Recent national trends in Salvia divinorum use and substance-use disorders among recent and former Salvia divinorum users compared with nonusers.

Abstract

CONTEXT: Media and scientific reports have indicated an increase in recreational use of Salvia divinorum. Epidemiological data are lacking on the trends, prevalence, and correlates of S. divinorum use in large representative samples, as well as the extent of substance use and mental health problems among S. divinorum users. OBJECTIVE: To examine the national trend in prevalence of S. divinorum use and to identify sociodemographic, behavioral, mental health, and substance-use profiles of recent (past-year) and former users of S. divinorum. DESIGN: Analyses of public-use data files from the 2006-2008 United States National Surveys on Drug Use and Health (N = 166,453). SETTING: Noninstitutionalized individuals aged 12 years or older were interviewed in their places of residence. MAIN MEASURES: Substance use, S. divinorum, self-reported substance use disorders, criminality, depression, and mental health treatment were assessed by standardized survey questions administered by the audio computer-assisted self-interviewing method. RESULTS: Among survey respondents, lifetime prevalence of S. divinorum use had increased from 0.7% in 2006 to 1.3% in 2008 (an 83% increase). S. divinorum use was associated with ages 18-25 years, male gender, white or multiple race, residence of large metropolitan areas, arrests for criminal activities, and depression. S. divinorum use was particularly common among recent drug users, including users of lysergic acid diethylamide (53.7%), ecstasy (30.1%), heroin (24.2%), phencyclidine (22.4%), and cocaine (17.5%). Adjusted multinomial logistic analyses indicated polydrug use as the strongest determinant for recent and former S. divinorum use. An estimated 43.0% of past-year S. divinorum users and 28.9% of former S. divinorum users had an illicit or nonmedical drug-use disorder compared with 2.5% of nonusers. Adjusted logistic regression analyses showed that recent and former S. divinorum users had greater odds of having past-year depression and a substance-use disorder (alcohol or drugs) than past-year alcohol or drug users who did not use S. divinorum. CONCLUSION: S. divinorum use is prevalent among recent or active drug users who have used other hallucinogens or stimulants. The high prevalence of substance use disorders among recent S. divinorum users emphasizes the need to study health risks of drug interactions.

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Open Access Full Text Article
Recent national trends in Salvia divinorum use
and substance-use disorders among recent
and former Salvia divinorum users compared
with nonusers
DOI: 10.2147/SAR.S17192
Li-Tzy Wu1
george e Woody2
chongming Yang3
Jih-heng Li4
Dan g Blazer1
1Department of Psychiatry and
Behavioral Sciences, Duke University
Medical center, Durham, nc, USA;
2Department of Psychiatry, University
of Pennsylvania and Treatment
Research institute, Philadelphia,
PA, USA; 3Social Science Research
institute, Duke University, Durham,
nc, USA; 4college of Pharmacy,
Kaohsiung Medical University,
Kaohsiung, Taiwan
correspondence: Li-Tzy Wu
Department of Psychiatry and
Behavioral Sciences, Duke
University School of Medicine,
Duke University Medical center,
Box 3419, Durham, nc 27710, USA
Tel +1 919 668 6067
Fax +1 919 668 5418
email litzy.wu@duke.edu
Context: Media and scientific reports have indicated an increase in recreational use of Salvia
divinorum. Epidemiological data are lacking on the trends, prevalence, and correlates of
S. divinorum use in large representative samples, as well as the extent of substance use and
mental health problems among S. divinorum users.
Objective: To examine the national trend in prevalence of S. divinorum use and to identify
sociodemographic, behavioral, mental health, and substance-use profiles of recent (past-year)
and former users of S. divinorum.
Design: Analyses of public-use data files from the 2006–2008 United States National Surveys
on Drug Use and Health (N = 166,453).
Setting: Noninstitutionalized individuals aged 12 years or older were interviewed in their
places of residence.
Main measures: Substance use, S. divinorum, self-reported substance use disorders, criminality,
depression, and mental health treatment were assessed by standardized survey questions admin-
istered by the audio computer-assisted self-interviewing method.
Results: Among survey respondents, lifetime prevalence of S. divinorum use had increased
from 0.7% in 2006 to 1.3% in 2008 (an 83% increase). S. divinorum use was associated with
ages 18–25 years, male gender, white or multiple race, residence of large metropolitan areas,
arrests for criminal activities, and depression. S. divinorum use was particularly common among
recent drug users, including users of lysergic acid diethylamide (53.7%), ecstasy (30.1%), heroin
(24.2%), phencyclidine (22.4%), and cocaine (17.5%). Adjusted multinomial logistic analyses
indicated polydrug use as the strongest determinant for recent and former S. divinorum use.
An estimated 43.0% of past-year S. divinorum users and 28.9% of former S. divinorum users
had an illicit or nonmedical drug-use disorder compared with 2.5% of nonusers. Adjusted
logistic regression analyses showed that recent and former S. divinorum users had greater odds
of having past-year depression and a substance-use disorder (alcohol or drugs) than past-year
alcohol or drug users who did not use S. divinorum.
Conclusion: S. divinorum use is prevalent among recent or active drug users who have used
other hallucinogens or stimulants. The high prevalence of substance use disorders among recent
S. divinorum users emphasizes the need to study health risks of drug interactions.
Keywords: alcohol-use disorders, drug-use disorders, ecstasy, lysergic acid diethylamide, major
depression, multiple race, nicotine dependence, phencyclidine, prescription drug abuse
Introduction
Recreational use of Salvia divinorum has become a matter of increasing concern in
the United States and elsewhere, but epidemiological data from large representative
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Wu et al
samples are lacking to delineate the prevalence of its use
across different population groups and the profiles of emerg-
ing users.1–8 S. divinorum, also known as Maria Pastora,
Pastora, Sage of the Seers, Diviner’s Sage, Sally-D, or Magic
Mint, is a perennial herb in the mint family.9 Its main active
ingredient, salvinorin A, is a kappa opioid receptor agonist
and is considered one of the most potent naturally occurring
hallucinogens.2,9–11 In the United States, S. divinorum and
salvinorin A have no approved medical use.9 S. divinorum
leaves and salvinorin A have been used to produce halluci-
nogenic effects. The half-life of salvinorin A in nonhuman
primates is estimated to be 56.6 ± 24.8 minutes.10 However,
the potential toxicity and metabolism of salvinorin A
have not been fully investigated in laboratory animals or
humans.10,12
To date, studies of S. divinorum have focused mainly
on its effects, which have been found to be intense, short-
lived, and diverse. In a study of qualitative data from 10
S. divinorum users collected by email interviews, Dalgarno13
found that subjective experiences due to S. divinorum use
were quite similar to those of ketamine use. In another study
of 32 recreational users of S. divinorum and other psyche-
delics, González et al14 found that smoking S. divinorum
produced intense and short-lived psychedelic-like changes
in visual perception, mood, and somatic sensations, as well
as a highly modified perception of external reality and the
self. Additionally, Albertson and Grubbs15 found a greater
number of users who reported S. divinorum experiences as
being more similar to those of marijuana use than to experi-
ences produced by psychedelic mushrooms or lysergic acid
diethylamide (LSD). More recently, Johnson et al12 used a
controlled design to study four healthy hallucinogen-using
adults and found that salvinorin A appeared to produce dose-
related changes in subjective effects similar to those from use
of classic hallucinogens. Recent data from a United States
statewide poison control system have shown that, among
patients who intentionally used S. divinorum, whether alone
or in combination with alcohol or other drugs, psychiatric,
neurologic, cardiovascular, or gastrointestinal effects were
evident and that polysubstance use could result in more
serious adverse effects (eg, seizures, intubations) than use
of S. divinorum alone.4
Because of its ready availability, its legality, its halluci-
nogenic effects, and the lack of empirical data on long-term
safety of S. divinorum in humans, S. divinorum has become
a drug of increasing concern.1–10 In particular, it is easily
obtained from sources that may increase exposure opportunity
to psychoactive drug use. S. divinorum and salvinorin A are
not currently controlled under the Controlled Substances
Act in the United States, although, as of September 2010,
24 states have enacted legislation placing regulatory controls
on S. divinorum and/or salvinorin A.9 Because it is legal to
use and sell S. divinorum products in many jurisdictions and
S. divinorum can be cultivated, the Internet has become one
of the venues for the distribution of information about and
sources of S. divinorum and other psychoactive substances.5,16
For example, Hoover et al5 found that many websites that sell
S. divinorum products either encourage its use (eg, provid-
ing potentially erroneous information about the substance)
or promote it as a safe or legal alternative to scheduled hal-
lucinogens or cannabis, and that very few websites provide
anti-use information. A recent study of college students found
that friends and head shops serve as the primary informa-
tion providers or sources of S. divinorum, suggesting that
S. divinorum use can occur in groups.17
Moreover, although little is presently known about
salvinorin A’s long-term health risks in repeated users,10 case
reports have demonstrated that repeated use of S. divinorum
can be associated with serious psychiatric conditions in young
or vulnerable individuals.2 For instance, Przekop and Lee8
reported on a 21-year-old man with no family or personal
psychiatric history who developed persistent psychosis
associated with S. divinorum use. Breton et al18 described a
case of a bipolar 17-year-old girl who developed prolonged
hallucinations and dissociative self-destructive behaviors
following S. divinorum use. Similarly, Singh19 discussed a
15-year-old boy with a history of S. divinorum and marijuana
use who presented to psychiatric emergency services with
acute onset of mental status changes characterized by para-
noia, déjà vu, blunted affect, thought blocking, and slow
speech of 3 days’ duration. Together, these findings point
towards a need to investigate the extent of use of this novel
substance and S. divinorum users’ sociodemographic, behav-
ioral, mental health, and substance use profiles to inform
research, prevention, and policy-making efforts. As noted
in several research reports, epidemiological data on the
prevalence of S. divinorum use in representative samples
are lacking.5,7,20,21
To date, there are only a few studies of prevalence and
correlates of S. divinorum use, and they have focused pri-
marily on college students.17,21,22 In a convenience sample
of undergraduate students at a large public university in the
southeastern United States (N = 825), 10.9% of men and
3.8% of women reported lifetime use of any S. divinorum;
S. divinorum use was associated with male sex, white race,
a high level of family income, marijuana use, and a low

