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Mephedrone and multiplicity: user accounts of effects and harms.

Recreational drug scenes across Europe, Australia, New Zealand, United States and Asia experienced varying degrees of change around 2009, with the emergence of mephedrone and other legal psychoactive substances that mirrored the effects of some popular illicit drugs (Dargan, Albert, & Wood, 2010; McElrath & O'Neill, 2011; McElrath & Van Hout, 2011; Measham, Moore, Newcombe, & Welch, 2010; Van Hout & Brennan, 2012). Initially dubbed "legal highs," these novel psychoactive substances (NPS) often fell outside the boundaries of traditional drug legislation (McElrath & O'Neill, 2011; McElrath & Van Hout, 2011; Measham et al., 2010). In Western Europe, particularly the United Kingdom (UK) and Northern Ireland (NI), the most popular and widely publicized NPS was mephedrone (McElrath & O'Neill, 2011; McElrath & Van Hout, 2011; Measham et al., 2010; Van Hout & Brennan, 2012). The drug is a "chemical cousin" of methylenedioxypyrovalerone (or MDPV), a substance better known as "bath salts," which surfaced in the US soon after the emergence of mephedrone.

"Mephedrone" is the name commonly applied to the research chemical 4-methylmethcathine. The substance is a synthetic derivative of cathinone--an active component in khat, (1) which is used as a psychoactive drug. Mephedrone is taken for its stimulant properties that reportedly induce effects similar to amphetamine-based drugs, including increased energy, talkativeness, empathy, and insomnia (Dargan et al., 2010; McElrath & O'Neill, 2011; McElrath & Van Hout, 2011; Measham et al., 2010; Van Hout & Brennan, 2012).

Mephedrone is generally found in powder form (Newcombe, 2009; Wood & Dargan, 2013) and usually consumed via nasal insufflation (i.e., "snorting") or orally, by dissolving in water or wrapping in cigarette paper and swallowing (often referred to as "bombing") (Measham et al., 2010; McElrath & O'Neill, 2011; Newcombe, 2009; Wood et al., 2010). More recent studies have noted intravenous use of mephedrone in Ireland (Van Hout & Bingham, 2012), as well as some post-soviet countries where the quality of heroin is generally poor, for example, Romania (Europol-EMCDDA, 20110). Injection as a route of mephedrone administration is much less common, particularly among recreational users (Carhart-Harris, King, & Nutt, 2011; Van Hout & Bingham, 2012; Wood et al., 2010).

Prevalence data on mephedrone use is somewhat scarce due to the recent emergence of the drug. Only a small number of countries collect data at a population level on the use of mephedrone (Wood & Dargan, 2013), including England, Wales (Home Office, 2013), and Ireland--North and South (National Advisory Committee on Drugs [NACD] and Public Health Information and Research Branch [PHIRB], 2011). Data collected soon after the emergence of mephedrone revealed lifetime prevalence estimates of 4.4% in England and Wales (Smith & Flatley, 2011) and 5.7% in Northern Ireland (NACD & PHIRB, 2011) among 15- to 24-year-olds. However, more recent prevalence data from England and Wales indicate a fall in the number of young adults reporting last-year use of mephedrone (from 3.3% in 2011-2012 to 1.6% in 2012-2013). Higher lifetime prevalence of mephedrone use has been reported among individuals who attend dance clubs (Winstock et al., 2011) and frequent ecstasy users (Matthews & Bruno, 2010).

Prior to April 2010, it was legal to possess mephedrone in NI and supply was not prohibited, providing the substance was not sold for human consumption. The Internet proved instrumental in the marketing of mephedrone prior to legislative control. Consumers were able to purchase this popular and potent product in significant quantities, at relatively low cost and without risk of legal sanction (dependent on product labeling). The Internet also served as a platform for knowledge exchange, with users sharing accounts of positive experiences and adverse side effects, and advising upon issues around dosage.

Prior to legislative control, mephedrone was available from online and street-based head shops, as well as dealers involved in the supply of traditional drugs (Dargan et al., 2010; McElrath & O'Neill, 2011; McElrath & Van Hout, 2011; Measham et al., 2010; Van Hout & Brennan, 2012). The substance was often sold in packaging marked with "not fit for human consumption" in order to bypass existing UK and Irish food and medicinal controls (McElrath & O'Neill, 2011). The product was traded under the guise of "plant food" in the UK and "bath salts" in the US (2) (Wood & Dargan, 2013; EMCDDA, 2011; McElrath & O'Neill, 2011; Measham et al., 2010; Newcombe, 2009).

