Examining symptoms of stimulant misuse and community support among members of a recovery-oriented online community

Abstract

Misuse of prescription and non-prescription stimulants and related overdose deaths represent a growing public health crisis that warrants immediate intervention. We examined 100 posts and their respective comments from a public, recovery-oriented Reddit community in January 2021 to explore content related to DSM-V stimulant use disorder symptoms, access and barriers to recovery, and peer support. Using inductive and deductive methods, a codebook was developed with the following primary themes: 1) DSM-V Symptoms and Risk Factors, 2) Stigma/Shame, 3) Seeking Advice or Information, 4) Supportive or Unsupportive Comments. In 37% of posts community members reported taking high doses and engaging in prolonged misuse of stimulants. Nearly half of posts in the sample (46%) were seeking advice for recovery, but 42% noted fear of withdrawal symptoms or a loss of productivity (18%) as barriers to abstinence or a reduction in their use. Concerns related to stigma, shame, hiding use from others (30%), and comorbid mental health conditions (34%) were also noted. Social media content analysis allows for insight into information about lived experiences of individuals struggling with substance use disorders. Future online interventions should address recovery barriers related to stigma and shame as well as fears associated with the physical and psychological impact of quitting stimulant misuse.

Introduction

Stimulant misuse, including misuse of prescription stimulants and non-prescription stimulants, is a growing concern in the United States (U.S.), with dramatic increases in stimulant drug overdoses in the last decade (Weyandt et al. 2016, Chen et al. 2016, Hadland and Marshall 2021, Han et al. 2021). From April 2019 to April 2021 alone, stimulant overdose deaths in the preceding 12 months nearly doubled from approximately 14,000 to just under 28,000 deaths (CDC 2022). Stimulants are a class of psychoactive drugs that can provide the user with euphoric effects, alertness, and energy (NIDA 2018b). Commonly misused stimulants include cocaine, methamphetamine (i.e., crank, speed, crystal meth), 3,4-methylenedioxy-methamphetamine (i.e., MDMA, molly, ecstasy), and prescription stimulants such as amphetamine/dextroamphetamine and methylphenidate (i.e., Adderall and Ritalin). Though stimulant medications can be effective in treating conditions such as attention-deficit/hyperactivity disorder (ADHD) and narcolepsy (Charach, Ickowicz, and Schachar 2004, Thorpy 2007), misuse can lead to adverse health effects such as psychosis, seizures, cardiovascular events, and induced schizophrenic-like states (Lakhan and Kirchgessner 2012, Francis et al. 2021). In 2018, more than 1.6 million U.S. adults reported misusing methamphetamine and nearly 493,500 reported misusing cocaine within the prior 12 months (Jones, Compton, and Mustaquim 2020). More than half of these individuals reported a stimulant use disorder (Jones, Compton, and Mustaquim 2020).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) outlines eleven criteria for stimulant use disorder related to impaired control over use, social problems, risky use, and physical dependence (APA 2013). Behavioral patterns associated with stimulant use disorder include exhibiting excessive energy or motivation, aggressive outbursts, and risky or impulsive behaviors (SAMHSA 2020). Physical symptoms common during stimulant use or withdrawal from stimulants include changes in appetite, twitches or jitteriness, rapid heartbeat, elevated blood pressure, weight loss, hair loss, sweating, and skin problems (SAMHSA 2020). Mental health comorbidities such as depression, anxiety, and bipolar disorder are also commonly reported among individuals with stimulant use disorder (Quello, Brady, and Sonne 2005, Warden et al. 2016, Sara et al. 2012). Specifically, those who misuse stimulants are more likely to report psychological distress and internal restlessness (Weyandt et al. 2009, Verdi, Weyandt, and Zavras 2016) and other illicit drug use (Timko et al. 2018, Novak et al. 2016).

With stimulant misuse on the rise across the U.S., and a high reported prevalence of use among young people specifically, more nuanced insights into the drivers and consequences of the stimulant use epidemic are needed. Social media content from platforms such as Reddit, Twitter, or Facebook can provide an important window into mental health and substance misuse recovery communities (Naslund et al. 2016, Sowles et al. 2017). These sources can be particularly illuminating as the support and anonymity provided through use of these platforms may encourage individuals to share their personal stories and struggles related to their behaviors with less fear of stigma or judgement (De Choudhury and De 2014). In the past, social media content from a variety of platforms has been used to garner information among those who misuse stimulants that may have been difficult to ascertain otherwise (Ellway et al. 2019, Kazemi et al. 2017). For example, social media data have been harnessed to monitor prescription medication misuse and identify at-risk individuals, characterize online support networks among those in stimulant misuse recovery (Sarker et al. 2016, Ellway et al. 2019), and understand motivations for stimulant misuse and the side effects resulting from stimulant misuse (Kim et al. 2020, Chen et al. 2018, Hanson et al. 2013).

