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. Author manuscript; available in PMC: 2024 Apr 5.
Published in final edited form as: Subst Use Misuse. 2023 Apr 5;58(7):920–929. doi: 10.1080/10826084.2023.2196574

Using Social Media to Examine Themes Surrounding Fentanyl Misuse and Risk Indicators

Erin Kasson a, Lindsey M Filiatreau a, Nina Kaiser a, Kevin Davet a, Jordan Taylor a, Sanjana Garg b, Mai El Sherief b, Talayeh Aledavood b, Munmun De Choudhury b, Patricia Cavazos-Rehg a
PMCID: PMC10464934  NIHMSID: NIHMS1923451  PMID: 37021375

Abstract

Background:

Opioid misuse is a crisis in the United States, and synthetic opioids such as fentanyl pose risks for overdose and mortality. Individuals who misuse substances commonly seek information and support online due to stigma and legal concerns, and this online networking may provide insight for substance misuse prevention and treatment. We aimed to characterize topics in substance-misuse related discourse among members of an online fentanyl community.

Method:

We investigated posts on a fentanyl-specific forum on the platform Reddit to identify emergent substance misuse-related themes potentially indicative of heightened risk for overdose and other adverse health outcomes. We analyzed 27 posts and 338 comments with a qualitative codebook established using a subset of user posts via inductive and deductive methods. Posts and comments were independently reviewed by two coders with a third coder resolving discrepancies. The top 200 subreddits with the most activity by r/fentanyl members were also inductively analyzed to understand interests of r/fentanyl users.

Results:

Functional/quality of life impairments due to substance misuse (29%) was the most commonly occurring theme, followed by polysubstance use (27%) and tolerance/dependence/withdrawal (20%). Additional themes included drug identification with photos, substances cut with other drugs, injection drugs, and past overdoses. Media-focused subreddits and other drug focused communities were among the communities most often followed by r/fentanyl users.

Conclusion:

Themes closely align with DSM-V substance use disorder symptoms for fentanyl and other substances. High involvement in media-focused subreddits and other substance-misuse-related communities suggests digital platforms as acceptable for overdose prevention and recovery support interventions.

Keywords: fentanyl, Reddit, social media, overdose, substance misuse, opioid use disorder

Introduction

Opioid misuse is a public health crisis in America with approximately 250 individuals fatally overdosing each day in 2020 (Ahmad, Rossen, & Sutton, 2021). During the COVID-19 pandemic, the number of annual overdose deaths increased dramatically, from around 75,000 in March 2020, to over 100,000 in April 2021 (Ahmad et al., 2021). Fentanyl, a highly-addictive, synthetic opioid, has contributed significantly to the most recent wave of opioid overdose deaths (Han et al., 2019). Of the 100,000 overdose deaths occurring in the 12-month period preceding April 2021, nearly 65,000 involved synthetic opioids such as fentanyl (Ahmad et al., 2021). The perceived effects of fentanyl are similar to those of heroin, both of which bind to opioid receptors in areas of the brain that control pain and emotion. Side effects include feelings of extreme happiness, drowsiness, nausea, confusion, sedation, respiratory depression, unconsciousness, coma, and death (NIDA, 2015).

Fentanyl is lethal in much smaller doses compared to heroin (Bremer et al., 2016), comes in many analogues making dosage and purity identification difficult (Boddiger, 2006; Pergolizzi Jr et al., 2018), and can be laced in drugs such as ecstasy or cocaine causing accidental overdose deaths among those who have not established a tolerance (Boddiger, 2006; Rodda et al., 2017; Turock et al., 2009). It is not uncommon for those intentionally misusing fentanyl to concurrently use additional substances (NIDA, 2017), overdose more than once in their lifetime, and experience cognitive and physical impairments (Carroll et al., 2017) such as decreased cognitive performance and motor skills, increased symptoms of depression and suicidal ideation and hypoxic-related brain injuries (Friesen & Kurdyak, 2020; Karila et al., 2019; Kosten et al., 2020; Zibbell et al., 2019). Due to these negative effects and the role of fentanyl in increasing overdose deaths nationally, it is vital to better understand emerging perceptions of fentanyl, and fentanyl misuse habits, among individuals who misuse substances, or who are at risk for misusing substances, in order to inform timely, novel, and efficient outreach efforts.

