Understanding the patterns of use, motives, and harms of new psychoactive substances in Scotland

4. Motives for NPS Use

4.1 Introduction

This chapter examines the motivations for initially trying NPS, stopping use after trying, and continuing to use. It also draws on staff explanations from the focus groups as to why some clients do not try NPS at all. This data is supplemented by quotes from the qualitative analysis of interviews with people who had used NPS and from focus groups with frontline staff.

The analysis focuses primarily on the use of synthetic cannabinoids, benzodiazepine-type NPS, stimulant-type NPS, and mephedrone as these were the most popular NPS across all populations. The exception to this was amongst MSM who reported low rates of synthetic cannabinoid use and high rates of GHB/ GBL use. Where relevant, the analysis is broken down by groups.

The four most frequently reported reasons given for trying NPS were ease of access, curiosity, the socially embedded nature of substance use, and price. In addition, substitution for other drugs (both deliberate and accidental), improving sex, and health-related reasons were key motivations associated with specific substances.

4.2 Trying NPS

4.2.1 Ease of Access

Of those who reported using a substance within the last 6 months, ' It was easy to get' was given as one of the most common reasons for trying NPS. This was the case for:

• 38% (n=40) of the 104 people who reported synthetic cannabinoid use
• 43% (n=23) of the 53people who reported stimulant-type NPS use, and
• 40% (n=41) of the 102 people who reported benzodiazepine-type NPS use.

This also emerged in the interviews, with participants discussing ease of access:

• online (" It was just easier to get them [ NPS] online)" ^[55]
• via shops (" I found out where to get it [synthetic cannabinoid] during the day)" ^[56] , and
• from dealers: "It's easier to get a hold of than hash or grass and stuff. Everyone is buying from down the street [i.e. from a street dealer] because it's £6 bags" ^[57] .

4.2.2 Curiosity and Friendship

Amongst those who reported using a substance within the last six months, the statement 'Because I wanted to try it' was given as another main reason for trying NPS. This was the case for:

• 44% (n=21) of the 48 people who reported mephedrone use
• 34% (n=18) of the 53 people who reported stimulant-type NPS use, and
• 17% (n=17) of the 102 people who reported benzodiazepine-type NPS use.

This was supported by data from the staff survey, with 66% (n=122) of those working in services reporting that they believed their clients experimented with NPS because they had wanted to try it.

The statement 'My friend had it' was another common reason for trying NPS amongst those who reported using NPS in the last six months. This was the case for:

• 42% (n=44) of the 104 people who reported synthetic cannabinoids use, and
• 42% (n=20) of the 48 people who reported mephedrone use.

This was similarly supported by data from the staff survey, with 56% (n=103) of those working in services reporting that they believed their clients experimented with NPS because they were offered it by a friend.

In the qualitative interviews, participants often linked curiosity and sociality. When discussing trying mephedrone for the first time, various reasons were given. The common themes were:

• meeting new people ( "It was a new crowd of people that I started going about with") ^[58]
• hearing friends enthuse about NPS ( "Everybody was raving about it [mephedrone], so why not, eh?") ^[59] , and
• seeing a given substance's effects on others: "My pal looked like she was having a ball and I thought I want to try this [Ching - a stimulant]" ^[60] .

4.2.3 Price and Potency

While price and potency was not the primary motive for the use of any specific substance, the statement 'it was cheap' was amongst common reasons given by those who had used NPS in the last 6 months. This was the case for:

• 28% (n=29) of the 102 people who reported benzodiazepine-type NPS
• 30% (n=31) of the 104 people who reported synthetic cannabinoids use, and
• 30% (n=16) of the 53people who reported stimulant-type NPS use.

This was supported by data from the staff survey, with 58% (n=106) of those working in services reporting that they believed their clients experimented with NPS because they were cheap.

Price emerged as a common theme in the interviews and focus groups, although it was often linked to potency in discussion, as illustrated in the following quote:

"I think that's why I liked it [synthetic cannabinoids] so much when I started smoking it because it was £10 for a gram. You would literally roll it, you would take one draw, and that was all my thoughts and fears blocked out and that was me wasted instantly." ^[61]

4.2.4 Substitution for other substances

Almost a quarter of synthetic cannabinoid users (22%, n=23) reported first using synthetic cannabinoids thinking they were something else.