While studies have explored recovery-related social networking among those who misuse substances (e.g., alcohol, marijuana, opioids) on Reddit (Gauthier, Costello, and Wallace 2022, Lu et al. 2019, Kepner, Meacham, and Nobles 2022, Sowles et al. 2017), no known studies have examined online content using the eleven DSM-V stimulant use disorder (SUD) criteria as a guide for assessing SUD risk and characterizing SUD symptoms or themes related to recovery among stimulant recovery-focused community. Further, limited investigations have centered on recovery-focused platforms (Lu et al. 2019), specifically. Additional research is needed to identify what supports are available and accessed within these communities recovering from stimulant misuse. The current study leverages publicly available, user-generated content from a recovery-oriented Reddit community to examine DSM-V stimulant use disorder symptoms, associated risks and functional impacts, as well as types of support shared among users in this community.

Methods

During January 2021, 100 posts and their respective comments were manually pulled from the stimulant recovery focused community r/QuitStims (community name changed to protect user anonymity). Reddit is a pseudonymous social media platform comprised of communities of members networking around a central topic, known as subreddits. Subreddit members can socially network by submitting posts, commenting on others’ posts, and up-voting and down-voting posts. Previous literature has found that engaging with these communities in an anonymous way may empower members to discuss stigmatized topics, including substance misuse (Robinson et al. 2019, De Choudhury et al. 2016, Garg et al. 2021, Cavazos-Rehg et al. 2019). At the time of data collection this community was comprised of 16,000 members seeking and sharing advice for quitting stimulants. These subreddit members included individuals in stimulant use recovery as well as friends and family members of individuals in recovery. Posts were collected from the community’s home page after being filtered based on Reddit’s “Top” sorting algorithm, a method of sorting based on the number of upvotes a post receives within a given time frame. This approach to data sampling and collection has been used in previous content analysis studies on Reddit, and sample sizes of approximately 100 “top” posts and associated comments (e.g., discussion threads) have been found to be representative of main topics of discussion within these communities (Sowles et al. 2017, Lea, Amada, and Jungaberle 2020, Slemon et al. 2021). Due to content on this subreddit being publicly available, Washington University Institutional Review Board (IRB) determined that this study was exempt from institutional review.

Through inductive and deductive methods, a qualitative codebook was developed and refined to analyze post content. First, using an inductive approach to identify topics discussed among members of r/QuitStims, a small subset of posts (n=20) from this subreddit were reviewed to identify primary themes. Second, using a deductive approach, current literature on individuals misusing stimulants and those in substance use recovery was reviewed to confirm these emergent themes and to incorporate themes relevant to assessing risk and protective factors among this population. Using this approach allowed us to create both a tailored and comprehensive codebook for analysis of this subreddit, and similar procedures have been used in previous content analyses on data from Reddit (Brett et al. 2019, Sowles et al. 2018, Pestana, Beccaria, and Petrilli 2021). After these codebook development steps, the following primary themes were established: 1) DSM-V symptoms and risk, 2) Stigma and shame, 3) Advice or information sharing/seeking.

Theme 1: DSM-V symptoms and risk encompassed any posts demonstrating specific DSM-V symptoms or potential risk factors for developing a DSM-V substance use disorder (e.g., poly-substance use, mental health co-morbidities, persistent barriers to or fears regarding recovery). Sub-codes under Theme 1included eleven specific DSM-V substance use disorder symptoms (i.e., including dependence, high dose/prolonged use, functional impairment resulting from use, withdrawal, cravings, self-medication, frequent use, relationship impairments, loss of meaningful activities, overdose, and stimulant tolerance), mental health comorbidities ( i.e., depression, ADHD, and anxiety), polysubstance use ( i.e., use of alcohol, marijuana, tobacco, opioids, and other prescription drugs), and fears/consequences regarding stimulant use cessation (i.e., feelings of emptiness, loss of productivity, changes in weight). Theme 2: Stigma/shame encompassed any posts that reflected (internally or externally motivated) feelings of stigma or shame in relation to one’s stimulant misuse. Theme 3: Advice or information sharing/seeking encompassed any posts that reflected advice or information sharing or seeking with subcodes indicating if this advice or review was meant to support recovery from stimulant misuse. In addition to these primary themes, two secondary codes were also integrated to reflect whether a post referred to one’s own stimulant misuse or the stimulant misuse of another individual (e.g., friend or family member) and the specific stimulant misused (i.e., prescription stimulants, crack/cocaine, MDMA, methamphetamine).