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Salvia divinorum use
level of self-control.17,21 In another study of college students
drawn from a large public university in the southwestern
United States (N = 1516), Lange et al22 found that 4.4% of
the sample reported using S. divinorum at least once in the
past 12 months, and that whites, males, fraternity members,
illicit drug users, and heavy episodic drinkers reported
a higher prevalence than other groups. However, after
controlling for the other covariates in the logistic regres-
sion analysis, only past-year drug use was associated with
S. divinorum use, suggesting drug use as a robust correlate
for S. divinorum use.22
Of note, no studies have explored the trend in S. divinorum
use despite the fact that several reports have mentioned its
increasing popularity among young people. Here, we seek to
address the gaps in knowledge regarding population-based
prevalence estimates and correlates of S. divinorum use by
examining prevalence rates of recent (past-year) and former
(prior to the past year) S. divinorum use and their correlates
in a large nationally representative sample of individuals aged
12 years or older. The data are drawn from multiple waves of
the United States National Surveys on Drug Use and Health
(NSDUH). Beginning in 2006, the NSDUH added assess-
ments of S. divinorum use to the annual survey.23 In a recent
NSDUH report, past-year S. divinorum use (1.7%) among
young adults aged 18–25 years in 2006 was found to be less
common than past-year ecstasy use (3.8%) but more common
than past-year use of LSD (1.2%) and phencyclidine (PCP)
(0.2%).23 Since the inclusion of S. divinorum use questions,
the NSDUH data have not been utilized fully to explore
changes in the prevalence of S. divinorum use across diverse
population subgroups and correlates of use.
This study examines a geographically diverse national
sample to inform recent trends in S. divinorum use (with
a higher level of generalizability to population subgroups
than a convenience sample) and to elucidate S. divinorum
users’ sociodemographic (age, sex, race/ethnicity, total
family income, and population density of the respondent’s
residence), behavioral (criminal behaviors), mental health
(depression, use of mental health treatment), and substance
use (tobacco, alcohol, illicit or nonmedical drug use) profiles.
Recent (in the past year) and former (prior to the past year)
S. divinorum use is distinguished in the analysis to inform
research and prevention efforts. These research questions
have not been systematically addressed in prior NSDUH
reports.
Four main questions are addressed:
1. Are there increases in S. divinorum use across different
sociodemographic groups?
2. To what extent are sociodemographic, behavioral, mental
health, and substance-use characteristics associated with
recent or former S. divinorum use?
3. Are recent S. divinorum users more likely than former
S. divinorum users and nonusers to have depression and
substance-use disorders (nicotine, alcohol, and drug-use
disorders)?
4. Among recent S. divinorum users, to what extent are
sociodemographic, behavioral, mental health, and
substance-use characteristics associated with having a
substance-use disorder?
Methods
Data source
Data were from the public-use data file of the 2006–2008
NSDUH, the only survey designed to provide ongoing
national estimates of substance use and disorders in the
United States.24–26 The target population includes residents
of households from the 50 states (including shelters, room-
ing houses, and group homes; civilians residing on military
base) plus the District of Columbia. Participants are selected
by multistage area probability methods to ensure that each
independent and cross-sectional sample is representative of
persons aged 12 years or older.
Respondents are interviewed privately at their places
of residence. Prospective respondents are assured that their
names will not be recorded and their responses will be kept
strictly confidential, and all study procedures and protections
are carefully explained. For adolescents aged 12–17 years,
the field interviewer first seeks verbal consent from their
parents/guardians. Once parental permission is granted, field
interviewers then approach the adolescents and obtain their
agreement to participate in the study. Parents are then asked
to leave the interview setting to ensure the confidentiality of
their children’s responses.
The interview uses computer-assisted interviewing
to increase valid reports of substance use behaviors.
Sociodemographic questions are administered by interviewers
using computer-assisted personal interviewing. Other ques-
tions of a sensitive nature (substance use and disorders,
criminal behaviors, mental health) are administered with
audio computer-assisted self-interviewing (ACASI), which
provides respondents with a highly confidential means of
responding to questions to increase honest reporting of sensi-
tive behaviors. In this mode, respondents read questions on
the computer screen, or questions are read to them through
headphones, and they enter responses directly into a computer
provided by the interviewer.

