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