How to accurately assess use of new psychoactive drugs such as 'bath salts'

Hundreds of new psychoactive substances have emerged in recent years, and determining their prevalence is essential to cultivating effective prevention efforts. One example of new street drugs is synthetic cathinones, a.k.a.: "bath salts." "Bath salts" are new amphetamine-like stimulants, and researchers and users know little about their effects. The "bath salt" called "Flakka" (alpha-PVP) has been linked to widespread and bizarre incidences of behavior in Florida.

Current methods to monitor use of new street drugs rely mainly on data from seizures and poisonings, with little effective survey data on self-reported use. Adding to the limitations of survey data, use of new substances is often unknown or unintentional, since drugs such as ecstasy ("Molly") are commonly adulterated with one or more of these new substances. This makes it harder to gauge specific usage from traditional drug-use survey methods.

"Research was needed to determine how to ask about use of these new drugs on health surveys," said Dr, Joseph Palamar, PhD, MPH, of the New York University Rory Meyers College of Nursing's Center for Drug Use and HIV Research (NYU CDUHR). "There are hundreds of new drugs, and many go by multiple street names, so it is difficult to accurately ask about use on surveys".

To address these current limitations in research, Dr. Palamar and his team conducted a study, "Assessing Self-Reported Use of New Psychoactive Substances: The Impact of Gate Questions," published in the American Journal of Drug and Alcohol Abuse. This is the first paper published in the journal's new Methods in Addiction Research section. The study tested the impact of "gate" questions as a method of reducing respondent burden when presented with lists of possibly unfamiliar new and/or uncommon substances.

Used on major health surveys such as the National Survey of Drug Use and Health, gate questions ask a single yes/no question to establish whether the participant has ever used a particular substance from a list of drugs in a particular drug class. If the response is "yes," then subsequent drug-specific follow-up questions are provided on the following page(s). Answering "no" allows the participant to skip the follow-up questions and proceed to the following section.

"We know that gate question methods work well on national surveys, but these studies don't ask about hundreds of new drugs, so it was unknown how survey participants would respond," notes Dr. Palamar. "In addition, it is likely that most participants on major drug surveys have at least heard of the majority of drugs queried. Lists of potentially unfamiliar drugs can confuse participants."

The team surveyed 1,048 individuals entering electronic dance music (EDM) parties in New York City throughout the summer of 2016 about their drug usage, randomly assigning surveys with and without gate questions.

Since "bath salts" were of particular interest of the researchers, participants were asked about use of specific "bath salts" regardless of their answer to the gate question. Interestingly, almost one out of ten participants who reported no "bath salt" use as per the gate question then reported use of one or more drugs in this class, providing evidence of under-reporting.

"There are a lot of people using drugs such as methylone in the EDM scene, but many users are unaware that methylone is a 'bath salt'," said Dr. Palamar. "It seems that some people didn't pay attention to the list of drugs that are considered 'bath salts' and simply checked off 'no' to use. 'Bath salts' are now highly stigmatized drugs by a lot of partiers, yet many don't even know some of the drugs they use are in fact 'bath salts'. Adding to this, in another study we detected 'bath salts' in ecstasy users' hair samples who were unaware they were using these drugs."

Of the eight drug classes queried, prevalence of reported use was higher when the gate question was not used regarding use of DOx (such as DOM, a.k.a.: STP), "other" stimulants (such as 4-FA), and "other" psychedelics (such as LSZ), with some differences in reported prevalence as high as 5%.

These findings suggest that providing participants with the actual list of drugs, initially, may be associated with more attention paid to the list and it also may reduce survey burden, resulting in more accurate answers.

"As NPS continue to emerge at a fast pace, there is an urgent call for research focusing on use of these compounds, as it is essential in order to inform prevention," said Dr. Palamar.