Two independent coders (KD, AD) reviewed posts in batches of 25–35 and assigned primary themes and secondary codes. Primary themes were not mutually exclusive and subcodes were only assigned to a post if applicable (i.e., posts that did not have enough information or specificity to be categorized under a subcode were only assigned a primary theme). Themes assigned by the two independent coders for all of the primary posts demonstrated sufficient agreement with an average Kappa of 0.67. A third coder (EK) resolved all coding discrepancies and finalized master codes for each post. These master codes were used to provide frequency counts for each of the primary themes and secondary codes within the codebook.

We also coded all comments associated with primary posts indicating the secondary code of referring to one’s own stimulant misuse (n = 490). A unique comment codebook was developed based on comment content, with exclusive codes for: 1) Supportive/positive comments, 2) Unsupportive/negative comments, and 3) General/neutral comments. Supportive/positive comments were further sub-coded to reflect content related to sharing personal experiences, offering advice, installations of hope, or validation of experiences or feelings. The process of finalizing codebook frequencies for comments was similar to that utilized in primary post analysis where two independent coders reviewed the set of comments and a third expert coder resolved any discrepancies.

Results

The original dataset contained 100 posts. One post was omitted because it was a duplicate. Among the 99 included posts, a majority (n = 87; 87.9%) mentioned one’s own use while under 10% mentioned someone else’s use (n = 8; 8.1%). The most cited stimulant used was prescription stimulants such as Adderall, Ritalin, and Vyvanse (n = 50 posts; 50%). Over a quarter of posts indicated meth misuse (i.e., use of non-prescription methamphetamine; n = 28 28%), while just 9 posts (9%) indicated misuse of cocaine/crack, and 4 (4%) indicated misuse of MDMA. A total of 87 posts (87%) included Theme 1: DSM-V symptoms and risk content, 34 posts (34%) included Theme 2: Stigma/shame content, and 30 posts (30.3%) included Theme 3: Advice or information sharing/seeking content. Most posts (n = 56; 56%) included content representing at least two of the three themes explored (Table 1).

Table 1.

Sample Post Characteristics (N=99)

	N (%)
Relationship with stimulant user
Self	87 (87.9)
Non-self (e.g., friend)	8 (8.1)
Specific stimulant misused
Prescription Stimulants (Adderall, Ritalin, etc.)	50 (50.5)
Cocaine / Crack	9 (9.1)
Meth	28 (28.3)
MDMA	4 (4.0)
Number of Primary Themes Per Post
0	2 (2.0)
1	15 (15.2)
2	64 (64.6)
3	18 (18.2)
Number of Comments
Below 5	28 (28.3)
6 to 10	29 (29.3)
11 to 15	19 (19.2)
16 or more	23 (23.2)
Number of Upvotes
Below 5	37 (37.4)
6 to 10	19 (19.2)
11 to 15	13 (13.1)
16 to 20	4 (4.0)
21 or more	26 (26.3)
DSM-V Symptom Severity
N/A (0–1 symptoms)	35 (35.4)
Mild (2–3 symptoms)	29 (29.3)
Moderate (4–5 symptoms)	19 (19.2)
Severe (6 >= symptoms)	16 (16.2)

Theme 1: DSM-V symptoms and risk

Broadly, posts demonstrating multiple DSM-V symptoms were common. For example, one individual posted “I’m grateful to state I’ve sober for five weeks, cold turkey off of both. The first couple weeks were absolutely awful – dozing off to sleep, relentless brain zaps, ZERO motivation, etc.” More specifically, a total of 35 (35%) posts mentioned one or fewer of the DSM-V stimulant use disorder symptoms explored, 29 (29%) mentioned two to three symptoms, 19 (20%) mentioned four to five symptoms, and 16 (16.2%) mentioned six or more symptoms, representing no, mild, moderate, and severe substance use disorder symptomatology, respectively. Losing control over use or feeling dependent on stimulants was mentioned in 45 (51%) posts. For example, one user stated “I swore to myself to use dex only for school because it helped my productivity when completing assignments, but my body suffered and I became dependent.” Over one-third of posts (n = 37) reported prolonged use or high dosages. Of these, 78% (n = 29) specifically indicated using a stimulant for a prolonged period of time while 45% (n = 17) described taking high dosages. Functional impairments (n = 34; 39%) and symptoms of withdrawal (n = 37; 33%) were also disclosed in more than a third of posts. Descriptions of cravings or urges to use stimulants were identified in 31 (35%) posts while physical tolerance to stimulants was mentioned in 7 (8%) posts.