Individuals with substance use disorders often fear the legal implications and stigma that may result from disclosing their substance misuse to healthcare providers, or are distrusting of the medical system, broadly (Livingston et al., 2012; Nelson & Perrone, 2012). As such, these individuals may use the Internet and online communities for support- and information-seeking (Sowles et al., 2017; Wombacher et al., 2020), as the anonymity of online platforms can protect users from the offline consequences of self-disclosure and connect them with others with similar experiences (Andalibi et al., 2016). Previous studies have found that some individuals disclose their personal experiences with substance misuse, cravings, past overdoses, and difficulties with reducing use and cessation on pseudonymous social media platforms such as Reddit (Andalibi, et al., 2016; De Choudhury & Kiciman, 2017; De Choudhury et al., 2016). Reddit is a social media site used by about a tenth of American adults (Perrin & Anderson, 2019) that is composed of subgroups, called subreddits, which are centered on specific topics and managed by volunteer moderators who control the rules of the community. Within subreddits, a member can create a post containing text and media, comment on posts, or comment on other comments. Reddit users can “upvote” or “downvote” the posts and comments they approve or disapprove of, respectively. Notably, Reddit allows one to create multiple user accounts using the same email address, which, in turn, allows for multiple “anonymous” accounts to facilitate online discussions about private or highly stigmatized topics (Pavalanathan & De Choudhury, 2015; Singer et al., 2014). While exact identities of Redditors are unknown, research suggests that users on Reddit tend to be male, aged 18-29, and have higher degrees of educational attainment (Barthel, Stocking, Holcomb, & Mitchell, 2016; Statista, 2021).

Examining publicly available, user generated content on pseudonymous social media sites like Reddit can be useful for understanding emergent themes and topics of discussion around fentanyl misuse (Chan et al., 2015; Kim et al., 2017), including topics related to behaviors that may increase likelihood of overdose or other adverse health outcomes. Previous studies have used machine learning methods and natural language analytics to study Reddit posts about casual drug discussions, opioid misuse, and treatment for substance use disorders (Chancellor et al., 2019; Lu et al., 2019). Other studies have investigated content on social media related to opioids, finding that the source, composition, and content of posts concerning opioids and prescription drugs directly influences whether posts will be shared among Reddit users (Jain et al., 2020). For example, posts mentioning the term ‘addiction’ were less likely to be shared because of the stigmatizing rhetoric surrounding substance misuse and opioid use disorder (OUD) (Kelly et al., 2010). On the other hand, posts that used first person pronouns tended to get more social support, upvotes, and comments with anonymous Reddit users mentioning their anxieties, sadness, and health struggles (Pandrekar et al., 2018).

Despite the previous literature in this area and the ongoing opioid epidemic, there is limited work examining social media content specific to fentanyl (Beletsky et al., 2020). Online communities can give insight into what individuals choose to share with peers with similar life experiences, which may not be accessible within a lab or clinical setting. As such, gathering data and testimonies from social media on fentanyl and its misuse can provide valuable insights into emerging perspectives and topics of discussion among individuals who have misused fentanyl in the past, currently misuse fentanyl, or are at risk for misusing fentanyl in the future. Given the high risk for overdose and severe functional impairments related to fentanyl misuse (CDC, 2020), low rates of treatment seeking, and persistent barriers to care for this population (Wakeman & Rich, 2018), leveraging social media content related to fentanyl misuse may bring to light crucial information for understanding current risks being incurred among individuals who misuse or are at risk for misusing fentanyl (e.g., which fentanyl-laced substances may be actively circulating) and appropriate modalities for deploying substance misuse interventions or educational materials (e.g., media-related social networking platforms). Therefore, the aims of the current study were to 1) identify risk indicators related to fentanyl misuse, overdose, and other adverse health outcomes mentioned in posts and comments within a fentanyl-focused online community, and 2) examine other online communities with which these members engage to identify other interests that could inform substance-misuse related interventions and clinical screening for substance misuse and related disorders in this group.

Method

Data generation

We harnessed data from a prior study that aimed to develop a machine learning classifier to detect high risk posts (i.e., posts that could be indicative of heightened risk of substance misuse , overdose, or other adverse health outcomes) within the r/fentanyl subreddit, a forum that classifies itself as a harm-reduction site where Reddit users can share personal experiences with fentanyl. Data generation methods for this work have been previously described in detail (Garg et al., 2021). Briefly, we collected all posts and comments from the r/fentanyl subreddit from its inception in May 2015 to January 2020 using the Reddit API and Google Big Query. After removing posts without a text body from the original sample of 804 posts and 5,655 comments, we randomly sampled 27 posts and 338 comments to use as a training dataset for the development of the machine learning classifier. These posts and comments served as the dataset for the primary qualitative analysis in the current study.

To further investigate the behaviors and interests of r/fentanyl users, we also collected 1,000 of the most recent posts and comments on other subreddits as of February 2020. From these 1000 posts, a list of the top 200 subreddits that were posted to by members of r/fentanyl was created and coded within the secondary qualitative analysis in this study.