As illustrated below, this was rarely welcomed by those who discussed such experiences in the interviews:

"I didn't know what it was. I was just thinking that it was a normal joint, and then I had a weird taste in my mouth. Then, all the effects started happening…. I don't think I would have tried it [had I known what it was] because when I was in [prison] there was people dropping dead, obviously. ^[62,63]

A slightly higher proportion of people who had used benzodiazepine-type NPS in the last 6 months (29%, n=30) reported they tried them because ' I thought it was something else'. However, not all substitution was accidental. 26 people reported that they did so for 'other' reasons (including for example, that they ' couldn't get a Valium prescription'). Over a quarter (28% of reported benzodiazepine use, n=29) did so for health-related reasons:

"They [benzodiazepine-type NPS] were advertised as benzos and I knew - I'd taken Valium, benzos - so I knew that they worked [for managing sickness]. So these legal highs were not only cheaper but I was getting a lot more for my money… I was able to keep it going, maintain it instead of buying street Valium where I wouldn't be able to maintain it. So it was only about the sickness." ^[64]

Others specified the kinds of mental health problems they felt benzodiazepine-type NPS could help with, captured in the statement below:

"I was prescribed diazepam for anxiety and I no longer had any of that so it was to kind of go on with that." ^[65]

These references to prior benzodiazepine-use (prescribed or otherwise) and the emphasis on managing health rather than curiosity or pleasure-driven motives suggests that substitution (either deliberate or accidental) may play a much greater part in motives for trying benzodiazepine-type NPS than other types of NPS.

4.2.5 Improving Sex

15% (n=7) of the 48 respondents who ticked the 'other' box as a motivation for trying mephedrone stated they had used it to enhance sex. Six of these seven respondents were MSM. Similarly, in interviews the use of mephedrone and other NPS to enhance sex was discussed primarily, but not exclusively, by MSM:

[You] get a buzz from it [mephedrone] but it's also part of a sexual experience as well.... It just makes the contact with, and normally there's one or two others at the same time so it just makes it much more sort of, yes, I mean, it is a more enjoyable experience I think." ^[66]

During the interviews, four participants who did not identify themselves as MSM also described the use of NPS to enhance sex:

"It ['Burst' - ethylphenidate] makes you f***ing sex daft. Total sex daft. You think you're a porn star, it's f***ing mad." ^[67]

Male service users who identified as homosexual or bisexual were invited to complete an additional section of the NPS survey on chemsex. This was completed by twenty-nine of the 38 (76%) MSM who completed the main survey. Fig.4.1 illustrates that just under half (n=10) of the 23 individuals who identified as engaging in chemsex reported that over half of their sexual encounters involved the use of chems.

Figure 4.1: MSM reporting experiences of chemsex and slamming

Base (respondents to question on chemsex n=23, slamming n=6)

Twenty-six MSM responded to a question asking what led them to use chems during their last chemsex encounter, the main reasons given were to enhance sensation (n=13), followed by being drunk or high (n=9) and because their partner/s were doing it (n=8 ^[68] ).

Enhanced sensation also emerged as a theme in the interviews and focus group discussions with staff, as illustrated below:

"When they [ MSM] inject mephedrone it really heightens the sensitivity of the whole body." ^[69]

MSM also reported increased confidence (n=14) and increased sexual function e.g. maintaining an erection (n=13) whilst under the influence of NPS.

4.2.6 'Legal' Highs

Survey and interview participants were also asked about the importance of legality for trying NPS. However, this motive appeared to be less influential than those described earlier.

' It was legal' was descibed as a reason for trying NPS by less than one in eight (11%, n=21) NPS survey respondents. This suggests that legality was not a strong motivator for choosing NPS over 'traditional' drugs, although the fact that some NPS were legal at time of use may have increased the ease of access.

Legality did feature more prominently in focus group discussions with staff in services, as illustrated:

"For our young women it's the cost, it's about cost. And it being legal as far as they're concerned as well, they're not going to end up in court for it." ^[70]

Legality was also discussed by staff in relation to avoiding detection in drug tests and not risking arrest for possession.

Links between legality and perceived safety were explored in the survey. Only a very small number of participants who had used NPS equivalents to 'traditional' drugs in the last 6 months did so because they thought they would be safer. This was the case for:

• 4% (n=4) of the 104 people who reported synthetic cannabinoid use
• 3% (n=3) of the 102 people who reported benzodiazepine-type NPS use, and
• 6% (n=3) of the 53people who reported stimulant-type NPS use.