Mental health comorbidities were indicated in approximately one-third of posts (n = 34; 34%) (Table 2). Of these 34 posts, 58% (n = 20) reported symptoms of depression and 7% (n = 7) mentioned symptoms of anxiety (Table 2). Some individuals reported symptoms of multiple mental health disorders. For example, one user posted, “I tried only talk therapy when I first started counseling, but I was still suffering from MDD, anxiety and ADHD after a couple months of this.” Polysubstance use was also indicated in nearly one third of posts (n = 32; 32%) (Table 2). Of these posts, 14 (43%) reported alcohol use, 12 (37%) reported the misuse of prescription medications such as benzodiazepines, ketamine, selective serotonin reuptake inhibitors (SSRIs), and mood stabilizers, and 9 (28%) reported marijuana use (Table 2). Finally, expressions of fear or consequences from quitting stimulants (i.e. physical withdrawal, functional impairments) were mentioned in 42 posts (42%) (Table 2). Of these posts, 18 (43%) expressed fear of productivity loss or declines in cognitive performance and 14 (33%) expressed fears of feeling hollow/empty while quitting (Table 2). Again, many users expressed multiple fears. For example, one user posted, “Slowly tapered off the drug for several weeks. I was sleeping, eating, gained 25lbs, and flipped between anger, rage, sadness and lethargy. I was a useless slug.”

Table 2.

Theme 1: DSMV Symptoms and risk factors content (N=99 posts)