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The survey is conducted from January through December
in every independent survey year. Participants are offered
a US$30 incentive for participation in the interview.
In 2006–2008, approximately 67,500 unique persons aged
12 years or older were interviewed annually; weighted
response rates for household screening and interviewing
were 89.0%–90.6% and 73.9%–74.5%, respectively.24–26
The public-use de-identified data file contains about
55,000 respondents yearly due to exclusions to ensure
anonymity. In response to reports suggesting the emer-
gence of S. divinorum use, specific questions about this
hallucinogen were added to the survey beginning in 2006.23
This study examined data from 2006 to 2008 to determine
recent national trends in S. divinorum use and to identify
subgroups showing elevated odds of use (N = 55,279 in
2006; N = 55,435 in 2007; N = 55,739 in 2008). The same
survey items were examined across the years. Per NSDUH
designs, the use of the pooled data from 3 years to examine
yearly changes in prevalence rates of use is appropriate.24,25
Study variables
Substance use
NSDUH assessments of substance use were conducted via
ACASI. Tobacco, alcohol, and another nine drug classes
(not including S. divinorum) were assessed separately in
11 different sections. Each section included a detailed
description of the substance class and a list of substances
belonging to the class; for nonmedical use of prescription
drugs, respondents were provided with pill cards showing
color pictures of tablets for opioid analgesics, tranquilizers,
stimulants, and sedatives. The survey asked each respondent
about his/her use of each substance group and recency of use.
Past-year tobacco use included use of cigarettes, chewing
tobacco, snuff, dip, or pipe tobacco in the 12 months prior
to the interview. Binge alcohol use was defined as drinking
five or more drinks on the same occasion (ie, at the same
time or within a couple of hours of each other) on at least
1 day in the past 30 days.
Drug use
Drug use included illicit use of marijuana or hashish, cocaine
or crack, heroin, or hallucinogens (eg, LSD, PCP, ecstasy/3,4-
methylenedioxymethamphetamine [MDMA]); inhalant use
(eg, nitrous oxide, amyl nitrite, cleaning fluids, gasoline,
spray paint, glue); and nonmedical use of prescription anal-
gesic opioids, stimulants (amphetamines), tranquilizers, or
sedatives. Nonmedical use was defined as self-reported use
of prescription drugs (pain relievers/opioids, stimulants,
sedatives, and tranquilizers) that were not prescribed for the
respondent or that the respondent took only for the experience
or feeling they caused; use of over-the-counter drugs and
legitimate use of prescription drugs were not included.
S. divinorum use
Questions about S. divinorum use were included in a separate
‘Special drugs’ section. Lifetime S. divinorum use was
based on the following question: “Have you ever, even once,
used Salvia divinorum?” Among respondents who responded
affirmatively to this question, the survey then asked about
recency of use: “The computer recorded that you have used
Salvia divinorum. How long has it been since you last used
Salvia divinorum (eg, within the past 12 months or more
than 12 months ago)?” Based on responses to these two
questions, we categorized respondents into three mutually
exclusive groups: nonuser, past-year S. divinorum users (use
within the past 12 months), and former users (use prior to
the past 12 months).
Diagnostic and Statistical Manual of Mental Disorders
(DSM)-iV alcohol- or drug-use disorders (abuse,
dependence)
Respondents who reported alcohol or drug use in the past year
were asked a set of structured and substance-specific ques-
tions designed to operationalize DSM-IV criteria for abuse
of or dependence on each substance class in question.26,27
nicotine (cigarette) dependence
Nicotine dependence was defined as specified by the nicotine
dependence syndrome scale (NDSS) and the Fagerstrom
test of nicotine dependence (FTND).28–30 NDSS questions
assess dependence similar to the concepts specified by the
DSM-IV, while FTND discriminates between dependent
smokers and nondependent smokers by assessing how soon
after waking that smokers have their first cigarette. To opti-
mize the number of respondents classified as having current
nicotine dependence, the NSDUH categorizes respondents
as having nicotine dependence in the past month if they meet
criteria for dependence as specified either by the NDSS or
FTND.26 Past-year measurement of nicotine dependence
was not available.
criminal activities and mental health
Guided by prior research showing an association of halluci-
nogen use with criminality and depression,31–33 criminality,
depression, and mental health treatment variables were
examined as potential correlates of S. divinorum use. Lifetime

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Salvia divinorum use
criminal activity was assessed by the following question:
“Not counting minor traffic violations, have you ever been
arrested and booked for breaking the law?”. The survey
explicitly defined “being booked” as having ever been taken
into custody and processed by the police or by someone
connected with the courts, even if the respondent was then
released. Among respondents who gave a positive response
to this question, the survey then asked the number of times
during the past 12 months that they had been arrested and
booked.
Questions assessing major depressive episodes (MDE)
were based on DSM-IV criteria and were adapted from
the National Comorbidity Survey-Replication.26,27,34
A respondent was defined as having an MDE in the past
year if he/she met criteria for a lifetime MDE (ie, having
met at least five criteria in the same 2-week period, in
which at least one of the symptoms was a depressed mood
or loss of interest or pleasure in daily activities) and had
a period of time in the past 12 months when he/she felt
depressed or lost interest or pleasure in daily activities for
2 weeks or longer while also having other symptoms of a
lifetime MDE.26
The survey defined mental health treatment for adoles-
cents aged 12–17 years as receiving treatment or counseling
for emotional or behavioral problems from specific mental
health or other health professionals in school, home, outpa-
tient, or inpatient settings within the 12 months prior to the
interview; for adults aged 18 years or older, it was defined
as treatment or counseling for any problem with emotions,
nerves, or mental health in the 12 months prior to the inter-
view in any inpatient or outpatient setting, or the use of pre-
scription medication for treatment of a mental or emotional
condition. Treatment for a substance-use problem only was
excluded for adolescents and adults.
Sociodemographics
Respondents’ age, sex, race/ethnicity (non-Hispanic white,
non-Hispanic black, Native American [American Indian/
Alaska Native], Asian/Pacific Islander/Native Hawaiian,
multiple-race, Hispanic), total family income, and population
density of residence were examined as potential correlates
for S. divinorum use.17,21,22,31–33 For adolescents who were
unable to respond to the income questions, proxy responses
were accepted from a household member. NSDUH-defined
population density was based on 2000 census data and the
June 2003 Core-Based Statistical Area (CBSA) classifica-
tions, and was categorized into large metro (area with at
least 1 million population), small metro (area with less than
1 million population), and nonmetropolitan (area not in a
CBSA) areas.
Data analysis
The distribution of study variables by survey year were deter-
mined by χ2 tests. Lifetime prevalence rates of S. divinorum
use in each year by demographic, behavioral, mental health,
and substance use variables were then determined. To ease
interpretation, the percentages of increase between years
are reported. Next, we examined the prevalence and cor-
relates of past-year and former use using χ2 and unadjusted
multinomial logistic regression procedures to distinguish
between characteristics of past-year users and former users
as compared with nonusers. In the total sample, adjusted mul-
tinomial logistic regression analyses were then conducted to
estimate the strength of associations between each covariate
and S. divinorum use while adjusting for other variables
to mitigate for their confounding effects on the estimated
associations.
Finally, we determined whether past-year S. divinorum
users had higher prevalence rates of depression and
substance-use disorders than former users, and whether
both groups had higher prevalence rates of these conditions
than individuals who had never used S. divinorum. Adjusted
logistic regression analyses also were conducted to evalu-
ate further whether former and past-year S. divinorum users
had greater odds of having depression and substance-use
disorders than past-year alcohol or drug users who did
not use S. divinorum and to identify subgroups of past-
year S. divinorum users that had elevated odds of having
a substance-use disorder. All analyses were conducted
with SUDAAN® to take into account NSDUH’s complex
designs (eg, weighting, clustering).35 All results reported
here are weighted figures except for sample sizes, which are
unweighted figures.
Results
Demographic characteristics
of the study sample
There were no significant differences in the distribution of
respondents’ age, sex, and racial/ethnic groups across the
3 years. In the total sample (N = 166,453), males (49%)
and females (51%) were equally distributed; 10% were
adolescents aged 12–17 years; 27% were young adults aged
18–34 years; and 32% were of nonwhite race (blacks, 12%;
American Indians/Alaska Natives, 0.5%; Asians/Pacific
Islanders/Native Hawaiians, 4.5%; multiple-race individuals,
1%; Hispanics, 14%).