Qualitative Analyses

To develop a qualitative codebook to identify themes surrounding commonly discussed risk behaviors in the 365 posts and comments in the machine learning classifier training dataset, we used an inductive content analysis approach to capture themes present in the data from our current dataset as well as deductive strategies to compare these identified themes with those present in previous literature on substance misuse and overdose-related risks (Braun et al., 2017). Identified codes included: (1) mentions that they regularly misuse/currently misuse substances (Degenhardt et al., 2010), (2) mentions high tolerance or withdrawal (Bluthenthal et al., 2020; Darke & Hall, 2003), (3) mentions currently having or seeking a vendor (Paulozzi, 2012), (4) mentions past overdoses (Britton et al., 2010), (5) mentions use of additional substances (Betts et al., 2015; Coffin et al., 2003), (6) social comparison or showing off (Krauss et al., 2015; Steers et al., 2016), (7) functional and quality of life impairments (e.g., side effects, social or occupational issues, and or loss of friends or family due to use) (Tamargo et al., 2020; Zibbell, et al., 2019), (8) mentions intravenous method of use, (Britton, et al., 2010), (9) mentions drug attributes for the purpose of identification (Somerville et al., 2017), (10) mentions that fentanyl is cut with another substance (LaRue et al., 2019), (11) seeking advice or questions on how to get the best high (Balsamo et al., 2021; Pandrekar, et al., 2018), and (12) comment supporting risky drug use (Pandrekar, et al., 2018; Webster, 2017).

Domain expert coders (graduate and undergraduate students trained specifically in annotation of online substance misuse and mental health content) applied our codebook to posts on a binary scale (i.e., “1” if a code was present, and “0” if the code was not). After each post was coded by two independent coders, a third consensus coder compared results and resolved discrepancies, creating a finalized set of post risk levels (Syed & Nelson, 2015).

In addition to coding the 365 posts and comments in the machine learning classifier training dataset, the 1,000 most recent posts and comments members of r/fentanyl had made on other subreddits as of February 2020 were qualitatively analyzed. We compiled a list of the top 200 subreddits with the most unique Reddit users from r/fentanyl and reviewed the data to develop categories of themes using an inductive approach. Based on these data and informed by our primary codebook themes (e.g., polysubstance use), our final subreddit codebook included the following themes: (1) media-centered, (2) non-drug related/general information, (3) drug related, and (4) mental health related. Annotations were completed by the two independent coders for the primary posts/comments, and discrepancies were resolved by a consensus coder using the same approach as with the primary posts/comments.

Ethics

Since this data was collected from the publicly available subreddit r/fentanyl and there was no direct interaction with the Reddit users of this community, this study was determined not to constitute human subjects research by the authors’ institutional review board. Nevertheless, to protect user identities, we have not included usernames nor direct quotes (example quotes are paraphrased to reduce traceability).

Results

Average character count of the 27 included posts and 337 included comments was 1,011 and 347, respectively. In analyzing the frequency of codebook themes in posts and comments, most of the posts and comments had few themes, with 161 (44.1%) having no codebook theme and 74 (20.2%) having only one. Among posts or comments with multiple themes, there were 44 (12.0%), 43 (11.7%), and 45 (12.3%) posts and comments that had two, three, and at least four themes represented, respectively (Table 1).

Table 1.

Characteristics of sample post/comments on r/fentanyl (N=365)

N (%)
Posts 27
Comments 338
Character Length
4 to 65 92
66 to 146 92
148 to 395 92
398 to 4,994 89
Number of content themes
0 161
1 74
2 44
3 43
4+ 45
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From the 365 comments and posts, the theme of functional quality of life impairments was present in nearly a third of excerpts (n=105, 28.8%; Table 2). For example, one comment read “even though I been using for over a decade it’s ruined me so bad … not being able to function and being really sick.” Over a quarter of posts and comments (n=98, 26.9%; Table 2) also mentioned use of additional substances; for instance, “I started using cocaine to get off it too.” One-fifth of posts/comments (n=73, 20.0%; Table 2) noted a high tolerance for fentanyl or experiences of withdrawal, for example, “My tolerance was off the charts from using fentanyl.”

Table 2.

Clinical themes and associated risk factors identified on r/fentanyl

Theme/Feature Participant Quotations
N (%)
Functional and Quality of Life Impairments (mentions side effects, social/occupational issues, others dying) 28.8%
(105/365)

  • I’ve never been about any of that crap. For me even though I been using for over a decade it’s ruined me so bad and I hate it so much it’s just the getting over not being able to function and being really sick that I have struggled with.

  • same experience…. i couldnt walk for almost a day…. felt pins and needle sensation like crazy…

  • I have been through so many bad withdrawals wishing for it all to end but in the end I always find myself using it [fent or fentalogues] again. Making this substance easily my life's hardest addiction to overcome even when compared to my years addicted to meth.

  • Very disturbed by what I saw myself doing and obviously will make sure to lower my doses to make sure this never happens again.