Theme/Feature		Participant Quotations
	N (%)
Theme 1.1: MENTIONS DSM-V SYMPTOMS	87 (87%)
Loss of Control Over Use / Dependence	45 (51.7%) b	I swore to myself to use dex only for school because it helped my productivity when completing assignments, but my body suffered and I became dependent. I’m aware that I am physically dependent on Vyvanse.
High Dose / Prolonged Use	37 (42.5%)	I have been using for the past seven months I was coming down from a 300 mg Vyvanse binge I was 25 when I first started using now I’m 31. It’s been six years.
Prolonged use	29 (78.4%) c	I used dex for 5 years and cymbalta for 1 year I am long term user over the past four years, with two years using Adderall and Ritalin (buying from other students) every day to pass classes. The next two years I was binging cocaine at day parties. I was addicted to Adderall for more than ten years
High dose	17 (45.9%)	I usually take from 50mg to 80mg every day. I am currently using anywhere from 60mg up to 80mg for several days straight. I do this about every month.
Functional Impairments	34 (39%)	I’ve been suffering from bad brain fog, forgetfulness and strange inability to remember random celebrities’ names and other things (I understand it’s trivial but still messes with my head). I am constantly tired during the day. It does not matter how much sleep I get. Right now it is impacting my job so much and I have no idea what I should do.
Withdrawal / Withdrawal Management	33 (37.9%)	I’m grateful to state I’ve sober for five weeks, cold turkey off of both. The first couple weeks were absolutely awful – dozing off to sleep, relentless brain zaps, ZERO motivation, etc. I’m experiencing cold sweats, anxiousness, fatigue, and irritability and it’s not even 24 hours in. I’ve had adderall withdrawals for the past five days
Cravings / Urges	31 (35.6%)	I yearn to take those little orange footballs I’ve been noticing cravings lately but they’re manageable
Associations with Mental Health	23 (26.4%)	I probably won’t end my own life, because I don’t have the stones. But I hope the speed pushes me to go through with it. I don’t deserve to live anymore. Everything was managable and within reach once I took you, until one day, you were the only thing I could think about, you ruined my future and you destroyed my mental health
Detriment to Mental Health	15 (65.2%)	I took my sixth Focalin 20mg XR in a 10 hour span, and I finally realized I’ve been abusing my prescription for the past year not solely because I was addicted, but as a way of self-harm. It took me a while to realize it was pure addiction driving me and that the medication was actually harming my health and social life.
Improvements to Cognition/Mental Health	12 (52.2%)	I used adderall IR many times recreationally, and had a blast being hyperfocused on all of my duties. It started how it usually does; my friend offered me speed to help me study. I could not believe at how well it worked and how much more I was able to do on adderall
Daily / Frequent Use	23 (26.4%)	I’ve tried to refrain from full-on crazy binges, but I have been taking daily I was never on that high of a dose, but I took it every single day from the ages of 16 to 23...
Relationship Impairments	22 (25.2%)	I am so disappointed with myself, prioritizing drugs over checking on my mom after she was hospitalized. Without thinking twice, I was using amphetamine and then being unable to look my dad in the eyes. My last memory of her I was high, and while I’m high I am usually rude and abrupt I noticed I rarely made conversation with any of my coworkers because I was high on addy when they stopped by my cubicle, I didn’t get any text messages from anyone all day, and if it’s a Friday, that I have no one to be with for the weekend.
Loss of Meaningful Activities	16 (18.3%)	I am constantly lacking energy and my motivation is at an all-time low. Life is so dull. I don’t get how most people can possibly work their 9 to 5 jobs without being on something.
Overdose / Infection / Side-Effects	8 (9.2%)	I have weekly sudden nose bleeding, sometimes on back-to-back days. Did/does anybody ever briefly twitch when hearing static noises or viewing subtle peripheral movements while recovering. I didn’t have this before and it has kinda been freaking me out
Tolerance	7 (8%)	at this point, taking pills twice daily will feel like nothing compared to where my tolerance is currently I was recreationally using on and off for a couple years I found myself taking higher doses and more frequently until I was using nearly every single day
THEME 1.2: MENTIONS MENTAL HEALTH COMORBIDITIES	34(34%)	I tried only talk therapy when I first started counseling, but I was still suffering from MDD, anxiety and adhd after a couple months of this My addiction to prescription stimulants was actually a by product of my bipolar disorder. I had no clue. When I began getting treatment for my bipolar depression, I no longer felt the desire to use My depression will not leave me
Depression	20 (58%)	I’m suffering from horrible depression. Feel like I have more control over my life but I’m still so depressed. I’m so close to completely giving up. Possibly killing myself but those are more just temporary thoughts. I have been getting high and trying to hide it at my parent’s house, I feel horrible
ADHD	11 (32%)	I am severely ADHD I know without adderall I still will have ADHD and it will be difficult to do normal every day tasks but I’ll take that over being emotionally tied to a fucking pill.
Anxiety	7 (7%)	Work has been getting busier and it’s causing nothing but anxiety. I have maximum anxiety. The last time this happened I refilled my prescription after a little less than three weeks because I could not stand the depression and anxiety.
THEME 1.3: POLY-SUBSTANCE USE	32 (32%)	I’m not sure what happened, but I was so stressed out which led to me getting some benzos. Along with quitting stimulants stopped taking benzos after using for more than five years, which I misused every Adderall comedown, so everyday
Alcohol	14 (43%)	I keep drinking during the day and afternoon along with using meth. I recently started taking stimulants (past 2 or 3 years) but I used alcohol as my original mood stabilizer and kept using it while I was recovering but alcohol isn’t medicine.
Non-stimulant prescriptions (e.g., Benzos, Ketamine, etc.)	12 (37%)	I had a severe adderall addiction which grew into a benzo addiction as a result.. I planned getting there at 5am but popped a benzo at 4pm yesterday thinking it’ll put me to sleep and wake me up at 4am. Guess again. Woke up at 8am to a million missed calls and messages.
Marijuana	9 (28%)	I’ve noticed a cycle. Either I’m addicted to meth, pot, or social media. I don’t really have a period in-between where I am not using one of these and I’m not sure how to break this patter. After smoking ganja, I usually eat until I puke. I was clean from amphetamines for over two months, but I smoked marijuana yesterday.
Tobacco	5 (15%)	Parked in my driveway for a half-hour smoking cigarettes one after another. My psych initially wrote a script for wellbutrin to help with the ADHD and depression. I am still taking it because it helped me quit cigarettes once and for all Not only am I concerned for his general well-being, as this leads to other habits such as smoking cigarettes, fasting all day, and poor sleep schedules. Also he is acting increasingly irritated and lazy.
Opioids	3 (9%)	he was shooting up heroin for more than 7 years. he stopped for a few years but didn’t get off meth. I mostly use meth, but i am addicted to heroin and other street drugs as well.
THEME 1.4: Experienced or Feared Consequences after Quitting Stimulants	42 (42%)	Can anyone please inform me what the benefits of stopping Adderall are? My script was cut off and I have been waning, I’ll have none left soon and I am terrified. However, I want to be a normal person and not limit my success. In my opinion the pros of staying on adderall are greater the cons so I have not stopped using recently..
“Hollow/empty feeling” or dopamine crash	14 (33.3%)	I have absolutely no energy… I have never experienced such an absence of motivation At this time, even though I’m in outpatient therapy most weekdays and a meeting every day, I just feel so emotionally empty. In terms of getting things done, I could do anything I needed to but I felt empty and a little numb
Productivity loss/declining performance	18 (42.9%)	The stakes in my life kept rising to the point where the thought of stopping use seemed more and more unrealistic, even though the meds seemed to get less effective for me. Adderall certainly helps me keep working. I’m nearly 3 weeks off of adderall. And I am not sure that I will be able to stop refilling my script after this year. Since using vyvanse I have gotten a college degree and other accomplishments that i truly attribute to this drug, but I’m using my entire prescription in a third of the time it’s supposed to last me, I am scared that I will regress if I stop using but I know that I cannot sustain this lifestyle for my health
Eating/weight changes	8 (19.0%)	Slowly tapered off the drug for several weeks. I was sleeping, eating, gained 25lbs, and flipped between anger, rage, sadness and lethargy. I was a useless slug. I’ve gained so much weight and have been feeling depressed almost every day.

