“I just wanted to tell you that loperamide WILL WORK”: A web-based study of extra-medical use of loperamide

doi:10.1016/j.drugalcdep.2012.11.003

Drug and Alcohol Dependence

Volume 130, Issues 1–3, 1 June 2013, Pages 241-244

https://doi.org/10.1016/j.drugalcdep.2012.11.003 Get rights and content

Abstract

Aims

Many websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users.

Methods

A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use.

Results

There has been an increase in discussions related to loperamide's use by non-medical opioid users, especially in 2010–2011 Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as “poor man's” methadone. Typical doses ranged 70–100 mg per day, much higher than an indicated daily dose of 16 mg.

Conclusions

This study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a “leading edge” data source in identifying emerging drug use practices.

Introduction

To design effective prevention and policy measures, the substance abuse field requires timely and reliable information on new and emerging drug trends. Although existing epidemiological data systems, such as the National Survey on Drug Use and Health (NSDUH), the Community Epidemiology Work Group (CEWG), and the Drug Abuse Warning Network (DAWN), provide critically important data about drug abuse trends, they lag in time. Additional methods are needed to expand access to hard-to-reach populations and to enhance early identification of emerging trends.

There is an enormous amount of information available online about illicit drugs (Bogenschutz, 2000, Halpern and Pope, 2001, Boyer et al., 2001, Wax, 2002, Deluca et al., 2007, Nielsen and Barratt, 2009), and the World Wide Web has been identified as one of the “leading edge” data sources for detecting patterns and changes in drug trends, and as a useful tool for reaching hidden populations (Griffiths et al., 2000, Schifano et al., 2006, Butler et al., 2007, Butler et al., 2008, Murguia et al., 2007, Mounteney et al., 2010, Miller and Sonderlund, 2010). Many Web 2.0 empowered social platforms, including Web forums, provide a means for individuals to freely share their experiences, and post questions, comments, and opinions about different drugs. Such user-generated content (UGC) can be used as a very rich source of unsolicited, unfiltered and anonymous self-disclosures of drug use behaviors from hard-to-reach populations of illicit drug users (Boyer et al., 2001, Boyer et al., 2005, Boyer et al., 2007b, Boyer, 2004, Falck et al., 2004, Miller and Sonderlund, 2010, Lange et al., 2010). Prior studies have utilized such sources to explore a variety of topics within the drug abuse field. For example, by monitoring user discussions on a website that also facilitates online purchases of pharmaceutical opioids, Boyer et al. identified striking increases in the use of kratom to modulate opioid withdrawal symptoms (Boyer et al., 2007a). UGC has been also used to monitor the non-medical use of tramadol (Cicero et al., 1999), explore user endorsement of the illicit use of acetaminophen and hydrocodone, oxycodone and morphine sulfate ER (Butler et al., 2007), examine tampering methods for selected pharmaceutical products (Cone, 2006), and assess the effects of recreational use of salvia divinorum (Lange et al., 2010). Although there is a growing recognition that the web provides unprecedented opportunities for research across a wide range of topics within the drug abuse field, web-based studies and especially those that rely on UGC remain under-utilized (Miller and Sonderlund, 2010).

This study builds on interdisciplinary collaboration between researchers at the Center for Interventions, Treatment, and Addictions Research (CITAR), and the Ohio Center of Excellence in Knowledge-enabled Computing (Kno.e.sis). In 2011, the centers initiated an exploratory study to develop automated data collection and analysis tools to process web-based data on knowledge, attitudes, and behaviors related to the illicit use of buprenorphine and other pharmaceutical opioids.

In the process of developing techniques to automate the coding and analysis of web forum data on buprenorphine, we identified extensive web-based discussions about the extra-medical use of loperamide, a piperidine derivative that acts on opioid receptors in the intestine. It is approved by the U.S. Food and Drug Administration for the control of diarrhea symptoms. Because of its general inability to cross the blood–brain barrier, loperamide is considered to have no abuse potential and is therefore available without a prescription (Ericsson and Johnson, 1990). To date, little is known about the extra-medical use of loperamide among illicit opioid users. This content analysis study was designed to examine intentions of loperamide use as reflected in web-based discussions as well as dosage and side effects.