Pre-ban, mephedrone could be purchased at an approximate cost of 10-15 [pounds sterling] (GBP) per gram (McElrath & O'Neill, 2011; Measham et al., 2010; Winstock et al., 2010), however, this cost reportedly increased by almost 150% following the control of mephedrone (McElrath & O'Neill, 2011; Winstock et al., 2010). As well as driving up the cost of mephedrone, prohibition has reportedly increased the potential for adulteration (Camilleri, Johnston, Brennan, Davis, & Caldicott, 2010; McElrath & O'Neill, 2011; Measham et al., 2010; Newcombe, 2009), arguably exacerbating potential health risks for users. However, research suggests drug adulteration occurs on a much smaller scale than anecdotally perceived, and indicates the use of relatively innocuous substances in the adulteration process (Cole et al., 2010; Coomber, 1997).

Research on mephedrone use pre-legislative ban, and shortly after, suggests that the popularity of the drug was associated with legality, availability, and deteriorating potency of some popular illicit drugs, such as ecstasy and cocaine (Brunt, Poortman, Niesink, & van den Brink, 2011; Matthews & Bruno, 2010; McElrath & O'Neill, 2011; Measham et al., 2010; Newcombe, 2009; Van Hout & Brennan, 2012). Local studies post-ban questioned whether displacement of mephedrone might occur, due to legislative control and reduced availability; for some drug users, mephedrone emerged as a drug of choice, despite its prohibition (McElrath & O'Neill, 2011; McElrath & Van Hout, 2011; Measham, Wood, Dargan, & Moore, 2011; Wood, Measham, & Dargan 2012) , while the drug waned in popularity for other drug users (Van Hout & Brennan, 2012). Among some gay dance clubbers, mephedrone was integrated into existing drug repertoires, alongside ecstasy, cocaine, and ketamine (Moore et al., 2013) , while other groups reverted back to, or did not deviate from, their use of established illicit drugs.

British media portrayed the rising popularity of mephedrone as a "moral epidemic"; suppliers were demonized and users stigmatized. Mephedrone was prematurely implicated in the deaths of more than 50 people in the UK, yet only directly related to two (Ghodse et al., 2010). During this period, politicians, police and media shared a wealth of unsubstantiated, and often unreliable, information about mephedrone. Upon recommendation from the Advisory Council on the Misuse of Drugs (ACMD), an amendment to the Misuse of Drugs Act 1971 in April 2010 controlled the use of mephedrone and other cathinone derivatives in the UK, classifying the substances as Class B drugs. (3) This legislation enforced a maximum penalty of five years for possession of mephedrone and 14 years for supply.

Some toxicological and social research has highlighted the potential health risks associated with mephedrone use, particularly around toxicity, compulsive use and adverse side effects, including painful nasal passages, hot flushes, loss of appetite, nausea, and insomnia (ACMD, 2010; Dargan et al., 2010; Deluca et al., 2009; EMCDDA, 2011; James et al., 2011; Winstock et al., 2011; Wood, Measham, & Dargan, 2012). Long-term effects are merely speculated upon and existing knowledge is based on a range of sources which include anything from hospital admission records to information posted through online drug forums.

Research suggests high incidence of simultaneous, polydrug consumption among mephedrone users--that is, the consumption of two or more different substances (licit and/or illicit) during a single episode (McElrath & O'Neill, 2010; Measham et al., 2010; O'Neill & McElrath, 2012). There exists a dearth of knowledge around patterns of polydrug use involving NPS, and the ways in which users perceive associated harms, often relayed through common discourse. From an epidemiological stance, the recent emergence and changing compounds of these novel substances make it difficult to identify potential harms, in comparison with more established illicit drugs.

Drug use per se is portrayed as "high-risk" behavior that can result in harm (Austen, 2009; Duff, 2003). Such portrayals are often informed by epidemiological discourses and transmitted by government representatives, health officials, and the media. As such, these perspectives are often far removed from the lived experience of the drug user, creating a dichotomy of "expert" versus "lay" knowledge on drug-related risk. Such disparities are highlighted in the work of Austen (2009), Beck (1992), Duff (2003) and Kelly (2007), although the distinction itself has been criticized for presuming that so-called experts have access to superior scientific knowledge, while lay people rely on "folk wisdom" (Zinn, 2008, p. 440). Furthermore, this position assumes that drugs are concrete entities that possess intrinsic characteristics and produce predictable effects (Fraser & Moore, 2011), thus inferring that risk is static, stable and isolated.

