Non-medical prescription opioid use is a rising public health concern. Prescriptions for opioid medications have nearly doubled between 1994 and 2007.[1] The burden of illness is high; opioid prescription related deaths (14,800) made up 73.8% of the 20,044 prescriptions drug overdose deaths in 2008.[2] The prevalence of patients who report a non-physician source of opioid medicine is reported to be more than double (69%) those who report a physician source (31%) in a recent analysis of the National Survey on Drug Use and Health.[3] With the concern over the growing epidemic of non-medical use of prescription opioids,[4, 5] there is a need to understand the changing public attitudes and beliefs about these medications. The traditional methods of characterizing non-medical use, such as large government-funded telephone surveys, carry limitations including underreporting, and a significant delay between data collection and public data availability.[6, 7]

Social media is a means to enhance real-time understanding of attitudes and beliefs regarding opioid use, because it provides an opportunity to share ideas, opinions, and information instantaneously and publicly online. The micro-blogging site Twitter has experienced rapid growth over time with an estimated 18% of US online adults using Twitter in 2013, and about half of those reporting daily use of the application.[8] Twitter permits communication with real-life social networks to be both public and online; therefore, personal information and potentially stigmatizing behaviors that individuals would previously share only with close contacts, such as substance abuse,[9] are often available for research and to inform public health efforts and policy.

We conducted an exploratory, mixed-methods analysis of Twitter messages to characterize the nature of the content relating to opioid medications. In this study, we aimed to describe who uses social media to discuss opioid use or misuse, and what attitudes, themes, and behaviors social media users message about. Our hypothesis was that the anonymity of social media allowed for more candid discussion of opioid misuse and abuse behaviors.

Overall, we searched a total of 540 Twitter messages. Of these, we excluded 182 (33%) messages for the following reasons: non-English content (20, 4%), content referring to non-opioid use of search term (138, 26%), and inability to discern the context of the message in a meaningful manner (24, 4%). For example, 48 of 50 messages using the search term “Vikes”, a slang term for Vicodin, contained content relating to the Minnesota Vikings football team. We also excluded messages originating from users names that contained search terms but whose messages did not. We coded the remaining 375 messages.

Of the 375 messages, 333 were from unique user accounts (89%). Individual accounts made up the majority of authored messages (316, 84%), compared to organizations or news outlet sources (59, 16%). The distribution of author type varied depending on the search term (Fig 3). The majority of messages authored by individuals were general comments on opioid use (191, 60%), and included 65 “retweets,” messages that are seen by a Twitter users “followers” and subsequently re-sent on their own network. There were 125 (40%) messages reflecting personal experience.

In this qualitative analysis of self-reported attitudes and behaviors about opioids online, we found that Twitter users publicly message both personal experience with opioid medications, and general perceptions regarding opioid medications, including content related to non-medical use of opioid medications. While Twitter messages should not replace traditional survey methods of opioid use, the content contained in social media messages can be a useful, real-time, publicly-available source of information to be used in conjunction to identify emerging trends in use and misuse behavior, as well as a forum to communicate public health awareness on non-medical use of opioids.

The personal experience messages captured a wide variety of opioid related behaviors and are consistent with reported behaviors found in other survey methods about misuse and abuse of opioid medications.[3] Authors messaged about their aberrant use of opioids as a sleep or anti-anxiolytic, or as a way to obtain a high sensation. Similarly, authors shared openly messages about co-use of opioids with other medications, illegal drugs, or alcohol. Although we cannot quantify the magnitude of positive opioid-related sentiment based on our manual sample, the high frequency of messages that display aberrant opioid behaviors in a positive light are deeply concerning, and suggest that the public still lacks sufficient awareness of the mounting harm associated with opioid misuse. Twitter may be useful in the future for tracking public awareness of opioid misuse.

These messages also provide data for public health practitioners in real-time, providing data that is complementary to traditional methods. Characterizing risky behaviors through health surveys or adverse events is subject to limitations in response rates and significant time delays.[7] In-clinic patient reported screening tools are limited by recall bias, social-desirability bias, and concerns about receiving medication.[23, 24] The real-time nature of Twitter messaging, as well as the relative anonymity of Twitter, can complement data from current surveys and reporting systems.

Our findings are similar to studies that used Twitter to characterize potential misuse of other prescribed medications, like the use of Adderall as a study aid.[19] Prior studies report Twitter as a means for studying behavior with other health related behaviors such as smoking and drinking alcohol.[21, 25] These prior studies have all used automated algorithms to study text data from twitter, while we used traditional qualitative analysis, which permitted some additional insight into each message that automated “big data” analyses cannot provide. As an example, the initial automated search terms in our sample did not result in a precise identification of opioid-related messages, and we restricted our analysis to pertinent messages. There is promise in combining traditional qualitative analysis with automated approaches, such an approach led to greater precision in a study of online doctor ratings.[26]

Our results reveal several lessons in future use of social media data sources for opioid misuse surveillance. First, themes related to personal experience with opioids differ from themes related to general perceptions of opioids, the latter which is influenced by one’s social network, pop culture, news, and entertainment sources. If actual behaviors are to be studied, future search algorithms will need to differentiate personal from general experiences. Second, searching of slang terms (“oxy”) or misspelled opioid search terms (“oxycotin”) yielded informative messages that referenced opioid use, misuse, and abuse. Design of social media surveillance programs need to consider how to include misspellings or slang terms into their algorithms to improve effectiveness.”

In addition to potential use as a surveillance tool, we also found that Twitter can be a source of information for the public. Organizations tended to message about the potential risks and harms of opioid medications, or retweeted new stories about criminal activity involving opioid medications. Prior use of twitter during political movements underscores the immediacy of the medium,[27] and we believe this is an advantage for public health applications as well.

Social media has changed the way individuals communicate about health-related behaviors, including behaviors that are illicit and difficult to capture otherwise. A next step is combining results from a qualitative analysis with larger automated data in order to develop search strategies to monitor opioid use and misuse behaviors that can be compared to gold standard surveillance systems currently in place. In addition, user location information provided on messages may offer additional information to identify incipient public health concerns. Twitter has potential to complement existing public health approaches to characterize opioid medication misuse and to develop effective public health campaigns to address this growing epidemic.