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We identified hashtags and searchable text phrases associated with codeine misuse by analyzing 1156 sequential Instagram posts over the course of 2 weeks from May 2016 to July 2016. Content analysis of posts associated with these hashtags identified the most common themes arising in images, as well as culture around misuse, including how misuse is happening and being perpetuated through social media.

A majority of images (50/100; 50.0%) depicted codeine in its commonly misused form, combined with soda (lean). Codeine misuse was commonly represented with the ingestion of alcohol, cannabis, and benzodiazepines. Some images highlighted the previously noted affinity between codeine misuse and hip-hop culture or mainstream popular culture images.

The prevalence of codeine misuse images, glamorizing of ingestion with soda and alcohol, and their integration with mainstream, popular culture imagery holds the potential to normalize and increase codeine misuse and overdose. To reduce harm and prevent misuse, immediate public health efforts are needed to better understand the relationship between the potential normalization, ritualization, and commercialization of codeine misuse.

We collected and content analyzed publically available, user-generated content about prescription opioid misuse posted to Instagram to understand the motivations and narratives related to uptake and misuse. As we used publically available data and did not collect or store identifying information, the University of California, San Francisco Institutional Review Board determined that this study did not require review. For preliminary analysis, we explored posts tagged with hashtags derived from generic and brand names of opioids (eg, #vicodin). Except for posts under #codeine, other generic and brand names were predominantly associated with sale. For primary analysis, we downloaded and analyzed all posts under #codeine for 1 week, listing all of the other hashtags associated with these posts. Among these, we downloaded the first 10 posts under the 10 most salient codeine-related hashtags for secondary analysis. Figure 1 visually represents our study design, which is described in detail below.

A preliminary analysis of Instagram posts related to opioids revealed that virtually all used multiple hashtags. We manually collected screenshots and video captures of posts with opioid-related hashtags, starting first with generic and brand names (eg, hydrocodone and vicodin) for opioid medications and then iteratively expanding the search terms as we uncovered the hidden lexicon of opioid misusers. Researchers conducted analysis of videos and images by noting the most prominent features in images and using a narrative summary for the videos. To uncover the hidden lexicon, we noted all of the hashtags that were associated with the posts we collected under #codeine. From there, we used simple counts to determine which of these associated hashtags were most prominently associated with codeine misuse (Multimedia Appendix 1).

We downloaded screenshots and video captures of the 75 most recent Instagram posts for the eight most common opioid hashtags for this preliminary search (#hydrocodone, #vicodin, #norco, #lortab, #percocet, #fentanyl, #oxycodone, and #codeine) on May 27, 2016. We selected these eight hashtags as they are all well-known generic or brand names for opioids [6]. Preliminary analysis demonstrated that, respectively, 56% (42/75), 59% (44/75), 87% (65/75), 72% (54/75), 39% (29/75), 78% (59/75), and 84% (63/75) of posts related to the hashtags #hydrocodone, #vicodin, #norco, #lortab, #percocet, #fentanyl, and #oxycodone depicted photographs of loose pills or pill bottles and appeared to offer to sell opioids or were ambiguous. Posts with the hashtag #codeine, however, depicted varied images and text related to codeine misuse, including but not limited to codeine misuse being associated with cartoon characters, hip-hop artists, and larger lifestyle choices. Given the high level of variability of imagery and its hypothesized role as a gateway to opioid misuse and addiction [21], posts with the hashtag #codeine demonstrated a clear public health significance and were thus chosen for further content analysis.

Using the iterative sampling methods of grounded theory, we identified other opioid-related hashtags within #codeine posts to capture representations of codeine misuse that are not well known (eg, #sizzurp and #oilmobb) and identify slang terms for codeine, and thereby, understand how users represent misuse on Instagram [23]. The advantage of this approach is that it allows us to capture how users discuss codeine misuse on Instagram inductively and minimize the impact of our preconceived theories of misuse [23]. As the behaviors, as well as their associated meanings and representations tied to codeine misuse can change over time, it is important to have an agile, analytic approach capable of capturing not only preexisting patterns and narratives of misuse but new representations and subcultures as well.