Law and Mol (2002) argue that no phenomena are singular; rather phenomena are enacted multiply via different practices, with different realities. Applying this insight to the study of drugs, drug effects are not stable and may induce varying effects among different users, within different social and cultural contexts. As Duff (2013, p. 172) notes, "one body may encounter a drug and experience only enabling affects, while another may experience disabling a/effects." Risk, therefore, emerges as an effect of spatial, social and cultural relations (Duff, 2013; Law & Mol, 2002; Rhodes, 2002). The aim of this article is therefore not to predict risks associated with mephedrone use, but, rather, this article seeks to contribute to existing knowledge on the multiple ways in which mephedrone is experienced and its effects are discussed.

Methods

This article draws on data from two qualitative studies conducted with self-reported drug users in NI. Combined, data present a more holistic representation of mephedrone use among a small sample of Northern Irish adults. Prior to the commencement of both studies, ethical approval was granted by the Ethics Committee in the School of Sociology, Social Policy and Social Work, Queen's University Belfast. Study One (McElrath & O'Neill, 2011) included 23 individuals who reported using mephedrone during the six months prior to interview. Respondents were recruited through personal contacts of the researchers, chain referral, and a social networking site. Semistructured interviews were conducted within 10 weeks of the legislative ban on mephedrone (May-June 2010). The interview schedule focused on a number of issues including availability of mephedrone pre- and post-ban, sources of supply, perceived effects, and settings for use. Interviews lasted between 1 and 2 hours and were conducted in locations chosen by respondents, providing the choice of place posed no immediate danger to the researcher; settings included private residences and shared public places (e.g., public parks).

Approximately half of the respondents in Study One were male (11 of 23) with ages ranging from 19 to 51 years. The majority of respondents were employed (19 of 23) and most occupations were associated with business, trades and service industry. Fifteen respondents lived in the greater Belfast area; the remainder resided in or around a small town in NI.

Study Two (O'Neill & McElrath, 2012) was conducted in fulfillment of a doctoral thesis and used ethnographic methods to examine user accounts of risk associated with patterns of drug consumption which could be described as less problematic. Semi-structured interviews were conducted with 45 self-reported recreational drug users, between September 2007 and August 2011. The researcher had ready access to a large proportion of the sample (often referred to as the "base sample"), having formed friendships with a number of respondents prior to the commencement of (or even intention to conduct) the research.

Twenty of the 45 respondents also participated in the observational component of the study, which spanned intermittently from September 2007 to April 2012. Observations were conducted on an ad hoc basis, with frequency varying in accordance with the group's patterns of drug use. In total, more than 50 observation sessions were conducted during the course of the research. These sessions predominantly took place in private residences and also included nights socializing in pubs and/or clubs, as well as music festivals. The majority of respondents from Study Two were male (28 of 45). Respondents' ages ranged from 19 to 49 years, with most aged between 20 and 30 years (39 of 45). The majority of respondents were employed (40 of 45) and most occupations were affiliated with trades, business and the service industry. Seventeen respondents lived in the greater Belfast area, while the majority resided in or around a small town in NI (n = 28).

A flexible inductive approach was adopted for analyzing data from the two studies, using content analysis and avoiding the use of preconceived themes. This analytic approach is particularly well-suited to phenomena and practices about which there is limited knowledge and literature (Hsieh & Shannon, 2005). Data from Study One were analyzed after reading transcripts several times. Emerging themes were noted and a coding scheme was developed. Preliminary patterns in the data were analyzed and outliers were noted and discussed among the research team. Periodic briefing sessions were held between researchers and those connected to the mephedrone "scene" in order to offer interpretive clarity. Study Two incorporated the use of a computer software package (MAXQDA) to organize data, which were then analyzed thematically. Themes were explored at a semantic level, whereby data progressed from description to interpretation. Similar to Study One, intermittent discussions were held with members from the "base sample" to offer perspective and add weight to interpretation of data.

Results

This section presents data on the effects of mephedrone use as reported by users. It is not assumed that these experiences and accounts are representative of the wider mephedrone-using population. The mephedrone effects, specifically those identified as harmful or risky, explored in this section are not static, definite or singular; rather, they are socially constituted phenomena wherein "different versions, different performances, different realities ... co-exist in the present" (Mol, 1999, p. 79).