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Prevalence and characteristics of lifetime
S. divinorum use (Table 1 and Figure 1)
Among individuals aged 12 years or older, 0.7% (95%
confidence interval [CI] 0.63–0.79) reported having ever
used S. divinorum in 2006, and the prevalence increased
to 1.0% (95% CI 0.94–1.12) in 2007 and to 1.3% (95% CI
1.19–1.42) in 2008.
Table 1 shows that lifetime S. divinorum use was associ-
ated with all study variables examined in each year (P , 0.01).
In 2008, comparatively high rates of lifetime use were noted
among adults aged 18–25 years (6.1%), multiple-race individu-
als (3.0%), individuals arrested for criminal activities (7.8%),
or those who had depression (2.5%) in the past year.
Of note, S. divinorum use was common among individu-
als who used hallucinogens or stimulant drugs in the past
year. Figure 1 indicates that, in 2008, lifetime S. divinorum
use was prevalent among past-year users of LSD (53.7%),
ecstasy (30.1%), heroin (24.2%), PCP (22.4%), cocaine
(17.5%), tranquilizers (15.3%), inhalants (15.2%), sedatives
(12.3%), opioid analgesics (10.5%), or marijuana (9.9%).
Past-year S. divinorum users
versus former S. divinorum users
(Tables 2 and 3)
Table 2 distinguishes between past-year S. divinorum
use and former use. Among all lifetime S. divinorum
Table 1 Lifetime prevalence of Salvia divinorum use among individuals aged 12 years or older: 2006-2008 national Surveys on Drug
Use and health (n = 166,453)
Prevalence of Salvia divinorum
use by study variables
2006200720082006 versus 2007:
increase in %
2006 versus 2008:
increase in %
Sample size
Overall prevalence, % (Se)
Age group in years
12–17
18–25
26–34
$35
Sex
Male
Female
Race/ethnicity
White
Black
American indian/Alaska native
Asian/Native Hawaiian/Pacific
islander
Multiple race
hispanic
Total family income (USD)
$0–$39,999
$40,000–$74,999
$$75,000
Population density of residence
Large metro areas
Small metro areas
nonmetro areas
Past-year arrest for criminal activity
Yes
no
Past-year depression
Yes
no
Past-year mental health treatment
Yes
no
n = 55,279
0.71 (0.04)
n = 55,435
1.02 (0.05)
n = 55,739
1.30 (0.06)a
44b
83b
0.88 (0.09)c
3.39 (0.20)
0.78 (0.12)
0.09 (0.02)
1.18 (0.11)c
5.00 (0.22)
1.15 (0.19)
0.13 (0.03)
1.57 (0.13)c
6.10 (0.26)
1.73 (0.23)
0.15 (0.04)
34
32b
47
44
78b
80b
122b
67
1.17 (0.07)c
0.27 (0.03)
1.59 (0.07)c
0.49 (0.04)
1.93 (0.09)c
0.71 (0.06)
36b
81b
65b
163b
0.86 (0.05)c
0.11 (0.04)
0.68 (0.48)
0.32 (0.11)
1.22 (0.05)c
0.23 (0.08)
2.04 (1.26)
0.45 (0.28)
1.58 (0.08)c
0.21 (0.05)
1.18 (0.35)
0.40 (0.11)
42b
109
200
41
84b
91
74
25
1.18 (0.39)
0.56 (0.10)
2.35 (0.61)
0.80 (0.13)
2.95 (0.81)
1.01 (0.14)
99
43
150
80
0.85 (0.06)c
0.56 (0.06)
0.65 (0.08)
1.20 (0.08)d
0.82 (0.08)
0.99 (0.09)
1.61 (0.10)c
1.15 (0.10)
1.07 (0.07)
41b
46b
52b
89b
105b
65b
0.75 (0.06)c
0.70 (0.07)
0.37 (0.08)
1.03 (0.07)c
1.12 (0.07)
0.41 (0.09)
1.22 (0.08)c
1.50 (0.09)
0.60 (0.11)
37b
60b
11
63b
114b
62
4.75 (0.59)c
0.59 (0.03)
5.75 (0.66)c
0.89 (0.04)
7.80 (0.75)c
1.10 (0.05)
21
51b
64b
86b
1.44 (0.20)c
0.64 (0.04)
2.12 (0.26)c
0.93 (0.04)
2.46 (0.28)c
1.21 (0.05)
47
45b
71b
89b
1.05 (0.11)c
0.66 (0.04)
1.56 (0.14)c
0.94 (0.05)
2.01 (0.19)c
1.19 (0.06)
49b
42b
91b
80b
Notes: aχ2 test = 62.15, degrees of freedom = 2, P , 0.001; bP # 0.05; cχ2 test for survey year and the covariate in the first column: P , 0.001; dχ2 test for survey year and
the covariate in the first column: P , 0.01.
Abbreviation: Se, standard error.

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Salvia divinorum use
users, 40% were recent S. divinorum users in the past
12 months.
Demographic, behavioral, and mental
health characteristics
Young adults aged 18–25 years (2.0% and 2.9%, respectively)
and individuals who were arrested for criminal activities
(2.5% and 3.6%, respectively) showed comparatively high
rates of past-year use and former use, respectively (Table 2).
Additional groups showing higher rates of past-year use and
former use than other groups included: males (0.6%, 1.0%),
multiple-race individuals (0.8%, 1.5%), and individuals who
reported depression (0.8%, 1.2%) or who received treatment
for mental health problems (0.7%, 0.9%) in the past year.
Substance-use characteristics
As displayed in Table 3, past-year and former use of
S. divinorum were more prevalent among illicit or nonmedi-
cal drug users (3.3%–21.3% and 3.9%–20.2%, respectively)
than among alcohol or tobacco users (1.0%–1.2% and
1.6%–1.8%, respectively). Specifically, users of LSD
(21.3%) had the highest prevalence of past-year S. divinorum
use, followed by users of PCP (13.4%), ecstasy (11.1%),
heroin (9.8%), inhalants (6.6%), stimulants (6.1%), cocaine
(5.8%), tranquilizers (5.7%), and other drugs (3%–4%).
A similar pattern was noted for former use.
Multinomial logistic regression
of S. divinorum use (Table 4)
Adjusted multinomial logistic regression analyses of
S. divinorum use were conducted to estimate the strength of
associations with each covariate. To account for correlations
among various drug use and produce stable estimates, the 11
drug classes (marijuana, inhalants, cocaine, heroin, ecstasy,
LSD, PCP, opioids, stimulants, sedatives, tranquilizers)
were summed and examined as a categorical polydrug use
variable in the adjusted model. The adjusted model included
survey year, age, sex, race/ethnicity, annual family income,
population density of residence, arrest for criminal activity,
depression, mental health treatment, tobacco use, binge
drinking, and polydrug use.
Adjusted analysis confirmed an increased rate of
S. divinorum use in 2007 and 2008 and revealed illicit/
nonmedical drug use as the strongest correlate for either
past-year or former S. divinorum use (Table 4). There was
a graded association of past-year S. divinorum use with
polydrug use in the past year; that is, individuals who used
one drug class were about nine times more likely than
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
55%
60%
65%
Tobacco
Binge Drinking
Sedative
Opioid analgesic
Prevalence of Salvia divinorum use among substance users
Marijuana
Tranquilizer
Stimulant
Cocaine
Inhalant
PCP
Heroin
Ecstasy
LSD
Salvia divinorum use, %
2006 20072008
Figure 1 Prevalence of lifetime Salvia divinorum use among past-year substance users aged 12 years or older by type of substance used: 2006–2008 national Surveys on Drug
Use and health (n = 166,453). Lines extending from bars indicate 95% confidence intervals of the estimates; due to a very narrow range of 95% confidence intervals for the
prevalence of lifetime Salvia divinorum use among tobacco users and binge drinkers, they are not shown in the figure.
Abbreviations: LSD, lysergic acid diethylamide; PcP, phencyclidine.

