Till exempel användes nya hallucinogener huvudsakligen till självutforsk- ning och andligt sökande medan stimulanter i högre utsträckning användes för prestationshöjande ändamål, och opioider användes främst för coping. Bruket av syntetiska cannabinoider var företrädesvis motiverat av yttre omständigheter så som pris, tillgänglighet och laglighet, och de framstod som mindre önskvärda och mer hälsovådliga substitut till växtbaserad cannabis. En studie av använ- darnas egna och självrapporterade anledningar till bruket av NPS resulterade i en mängd detaljrika och mer omfattat beskrivna anledningar än vad som före- kommit i litteraturen. Ett av de mer iögonfallande incitamenten inbegrep sö- kandet efter nya och spännande äventyr. NPS användes också för att möjliggöra mer fördelaktiga och tryggare drogomständigheter jämfört med etablerade ga- tudroger, vilket är anmärkningsvärt med tanke på den mediala och allmänna diskursens växande oro inför NPS. Det framkom även att bruket av NPS drivs av en ”försökskanins-liknande” service till drogforumen och det skademinime- rande ändamålet. Slutsatser Föreliggande resultat kan förhoppningsvis bidra till mer nyanserad kunskap om NPS och dess brukarkultur som kan vara till nytta för alla parter involverade i förebyggandet av NPS-relaterade skadeverkningar. I syfte att minimera drogre- laterade skadeverkningar och alienering av brukare behöver vi närma oss NPS fältet på ett mer sofistikerat sätt än enbart med svepande och övergripande per- spektiv på droger och droganvändare i största allmänhet. Tillämpning av endast en preventiv strategi på ett så mångfacetterat område med substansgrupper, brukartyper, effekter och motivationer kommer sannolikt vara ineffektiv som bäst och kontraproduktiv som värst. Resultaten lyfter även den omdebatterade 5 frågan huruvida prevention bör fokusera på nolltolerans mot droger eller noll- tolerans mot drogrelaterade skadeverkningar. Dagens riskfokuserade och över- vägande förbudsinriktade preventionsstrategi skulle kunna dra nytta av vetskap- en om att en stor del av droganvändande har en adaptiv funktion med instru- mentalt värde. Utan en sådan ansats riskerar patologiserandet av droganvändare att resultera i riskfyllda beteenden såsom sensationssökande, självmedicinering och undvikande av vård och akutsjukvård. Vidare förefaller förbud och kontroll bidra till utvecklandet och konsumtionen av ytterligare nya droger med okända risker och effekter. Dessutom utgör förbud i sig självt ett incitament för risk- fyllda beteenden hos droganvändare med sensationssökande karaktärsdrag. Överdriven extern kontroll kan också leda till en ökning av den redan före- kommande alieneringen och stigmatiseringen av droganvändare. Föreliggande forskning kan utgöra en utgångspunkt för evidensbaserade risk-vinst- evalueringar och mer ändamålsenlig prevention som inkluderar både risker och fördelar i syfte att göras mer trovärdig för brukarna. Vidare kan identifieringen av både explicita anledningar för bruk av NPS samt fastställandet av typ av mo- tivation effektivisera preventionssinsatser. Slutligen bör brukarnas perspektiv erkännas, beaktas och arbetas med istället för emot. Nyckelord Nya psykoaktiva substanser, droger, internetdroger, Internet, forum, etylfenidat, diskussioner, motivation, drogsubstitution, skademinimering 6