Effects of mephedrone

The majority of respondents recalled positive experiences with mephedrone. Drug episodes involving mephedrone were often characterized by feelings of euphoria, wellbeing, talkativeness, and bonding of friendships. However, these accounts were often reported in conjunction with adverse side effects and health risks, particularly around routes of administration, patterns of consumption, and the aftermath of mephedrone use. That said, adverse side effects were often reported as necessary components of the overall mephedrone experience, which was perceived as largely positive.

Route of administration

Most respondents reported nasal insufflation--snorting--as the most common means of consuming mephedrone. Ingesting the drug via insufflation was reported to induce immediate pain and a sensation of "burning" in the nasal passages, as reported by one female user (26): "The next day and at the time, mephedrone burns my nose so badly, it's so sore."

This effect was reported as negative by most and some respondents likened the sensation to snorting razor blades or glass. Numerous respondents also reported experiencing nosebleeds following nasal ingestion of mephedrone, as described by one female respondent (aged 49), "With mephedrone ... the nose bleeds, that's not normal. It's not normal that you take something that's going to cause your body to be damaged straight away basically with it."

In order to avoid this effect, some respondents preferred to orally ingest or "bomb" mephedrone. The term "bombing" was used by respondents to refer to mephedrone consumption by dissolving a quantity of the drug in liquid or wrapping a quantity of powder in paper and swallowing:

When you're bombing it, it takes that bit longer to hit you but it's no different [in terms of] the effect you get. None at all like. People say the effect is better if you snort it; the truth is it's not, it's just quicker. Anything's quicker if you snort it. But if it's that sore on your nose and it burns that much, you should know not to do it. (Male respondent, 31)

The position held by this respondent coincides with dominant discourse that drug effects are singular, stable and static and he believes that his view reflects the real "truth," that is, that the effects of mephedrone do not vary according to route of administration or user.

Simultaneous polydrug use

Simultaneous polydrug use, wherein mephedrone is consumed with other drug(s) in the same episode, was common among the sample. According to one female respondent (29), "I would take meph[edrone] and pills [ecstasy] together, no discrimination like--I'll literally take whatever's going [available]."

Observational methods were particularly useful in gathering primary data on the extent of polydrug use among respondents in Study Two. Data were gathered on drug combinations involving mephedrone, sequential consumption of drugs, and observed and/or reported side effects. The notion of consuming drugs in a sequential order was common among respondents and coincides with the findings of Hunt, Evans, Moloney, and Bailey (2009) that simultaneous polydrug use is often strategically carried out to produce certain effects. As one male respondent (27) shared, "There's nothing I wouldn't combine. All I do is take them at different stages. I always take coke first, usually because it's during the day and the effects aren't noticeable [to others] or there's no smell of it." (4)

Field notes from one observation session, spanning approximately 14 hours, documented simultaneous polydrug consumption that could be described as high-risk behavior. The incident involved a 30-year-old male, who had a long history of weekend drug use and an extensive repertoire. This individual commenced one particular drug episode by drinking alcohol. He then consumed two ecstasy tablets, five alcohol shots, two lines of cocaine and an unmeasured, but substantial, quantity of mephedrone. He also inhaled amyl nitrite (poppers) a number of times and concluded the drug episode by smoking cannabis. While this particular drug combination may appear extremely risky to an "outsider," neither the individual in question, nor his friends appeared concerned. The data illustrate the multiplicity of drug experiences and effects.

Increased use

In both studies, a number of respondents described mephedrone as quite a "moreish" (meaning it makes you want more) drug that was difficult to stop taking during any one episode, unless the supply ran out. For most, this desire for more ceased when the drug episode came to a close. However, some individuals observed and/or experienced more long-term and problematic urges to consume mephedrone, which suggests that dependency is another perceived health risk: "[Mephedrone] never really affected me like that, but I [saw] people ... who I was taking it with, going from being a very low drug user to wanting it and craving it all the time like" (Male respondent, 25). This comment is indicative of the way in which the same drug can affect (or be perceived to affect) different users in various ways, that is, the respondent himself did not report mephedrone as a "moreish" drug, but reported observing this effect among other users.