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individuals who did not use any illicit/nonmedical drug in
the past year to use S. divinorum in the past year (adjusted
odds ratios [AOR] 8.95, 95% CI 6.18–12.96). The strength
of associations increased to about 19 times (AOR 18.51,
95% CI 13.27–25.82) and 46 times (AOR 45.98, 95% CI
32.99–64.10) for individuals who used two drug classes and
three or more drug classes, respectively. A similar pattern of
association, but of lesser magnitude, was noted for polydrug
use and former S. divinorum use (AOR ranging from 6.17
to 17.36).
Adjusted analysis also showed that young adults aged
18–25 years, males, individuals who used treatment for
mental health problems, and tobacco users had elevated
odds of using S. divinorum in the past year, while blacks as
compared with whites and those in the lowest income group
as compared with those in the highest income group had
decreased odds of past-year S. divinorum use.
Regarding former use, young adults aged 18–25 years
or 26–34 years, males, residents of large or small metro-
politan areas, individuals who were arrested for criminal
activity recently, and tobacco users exhibited elevated odds
of former S. divinorum use, while blacks, American Indians/
Alaska Natives, and Hispanics had lower odds of former use
than whites.
Table 2 Demographic, behavioral, and mental health characteristics of recent (past-year) and former (prior to past year) use of Salvia
divinorum among individuals aged 12 years or older: 2006-2008 national Surveys on Drug Use and health (n = 166,453)
Prevalence of Salvia
divinorum use
Past-year
use, % (SE)
Crude odds ratio of past-year
use versus never use
Former
use, % (SE)
Crude odds ratio of former
use versus never use
Overall prevalence, % (Se)
Year
2006
2007
2008
Age group in years
12–17
18–25
26–34
$35
Sex
Male
Female
Race/ethnicity
White
Black
American indian/Alaska native
Asian/Native Hawaiian/Pacific
islander
Multiple race
hispanic
Total family income (USD)
$0–$39,999
$40,000–$74,999
$$75,000
Population density of residence
Large metro areas
Small metro areas
nonmetro areas
Past-year arrest for criminal activity
Yes
no
Past-year depression
Yes
no
Past-year mental health treatment
Yes
no
0.40 (0.02)0.61 (0.02)
0.28 (0.02)
0.41 (0.03)
0.49 (0.03)
1.00
1.46 (1.21–1.77)a
1.76 (1.44–2.14)a
0.42 (0.03)
0.61 (0.03)
0.81 (0.05)
1.00
1.45 (1.19–1.76)a
1.91 (1.54–2.36)a
0.76 (0.05)
1.98 (0.08)
0.26 (0.06)
0.03 (0.01)
1.00
2.70 (2.34–3.11)a
0.34 (0.22–0.54)a
0.04 (0.02–0.08)a
0.45 (0.04)
2.85 (0.10)
0.96 (0.09)
0.09 (0.02)
1.00
6.62 (5.48–7.99)a
2.15 (1.70–2.70)a
0.19 (0.13–0.29)a
0.62 (0.03)
0.19 (0.02)
3.29 (2.76–3.91)a
1.00
0.95 (0.04)
0.30 (0.02)
3.19 (2.73–3.73)a
1.00
0.47 (0.02)
0.08 (0.02)
0.88 (0.47)
0.18 (0.04)
1.00
0.17 (0.10–0.28)a
1.89 (0.64–5.57)
0.38 (0.24–0.61)a
0.75 (0.03)
0.10 (0.03)
0.43 (0.12)
0.21 (0.09)
1.00
0.13 (0.08–0.23)a
0.57 (0.32–1.00)b
0.28 (0.12–0.67)c
0.75 (0.17)
0.35 (0.06)
1.62 (1.02–2.57)b
0.75 (0.54–1.05)
1.46 (0.34)
0.44 (0.06)
1.96 (1.21–3.16)c
0.58 (0.43–0.78)a
0.43 (0.02)
0.36 (0.03)
0.39 (0.03)
1.09 (0.90–1.31)
0.91 (0.72–1.14)
1.00
0.78 (0.05)
0.49 (0.04)
0.52 (0.04)
1.51 (1.25–1.83)a
0.94 (0.76–1.17)
1.00
0.39 (0.03)
0.43 (0.02)
0.25 (0.04)
1.00
1.12 (0.96–1.30)
0.65 (0.46–0.92)b
0.61 (0.03)
0.68 (0.04)
0.21 (0.03)
1.00
1.11 (0.94–1.31)
0.33 (0.24–0.46)c
2.51 (0.22)
0.33 (0.02)
7.93 (6.47–9.71)a
1.00
3.62 (0.34)
0.53 (0.02)
7.25 (5.92–8.87)a
1.00
0.82 (0.08)
0.36 (0.02)
2.30 (1.88–2.82)a
1.00
1.18 (0.11)
0.57 (0.02)
2.10 (1.72–2.56)a
1.00
0.65 (0.06)
0.36 (0.02)
1.83 (1.51–2.22)a
1.00
0.89 (0.07)
0.57 (0.02)
1.56 (1.33–1.83)a
1.00
Abbreviation: Se, standard error.
Notes: cP , 0.001, bP , 0.01, aP , 0.05.

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Salvia divinorum use
Depression and substance use disorders
among S. divinorum users (Figure 2)
Prevalence rates of depression and all substance-use disorders
(abuse or dependence) were markedly higher among past-year
and former users of S. divinorum than among nonusers (χ2,
degrees of freedom [df] = 2, P , 0.001 for each disorder by S.
divinorum use status). Approximately 15% of past-year (95% CI
11.2–19.0) and 14% of former (95% CI 11.7–16.1) S. divinorum
users had self-reported depression in the past year compared
with 7.2% (95% CI 6.9–7.4) of nonusers of S. divinorum.
As summarized in Figure 2, 69.7% of past-year
S. divinorum users and 66.9% of former users had a
self-reported nicotine, alcohol, or drug use disorder in the
past year compared with 19.7% of nonusers. Past-year
S. divinorum users had higher rates of alcohol and most
drug use disorders (ie, any drug, alcohol, marijuana, opi-
oid, cocaine, hallucinogen, and stimulant use disorders)
than former users, but they had a similar rate of nicotine
dependence and of heroin, sedative, and tranquilizer use
disorders. Specifically, an estimated 43.0% of past-year
Table 3 Substance use characteristics of recent (past-year) and former (prior to past year) use of Salvia divinorum among individuals
aged 12 years or older: 2006-2008 national Surveys on Drug Use and health (n = 166,453)
Prevalence of Salvia
divinorum use
Past-year
use, % (SE)
Crude odds ratio of past-year
use versus never use
Former
use, % (SE)
Crude odds ratio of former
use versus never use
Past-year tobacco use
Yes
no
Past-month binge drinking
Yes
no
Past-year marijuana use
Yes
no
Past-year inhalant use
Yes
no
Past-year cocaine use
Yes
no
Past-year heroin use
Yes
no
Past-year ecstasy use
Yes
no
Past-year LSD use
Yes
no
Past-year PCP use
Yes
no
Past-year opioid analgesic use
Yes
no
Past-year stimulant use
Yes
no
Past-year sedative use
Yes
no
Past-year tranquilizer use
Yes
no
1.04 (0.05)
0.06 (0.01)
17.32 (13.05–22.99)a
1.00
1.56 (0.06)
0.12 (0.01)
13.27 (10.79–16.32)a
1.00
1.19 (0.05)
0.16 (0.01)
7.88 (6.69–9.28)a
1.00
1.80 (0.08)
0.26 (0.02)
7.19 (6.06–8.53)a
1.00
3.34 (0.15)
0.06 (0.01)
21.40 (16.89–27.11)a
1.00
4.53 (0.18)
0.17 (0.01)
10.47 (8.38–13.09)a
1.00
6.55 (0.69)
0.34 (0.01)
21.40 (16.89–27.11)a
1.00
5.35 (0.54)
0.57 (0.02)
10.47 (8.38–13.09)a
1.00
5.77 (0.38)
0.27 (0.01)
24.43 (20.76–28.75)a
1.00
7.19 (0.51)
0.46 (0.02)
17.85 (15.15–21.03)a
1.00
9.84 (2.03)
0.38 (0.02)
31.98 (20.11–50.85)a
1.00
9.70 (1.81)
0.60 (0.02)
19.97 (13.12–30.38)a
1.00
11.06 (0.83)
0.30 (0.01)
46.22 (37.37–57.16)a
1.00
10.67 (0.92)
0.53 (0.02)
25.66 (20.61–31.96)a
1.00
21.27 (1.79)
0.33 (0.01)
107.78 (84.40–137.65)a
1.00
20.19 (1.93)
0.56 (0.02)
61.44 (47.17–80.03)a
1.00
13.36 (3.07)
0.39 (0.02)
41.25 (23.47–72.51)a
1.00
4.29 (1.63)
0.61 (0.02)
8.42 (3.67–19.32)a
1.00
3.96 (0.23)
0.21 (0.01)
20.31 (17.15–24.07)a
1.00
4.36 (0.25)
0.42 (0.02)
11.26 (9.37–13.06)a
1.00
6.14 (0.52)
0.33 (0.01)
21.36 (17.39–26.24)a
1.00
7.04 (0.62)
0.54 (0.02)
14.94 (12.16–18.35)a
1.00
3.63 (0.61)
0.39 (0.02)
10.06 (7.02–14.42)a
1.00
3.90 (0.74)
0.60 (0.02)
6.90 (4.62–10.29)a
1.00
5.68 (0.42)
0.29 (0.01)
22.24 (18.20–27.19)a
1.00
5.95 (0.42)
0.50 (0.02)
13.27 (11.19–15.74)a
1.00
Note: aP , 0.001.
Abbreviations: LSD, lysergic acid diethylamide; PcP, phencyclidine.