Note: Subcodes within a parent code are not mutually exclusive, total subcode percentage sum may be less than or equal to 100% due to overlap or posts not having applicable subcodes

^aPercentages for primary codes are out of total 99 post sample

Theme 2: Stigma/Judgement

Stigma surrounding misuse of stimulants and perceived judgement related to use and relapse was mentioned in 30 posts (30.3%) (Table 3). Some users specifically expressed self-stigma/judgement, with one individual commenting, “Relapsed again last weekend and I cannot shake the guilt and regret.” Others articulated external stigma/judgment with one user stating “I have horrified my mother all because I wanted to go faster”.

Table 3.

Theme 2: Stigma/Shame content (N=30 posts)

Theme/Feature		Participant Quotations
	N (%)
STIGMA/SHAME IN RELATION TO USE / RELAPSE	30 (30.3%) a	I’m ashamed to admit I’ve been abusing my script so much that I’m completely out within a week. while my gf knows the how much i use, i mask how ashamed i am about it and it’s torturing me. I feel like a poor man who can’t live life out without abusing substances. Relapsed again last weekend and I cannot shake the guilt and regret

Note: Subcodes within a parent code are not mutually exclusive, total subcode percentage sum may be less than or equal to 100% due to overlap or posts not having applicable subcodes

^aPercentages for primary codes are out of total 99 post sample

Theme 3: Seeking/Sharing Advice

Of the 56 posts (56.5%) containing Theme 3 content (Table 4), 56 posts (100%) were seeking advice/information while 18 posts (32%) provided a review of products or advice. Of the 56 posts seeking advice/information, a majority (n = 46, 83.4%) were specifically seeking recovery advice. For example, one user posted, “I have spare dopa mucuna because I never took it. Would this elevate my energy? Or is it counterproductive to my withdrawal and recovery?” Of the 18 posts reviewing products or providing advice, 15 (83.3%) were specifically providing recovery advice. For example, one user posted, “Recovery isn’t linear all the time, and that’s alright.”

Table 4.

Theme 3: Advice or information sharing/seeking content in primary post (N=56 posts)

Theme/Feature		Participant Quotations
	N (%)
SEEKING ADVICE / INFORMATION	56 (56%)	I’m noticing rash / scabs on my face for the first time. Does anyone know when this should clear up? So, who here has tried Strattera before? What was your experience? Any advice for how to stay on track when reading after quitting stimulants?
Seeking Advice for Recovery	46 (83.4%) b	Does anyone know of a healthy way to cope with the increased appetite? I have spare dopa mucuna because I never took it. Would this elevate my energy? Or is it counterproductive to my withdrawal and recovery? What are some of the positives and negatives to quitting Adderall completely vs tapering off?
REVIEWING PRODUCT / PROVIDING ADVICE	18 (18%)	Though this may sound like an advertisement, I began Noom 10 days ago and it has completely changed my eating habits. To anyone looking for help: my advice is to investigate your mental well being and at what is causing you to turn to drugs. It’s not always what you’d first expect. Good luck.
Advice for Recovery	15 (83.3%)	I’ve been feeling so much better lately! It has been ten days since my last use. Getting a treadmill was an incredible investment Today marks 40 days without use. I’ve gotten this far three time and I’d like to share that I’ve been meditating before work and it has unbelievable effects! Recovery isn’t linear all the time, but that’s alright.

Note: Subcodes within a parent code are not mutually exclusive, total subcode percentage sum may be less than or equal to 100% due to overlap or posts not having applicable subcodes

^aPercentages for subcodes are out of total 99 post sample

^bPercentages are out of primary code “Seeking Advice/Information”

Of the 490 comments analyzed (Table 5), 371 (71%) were supportive/positive, such as “What you’re feeling gradually gets better, but I know during the first couple months it seems to intensify, you are in the same boat as the rest of us I believe me!”, with 54% of positive comments (n = 170) specifically sharing personal experiences, 48.5% (n = 154) offering advice, 31.9% (n = 101) instilling hope, and 22.1% or (n = 70) validating experiences or feelings. Twenty-one comments (4.3%) were negative/unsupportive, such as “Will you just f*** off,” and 101 (20.6%) were neutral/general, such as “I smoke weed very rarely.” Forty-nine comments were auto-generated moderator comments.