Some respondents reported patterns of mephedrone use that could be described as "problematic" from an "outsider's" perspective. However, this contention and neoliberal episteme of "normal" versus "chaotic" behavior is critiqued by Fraser and Moore (2008). Such patterns of use were often not deemed problematic by users, as illustrated in the following excerpt from an interview with a low-level, male mephedrone dealer, whose stockpile was often used to self-indulge:

I end up taking wee sneaky blasts [of mephedrone] to get me through the week like ... I've only taken it once or twice at work. I don't think it's an addictive thing though, I don't get a craving for it, I just take a notion for it and so I have a wee blast ... When you're dealing it as well, you need to reach that point where you're not just taking it [because] it's there. Otherwise you'll snort and snort until it's not there, and neither is your sanity and neither is half your nose. You need to be able to leave it, and I can when I have to ... sometimes I just don't want to. (Male respondent, 28)

In terms of quantity and frequency of use, this respondent's patterns of mephedrone consumption could be described as problematic from an outsider's perspective, but were not identified as such by the user, reinforcing the multiplicity of drug experiences and the complexity of risk. There are no fixed risks; rather, there are numerous common discourses that users may take on board. These discourses can include hearsay, media, formal risk discourse, personal experience, and reported experiences from friends.

"Coming Down"

The aftereffects of consuming mephedrone were described as negative by most. Respondents reported unpleasant "come downs" which were often characterized by nausea, inability to sleep, loss of appetite, paranoia, and heightened emotions, particularly feelings of melancholy. Many respondents stated that the side effects that followed mephedrone use were more difficult to manage in comparison with many other stimulant drugs: "There's definitely a way worse come down with meph than any of the drugs I've taken before" (Female respondent, 29).

Conducive with the virtues of multiplicity, these side effects appeared to vary in severity according to the individual, the quantity of mephedrone consumed, drug combinations, and the duration over which the drug episode spanned. Some users reported feeling lethargic and melancholic after using mephedrone while others reported feeling suicidal:

I've taken plant food [mephedrone] and I honestly had the worst come-down ever, like I was ready to drive off the bridge when I was driving home. I was so sick and mentally I was just ... depressed, totally depressed. (Female respondent, 24)

In contrast to the comment above, one male respondent (27) reported enjoying the process of withdrawal from mephedrone, particularly when consuming alcohol and tobacco the following day: "I don't get come downs, just a bit tired after partying for two or three days ... Pints and [cigarettes] taste better the next day ... I be real happy and giggly the next day."

The data highlight multiplicity in relation to the effects reported following drug episodes involving mephedrone. While this process was deemed extremely negative by one participant, it was described as particularly enjoyable by another.

Mephedrone and prohibition

A small number of respondents from both studies (n = 5) reported concern that legislative control of mephedrone had forced the substance on to the black market, resulting in exposure to legal risks when accessing and using the drug: "Now ... [mephedrone is] not legal and if you want to get it ... you're going to have to break the law" (Male respondent, 24).

In accordance with existing research on recreational user accounts of legal risk (Deehan & Saville, 2003; Wilkins & Sweetsur, 2013), the majority of respondents seemed unconcerned about the repercussions relating to the prohibition of mephedrone. It is difficult to ascertain whether this complacency is affiliated with recreational drug use per se, or whether this lack of concern can be attributed to "tribulations of transition" in relation to the rapid change in legality, as advocated in the excerpt below:

Most people I know, including myself, are still looking it and still taking it ... I still don't even consider it an illegal drug yet. When I go out ... with coke ... I would have thought, "Shit, if I'm caught with a gram of coke what will happen?" Whereas with mephedrone, I don't have that fear and it's because I started taking it when it was legal. (Female respondent, 23)

Respondents were, however, concerned about the impact prohibition could have through increased potential for adulteration. Eight respondents from Study Two expressed concern that the prohibition of mephedrone facilitated drug adulteration. One individual who was engaged in low-level supply of mephedrone compared the state in which he purchased the drug preceding and following the legislative ban:

You know yourself, it's cut with something. I don't even get it in a brick anymore, I used to get it in a brick but now I get it in the wee bags and stuff, and you just know deep down it's cut with [something]. (Male respondent, 24)

This potential for adulterating mephedrone was described by a number of respondents as risky, primarily due to the fact that users were unaware of perceived dilutents:

What are they cutting it with? If they're cutting it, in their eyes it's legit, but say what it is then. Like they don't advertise and say for example, "Ok this is half a gram of meph but it's also half a gram of washing powder." If you're giving me teething gel I would like to know. (Female respondent, 29)

One respondent from Study Two recounted socializing with two mephedrone suppliers at a house party. These individuals reportedly divulged their techniques of adulteration and stated that they diluted mephedrone with glucose at a ratio of 60:40. This account appears to support existing literature and forensic evidence that suggest that relatively innocuous substances are used to adulterate drugs, in order to increase the weight and maximize profits (Coomber, 1997).