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Table 4 AORsa of past-year and former (prior to past year) use of Salvia divinorum among individuals aged 12 years or older:
2006-2008 national Surveys on Drug Use and health (n = 166,453)
Selected characteristics of
Salvia divinorum use
Past-year Salvia divinorum
use versus never use
AOR (95% CI)
Former Salvia divinorum
use versus never use
AOR (95% CI)
Year (versus 2006)
2007
2008
Age group in years (versus 12–17 years)
18–25
26–34
$35
Sex (versus female)
Male
Race/ethnicity (versus white)
Black
American indian/Alaska native
Asian/Native Hawaiian/Pacific Islander
Multiple race
hispanic
Total family income (USD) (versus $75,000+)
$0–$39,999
$40,000–$74,999
Population density (versus nonmetro areas)
Large metro areas
Small metro areas
Past-year arrest for criminal activity (versus no)
Yes
Past-year depression (versus no)
Yes
Past-year mental health treatment (versus no)
Yes
Past-year tobacco use (versus no)
Yes
Past-month binge drinking (versus no)
Yes
Past-year polydrug use, number of the 11 drug classes used in the past yearg (versus none)
1
2
$3
1.66 (1.36–2.03)b
2.19 (1.78–2.70)b
1.56 (1.28–1.91)b
2.24 (1.81–2.78)b
1.33 (1.12–1.58)c
0.25 (0.15–0.41)b
0.08 (0.04–0.15)b
3.27 (2.66–4.03)b
1.57 (1.23–2.02)b
0.29 (0.20–0.42)b
2.78 (2.27–3.39)b
2.58 (2.16–3.07)b
0.20 (0.13–0.33)b
1.52 (0.58–3.98)
0.71 (0.44–1.13)
1.32 (0.82–2.11)
0.78 (0.54–1.11)
0.13 (0.07–0.22)b
0.48 (0.27–0.87)d
0.43 (0.17–1.09)
1.56 (0.89–2.75)
0.54 (0.40–0.74)b
0.74 (0.61–0.91)c
0.85 (0.67–1.08)
1.05 (0.85–1.30)
0.84 (0.67–1.05)
1.32 (0.92–1.88)
1.35 (0.96–1.90)
2.71 (1.90–3.86)b
2.60 (1.83–3.71)b
1.14 (0.91–1.42)1.28 (1.03–1.60)d
1.24 (0.98–1.58)e
1.24 (0.98–1.56)e
1.33 (1.06–1.67)d
1.21 (0.99–1.49)f
2.76 (2.03–3.76)b
2.62 (2.03–3.40)b
1.16 (0.93–1.44)1.19 (0.97–1.46)
8.95 (6.18–12.96)b
18.51 (13.27–25.82)b
45.98 (32.99–64.10)b
6.17 (4.81–7.90)b
9.08 (6.86–12.02)b
17.36 (13.51–22.31)b
Notes: aAdjusted multinomial logistic model included all variables listed in the first column; bP , 0.001; cP , 0.01; dP , 0.05; eP = 0.07; fP = 0.06; gincluding marijuana, inhalants,
cocaine, heroin, ecstasy/MDMA, LSD, PcP, analgesic opioids, stimulants, sedatives, and tranquilizers.
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; LSD, lysergic acid diethylamide; MDMA, 3,4-methylenedioxymethamphetamine (ecstasy); PCP,
phencyclidine.
users and 28.9% of former users had a drug-use disorder
compared with only 2.5% of nonusers of S. divinorum.
Alcohol (42.8%, 35.8%, respectively), marijuana (33.0%,
21.5%, respectively), nicotine (31.0%, 36.1%, respectively),
opioid (10.5%, 6.0%, respectively), and cocaine (10.5%,
5.0%, respectively) use disorders were comparatively com-
mon among past-year and former users of S. divinorum,
respectively. Prevalence rates of these disorders, however,
were comparatively low among nonusers of S. divinorum
(0.6%–13.8%).
Logistic regression of depression
and substance use disorders among
S. divinorum users compared with
other substance users (Table 5)
Adjusted logistic regression analyses were conducted to
determine whether S. divinorum users were more likely than
other substance users to have depression or a substance-
use disorder. Table 5 shows that former and past-year
S. divinorum users were about 1.4 times more likely than past-
year alcohol or drug users who did not use S. divinorum to

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Salvia divinorum use
have depression in the past year. Both groups of S. divinorum
users also were about 3–4 times more likely than past-year
alcohol or drug users who did not use S. divinorum to have
an alcohol or drug-use disorder in the past year.
Logistic regression of substance-use
disorders among S. divinorum
users (Table 6)
Finally, adjusted logistic regression analyses were conducted
to identify subgroups of past-year S. divinorum users that had
elevated odds of having a substance-use disorder (Table 6).
Among past-year S. divinorum users (N = 1585): young
adults aged 26–34 years, low- and middle-level income
groups, individuals who were arrested for criminal activities
or who had depression, and binge drinkers had elevated odds
of nicotine dependence; depression, use of mental health
treatment, and binge drinking increased odds of having an
alcohol-use disorder; and American Indian/Alaska Native
race, being arrested for criminal activity, depression, use
of mental health treatment, tobacco use, and binge drinking
increased odds of having a drug-use disorder.
Discussion
Main findings
This study of a large nationally representative sample docu-
ments a significant increase in S. divinorum use, identifies
several groups showing elevated odds of S. divinorum use,
and provides a comprehensive profile of substance-use
disorders for S. divinorum users. These findings are useful
to concerned citizens and health professionals, and have
implications for prevention and research efforts. First, over a
3-year period, the prevalence of S. divinorum use nationally
0%
10%
20%
30%
40%
50%
60%
70%
80%
Any substance
Alcohol
Any drug
Marijuana
Nicotine
Opioid analgesic
Cocaine
Hallucinogen
Stimulant
Tranquilizer
Heroin
Sedative
Inhalant
Prevalence of substance use disorders by Salvia divinorum use status
Prevalence of disorders, %
Non-users Former salvia divinorum users
Past-year salvia divinorum users
Figure 2 Prevalence of substance use disorders (abuse or dependence) among past-year and former (prior to the past 12 months) users of Salvia divinorum compared with
nonusers aged 12 years or older: 2006–2008 national Surveys on Drug Use and health (n = 166,453). χ2 (degrees of freedom = 2) P , 0.001 for each disorder by Salvia
divinorum use status. Any drug abuse or dependence included abuse of or dependence on marijuana, inhalants, cocaine, heroin, hallucinogens, opioid analgesics, stimulants,
sedatives, and tranquilizers in the past year. except for nicotine dependence, which refers to dependence in the past month, all other substance use disorders include abuse
of or dependence on that substance class in the past year. Lines extending from bars indicate 95% confidence intervals of the estimates; due to a very narrow range of 95%
confidence intervals for nonusers, they are not shown in the figure.
Table 5 AORs of depression and substance-use disorders among Salvia divinorum users compared with alcohol or drug users who did
not use Salvia divinorum in the past year: 2006-2008 national Surveys on Drug Use and health (n = 106,042)
Substance use status AOR of depression1
(95% CI)
AOR of alcohol or drug use disorders1
(95% CI)
Former Salvia divinorum users
Past-year Salvia divinorum users
Past-year alcohol or drug users
who did not use Salvia divinorum2
1.44 (1.13–1.82) P , 0.01
1.45 (1.12–1.88) P , 0.01
1.00
2.97 (2.54–3.48) P , 0.01
4.33 (3.55–5.29) P , 0.01
1.00
Notes: 1The adjusted logistic regression model controlled for survey year, age, sex, race/ethnicity, population density, arrests for criminal activity, and mental heath
treatment; 2including past-year users of alcohol, marijuana, inhalants, cocaine, heroin, ecstasy, LSD, PcP, analgesic opioids, stimulants, sedatives, and tranquilizers.
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; LSD, lysergic acid diethylamide; PCP, phencyclidine.

