Synthetic Cannabinoids (SCs) in Metaphors: a Metaphorical Analysis of User Experiences of Synthetic Cannabinoids in Two Countries

NPS are marketed as illicit drug replacements, but carry user risk and harm due to the lack of information on toxicology and content (EMCDDA 2015). One such NPS are the synthetic cannabinoids (SCs) known as Spice, K2, Kronic (Bright et al. 2013; Baumann et al. 2014; Fantegrossi et al. 2014; Zawilska and Wojcieszak 2014), intended to replace natural cannabis and generally sold as herbal smoking mixtures. SCs emerged in Europe as early as 2004 (Griffiths et al. 2010; Schifano et al. 2009). Most prevalent synthetic cannabinoids compounds are CP 47,497-C8, JWH-081, JWH-250, JWH-018 and JWH-073 (Gunderson et al. 2012; Zawilska and Wojcieszak 2014). New-generation SCs include the hexyl homolog JWH-019 (Dresen et al. 2011), the aminoalkylindoles JWH-073 (Lindigkeit et al. 2009), JWH-250 (Westphal et al. 2010) and JWH-398 (Hudson et al. 2010) and JWH-015, JWH-122, HU-210 and AM-694 (EMCDDA 2009; Ernst et al. 2011). More recently, 5f-AKB48 and 5F-PB-22 have been detected in both seizures and fatalities (Roussel et al. 2015; Van Hout and Hearne 2017). These synthetic psychoactive compounds are sprayed or added to the herbal mixtures (Uchiyama et al. 2010) generally sold in metal foil sachets containing 1–3 g of dried leaves, resin or flowers (Dresen et al. 2011; Zuba et al. 2011; Kikura-Hanajiri et al. 2011; Zawilska and Wojcieszak 2014). Labelling on these herbal products often denotes ‘not for human consumption’ or ‘for aromatherapy only’ (Zawilska and Wojcieszak 2014). SCs in contrast to natural cannabis or phytocannabinoids (delta-9-tetrahydrocannabinol or THC) which are partial agonists are potent high efficacy cannabinoid receptor full agonists (Lindigkeit et al. 2009; Vardakou et al. 2010; Tuv et al. 2012). Prevalence data reports on use of SCs in adolescents and young adults (primarily male) estimated to be around 10% (Hu et al. 2011; Forrester et al. 2011; Vandrey et al. 2012), with global data suggesting lifetime use is higher (16.8%) (Winstock and Barratt 2013).

Motivations to experiment and use SCs centre on their availability, low pricing and inability to be detected in standard drug testing (Castellanos et al. 2011; Meshack et al. 2013; Arfken et al. 2014; Van Hout 2017). SC users report on euphoric pleasurable effects both similar to natural cannabis and distinct to SCs (drowsiness, time distortion, inability to think clearly, hallucinations) and general use for intoxication and relaxation purposes (Schneir et al. 2011; Fattore and Fratta 2011; Vandrey et al. 2012; Barratt et al. 2013; Soussan and Kjellgren 2014; Bonar et al. 2014; Van Hout and Hearne 2017; Kassai et al. 2017a). Decisions to use herbal mixtures are also grounded in a perception of safety (Fattore and Fratta 2011; Vandrey et al. 2012; Van Hout and Hearne 2017).

In comparison to natural cannabis, available literature indicates that more unpredictable and adverse symptomatology is reported by users (Bonar et al. 2014; Castaneto et al. 2014; Fantegrossi et al. 2014; Van Hout and Hearne 2017; Kassai et al. 2017a). Users describe intense and rapid trajectories of SC use from positive toward the negative and with dependent resulting in severe psychopathological and withdrawal symptoms (Zimmermann et al. 2009; Van Der Veer and Friday 2011; Nacca et al. 2013; Macfarlane and Christie 2015; Bilgrei 2016) and solitary daily use (Van Hout and Hearne 2017; Kassai et al. 2017a). Continued and compulsive use characterized by craving and multiple re-dosing, despite fear around psychotic and other unpleasant effects (panic, paranoia, aggression, chest pain, palpitations, anxiety, insomnia) is common (Vandrey et al. 2012; Winstock and Barratt 2013; Barratt et al. 2013; Fattore 2016; Van Hout and Hearne 2017; Kassai et al. 2017a).