Nonetheless, the prospect that the description of substances as 'legal' could lead people to the mistaken view that they were also safe was raised during the interviews:

"Like the way like it's put out, like as in, they say legal highs, it makes you think it's safe because it's legal". ^[71]

However, Samuel, went on to reflect that:

"The first time folk take it, they take it because they think it's safer, cheaper and better. But, it isn't safer, it's cheaper and like the strength, the intention to it obviously gets stronger, but it doesn't mean it's better." ^[71]

Interviews also revealed that while apparent legality was not a motivator, the language of legality did shape how NPS were talked about. The most commonly used terminology to describe NPS was 'legal highs', or 'legals'. This extended to some participants describing being under the influence of particular NPS, particularly synthetic cannabinoids, as being 'legalled' (for example, "I just wanted to be high and legalled the whole time"). ^[72]

It was clear from the interviews that knowledge about the legal status of various substances was inconsistent and could be confused:

"I mean, they're all legal as far as I understand it. To be honest I never have paid much attention, but when it's something like that, yes, it's [mephedrone] not illegal, definitely not." ^[73,74]

For some participants the legal status of substances when trying them for the first time was irrelevant (" I did not know and I did not care"). ^[75]

Although the language of legality pervaded the ways in which some people who had taken, or continued to take, NPS talked about these substances - as both a category of drugs ( 'legals') and an effect ( 'being legalled') - knowledge about legal status was limited and had minimal impact on informing decisions to try NPS.

4.3 Not Trying and Stopping Use

While interviewees and participants who completed the NPS survey beyond the demographics section had all used NPS, focus group participants and people completing the staff survey worked in services which also support people who have not used NPS but who have used traditional drugs. These participants were able to give an insight into some of the reasons for not experimenting with NPS. The primary motives given by staff focused on relationships, perceptions of effects and effects on health. These are further discussed below.

4.3.1 Information and Effects on Others

The key reason for not using NPS identified by staff in the survey was that their clients had seen the effects of NPS in others. This was stated by over half of participants (56%, n=103). In the focus groups it was suggested that this may have been influenced by both seeing others, and information gathered from other sources:

"A couple of young men that I work with I think it's just about information, that they've read about it or they've heard about it and have all said, "No I'm not going to touch that s**t, no way".... They'd rather do whatever else it is they're doing than take a legal high." ^[76]

These reasons also featured in interviewee accounts of stopping:

"[I stopped because of] all the different stuff that I've seen with other people that took it, like obviously ma pal jumping into the [River] and stuff like that. I've heard of other people who have just stopped breathing on them so aye never touched them again." ^[77]

"I did see on the Internet and stuff like that, and I have heard that just, because obviously I researched it myself, you know, and I do look at the documentaries and they've scared me a bit so then that was another reason to stop, you know?" ^[78]

Just as effects on others could operate as a positive inducement to experimentation, they could also act as a deterrent to initial experimentation and continued use. Similarly, while information was understood by many to be difficult to access ^[79] , what information they did access could discourage some people from using or continuing to use NPS.

4.3.2 'I didn't like it'

When asked why they had stopped using NPS, the main reason offered by people who had tried NPS in the NPS survey was 'I didn't like it'. This was the primary reason given by:

• 76% (n=42) of the 55 people who reported stopping synthetic cannabinoid use in the last 6 months
• 63% (n=19) of the 30people who reported stopping stimulant-type NPS use in the last 6 months, and
• 60% (n=18) of the 30 people who reported stopping mephedrone use in the last 6 months.

This was supported by data from the staff survey, with 38% (n=73) of those working in services reporting that they thought their clients stopped using NPS because they did not like the effects.

In contrast, ' I didn't like it' was a reason offered by less than a quarter of those who had stopped using benzodiazepine-type NPS. This was cited by five of the 23 respondents who answered this question. Instead, these participants were more likely to cite reasons around damage to physical health (n=8 respondents) and mental health (n=7 respondents).

Importantly, interview participants distinguished between disliking immediate, intoxication effects, ( "I wouldn't even try it [synthetic cannabinoid] again.... That really, really scared me") ^[80] and longer-term effects:

"It was just [ethylphenidate] before they sort of got banned… I was destroyed, I was a corpse… I was like having nervous breakdowns, like proper breakdowns." ^[81]

The theme of disliking intoxication effects and quickly stopping use featured most prominently in relation to synthetic cannabinoids, which is reflected in the very high rates of trying and stopping due to dislike of effects in relation to this class of substance.

4.3.3 Damage to Mental Health, Physical Health, and Relationships

Amongst those who had reported using NPS in the survey, the statement 'It was damaging to my mental health' was one of the main reasons given for stopping use. This was the case for:

• 44% (n=24) of the 55 people who reported stopping synthetic cannabinoid use in the last 6 months
• 43% (n=13) of the 30people who reported stopping stimulant-type NPS use in the last 6 months
• 33% (n=10) of the 30 people who reported stopping mephedrone use in the last 6 months, and
• 30% (n=7) of the 23 people who reported stopping benzodiazepine-type NPS use in the last 6 months.