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Wu et al
had increased moderately, suggesting a need to monitor
the trend in S. divinorum use. Females, individuals with
middle-level family income (US$40,000–US$74,999), and
residents of small metropolitan areas showed a substantial
(.100%) increase in use. Second, while S. divinorum use
in the general population is infrequent, young adults aged
18–25 years and individuals who were arrested for criminal
activity had a disproportionally high rate of lifetime and
recent use. Third, S. divinorum use was particularly common
among past-year users of hallucinogens or stimulants, and
the odds of past-year use increased with polydrug use, sug-
gesting that polydrug users who used hallucinogens or stimu-
lants have an increased probability of using S. divinorum.
Fourth, the majority of former (70%) and past-year (67%)
S. divinorum users were affected by symptoms of nicotine,
alcohol, or drug-use disorders in the past year, and past-year
S. divinorum users (especially binge drinkers and individuals
with depression or other mental health problems) manifested
the most problems related to alcohol and drug-use disorders.
Adjusted analysis helps to reveal that either former or past-
year S. divinorum users were more likely than past-year sub-
stance users who did not use S. divinorum to have depression
or a substance-use disorder in the past year.
What this study adds
This study represents the first effort to examine recent trends
in the prevalence of S. divinorum use. Previous studies of
prevalence or correlates of S. divinorum use have relied on
convenience samples, and some findings are constrained by
a small sample.17,21,22,36 State-level variations in legal status
Table 6 AORsa of substance use disorders among past-year Salvia divinorum users aged 12 years or older: 2006-2008 national Surveys
on Drug Use and health (n = 1585)
Selected characteristics of
Salvia divinorum users
AOR of nicotine dependence
(95% CI)
AOR of alcohol use disorders
(95% CI)
AOR of drug use disorders
(95% CI)
Year (versus 2006)
2007
2008
Age group (versus 12–17 years)
18–25
26–34
$35 years
Sex (versus female)
Male
Race/ethnicity (versus white)
Black
American indian/Alaska native
Asian/Native Hawaiian/Pacific Islander
Multiple race
hispanic
Total family income (USD) (versus $75,000+)
$0–$39,999
$40,000–$74,999
Population density (versus nonmetro)
Large metro areas
Small metro areas
Arrested for criminal activity (versus no)
Yes
Past-year depression (versus no)
Yes
Mental health treatment (versus no)
Yes
Current tobacco use (versus no)
Yes
Binge drinking (versus no)
Yes
1.13 (0.76–1.67)
1.01 (0.69–1.50)
0.95 (0.64–1.41)
1.22 (0.84–1.75)
0.85 (0.53–1.37)
1.03 (0.68–1.56)
1.06 (0.74–1.52)
2.80 (1.20–6.55)b
1.15 (0.79–1.68)
1.07 (0.74–1.57)
1.48 (0.57–3.80)
1.27 (0.30–5.26)
0.73 (0.51–1.05)
0.73 (0.30–1.80)
0.59 (0.21–1.66)
1.15 (0.79–1.68)0.88 (0.58–1.34)1.05 (0.73–1.52)
0.65 (0.18–2.32)
0.18 (0.03–1.05)
1.15 (0.45–2.91)
1.21 (0.55–2.66)
0.85 (0.44–1.63)
1.10 (0.37–3.28)
0.70 (0.19–2.66)
1.18 (0.38–3.68)
1.94 (0.79–4.76)
0.71 (0.37–1.36)
2.06 (0.71–5.97)
14.63 (2.20–97.15)c
0.66 (0.24–1.84)
1.26 (0.62–2.58)
0.77 (0.39–1.50)
1.55 (1.03–2.34)b
1.56 (1.10–2.20)b
0.86 (0.55–1.36)
1.01 (0.63–1.62)
1.05 (0.65–1.70)
0.96 (0.60–1.53)
0.91 (0.47–1.79)
1.10 (0.55–2.21)
1.12 (0.45–2.81)
1.31 (0.54–3.16)
1.10 (0.45–2.66)
1.08 (0.49–2.37)
2.06 (1.27–3.34)c
1.51 (0.95–2.40) 1.85 (1.25–2.73)c
1.85 (1.15–2.99)b
1.76 (1.05–2.93)b
2.24 (1.32–3.83)c
1.22 (0.77–1.92)1.17 (0.72–1.91)b
2.97 (1.91–4.62)d
–e
1.35 (0.70–2.58)2.01 (1.07–3.77)b
1.65 (1.11–2.45)b
7.87 (5.16–12.02)d
1.72 (1.13–2.62)b
Notes: aAdjusted logistic model included all variables listed in the first column; bP , 0.05; cP , 0.01; dP , 0.001; eTobacco use was not included in the model due to a high
level of correlation.
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval.