Emergency hospital presentations are characterised by patients presenting with panic attacks, agitation, paranoid ideation, tachycardia, nausea, psychotic reactions and hallucinations post SC use (Sobolevsky et al. 2010; Vearrier and Osterhoudt 2010; Forrester et al. 2011; Castellanos et al. 2011; Every-Palmer 2010, 2011; Schneir et al. 2011; Bebarta et al. 2012; Spaderna et al. 2013). Winstock et al. (2015), in their study on patients seeking emergency medical treatment following SC use, with the relative risk of severity of side effects estimated to 30 times greater than natural cannabis. Clinical treatment of acute intoxication generally remains symptomatic and short (intravenous saline and benzodiazepines) and targeted to deal with agitation, tachycardia and nausea lasting up to 24 h (Castaneto et al. 2014; Fattore 2016). Adverse medical events caused by SC use include hyperemesis, kidney failure, seizures, cardiovascular events and psychiatric presentations (Tait et al. 2016). Anxiety and psychotic symptoms following acute intoxication reportedly last several days to weeks (Every-Palmer 2011; Bassir Nia et al. 2016), and in some studies, deteriorate and persist subsequent to the SC episode (Müller et al. 2010; Hurst et al. 2011; Van Der Veer and Friday 2011; Tung et al. 2012; Van Hout and Hearne 2017). Kassai et al. (2017b), in their identity work on SC users, illustrate how SC experiences are similar to traumatic experiences, representing additional difficulties in recovery. Reviews indicate that SCs can exacerbate psychotic symptoms in previously stable individuals or trigger new onset psychosis in those with no previous history of psychosis (Fattore 2016). In terms of treating dependence, patients with SC withdrawal symptoms often require intense medical support and admission to inpatient detoxification (Macfarlane and Christie 2015; Van Hout and Hearne 2017; Van Hout 2017).

Metaphors are increasingly used to better understand drug user experiences and as medium to inform and guide clinical responses. Participants describe their drug-related experiences and a myriad of metaphors are recognizable in their depictions. Lakoff and Johnson (2008), in their conceptual metaphor theory, give a description of the metaphor as a common everyday linguistic practice that is not only present in the literary language as a rhetorical instrument. Moreover, metaphorical expressions are part of the language we live by, which are detectable in the pronouns and the linguistic structures we are unconsciously using. This is especially applicable to drug users and drug-related language and nomenclature.

Johnson and Lakoff (2002) suggest that conceptual metaphors are rooted in bodily understanding of the world surrounding us and that embodied concepts are rooted in the experiences of the individual. Experiences can be explored by understanding the metaphorical mapping of the structure, the conceptual target and the source domains of metaphorical expressions the individual is using in describing specific experiences (Gibbs 2006; Kövecses 2003, 2010; Lakoff and Johnson 1980).

The conceptual metaphor theory provides a basis for systematic metaphor analysis as a method of qualitative research in social science (Schmitt 2005). Conceptual metaphors are analysed in the different fields of social science and the importance of metaphors in drug use have been long recognized in drug policy issues (Moore et al. 2015; Perlman and Jordan 2017), in drug treatment (Gryczynski et al. 2007), in progression and recovery of alcoholism (Jellinek 1946) and in revealing the experience of addiction (Shinebourne and Smith 2010; Gerçek 2017).

Metaphors of everyday alcohol consumption and their implications for counselling and prevention are inevitable (Schmitt 2005). Authors Rácz and Kaló (2009), in a preliminary study, have recognized the different conceptual metaphors of substance use by comparing Hungarian narratives of the personal experiences of the effects of heroin, amphetamine and marijuana.

Kaló and colleagues Kaló et al. (2013) also designed a study to compare the conceptual metaphors of the first known NPS, (4-MMC, mephedrone) from interviews conducted with Hungarian and Irish users. The study found that mephedrone had a complex effect on users which was expressed with metaphors from similar source domains in both languages. Differences were found if the setting of the mephedrone taking was different (injecting, snorting) (Kaló et al. 2013).

Two qualitative studies with SC users were undertaken by authors in two European countries, namely Hungary (Kassai et al. 2017a, b) and the Republic of Ireland (Van Hout and Hearne 2017). NPS appeared in Hungary in 2010, with significant increases in popularity reported in 2014 (Rácz et al. 2016; Reitox National Focal Point 2016). User peer networks and online availability supported sourcing, despite generic regulation in Hungary (Reitox National Focal Point 2016). Similar patterns occurred in Ireland (Van Hout and Brennan 2011a, b, c; 2012; Van Hout and Bingham 2012; Van Hout 2017), and where SCs emerged as a significant community and clinical concern since 2015 (Van Hout and Hearne 2017; Van Hout 2017).