Most respondents obtained mephedrone from drug dealers prior to and following legislative control. Only a small number of participants from both studies reported purchasing mephedrone from online vendors or street-based head shops when the drug was legal. This preference/tendency to use dealers as sources of supply was predominantly associated with the widespread accessibility of mephedrone:

INTERVIEWER: "Did you ever buy mephedrone online ... before the ban came in?"

RESPONDENT: "No chance sure why would I go to all that bother when I only have to go to the end of the road if I'm looking it?" (Male respondent, 24)

For a number of respondents, particularly those from rural NI, dealers were preferred sources of supply in order to avoid perceived stigma associated with entering street-based head shops:

I was in [a headshop] in [urban NI]. I wasn't buying anything, but I know that they were selling herbal E's and stuff. I would never dream of going into one of those shops to buy anything like that, like mephedrone or herbal pills. Especially up the town and stuff, imagine what people watching would say. (Female respondent, 29)

The stigmatization of mephedrone use is explored further in the following section. Data suggest that prohibition had little impact on the availability of mephedrone, with some respondents reporting increased accessibility following the ban: "It's still as easily accessible. Availability has actually got better" (Male respondent, 26). For others, mephedrone was still available post legislative ban, but slightly more difficult to access: "I could still get meph if I wanted to, but I'd have to go through a few more people before I could get it" (Male respondent, 19).

Consistent with the findings from Winstock and colleagues' (2010) research, a number of respondents noted that some dealers increased the price of mephedrone following the ban. Field notes from Study Two recorded the cost of mephedrone increasing from 15 [pounds sterling] to 25 [pounds sterling] post legislative ban. Demand for mephedrone seemed greater among the sample from Study One, possibly due to the recent emergence of the substance and poor quality of established drugs. For a small number of respondents in Study Two, mephedrone was no longer the drug of choice and users often returned to consuming traditional illicit party drugs, such as ecstasy and cocaine. However, many respondents reported a continued preference for mephedrone, which was related to continuous poor quality of popular illicit drugs:

I take more [mephedrone] now than when it was legal. Nothing to do with the ban though, just timing. And probably the fact that it came along when e's [ecstasy] weren't the drug of choice and the quality of coke [cocaine] was [not good]. If coke had ... been great round here, few people would have felt the need to turn to meph. (Male respondent, 28)

Only one respondent reported displacement of mephedrone by other legal NPS, however, she stated that this was the case for the minority of her acquaintances and speculated that most would continue to use mephedrone:

Most people are still taking it [mephedrone] as normal. There's a few people who have went in search for the next legal high, but in general, most people I know who have taken it, will probably continue to take it. (Female respondent, 23)

Without forensically testing these substances, it is impossible to ascertain whether users were being sold mephedrone in its original molecular structure or if they were purchasing a different product with similar compounds.

Mephedrone and stigma

A number of respondents, particularly those from the rural location in NI, expressed concerns about the stigma associated with mephedrone use: "Even though [mephedrone was] legal, it wouldn't matter ... people would still look and think 'Look at that scumbag"' (Female respondent, 26). One male interviewee (25) stated, "I wouldn't dare admit it [that I used mephedrone] to anyone I didn't know."

Research suggests that not all drugs are equally stigmatized (Ahern, Stuber, & Galeo, 2007). For example, cocaine is often associated with wealth due to glamorization of the drug in the media and its popularity among famous individuals (Clayton, 1996; Shildrick, 2008). Heroin, on the other hand, is a drug that carries a great deal more stigma, due to its association with poverty and marginalized populations (Jones et al., 1984). Mephedrone was one of the few drugs that were reported stigmatized by non-drug-users (through media) and some drug users (other examples included crack cocaine and heroin):

Cocaine is expensive and has that bit more prestige attached to it ... Whereas mephedrone ... when [it] was still legal, some people were anti-meph because they took the attitude of "Oh why can't you just afford to go out and get coke?" Like meph was like the cheap and scummy alternative to cocaine. (Female respondent, 23)