Section snippets

Methods

A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for the study. Although the larger project included additional websites, this exploratory study of loperamide use was limited to a website that focused primarily on illicit opioid use, as opposed to other websites that focused on other types of drugs or were broader in scope. The selected website limits the number of active memberships at any given time period, but it has had over

Results

The first post on loperamide use appeared in 2005, soon after the inception of the website in 2004. In 2010–2011, there was a notable increase in discussions related to loperamide (Fig. 1). Almost 70% of posts discussed loperamide as a remedy to self-treat opioid withdrawal symptoms. About 25% of the sample posts discussed issues related to loperamide's potential to cross blood–brain barrier to produce euphoric or analgesic effects. The remaining posts included a few mentions of its use as

Conclusions

The study contains several limitations that are inherent to many web-based studies, such as a lack of demographic indictors, inconsistently available geographic information, drug use characteristics, and an inability to validate self-reported data. Further, it is difficult to determine the representativeness of the sample and the generalizability of study findings. Difficulty in obtaining a representative sample of illicit drug users is a universal problem in research with hidden and

Role of funding source

This study was supported by the National Institute on Drug Abuse (NIDA), Grant No. R21 DA030571 (Daniulaityte, PI; Sheth, PI) and the Department of Community Health Grant, Boonshoft School of Medicine, Wright State University. The funding source had no further role in the study design, in the collection, analysis and interpretation of the data, in the writing of the report, or in the decision to submit the paper for publication.

Contributors

R. Daniulaityte, A. Sheth, R. Falck, R. Carlson, and D. Cameron designed the study. D. Cameron, S. Perera, L. Chen, and A. Sheth developed Web crawlers and extracted information from web sites. R. Daniulaityte performed manual coding and analysis of selected posts, reviewed literature and wrote the first draft of the paper. R. Carlson contributed to coder reliability assessment. All authors reviewed, commented, and edited the manuscript. All authors contributed to and have approved the final

Conflict of interest

All authors declare that there are no conflicts of interest.

Acknowledgements

The authors would like to express their gratitude to research assistant Erica M. Morgan for her help with the study. An earlier version of the paper was presented at the 74th Annual Meeting of College on Problems of Drug Dependence – June, 9–14, 2012, Palm Springs, California.

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Short communication“I just wanted to tell you that loperamide WILL WORK”: A web-based study of extra-medical use of loperamide

Abstract

Aims

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Conclusions

Role of funding source

Contributors

Conflict of interest

Acknowledgements

Lomotil overdose

Pediatrics

Assessing the impact of a regulatory intervention in Pakistan

Soc. Sci. Med.

Loperamide poisoning in children

Lancet

Drug information libraries on the Internet

J. Psychoactive Drugs

Realizing the potential of the internet for health and medical information

Stud. Health Technol. Inform.

Self-treatment of opioid withdrawal with a dietary supplement, Kratom

Am. J. Addict.

Dissemination of psychoactive substance information by innovative drug users

Cyberpsychol. Behav.

The Internet and psychoactive substance use among innovative drug users

Pediatrics

Web sites with misinformation about illicit drugs

N. Engl. J. Med.

National addictions vigilance intervention and prevention program (NAVIPPRO): a real-time, product-specific, public health surveillance system for monitoring prescription drug abuse

Pharmacoepidemiol. Drug Saf.

Internet surveillance: content analysis and monitoring of product-specific internet prescription opioid abuse-related postings

Clin. J. Pain

An ethnographic approach to targeted sampling: problems and solutions in AIDS prevention research among injection drug and crack-cocaine users

Hum. Organization

A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States

Drug Alcohol Depend.

Effect of abuse-deterrent formulation of OxyContin

N. Engl. J. Med.

Ephemeral profiles of prescription drug and formulation tampering: evolving pseudoscience on the Internet

Drug Alcohol Depend.

National changes in OxyContin, other oxycodone, and heroin exposures reported to poison centers with introduction of reformulated OxyContin

Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids

Drug Alcohol Depend.

Searching the Internet for drug-related web sites: analysis of online available information on ecstasy (MDMA)

Am. J. Addict.

Routes of administration and frequency of abuse of OxyContin and immediate-release Oxycodone in a rural Kentucky County following introduction of reformulated OxyContin

Safety and efficacy of loperamide

Am. J. Med.

Sources of information about MDMA (3,4-methylenedioxymethamphetamine): perceived accuracy, importance, and implications for prevention among young adult users

Drug Alcohol Depend.

Short communication
“I just wanted to tell you that loperamide WILL WORK”: A web-based study of extra-medical use of loperamide