  • Withdrawal from fentanyl makes giving up heroin seem like a blast.

Mentioning Use of Additional Substances 26.9%
(98/365)

  • For me it was about a day and a half after my last dose. I started using cocaine to get off it too just stay up instead of being restless haha

  • I was sedated the whole time on clonidine, zofran, and gabapetin or benzo

  • Then when I finally felt kind of sick, I started up with some etiz in the daytime & 1,4-BDO at night, clonidine & gabapentin, & lots of cannabis extract as needed.

  • I noticed no impact from tapering up until 1mg. Sure the withdrawal from opioids goes away but so does sanity. I quickly took a benzo (lucky to have a sitter) and slept this shit off and got rid of the remaining 10grams when I woke up.

Mentions high tolerance or withdrawal 20.0%
(73/365)

  • Ive been experiencing wicked spasms in my body while trying to fall asleep, horrible nightmares, night sweats, really fast heart rate. Ive noticed these symptoms since trying to cut back on my fentynal use, cause I was using a lot.

  • My tolerance was off the charts from using fentanyl and I used to require 1200 mcg per dose but I have managed to make that 400 mcg work, that is still crazy high of course but no longer insane

  • the next few months were spent in blissful sedation 24/7 followed by a transition to bromadol and then a nightmarish withdrawal

  • I was in the 100 to 200 mcg at the end for a big IV dose. This was after starting at between 10 and 20mcg so you can see tolerance develops quickly if you use all the time.

  • Got a batch of fake 30s that have fent in them, my tolerance is high but not super super high

Social Comparison / Showing Off (i.e., Mentioning Risky Type of Method Used / Amount of Drugs Used / Pictures) 16.7%
(61/365)

  • dude, when I was in my early 20s and only took percs and vics and roxys by the handfull at a time… I took a 500ug sublingual fentanyl tablet.

  • I was on 320mg oxy a day when I was a teen when it first came out….. oxy aint shit.

  • 25mg of oxy is like nothing to me. 100ug of fent is freaking euphoric

  • Back before fent started getting really well known I was doing fent right before seeing my parole officer and still passed every drug test they gave me.

Mentions that he/she is a regular user 10.1%
(37/365)

  • I found I’ve started getting major tolerance. It was around 100-150mg of fent a day.

  • I've recently come from a 3-month heroin binge, averaging 2-5 points a day, max 2 grams in three days.

  • I have used fent hcl almost every day for the last half of a decade, averaging 30mg a day nasal spray.

  • i have used opioids for the past 22 years of my life. because of extreme pain due to back injuries etc. (opiates dont touch my nerve pain like lyrica or a gaba) but fent work best for my muscoskelletal pain

Seeking advice/questions on how to get the best high (disregarding safety or side effects) 6.9%
(25/365)

  • So are there any fent analogues that aren't over the top potent but still feel pretty euphoric?

  • hello, I want to dissolve the fent in water as best as possible. will I need any citric acid or any heat?

  • Does anybody have experience with smoking a fentalogue mannitol mix through a pipe? I have only used foil until now but am looking into getting a meth style pipe to get a better hit.

  • I'm using fu f nasally and find it making me sleepy. Would plugging it have a different effect on me possibly?

  • Is there a way to change this substance into something else by mixing lemon juice in or something? I have more than 25G in my posession right now and have no idea what to do with it.

Does mention drug attributes for the purpose of identification (color/consistency, smell/taste) 6.3%
(23/365)

  • The substance is very powderish just like acryl-fent not crystal like MAF. It dissolves in water as well.

  • The color is interesting, looks like it may have been oxidized? . I would love to see this analyzed, as I’ve only seen CF as white or a yellowish waxy color.

  • The MAF seems to be very powdery, almost the same consistency as baby powder (I havent opened it yet, just feeling it in the bag) and the FUEF feels also looks really different, the fuef feels and looks more "crystalline", its not clear crystals but it has an kind of baking soda type of feel to it and it has a bunch of nice sized rocks on the top of the bag (and the MAF seems to have none that I can see, it just seems like very fine powder).

  • I've had pink, blue, grey, brown, black and white dope. Just saying color means nothing at all. Brown can come from milk lactose, that you cook on a stove. It carmalizes essentially.

Supportive Comment for Risky Drug Use (risky drug using or drug seeking behaviors) 6.0%
(22/365)

  • Go to a methadone clinic, buy some MJ and any dissos you can. Stick it out, or find some dope on the street.

  • I just got some a-php but am contemplating throwing it out before I experience it's seductive powers and insane paranoia. I DO want some meth tho lol

  • I overdosed and just about died after re-dosing just a little bit more than usual. I’d recommend buying powder and learning how to safely make your own.