A number of respondents believed that UK media were the driving force behind the stigmatization of mephedrone users by publishing what was perceived as unreliable and unsubstantiated information:

Anytime something new comes out or if there's an epidemic of a certain drug, there will always be scaremongering ... Look at all the meph horror stories, this person cut their face off ... they probably would have done that anyway when they were 30 and had a nervous breakdown ... That's why media perception never affected me in a way that would make me change my opinion or base my opinion on the media. (Male respondent, 24)

The data above demonstrate awareness of the role of media in public discourse constructions of mephedrone and the impact of such constructions on users, specifically stigmatization, through perceived scaremongering and distinguishing between "normal" and "deviant" behavior (Dwyer & Moore, 2013).

User accounts on managing risk

The data presented thus far demonstrate the multiple experiences and reported effects of mephedrone. The multiplicity of these perceptions are reinforced in the current section which examines reported strategies used to mitigate against potential harms, including purchasing drugs from familiar sources, consuming drugs in moderation, adopting a relatively active lifestyle, exchanging drug-using information amongst peers, and ensuring that drugs were generally used in a safe and comfortable environment. One male respondent (29) reflected upon the potential harms of mephedrone use and stated:

Bottom line, mephedrone probably isn't overly safe, something which can give you that good of a high can't be totally safe, it usually comes at a price, but you can make the process and experience as safe as possible by knowing your limits and being around people you trust to look after you if something does go wrong.

During an interview, another male respondent (25) stated:

Obviously when your hearts ticking a hundred times more than its used to, I'm aware that it shouldn't be happening and when the eyes are standing in my head, I know that it's not right. But as long as you can do something else physical to keep yourself right, you'll be alright, but if you're not doing anything else and you're stuck in a rut and you're not doing anything to keep your mind or body active.

Some respondents justified or "neutralized" the perceived harms of mephedrone use by comparing them with everyday risks, for example, the risk associated with crossing a road or eating fatty foods (Peretti-Watel, 2003). Respondents reported risk as an integral part of everyday life, thus, the reported risks associated with mephedrone and other drug use were accepted as part of contemporary life in a risk society (Beck, 1992; Giddens, 1991). As one male respondent (29) stated:

When you think about it ... there [are] a lot of things you shouldn't be doing, like smoking [and] drinking ... you can't even [eat] a fried egg now [without] causing health problems. But I think as long as you're doing [mephedrone] in moderation and in a controlled environment then it can't really do you much harm.

Similarly, one female respondent (23) stated:

You don't know what the effects of meph and all are ... it was only out recently so you don't know what it's done to you.... Although you could get hit by a bus tomorrow ... you have to live your life to a certain extent.

The multiple ways in which users reported managing perceived harms of mephedrone contribute to discussions around the value of "lay" knowledge and such constructions are often absent in public discourse. The same drug can affect individuals in different ways and users often construct their own discourse on drug effects and harms based on personal experience and that of friends. This knowledge can then be used to implement strategies that are perceived to mitigate against harm.

Discussion

The data presented in this article demonstrate that risk, as a concept, is neither stable nor consistent and the effects of drugs are multiple, incoherent, unstable, and inconsistent. Data highlight the complexity of drug-related risk and the multiplicity of drug experiences and effects, which are influenced by a range of individual, spatial, social and cultural relations. The research offers unique insight into patterns of mephedrone consumption, particularly the use of mephedrone in conjunction with other licit/illicit substances.

Data coincide with existing research on traditional illicit drug use, in that users reported few concerns about the legal implications of mephedrone use post-legislative ban (Deehan & Saville, 2003; Wilkins & Sweetsur, 2013). It is difficult to ascertain whether this observed complacency is affiliated with recreational drug use per se, or if this lack of concern can be attributed to "tribulations of transition" in relation to multiple understandings of risk pre- and post-legislative ban. Some users expressed concern around the impact of legislative control, specifically the increased potential for adulteration, resulting in perceived greater risks to health. Data revealed that prohibition had little effect on the availability of mephedrone and it remained a drug of choice for some respondents from both studies.

Stigma associated with mephedrone use was identified by some as a cause for concern, particularly those from rural NI. Existing literature focuses largely on stigma associated with problem drug use (Herek, 1999; Lloyd, 2010; Parker & Aggleton, 2003; White, 2009), thus, little is known about the role of stigma as it relates to non-problem drug use and mephedrone use. Mephedrone was one of the few drugs that were reported as stigmatized by some drug users, as well as the general public; many respondents stated that the stigmatization of mephedrone was fuelled by media, which were assumed biased and unreliable sources of information (Baxter, Gould, Kelly, Magarey, & Tayeh, 2002).