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Salvia divinorum use
of S. divinorum use also might influence the access to or
use of S. divinorum, resulting in regional variations in use.
Of note, results from these NSDUH data, which include a
large probability sample from all 50 states plus the District
of Columbia, delineate recent changes in S. divinorum use
across diverse age, sex, and racial/ethnic groups. Findings
reveal a significant 83% increase within a 3-year period, and
an increase was noted across different sex and income groups,
suggesting that this increase is robust. These findings are in
line with results from studies on S. divinorum use among
YouTube users, S. divinorum and salvinorin A seized data,
and Internet access to S. divinorum, which have indirectly
suggested the rising popularity in use of S. divinorum.5,37,38
The findings also are consistent with recent results from
studies of college students showing that whites, males, and
individuals of a higher level of family income have an ele-
vated rate of S. divinorum use.17,21,22 Additionally, with these
national data, we found that residents of metropolitan areas,
individuals who were arrested for criminal activities, and
individuals with depression or who use treatment for mental
health problems have increased odds of recent S. divinorum
use. These findings suggest some regional variations in
S. divinorum use and show that S. divinorum users, like users
of other hallucinogens and substance users in general, have
a higher likelihood of exhibiting externalizing or internal-
izing problems than nonusers of S. divinorum.31–33 Moreover,
because S. divinorum use was robustly associated with other
drugs connected with use in group settings,31 such as ecstasy
and LSD (http://www.clubdrugs.gov/), one possibility is
raised that S. divinorum is being used in groups.17 Given
that S. divinorum’s subjective effects are reportedly similar
to those of marijuana, LSD, and ketamine,13–15 research is
warranted to explore the context of S. divinorum use and to
assess health risks associated with its use in conjunction with
other substances (eg, risk for intoxication, accidents, injuries,
psychiatric events, and overdose).1,2,4,8,11,19
Furthermore, multiple-race individuals were the only
group in the adjusted model that showed greater odds of
both recent and former S. divinorum use than whites. Prior
research on club drug use (ie, use of methamphetamine,
ecstasy, LSD, ketamine, gamma hydroxybutyrate, or fluni-
trazepam; http://www.clubdrugs.gov/) among youth aged
16–23 years also found a high prevalence of lifetime club
drug use (29%) among multiple-race youth compared with
24% of whites or American Indians/Alaska Natives and
5%–15% of other racial/ethnic groups.31 Thus, in addition to
whites and young adults, multiple-race groups need research
to explore contextual and psychological factors that may
promote their use of S. divinorum and other hallucinogenic
or stimulant drugs.
Additional research also is recommended to monitor
S. divinorum use among females (eg, young white females),
as they demonstrate the highest level of increase (163%).
Although the majority of S. divinorum users were males,
recent results from an online survey of self-identified
S. divinorum users (N = 219) showed that females were
about twice as likely than males to be in the young age
group (,22 years).36 Possible research efforts might explore
whether ease of access, legal status, use of club drugs, and
the perception of S. divinorum as a legal or safer alternative
to illicit drugs promote experimentation or continued use of
S. divinorum.5–7,39
Lastly, these findings reveal that S. divinorum is most
likely to be used by active illicit drug users, particularly
substance users who have used hallucinogenic or stimulant
drugs, and that the vast majority of S. divinorum users were
affected by symptoms and consequences indicative of sub-
stance use problems (eg, role interference, use in hazardous
conditions that increase risk for injuries, physical dependence
on substances, compulsive drug use or seeking behaviors,
repeated substance use despite having substance-related
health problems). S. divinorum users also have a higher rate
of depression than nonusers, and S. divinorum users who had
depression or used treatment for mental health problems were
particularly more likely than those without mental health
conditions to have alcohol or drug-use disorders. Therefore,
repeated S. divinorum use for the purpose of “getting high”
or “obtaining hallucinogenic effects” could pose a health
concern (eg, drug interaction, intoxication) or increase the
likelihood of medical and other psychiatric conditions for
subsets of users who have been affected by other substance
use or psychiatric disorders.2,4,8,18,19
Limitations and strengths
These findings should be interpreted with caution. NSDUH
uses a cross-sectional design and relies on self-reports,
which can be influenced by memory error and under-
reporting. All results are considered estimates, and no
causal inference can be drawn. For example, the causal
relation between substance use and depression cannot be
determined by the NSDUH data. Study findings also are
limited by the lack of data on contextual factors associated
with S. divinorum use, motives or detailed frequency of
use, and S. divinorum-specific problems. Studies of con-

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66
Wu et al
venience samples of S. divinorum users have suggested
that S. divinorum was used for a variety of reasons (eg, for
fun, curiosity, social purposes, drug-induced states of con-
sciousness, getting high, self-defined spiritual purposes,
relieving boredom, reducing medical or psychological
problems) and that a very small subset of users were
frequent users.36,40,41 However, these results from small or
convenience samples need to be confirmed and extended
using data from surveys of a probability sample or con-
trolled studies.36,40,41 In addition, NSDUH assessments of
substance-use disorders and major depression are based on
standardized questions designed to operationalize DSM-IV
criteria for these disorders. These results are self-reported,
survey-based estimates and not clinical diagnoses (ie, not
being validated by clinicians). Moreover, because of a
lack of research data, there are no established criteria for
assessing abuse of or dependence on S. divinorum.27 Results
from this study also are not applicable to institutionalized
and homeless individuals because these groups are not
included in the NSDUH sampling.
Nonetheless, NSDUH has noteworthy strengths not
available in small-scale studies. NSDUH is the first national
United States survey to add S. divinorum use questions to
the assessment beginning in 2006.23 Because S. divinorum
and salvinorin A are not controlled substances under the
Controlled Substances Act in the United States and have no
approved medical use, there is a scarcity of data about their
use and adverse effects.38 For example, the annual reports
of the American Association of Poison Control Centers
(AAPCC), IMS National Prescription Audit Plus™ (a
database of prescription drugs), the Aggregate Production
Quota (a database for the maximum amount of Schedule I
and II substances manufactured in the United States), and
the ongoing United States Drug Abuse Warning Network
(DAWN) reports have not included data on use and problems
associated with S. divinorum and salvinorin A.38 Given the
lack of data, this study makes a timely and unique contri-
bution by presenting the most recent national trends in S.
divinorum use and by documenting a comprehensive profile
of substance-use problems among S. divinorum users.
These findings also have a higher level of generaliz-
ability to population subgroups than those of a convenience
or regional sample due to the large representative sample
consisting of geographically diverse racial/ethnic groups.
Lastly, the survey has high levels of response rates for house-
hold screening and interviewing, uses the most sophisticated
survey methods available to improve respondents’ honest
reporting of substance-use behaviors (ie, computer-assisted
self-administered interviewing and anonymous data col-
lection), includes detailed probes and color pictures of pre-
scription drugs to facilitate assessments for substance use
behaviors, and applies the 2000 census to improve sample
weight calibration.24–26
conclusion and implications
Nationally, the rate of S. divinorum use has increased
moderately. While young adults aged 18–25 years show an
elevated likelihood of recent S. divinorum use, S. divinorum
is most likely to be used by recent or active drug users who
have used hallucinogens or stimulants. Polydrug use is the
most robust determinant of S. divinorum use. S. divinorum
users who engaged in binge drinking, experienced depres-
sion, or used treatment for mental health problems had
particularly high odds of having substance use disorders. The
high prevalence of past-year substance use disorders among
recent S. divinorum users emphasizes the need for research
to address several open issues for S. divinorum use, including
its addictive potential, its influence on continuance of drug-
use behaviors or escalation to addiction (eg, as an alternative
to other drugs, cross-tolerance), adverse effects from drug
interactions (eg, intoxications, accidents, injuries, health
risk), and long-term effects on human health.1,2,4,8,10,39 Health
care professionals and individuals involved in substance
abuse care or services need to be aware of this new drug.39
Assessments of recreational S. divinorum use need to be
improved and considered for addition to the clinical assess-
ment for addiction problems. Finally, continuous surveillance
of S. divinorum use among high-risk groups is warranted.
Acknowledgments
This article was supported primarily by research grants from
the US National Institute on Drug Abuse of the National
Institutes of Health (R01DA019623, R33DA027503, and
R01DA019901 to L-T Wu). GE Woody was supported by
K05DA017009 and U10DA013043. J-H Li was supported
by the Committee on Chinese Medicine and Pharmacy
(CCMP100-CP-006) and the Food and Drug Administra-
tion (DOH100-FDA-61402) of the Department of Health,
Taiwan. Its contents are solely the responsibility of the
authors and do not necessarily represent the official views
of the National Institutes of Health. The Substance Abuse
and Mental Health Data Archive provided the public use
data files for NSDUH, which was sponsored by the Office of
Applied Studies of the Substance Abuse and Mental Health
Services Administration. We thank Amanda McMillan for
her editorial assistance.

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67
Salvia divinorum use
Ethical approval
This work was approved by the Duke University Institutional
Review Board.
Disclosure
GE Woody is a member of the RADARS post-marketing
study external advisory group, whose job is to assess abuse
of prescription medications. Denver Health administers
RADARS, and nine pharmaceutical companies currently
support its work. The other authors have no conflicts of
interest to disclose.
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