Mentions currently having or seeking a vendor 5.5%
(20/365)

  • I was sent a wonderful crystalline gram by a Chinese supplier…

  • Same problem here, got PAF from DNM and it is super painful I tried to smoke it and it burnt my throat and lungs

  • I used to get Fu-F from him and I was always super impressed with the quality. I received 2 samples of it, but sadly they didn't work for me.

  • I got a sample of what the seller told me was MAF. I don't think it was MAF.

  • Last time I brought MAF from vendor the quality was incredible. When I saw it was back in stock I ordered right away.

Mentions intravenous method of use (needles) 4.9%
(18/365)

  • I was in the 100 to 200 mcg at the end for a big IV dose.

  • I got two different kinds of of 4FIB. One was pure and one was a 1/10 caffine mix. The pure hit so bad when trying to IV and I couldn't IV.

  • But I've been on this for a substansial amount of time now. My tolerance is through the roof, I can go thru a g in one night, and I inject this stuff now.

  • i shot 200mg and felt nothing, so i did more and more, up tp 500mg and kinda felt high but still didnt even get a nod and this was after skipping my methadone for 36 hours. 1gram in under 15mins i was PISSED, i should have just bought tar. i wish i could still find pure carf

Mentions that it is cut with another substance 3.8%
(14/365)

  • I used powdered Fentanyl/HCl and BUFF/mannitol.

  • It is definitely a fentalogue + cut. Otherwise with that amount they would have killed all their customers by now. With some of the changes in quality I guess I'll cop some marquis and some fent test strips. Safety pays off I guess.

  • I tried a synthetic heroin with fent mix when this seller first appeared and I tried it and it was strong and I liked it but he has sold out of it by the time I went to get some more. It reminded me of some syth H when it first came out and how strong his was. He also sent me a sample of MAF:

  • I haven't officially tested my pills but I'm like 99% sure they’re cut with fentanyl they look just like the fent pills that are going around and I know they’re definitely not oxy so yeah just curious how long till fent causes withdrawls after my last dose

Mentions Past Overdoses 3.8%
(14/365)

  • I ain't got a lot of money right now, I had a severe OD -was in hospital for a really really long time

  • I’m sure I overdosed even though the effects profile wasn't obvious to me. And I was using around 100-200mg of oxycodone back then. My tolerance is what kept me from passing out and stopping my breathing.

  • I once got a synth cannabinoid instead of a fent analogue. It wasnt water soluable either so i didn’t bother snorting. So i started vaping one mg and freaked out. OD'd and went on a journey to psychosis.

  • Was overly confident I could handle something so intense. Didn't use gloves while handling it and some propably was also absorbed through my skin. I went unconcious and was starting to turn blue before I was successfully resuscitated.

  • I rubbed a good amount on my gums. I died. Got narcaned back to life. Died again after. Narcaned again. Wake up to find out I’m a real monkey.

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Less than 20% of posts/comments represented other identified themes (Table 2). A total of 61 posts and comments (16.7%) socially compared their misuse by mentioning amount used, risky methods of consumption, or acquisition of novel or rare types of fentanyl (i.e., analogues) with one post stating, “Back before fent started getting really well known I was doing fent right before seeing my parole officer and still passed every drug test they gave me” (Table 2). Just over 10% (n=37) of the post and comments mentioned regular drug use—"I have used fent hcl almost every day for the last half of a decade" (Table 2). Under 10% of posts and comments sought out advice/questions for how to get the best high (n=25; 6.9%); mentioned attributes of a substance for identification purposes (n=23; 6.3%); and provided supportive comments for risky drug use (n=22; 6.0%; Table 2). Examples of these themes include “Does anybody have experience with smoking a fentalogue mix through a pipe… am looking into getting a meth style pipe to get a better hit”, “The substance is very powderish…it dissolves in water as well,” and “Go to a methadone clinic, buy some MJ…or find some dope on the street,” respectively.

Few posts and comments (i.e. ~5%) specifically mentioned that one currently has or is seeking a vendor for accessing fentanyl despite the subreddit’s explicit rules against sourcing in the forum (n=20; 5.5%; e.g., “I was sent a wonderful crystalline gram by a Chinese supplier”); intravenously injecting fentanyl or other drugs (n=18; 4.9%; e.g., “My tolerance is through the roof, I can go thru a g in one night, and I inject this stuff now”); being aware that their fentanyl was cut with another substance (n=14; 3.8%; e.g., “I tried a synthetic heroin with fent mix when this seller first appeared” ); and an individual’s own experience of past overdoses (n=14; 3.8%; “I rubbed a good amount on my gums. I died. Got narcaned back to life”; Table 2).