The multiplicity of risk is reinforced through the various strategies respondents reported using to manage risk, including the use of familiar sources to purchase drugs, moderating drug consumption, adopting a healthy lifestyle, and limiting drug use to safe and comfortable environments. Findings highlighted significant disparities between so-called "lay" and "expert" discourse on risk. For example, respondents reported adulteration of mephedrone post-ban as a significant risk to health, a perception challenged in the work of Coomber (1997) and Cole and colleagues (2010). In a similar vein, epidemiological discourse identifies polydrug use as extremely high-risk behavior (Breen et al., 2006; Collins, Ellickson, & Bell 1998; Grov, Kelly, & Parsons 2009; Measham, Newcombe, & Parker, 1994; Parker, Aldridge, & Measham, 1998; Sterk, Theall, & Elifson, 2006), however, respondents reported polydrug use as posing relatively low risk. While this article highlights disparities between lay and expert discourse on risk, the author urges one not to feel compelled to take sides and decide which party is right in their stance. According to Mol (2002), knowledge should be understood as a matter of manipulation, as opposed to a matter of reference. The differences highlighted between lay and expert discourse on risk should no longer be considered as different perspectives on a single object but the "enactment of different objects in the different sets of relations and contexts of practice" (Law & Singleton, 2005, p. 342).

Conclusion

Despite its prohibition in 2010, mephedrone remains embedded within some recreational drug scenes in the UK, and consumption within a prohibition context may expose individuals to a range of harms considering the multiplicity of drug effects and experiences. It is acknowledged that risk is a complex phenomenon that is neither static nor singular. Thus, this article does not purport to provide a definite list of risks associated with mephedrone use, rather, it aims to shed light on the multiple experiences and effects of mephedrone, as reported by users. It is acknowledged that the two studies upon which the paper has focused have limitations in relation to sample size and the use of self-report data. However, findings are relevant in relation to the multiplicity of mephedrone and other drugs and NPS. Mephedrone is only one example in a long list of NPS that have emerged, and the incessant growth of this market is probably inevitable. Future drug research must be rigorous, enduring and fluid enough to accommodate the rapid emergence of NPS and document the multiplicity of effects and harms according to epidemiologists, as well as users. To underplay the significance of user accounts and multiplicity in future research has serious implications on policy, particularly in relation to harm reduction. Policies that are founded on the basis of drugs as static entities contribute to the stigmatization of users and entice drug strategies which reflect a "one size fits all" approach. The data presented in this article and elsewhere in the literature suggest that there is no single truth in relation to drug effects and the ways in which they are experienced and discussed by users. Shifting from traditional deterministic approaches to drug treatment, legislation, policy and practice towards alternative ontological approaches to harm reduction would enable the identification of the multiple "associations through which particular [drug] effects and realities emerge" (Race, 2011, p. 410) and facilitate consideration of "strengthening those associations productive of least harm" (Dwyer & Moore, 2013, p. 210).

AUTHOR'S NOTE: Some of the research reported in this paper was funded by Northern Ireland's Department of Employment and Learning (DEL) and supported by Queen's University, Belfast. I am grateful to Professor Karen McElrath for leading Study One and her mentorship during Study Two. Thanks are also due to Professor Ross Coomber, Kate Seear, and three anonymous reviewers for Contemporary Drug Problems for helpful comments on an earlier version of the article. For additional information on this article contact: nina.oneill@qub.ac.uk.

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Notes

(1.) Khat is an evergreen tree found in parts of Asia and Africa (Armstrong, 2008).

(2.) The term "bath salts" was used to refer to mephedrone in its early days, but more recently refers to substances derived from methylene-dioxypyrovalerone (or MDPV), which are similar in molecular structure to mephedrone and often dubbed chemical cousins (HDAP, 2009).

(3.) The report from ACMD came under much scrutiny for lacking scientific evidence and being rushed. This report led to the resignation of Professor David Nutt (who was then chairperson) and six other members of ACMD.

(4.) Unlike cocaine and/or some other established illicit drugs, mephedrone has a very strong and distinctive odor that reportedly clings to fabric and even skin after handling and/or use.
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