This was supported by data from the staff survey, with 69% (n=127) of those working in services reporting that they felt damage to mental health was a reason for their clients stopping NPS use.

This also featured in the interviews as illustrated in the following:

Interviewer: Tell me what made you stop [using mephedrone].

"I think hearing the voices and ending up in [a secure mental health unit]." ^[82]

Another main reason for stopping using NPS reported in the NPS survey was that 'It was damaging to my physical heath'. This was the case for:

• 47% (n=14) of the 30people who reported stopping stimulant-type NPS use in the last 6 months, and
• 35% (n=8) of the 23 people who reported stopping benzodiazepine-type NPS use in the last 6 months.

This was supported by data from the staff survey, with 39% (n=72) of those working in services reporting that they thought their clients stopped using because it was damaging to their physical health.

Physical health damage was seen to be less significant by some:

• 20% (n=11) of the 55 people who reported stopping synthetic cannabinoid use reported they stopped using because it was damaging to their physical health, and
• 17% (n=5) of the 30 people who reported stopping mephedrone use reported doing so because it was damaging to their physical health

Nonetheless, damage to physical health was discussed by interview participants:

Interviewer: And the main reason you stopped [Ching - a stimulant]?

"Was because I nearly lost my arm". ^[83]

Among survey respondents, damage to relationships was not a significant driver towards stopping. However in the interviews, participants reflected much more extensively on the damage their NPS use had done to their relationships, discussing this as a more important driver for stopping than damage to their physical and mental health ^[84] . This often related to damaged relations with family members:

"And then the family found out about it [synthetic cannabinoid use] and obviously they know about what it does… So I eventually just opened my eyes and realised what I was doing and stopped it again". ^[85]

Staff were asked to identify the key difficulties they saw clients experience when trying to stop use of NPS. Identified barriers included:

• anxiety (58%, n=106)
• sleeping difficulties (54%, n=100), and
• irritability (50%, n=92).

This highlights a particularly challenging context for recovery and barriers for service users engaging with services.

4.4 Continuing to Use NPS

Rates of current use varied by substance, as illustrated in Table 4.1 overleaf. The table illustrates use in the last 6 months and current use (although due to a significant proportion of the sample being recruited through treatment services, it should be noted that active use could be under-reported by clients who may have been concerned about disclosure of current drug use).

Benzodiazepine-type NPS had the highest rates of current use reported with 67% (n=58) reporting they currently used them.

Table 4.1: NPS Use: Reported six month and current use

NPS type	Taken in last 6 months		Currently take
	N	%	N	%
Synthetic cannabinoids	104	41	33	36
Benzodiazepine-type	102	41	58	67
Stimulant-type	53	21	13	28
Mephedrone	48	19	10	24

Those who reported using NPS in the survey gave various reasons for continuing to use their chosen NPS. These overlapped substantially with their reasons for trying. Ease of access was a main reason for continuing to use synthetic cannabinoids, benzodiazepine-type NPS and stimulant-type NPS. This was supported by the staff survey, where ease of access was the primary reason cited (54%, n=100).

Price was also reported as an important reason for continued synthetic cannabinoid and stimulant-type NPS use in the NPS survey. This was further reflected in the staff survey, with over half of respondents citing this as a reason for continued use amongst clients (51%, n=93).

Similarly consistent with reasons for trying, the two other main reasons for continuing to use given by users of benzodiazepine-type NPS were that they couldn't access Valium, and for 'health reasons'. One interviewee in the qualititative interviews described continued use of benzodiazpeine-type NPS connected to dependency issues and to managing mental health:

"Etizolam is something that I would say was more…like you know the other substances I would use them and then I would put them down but Etizolam I couldn't put that down. You know I had to have that every day, maybe like two or three times a day….. it took the edge off, it took the edge off just existing at this point" ^[86]

Where reasons for continued use did differ from reasons for trying was in relation to pleasure and compulsion:

• Of the 10 people who reported continuting to use mephedrone, 5 respondents (50%) reported continuing to use because they liked it, and
• Of the 13 people who reported continuing to use stimulant-type NPS, 6 respondents (46%) reported continuing to use because they liked it.

This was also supported by findings from the staff survey, where 47% (n=86) of respondents cited this reason for continued NPS use among their client group.