When analyzing the most common other subreddits visited by members of r/fentanyl, the most commonly coded were media-focused communities where Reddit users post pictures and videos (N=72; 36.0%; Table 3). Of these 72 subreddits, 29 (40.2% of media-focused communities; 14.5% of top 200 subreddits) were comedy and meme pages (Table 3). The next most common theme was related to non-drug discussion and information (n=67, 20.8%; Table 3). Subcode themes under this included advice (n=19, 9.5%), news & politics (n=9, 4.5%), science and technology (n=9, 4.5%), and art/music/movies (n=8, 4%; Table 3). Drug related communities were also frequently represented in the top 200 subreddits (n=57, 28.5%) with two-thirds of these communities (n=38) focused on a specific drug classification (Table 3). Drug categories included opioids (n=14, 7.0%), cannabis (n=6, 3.0%), stimulants (n=6, 3.0%), psychedelics (n=5, 2.5%), vaping (n=4, 2.0%), and alcohol (n=3, 1.5%; Table 3). Mental health related subreddits were the least represented code, constituting only 4.0% (n=8) of the top 200 subreddits (Table 3).

Table 3.

Most Common Subreddits of r/fentanyl Users

Theme/Feature Example Subreddit (Rank #. <Subreddit Name> - Percentage overlap
N (%)
Media Centered (Pictures / Videos / etc.) 36.0%
(72/200) 		7. pics – 25.0%
17. aww – 17.7%
22. videos – 16.8%
 Comedy / Memes 14.5%
(29/200)		 6. funny – 25.0%
14. trashy – 18.3%
39. RoastMe – 11.0%
Non-drug Discussion / Information 20.8%
(67/200) 		10. todayilearned – 20.4%
16. ShowerThoughts – 18.0%
18. Gaming – 17.6%
 Advice / Questions 9.5%
(19/200)		 3. AskReddit – 45.7%
47. relationship_advice – 9.6%
49. LifeProTips – 9.2%
 News & Politics 4.5%
(9/200)		 11. news – 20.3%
13. worldnews – 18.8%
32. politics – 12.7%
 Science & Technology 4.5%
(9/200)		 28. darknet – 14.2%
29. science – 14.1%
60. space – 8.3%
 Art / Music / Movies 4.0%
(8/200)		 41. Music – 10.8%
46. Movies – 9.7%
80. television – 7.4%
Drug Related 28.5%
(57/200) 		2. Drugs – 49.9%
8. DrugStashes – 22.9%
38. DrugNerds – 11.8%
 Opioid 7.0%
(14/200)		 1. Opiates – 65.4%
12. Heroin – 19.4%
20. OpiateChurch – 16.8%
 Cannabis 3.0%
(6/200)		 19. Trees – 17.5%
67. Weed – 8.0%
161. MicroGrowery – 4.6%
 Stimulant 3.0%
(6/200)		 9. Stims – 22.6%
24. Cocaine – 14.8%
40. MDMA – 10.8%
 Psychedelics 2.5%
(5/200)		 58. Psychonaut – 8.5%
65. DMT – 8.1%
78. Shrooms – 7.4%
 Vaping 2.0%
(4/200)		 124. Electronic_Cigarette – 5.6%
132. Vaping – 5.3%
178. OilPen – 4.1%
 Alcohol 1.5%
(3/200)		 179. Drunk – 4.1%
187. CripplingAlcoholism – 4.0%
Mental Health Related 4.0%
(8/200)		 31. tifu – 13.0%
61. iamatotalpieceofshit – 8.3%
93. confession – 6.9%
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Note: Codes are not mutually exclusive

Discussion

The present study leveraged social media data from a fentanyl-focused subreddit to better understand emergent discourse on risky behaviors related to fentanyl misuse. Broadly, our findings suggest individuals on the r/fentanyl subreddit frequently network about symptoms associated with substance use disorder, struggles with their use of or dependence on substances, and polysubstance use or use of unknown or unidentified substances. Some individuals also sought advice about drug use, suggesting Reddit users may be open to networking about harm reduction interventions and other ways to maintain their safety while using.

We identified multiple themes that are cause for clinical concern. Specifically, although this subreddit explicitly defined itself as an online community to discuss broad personal experiences with fentanyl use versus one in which recovery discussions were encouraged, the most common risk behavior related-themes that were identified tended to be indicative of Reddit users exhibiting DSM-V substance use disorder symptoms. For example, the most prevalent risk-behavior related theme in this subreddit was functional impairments related to fentanyl misuse (e.g., struggles with family functioning, employment, academic attainment, and activities of daily living; 29%). While our codebook was designed to identify broad risks related to potential substance misuse , overdose, or other adverse health outcomes rather than evaluate specific DSM-V substance use disorder symptoms, this high level of functional impairment found in posts is reflective of a core symptom for OUD and a strong indicator of disorder severity (APA, 2013). In addition, many posts (20%) mentioned one’s tolerance for fentanyl and personal experiences of withdrawal symptoms, which are also consistent with DSM-V criteria for a substance use disorder (APA, 2013). As observed by studies exploring social media content related to other substances (Rutherford et al., 2022), these findings support the notion that people who misuse fentanyl may turn to social media to post about their struggles with substance misuse or for support and guidance on how to cope with substance misuse-related symptoms. Importantly, this represents a critical opportunity to deliver information on harm reduction practices, treatment for substance misuse or substance use disorders, and other strategies for supporting long-term recovery efforts within the platform. As an example, one study demonstrated the viability of using a machine learning classifier to identify individuals who misuse substances with an “intention to recover”. The classifier then paired these individuals with a “mentor” who was in a more advanced stage of their recovery process to encourage peer support through the recovery process (Ghosh, Misra, Ghosh, & Podder, 2020). Other studies have also used mobile apps and other digital tools to deliver recovery or harm reduction content to individuals identified on social media (Ashford et al., 2020; Cavazos-Rehg et al., 2020).