We manually downloaded posts with the hashtag #codeine each day of the week to account for daily variation, beginning on July 10, 2016, and ending on July 16, 2016. Weekends had more posts with the hashtag #codeine, resulting in a range of 150 to 200 posts downloaded each day of the week. We set thematic saturation at the point where we began to see duplicate posts. We downloaded a total of 1156 posts for our primary dataset.

The primary dataset comprised posts with the hashtag #codeine. For each post, we documented all listed hashtags and deductively designated them into lists of those that directly represented codeine misuse (eg, #CodeineCrazy) and those that did not (eg, #Trap) [24]. After sorting and counting terms directly and indirectly related to codeine misuse, we used Tableau (Tableau Software), a data visualization software, to demonstrate the relative salience of slang terms for codeine misuse, as well as other terms associated with codeine misuse (Figure 2). In these visualizations, the size of each term corresponds to its frequency in the dataset and helps represent the hidden lexicon and social milieu of codeine misuse, respectively. From the list of hashtags that directly relate to codeine-misuse, we derived search terms for our secondary dataset.

We used the 10 most common hashtags from the codeine-related list to identify a more focused sample of posts for our secondary dataset. A hashtag that was chosen had to have at least 1000 posts associated with it on Instagram and demonstrate codeine misuse in the top results shown by Instagram. Therefore, hashtags for secondary analysis not only had to be common in the initial sample, but also had to be commonly associated with codeine misuse on Instagram more broadly. Hashtags and their definitions are listed in Multimedia Appendix 1.

Data visualization with prescription opioid hashtags demonstrated terms related to codeinemisuse (Figure 2) and to other activities that co-occurred with these hashtags (Figure 3). Among the terms related to codeine misuse, we came across a number of terms related to processing codeine into the form commonly used in nonmedical consumption, such as lean. Lean, also known as sizzurp or purple drank, is a concoction consisting of promethazine or codeine cough syrup, ice cubes, and soda, with the optional addition of hard candy [22,26]. Nonopioid hashtags that frequently occurred with codeine-related hashtags revealed a robust relationship between codeine misuse and polysubstance use, especially cannabis use (eg, weed, cannabis, and kush), Additionally, there was a less common association with hip-hop culture (eg, hip hop and rap; Figure 3).

Definitions and examples of emergent themes are in Multimedia Appendix 2. The greatest proportion of posts were limited to images of codeine or lean in everyday places (use-behavior). Posts grouped under use-behavior contained images or videos of consuming in their homes, cars, or public places such as the beach. The preparation of codeine from a liquid, cough-syrup formulation into its misused form (ie, lean) was its own theme (preparation). Similar to use-behavior, posts grouped under preparation depicted the preparation, but not consumption, of lean in an array of common venues. The next most common type of post represented co-occurrence of codeine misuse with recreational alcohol, cannabis, and benzodiazepine consumption (polysubstance use). Posts grouped under polysubstance use depicted codeine alongside other intoxicants, concurrent consumption, and hashtagged (eg, #cannabis) in the caption. In our thematic framework, use-behavior is distinct from polysubstance use, in that we only applied the former to posts that showed codeine misuse exclusively, whereas we applied the latter to posts where users represented codeine misuse alongside alcohol or other drugs.

Next were posts those that sought to sell codeine illicitly (sale). We grouped posts under sale if they included a phone number or a prompt to direct message the user to make an inquiry or purchase. Images or videos with references to popular culture icons (pop culture) or those that evoked codeine misuse as a commodity (commercialization) were also featured in our sample. The posts grouped under pop culture often featured popular culture icons often associated with youth, such as Bart Simpson, Mickey Mouse, and Pokemon. Posts characterized as commercialization utilized narratives related to recreational codeine misuse to sell commodities such as a wine cozy with the word Sizzurp.

Finally, we also observed posts representing an affinity between codeine misuse in the form of lean and the chopped and screwed genre of hip hop described in previous work [27], as well as a novel association with the trap genre of hip-hop (hip-hop). Posts grouped under hip-hop featured recognizable recording artists (ie, Future) from this genre in either the imagery or the accompanying text of posts we grouped into this theme. Multimedia Appendix 2 represents definitions, counts, and frequency, as well as examples of each theme. As the sample is 100 posts, counts are equivalent to proportion for each category. 59ce067264

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