Metaphors are increasingly used to better understand drug user experiences and as medium to inform and guide clinical responses. The main concern of this paper is about understanding the meaning of SC usage in terms of latent and implicit contents of users’ narratives; how the users of SC make sense of the world and how they experience SC usage across the trajectory of use, abuse and dependence. The theoretical background is defined by the conceptual metaphor analysis (Lakoff and Johnson 1980). Metaphors are culturally and socially defined, and yet they also represent a basic cognitive strategy of analogical problem solving. Metaphors are context-sensitive, yet at the same time, they are abstract models of reality much in the same way as mental models and schemata in cognitive psychology (Moser 2000). We are applying metaphor analysis to these SC narratives, to provide insight into the analogical problem solving as it relates to the use of SCs as described by the lived experiences of users in Hungary and Ireland. This type of work contributes to the literature on NPS and indeed illicit drug use by virtue of its new approach, which goes beyond the simple descriptor level and attempts to yield insight into problem solving as experienced by users of this addictive and destructive synthetic drug.

Hence, the focus of our study of SC metaphors based on user experiences was to gain a richer insight into the experience of SC usage by identifying and systematically comparing the language use and their conceptual metaphorical background related to SC use in English and Hungarian reports. By the comparison of different languages, we aimed to identify more information about the universal internal mental images and perspectives of SC use. The research questions were as follows;

We applied the conceptual metaphor theory as a method to understand universality of SC motivations, effects and consequences across to distinct cultural contexts, Hungary and Ireland. We used semi-structured interviews for data collection. We conducted interviews separately in the two countries, which were then transcribed verbatim. The data analysis was conducted by two independent researchers of the study.

We present here the first known attempt to analyse the conceptual metaphors (Lakoff and Johnson 1980) in user experiences of synthetic cannabinoids (SCs) in two countries, Ireland and Hungary. Users in our study were primarily young male adults, with reviews estimating that males appear more than twice as likely to use SCs (Castellanos et al. 2011; Forrester et al. 2011; Hu et al. 2011; Vandrey et al. 2012). We know that poly substance use is common among users of SCs (Castellanos et al. 2011; Hu et al. 2011; Vandrey et al. 2012). The selected narratives encompassed the motivations, the effects and the consequences which users encountered when using SCs in two distinct countries. We recognize that these SC narratives originate from both dependent users and users in recovery who are reflecting on their motivations, the effects and consequences of their SC usage.

According to the identified metaphors in the study, we consider the drug usage phenomenon as an embodied experience, that is indescribable by rigid, theoretical categories. Wallace (2004) argues that ‘addiction should be seen as a fluid, embodied process in which an organism moves towards and away from homeostasis (rather than a discrete mental state, “caused” by a drug)’ (Wallace 2004, p. 195). Thus, we demonstrate that the description of the drug usage experience can be understood by the conceptual metaphor analysis of language use of the drug users. Conceptual metaphor theory captures the embodied experience in language use by analysing the conceptual source domains.

The metaphorical analysis of these user narratives revealed that users perceive the SC to be everywhere they are and one which is especially overwhelming and all encompassing. This concept, as a metaphorical understanding, depicts SC as a magnetic force around the user, an inescapable trigger, always available, and one which renders the SC user powerless to decline, reduce or cease use. Extant literature underscores how SC is an NPS primarily ‘smoked for euphoria’ (Bebarta et al. 2012; Castellanos et al. 2011), initially regarded by users to incur positive personal experiences (Arfken et al. 2014) and with reasons for the first time use centring on curiosity, legality, availability and recreational effects (Barratt et al. 2013; Bonar et al. 2014). Desired effects for SC users are underpinned by the sense of elation and altered perception of reality (Fattore and Fratta 2011; Kjellgren and Jonsson 2013) and vary in the onset of effect and duration of action (Schneir et al. 2011).