The use of non-fentanyl substances was the second most commonly occurring theme in posts (27%). Moreover, drug related subreddits constituted more than a quarter of the top 200 communities which r/fentanyl users also followed. These results indicate that many individuals who posted content on r/fentanyl may be at risk for, or engaged in, polysubstance use given their dual interest in fentanyl and other substances. While this is unsurprising given recent data on increasing prevalence of polysubstance misuse and risk of overdose attributable to polysubstance misuse nationwide (Cicero, Ellis, Kasper, 2020), our finding that individuals’ openly network about polysubstance use represents an untapped opportunity to disseminate information about the dangers associated with polysubstance use including increased severity of side effects, acute health problems, complications due to co-occurring mental health issues, and overdose (Andreas, Lauritzen, & Nordfjærn, 2015; Morley et al., 2015; Kline et al., 2021; Zuckermann et al., 2020). Moreover, this finding reinforces the importance of 1) screening for fentanyl misuse and misuse of other substances across a broad range of substance misuse treatment programs and 2) more efficacious treatment approaches for polysubstance misuse (Compton, Valentino, DuPont, 2021).

Posts indicating social comparison, regular or risky use, and posts asking others within the subreddit to help identify the type of fentanyl or substance they possessed by sharing pictures and describing the substance’s color, consistency, physiological/ psychological effects were also comparatively common (i.e. >5%). While identification details may have been shared in an effort to use substances more safely, online inquiry cannot confirm substance purity and may not mitigate risk of overdose (Krieger, Goedel, et al., 2018; Krieger, Yedinak, et al., 2018; McLean et al., 2019; Peiper et al., 2019). Alternative motivations for sharing images within posts may be related to social comparison, where individuals boasted about the amount of product they have in their possession, the amount they are able to ingest, or the rarity of analogues they were able to acquire. Social comparison has been observed in other substance use literature and can lead to increased misuse in order to gain social capital, outdo others, show prowess with substance misuse, or demonstrate tolerance (Kilwein et al., 2018; Villalonga-Olives & Kawachi, 2017). There is particular concern regarding these posting behaviors given the relative ease by which this content can be observed (i.e., no age restriction to enter subreddit), that observed posts may lead to increased misuse among those who view the content, and the high potency of fentanyl and risk for overdose (Poklis, 1995; Zoorob, 2019).

Though limited (i.e. <5%), some posts reflected personal experiences or the experiences of others within their social networks with overdose. Individuals who misuse fentanyl or other opioids commonly experience multiple overdoses across their lifetime and relapse from opioid use disorder treatment is common (Carroll et al., 2017). Our finding that individuals may network about their experiences with overdose represents a critical opportunity to re-engage individuals in safe, effective treatment for substance misuse (e.g., medication for opioid use disorder), link individuals to community resources that may prevent future risk of death due to overdose (e.g., Narcan distribution centers), or identify, track, and notify individuals if clusters of highly-potent illicit opioids enter a particular community through online platforms.

Though many individuals with OUD suffer from comorbid mental health disorders (Jones & McCance-Katz, 2019; Kelly & Daley, 2013), mental health communities composed only 4% of the top 200 subreddits that r/fentanyl users engaged with. Previous evaluations of substance use recovery subreddits have found that mental health comorbidities are frequently discussed within these platforms (D’Agostino et al., 2017; Sharma et al., 2017; Sowles, et al., 2017). This suggests that there may be an unmet need for mental health treatment resources among r/fentanyl members. Promoting or distributing mental health-related resources within online substance use communities, including r/fentanyl, may help increase access to mental health care for individuals with comorbid mental health and substance use disorders.