Reflecting on their continued use of mephedrone one interviewee in the qualititative interviews captured this sense of pleasure when he explained:

"It's [mephedrone] a pleasurable thing. I think that's why anybody does anything, whether it's drugs or alcohol or get high on gambling or whatever. It's a pleasurable thing. Like most things probably that are pleasurable it's a) either illegal or b) expensive or c) you can only do so much of it." ^[87]

However, 41% (n=13) of people reporting continued synthetic cannabinoid use stated that they continued to use ' Because I can't stop', and this reason was also suggested by 39% (n=71) of staff. The interviews highlighted that some synthetic cannabinoids users found that while it was initially pleasurable, stopping proved to be difficult, and the withdrawal effects were challenging to manage. This could prompt continued use, as illustrated below:

"Like some people do enjoy it [synthetic cannabinoids], but like when they're trying to get off it they realise completely that they are addicted and that's when the withdrawals start coming in, and most people can't handle the withdrawals because like you get sweats, cramps, sickness, headaches, migraines, fucking, just, oh it's bad like. It really is." ^[88]

Overall the qualitative interview extracts suggested that pleasure and difficulty stopping were not necessarily straightforward to disentangle as motives.

Of note is the low proportion of people who use benzodiazepine-type NPS who described their reasons for continued use in terms of difficulty stopping (19% of reported benzodiazepine-type use, n=11). 14 respondents stated that they used benzodiazepine-type NPS because they could not get Valium as a free-text 'Other' response.

The difficulties reported in ensuring a continuous supply of benzodiazepines was illustrated in the qualitative interviews:

"Actually I have bought pills out a shop. D something. Because I ran out of my pink pills, I ran out of them and that's the ones I bought from the shop. And it was going to take a couple of days, a day or two, for my pink pills to arrive. So I went into the shop and asked them, "I need to get something like vallies [Valium], benzos [benzodiazepines]", and he said, "Try these"." ^[89]

4.5 Discussion

Motivations for trying, stopping and continuing NPS use varied. While the language used by interviewees to describe NPS emphasised legality ( "legals"), few of the NPS survey participants or interviewees reported either trying or continuing use because they thought a given substance was legal. Similarly, safety did not emerge as a motivation for continued use. The shift in perception between substances being 'safer' because they were legal before trying, then going on to identify them as unsafe, after use, is mirrored in the work of Sheridan and Butler on BZP-party pills during the period in which they were legally available in New Zealand. ^[90]

Instead, reasons for experimenting with and continuing to use focused for many onprice and ease of access, as is noted noted by other research . ^[91] In addition, curiosity,social relationships and pleasure were all important factors informing decisions to start, and stop use.Seeing effects in others could be an important draw to experimentation or an effective deterrent, highlighting the importance of social circles in normalising different types of drug use practices. ^[92]

Participants reported increased pleasure, confidence and happiness as reasons for use of specific substances during chemsex. This is supported by existing qualitative research , whichhas identified better sex (in which pleasure is increased and inhibitions decreased) as a key motivation for engaging in chemsex. ^[93] Enhanced sensation was also a key factor for those using NPS for chemsex. Research has identified sustained arousal, aided by the use of 'chems', and heightened sensation as important motivators for use ^[94] . In addition, existing research has also identified that the use of chems can be used in response to negative emotions such as low confidence or self-esteem, internalised homophobia and stigma around HIV status. This suggests that 'better sex' is complex to define, particularly in relation to MSM who engage in chemsex. Low rates of chem-free sex among MSM has been reported elsewhere ^[95] , highlighting the importance of use for sex among some MSM. This suggests that chemsex is a potentially important public health issue, which will require responses that take account of the roles of pleasure and disinhibition, and chemsex social norms.

The two main reasons for trying and continuing to use benzodiazepine-type NPS given by users were that they couldn't access Valium, and for 'health reasons'. This may simply reflect that dependency on these pharmaceuticals can be predicted after fairly short periods of regular use. ^[96] Health reasons may include self-medication but may also be associated with managing unpleasant and potentially dangerous withdrawals as is reported in other literature. ^[97]

Given that use of benzodiazepine-type NPS due to difficulty accessing diazepam was identified among the NPS survey respondents and taking account of the known issues of dependency and withdrawal with benzodiazepines ^[98] , this likely suggests this group did not report difficulties stopping because they were not seeking to stop their use. Rather, the difficulties people who took benzodiazepine-type NPS reported were around ensuring a continuous supply.

There is an extensive literature base which suggests that withdrawal from benzodiazepines involves potentially challenging symptoms. In some clients, withdrawal effects such as rebound anxiety and rebound insomnia, can have physical manifestations such as sweating and tremors ^[99] . Less well documented are the withdrawal effects of synthetic cannabinoid use, although respondents in the NPS survey identified similarly difficult withdrawal effects. Just as benzodiazepine withdrawal is ideally carefully clinically managed, clinical management may be beneficial to people who use synthetic cannabinoids and wish to reduce or cease their use. This is an area in need of further research with a view to the development of good practice guidelines.