Our analysis revealed that the general SC body experiences are dynamic and characterized by up-down orientation and are expressed consistently. Typical acute psychoactive effects as reported by our users include an energizing, disinhibiting, euphoric, relaxing experience with mild perceptual alterations, increased creativity and mild memory and attentional impairments (Spaderna et al. 2013; Van Hout and Hearne 2017). The SC as an embodied experience causes changes in the users’ perception and this change is reflected in the language used. These can range to the negative in altering cognitive and visual abilities, stimulating anxiety, hallucinations, extreme fear and motor impairment (Müller et al. 2010; Castellanos et al. 2011; Forrester et al. 2011; Gunderson et al. 2012). Perceptual changes on use of SCs reported in the literature include peripheral numbness, tingling, migratory flushing or cooling and altered depth perception (Schifano et al. 2009).

Metaphorical analysis across both countries revealed the inner experience of such symptoms. With both metaphors of SC as a magnetic field and SC as a destructive entity, users express and describe symptoms of anxiety (and de-realisation), unusual behaviours and thoughts, loss of reality or psychosis and fears around mental health conditions. Generally, SCs exhibit similar side effects to high-dose natural cannabis, but are more harmful (Hermanns-Clausen et al. 2013). Given the variability in content and potency of SC products, duration of effect (and residual effects) can last for hours (Schneir et al. 2011; Spaderna et al. 2013), and can contribute to a range of unpleasant experiences and risk of overdose (Tuv et al. 2012; Van Hout and Hearne 2017). Serious side effects include anxiety, decreased motor coordination, fast or irregular heartbeat, psychotic presentations and agitation (Every-Palmer 2011; Müller et al. 2010; Nacca et al. 2013; Barratt et al. 2013; Bassir Nia et al. 2016; Baumann et al. 2014; Fattore 2016; Hurst et al. 2011; Tuv et al. 2012). Emergency presentations describing such acute intoxication report on patient panic attacks, loss of consciousness, nausea, tachycardia, paranoid ideation, agitation, suicidal ideation, confused states and hallucinations, with symptoms emerging in the hours post consumption (Vearrier and Osterhoudt 2010; Sobolevsky et al. 2010; Van Der Veer and Friday 2011; Bebarta et al. 2012). Agitated delirium lasting for days has been observed (Berry-Cabán et al. 2013).

The conceptual metaphors of SC as a destroying entity reflect that the user becomes more and more powerless and the SC is perceived as something that holds the power and becomes progressively autonomous. Users described the intention to stop using, but an inherent sense of fear and panic around psychotic episodes and self-harming when abstinent. Kassai et al. (2017a, b) showed that SC users experience that their personality is ‘hijacked’ and they compared SC use to a type of trauma that ‘totally destroys their soul’. Across both countries, we found similar metaphorical concepts. This coupled with the sense that it (SC) is all around the users, contributes to the loss of power, and the objectification of SC (MacLachlan 2004). The protection of the self occurs whereby the user is distanced from the issue of SC and the distress it causes to the individual because it disconnects the ‘self’ from the thing (the SC) that is damaging him/her (MacLachlan 2004). The complexities around how to stop using SC across both countries were confounded by these discrepancies and conflicts. Disembodiment such as what is characterized within the SC experiences is that the body cannot organize or summon different feelings up and down at the same time or consecutively but very quickly (Merleau-Ponty 2002). Dependence and loss of control are well observed in the literature on SC abuse, and characterized by rapid tolerance development, SC craving, clear withdrawal symptomatology and continuous urge to consume (Zimmermann et al. 2009; Vardakou et al. 2010; Fattore and Fratta 2011; Van Hout and Hearne 2017). Hence, it is intended that these metaphors can be used to provide clinicians with an insight into the experiences of SC motivations, effects and consequences, and better inform and guide clinical and therapeutic responses in supporting SC recovering addicts. Limitations centre on small sample and that samples differed by virtue of situation within the addiction recovery pathway (Shinebourne and Smith 2010).

We present here a unique metaphorical insight into SC users’ experiences of motivation, effects and consequences. It is intended that these key insights underpinned by loss of control, fear and psychiatric illness can better inform and guide appropriate clinical and addiction responses to support recovery. ‘Standard diagnostic assessment’ relies on the description of symptom clusters often devoid of personal meaning and experiences, which is fundamental to the language of recovery (Mould et al. 2010). Effective communication with former SC users will become easier and better understood, as professionals can talk in ‘their language’ in therapy, in prevention and in harm reduction messages. This can be especially challenging in the case of NPS when the users themselves are not aware of what they have actually taken.