This study yielded a structured, qualitative analysis of posts and comments from an online community specifically centered around fentanyl. This unique approach granted us access to information and sentiment surrounding fentanyl misuse that may otherwise be inaccessible due to substance misuse-related stigma or illegality. Existing literature on other substance use or misuse discourse on Reddit has identified themes similar to those observed in our work. For example, in a study of 126,977 posts related to medical marijuana use among veterans, one of the most frequently occurring themes in posts was around use of other substances (i.e., polysubstance use; Rhidenour et al., 2022). Another study analyzing Reddit posts related to addiction and recovery identified three emergent themes closely related to ours: 1) personal sharing of one’s own struggle with recovery; 2) giving advice; and 3) getting advice (Valdez & Patterson, 2022). Additional work may be needed to explore how individual risk themes identified on Reddit are similar or dissimilar to population-level signals of fentanyl misuse risks on non-anonymous sites such as Facebook and Twitter using informatics and infoveillance approaches (Al-Rawi, 2019; Beletsky et al., 2020; Mackey et al., 2018; Paulose, Samy, & Jegatheesan, 2018). Broadly, our findings are consistent with previous literature and inform screening and prevention efforts by supporting the feasibility of leveraging information from social media to understand current trends of fentanyl misuse and risk factors at a population level. Further, individual-level risk indicators identified in this study can inform screening instruments for use in both online outreach to individuals not yet in treatment or those at various points of care (e.g., emergency departments, primary care, substance use treatment centers).

These results should be considered within the context of study limitations. First, we were unable to determine the demographic information of those who posted or commented on r/fentanyl and could not conclusively determine whether r/fentanyl users were individuals engaging in past or present fentanyl misuse, or merely had an interest in fentanyl. As such, we were unable to determine who (i.e., the demographic profile of) may be most at risk for fentanyl misuse or overdose. We were also unable to determine if any members of this community had created multiple anonymous accounts to engage with the subreddit. Second, due to data extraction methods utilized in the primary study, we were unable to reference the primary posts for comments analyzed, resulting in limited context and possible misinterpretation of comment purposes/themes. Third, the population of Reddit users is unlikely to be representative of the low-income communities and communities of color currently experiencing disproportionate increases in rates of overdose deaths (Kariisa, Davis, Kumar, et al. 2022). Thus, the findings reported in this study may not be generalizable to those most heavily impacted by the overdose crisis. Fourth, the codebook used for this study was informed by and developed specifically for use in identifying risk-behavior-related content on r/fentanyl using a random subset of posts/comments. As such, the identified themes and findings may not generalize to other opioid-related online communities. Finally, members of subreddits and other Reddit communities may engage with online content in both an active way by posting and commenting or in a passive way by viewing content and conversations. While previous literature has shown both negative (i.e., influencing cravings or relapse; Ashford, Lynch, & Curtis, 2018) and positive impacts (i.e., learning of harm reduction strategies, motivation for recovery/treatment; D’Agostino at al., 2017) of passively viewing online content related to substance use, the opinions and experiences of those who engaged with the r/fentanyl subreddit in this way were not reflected in the current study.

The results of this study demonstrate that users of the r/fentanyl subreddit often share information on their fentanyl and substance misuse broadly, and the personal effects or implications of fentanyl misuse which closely align with the DSM-V diagnostic criteria for opioid use disorder. Identification of functional impairments and polysubstance use as emergent themes in r/fentanyl posts and comments represents a critical unmet need for screening within the community, and presents an opportunity for online interventions that encourage substance use treatment readiness and uptake. Future studies could employ natural language processing and network structure analysis techniques to analyze substance use content on other social media platforms to identify Reddit users at potential risk of fentanyl misuse, overdose, or other adverse health outcomes; assist moderators in supporting the members of their online communities; inform proactive outreach efforts; and possibly deliver harm reduction information or recovery interventions. Such approaches should be developed with feedback from members of these communities to ensure any methods for risk detection promote individual safety and continued engagement with social networking among supportive communities while considering privacy and respect for where each individual is with regard to interest in treatment or recovery. While the current investigation provides a better understanding of the topics discussed in the r/fentanyl subreddit, future studies on social networking patterns across subreddits and between Reddit users are needed to determine how information and potential misinformation for misuse and/or recovery may spread on these platforms and impact risk of overdose and other adverse health outcomes.

Acknowledgements

We would like to acknowledge Vivian Agbonavbare and Nnenna Anako for their work to manually code posts and comments for this study.

Role of Funding Source

Funding for this work was provided by the National Institutes of Health (NIH) [Grant No: K02 DA043657 (Dr. Cavazos-Rehg) and Grant No: R01MH117172 (Dr. De Choudhury)], the National Institute on Minority Health and Health Disparities Research Training Program (MHRT) Grant No: T37 MD014218, and through a postdoctoral fellowship to Dr. Aledavood from the James S. McDonnell Foundation. No funding sources had any role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

Declaration of Interest

Patricia A. Cavazos-Rehg is a consultant for Rissana, LLC and PredictView.

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