Table 5.

Themes identified in comments to primary post (N=490 comments)

Theme/Feature		Participant Quotations
	N (%)
MODERATOR AUTO POST	49 (10%)	If you would like to talk to someone, we are on Discord would love for you to join us. This is an automated comment. Please reach out to the subreddit’s moderators if you have any questions or concerns.
1. SUPPORTIVE / POSITIVE	317 (64.7%)	I believe in you!! Stay strong!! I know that it’s incredibly hard but don’t give up! Hugs to you and keep moving onward. I swear you’ll feel better, I know it can be so challenging at first. I may seem like no light is at the end of the tunnel but take my word that there is!! Hang in, friend.
Sharing Personal Experiences	170 (54%)	I stopped taking Vyvanse for my ADHD two decades ago and have been coming here every day for a few years hearing everyone’s stories and trying to educate myself. I was abusing my adderall for most of last year- a script that is supposed to last me a month would barely last me two weeks.
Offering Advice	154 (48.5%)	You may want to talk to your doctor about trying a non-stimulant (i.e., Wellbutrin or Strattera). Things won’t return to normal overnight. This process takes time, and honestly that’s the only completely accurate advice I can offer. Coffee helps too. To aide with procrastination, I write lists breaking up tasks into 30 min segments so all I have to do is start with task number one.
Instillation of Hope	101 (31.9%)	I am sending you many hugs, good vibes, and love. You can do this! It will take time, but you’ll feel so much better when it’s all over! Your energy will return to normal. You will regain your motivation. You’ll feel happy again. Stay strong!
Validation of experience or feelings)	70 (22.1%) b	What you’re feeling gradually gets better, but I know during the first couple months it seems to intensify, you are in the same boat as the rest of us believe me! You are still recovering so I’m not shocked you’re feeling blah! Most likely it’ll take a couple months before you start to feel normal again - so hold on a little longer. We see this here ALL THE TIME So many of us have that experience where we are diagnosed with a condition and treated with medication and no longer feel like the screw-up that we’ve been our entire lives.
2. UNSUPPORTIVE/NEGATIVE	21 (4.3%)	Will you just f*** off. This is awesome, I wish my science teacher did meth like you I said what I said. Maybe it would help you best if you just grew a pair?
3. GENERAL/NEUTRAL	101 (20.6%)	Nice. I think that my addicted mind is still guilty about everything. Though alcohol is a drug, I don’t care for it that much. I’m not really worried about becoming addicted. I have the same attitude with LSD
Question	34 (33.7%)	Would taking it in water have the same detrimental effects on the body? Have you started picking scabs off your flesh or is this a skin reaction to merely consuming speed? How much were you taking every day? Just curious. Are you finding time to get in exercise every day? What about your diet?

Note: Subcodes within a parent code are not mutually exclusive, total subcode percentage sum may be less than or equal to 100% due to overlap or posts not having applicable subcodes (remaining in the parent code)

^aPercentages for subcodes are out of total 150 post sample

^bPercentages for subcodes are out of parent code “Supportive/Positive”

Discussion

With approximately 10 million people over the age of 12 with a stimulant use disorder in the U.S. (Bolívar et al. 2021), a high frequency of polysubstance use, and rising risk of overdose nationally (O’Donnell et al. 2017), stimulant misuse behaviors are a rapidly mounting public health crisis. Online discussion boards related to stimulant misuse or dependence can act as an anonymous means of seeking support for those contemplating or actively in recovery. The current study leveraged publicly available social media data from a stimulant-recovery focused subreddit to examine stimulant misuse habits, symptoms and risk of developing diagnosable DSM-V stimulant use disorders, and recovery efforts of community members.

Of the 100 posts reviewed, nearly two-thirds (65%) demonstrated two or more symptoms of a DSM-V substance use disorder and over one-third (35%) indicated four or more symptoms. The two most commonly reported symptoms were taking a high dose and engaging in prolonged use. These characteristics can often lead to stimulant dependence or heightened tolerance and pose substantial challenges for achieving sustained recovery (Parrott 2015, Parrott, Hayley, and Downey 2017). Consistent with findings from other studies, functional impairments characteristic of substance use disorders (e.g., lack of educational attainment, employment, limited social or life skills) were also commonly discussed (34% of posts) (Carlon, Peters, and Villarosa-Hurlocker 2022, Cole and Hussong 2020). Broadly, these findings suggest that members of this Reddit community of are at risk for poor health outcomes (e.g., overdose) and adverse effects related to substance misuse, and that this group may benefit from recovery-focused online resources or interventions.

Mental health support is likely an important component of recovery-focused interventions for this community as over one-third of comments reported symptoms of depression. Moreover, several individuals reported fears or experiences of feeling hollow or empty while in recovery which may be related to drops in dopamine levels often experienced during stimulant withdrawal (Parrott 2015). Current literature demonstrates similar associations between stimulant misuse and depression, or related adverse mental health outcomes (e.g., suicidal ideation, bipolar depressive episodes) (Leventhal et al. 2010, Jha et al. 2021, Carlson, Merlock, and Suppes 2004, Green 2019).

Though many posts expressed a desire to recover, fear of withdrawal symptoms or loss of productivity by quitting or reducing stimulant misuse was commonly endorsed. Approximately 42% of posts expressed at least one experienced or feared consequence of quitting stimulants including physiological and functional consequences. These fears likely serve as a significant barrier to substance misuse treatment seeking and should be directly addressed by programs aimed at promoting treatment readiness or supporting stimulant misuse recovery. Moreover, treatment programs should be specifically tailored to the individual given the diverse barriers to recovery experienced and the differences in substance misuse patterns or co-occurring risks.

Prescription stimulants were the most frequently mentioned stimulant misused at 50% followed by meth (28%) and crack/cocaine (9%). In the U.S., 16 million people are prescribed stimulants with 5 million having misused prescriptions at least once and 400 thousand people suffering from prescription stimulant use disorder (NIDA 2018a). Recovery from prescription stimulant misuse may be particularly challenging as individuals often have consistent access to stimulant medications over time, which may lead to the establishment of tolerance and decrease the likelihood of disclosing one’s misuse behaviors to health care providers (Compton et al. 2018). For those reporting misuse of other stimulants (e.g., meth, crack/cocaine), there is an increasing risk of stimulant impurities (i.e., substances may be laced with other drugs such as fentanyl or heroin) which can heighten the risk of overdose, and other consequences of substance misuse more broadly (LaRue et al. 2019).

Over half of all posts sought support or information, with many specifically seeking recovery support. While this is unsurprising given data were drawn from a recovery-focused subreddit, it represents a unique opportunity to fill an unmet need for individuals attempting recovery from stimulants. Qualitative analysis of comments indicated that support sought and received was both emotional (e.g., supporting and validating others experiences and feelings) and informational (i.e., providing information or advice for recovery), similar to findings among other Reddit communities for recovery from cannabis and opioid misuse (D’Agostino et al. 2017, Sowles et al. 2017). Online platforms such as Reddit have been found to be helpful for individuals recovering from substance misuse, as these platforms allow for anonymity and reduce fears of judgement. Anonymity may be particularly pertinent to the utility of online recovery support platforms, as stigma was commonly expressed in this sample of community posts. In addition to external stigma, self-stigma (i.e., judging one’s own use and inability to cease misuse) was common. Reports of self-stigma and perceived or actual social consequences of disclosing misuse render online communities a critical outlet for this population (Miller 2020, Green et al. 2021). Importantly, the sharing of dosages, withdrawal symptoms, and non-regulated advice may perpetuate misinformation about stimulant misuse recovery or trigger relapse. These risks should be considered during the development of any online-based recovery tools which include networking components.

Study limitations include the anonymous nature of Reddit users, limiting our ability to determine who (i.e., demographic characteristics of users) posted the content analyzed. However, previous literature has demonstrated that most Reddit users are young, educated, white males (Statista 2021). As such, study results likely highlight the views of a select group of individuals and may not be generalizable to the population of individuals who misuse stimulants more broadly. In addition, we analyzed 100 of the most popular posts using the “Top” filter in the r/Quitstims subreddit. This method of data abstraction omitted older posts and those with fewer user interactions. As such, less popular content may not be represented in our codebook or results. Finally, because we gathered data from a single subreddit, we cannot make any conclusions concerning stimulant recovery themes for the entire platform.

Few studies have examined stimulant misuse recovery-related content within online communities to elucidate emerging stimulant misuse recovery themes and the type of support provided or received within these groups. Our findings have significant implications for substance misuse recovery practitioners and online substance-misuse community moderators. Specifically, many individuals networking about stimulant misuse recovery online may have DSM-V diagnosable substance use disorders. As such, there is an unmet need for the development and delivery of evidence-based online substance misuse recovery interventions for those who may not feel comfortable seeking traditional in-person substance use recovery care. Importantly, such online interventions should directly address stimulant misuse related stigma and shame as well as fears regarding the physical and psychological effects of quitting stimulants.