I Took .2 Suboxone Fikm When Can I Feel Percocet Again
Am J Aficionado. Author manuscript; available in PMC 2016 Aug i.
Published in concluding edited form equally:
PMCID: PMC4527156
NIHMSID: NIHMS709848
"Sub is a weird drug:" A Spider web-based report of lay attitudes about apply of buprenorphine to self-treat opioid withdrawal symptoms
Raminta Daniulaityte
1Center for Interventions, Handling, and Addictions Research (CITAR) Department of Community Wellness, Boonshoft School of Medicine, Wright Country University
Robert Carlson
iCenter for Interventions, Treatment, and Addictions Research (CITAR) Department of Customs Health, Boonshoft School of Medicine, Wright State University
Gregory Brigham
2ADAPT, Roseburg, OR; University of Cincinnati, Department of Psychiatry
Delroy Cameron
3Ohio Centre of Excellence in Knowledge-enabled Computing (Kno.e.sis), Wright Land University: http://knoesis.org
Amit Sheth
3Ohio Eye of Excellence in Knowledge-enabled Computing (Kno.e.sister), Wright State University: http://knoesis.org
Abstract
Background
Illicit employ of buprenorphine has increased in the U.S., simply our understanding of its employ remains limited. This written report aims to explore Spider web-forum discussions nearly the utilize of buprenorphine to cocky-treat opioid withdrawal symptoms.
Methods
PREDOSE, a novel Semantic Web platform, was used to excerpt relevant posts from a Web-forum that allows free discussions on illicit drugs. Offset, we excerpt information about the full number of buprenorphine-related posts per year between 2005 and 2013. 2nd, PREDOSE was used to identify all posts that potentially contained discussions about buprenorphine and opioid withdrawal. A total number of 1,217 posts that contained these terms were extracted and entered into NVivo data base of operations. A random sample of 404 (33%) posts was selected and content analyzed.
Results
Buprenorphine-related posts increased over time, peaking in 2011. The posts were near equally divided between those that expressed positive and negative views almost the effectiveness of buprenorphine in relieving withdrawal symptoms. Web-forum participants emphasized that buprenorphine's effectiveness may become compromised because of the "size of a person habit," and/or when users repeatedly switch back and forth betwixt buprenorphine and other illicit opioids. Most posts reported apply of significantly lower amounts of buprenorphine ( 2 mg) than doses used in standard treatment. Concomitant use of other psychoactive substances was also commonly reported, which may present meaning health risks.
Conclusions
Our findings highlight the usefulness of Web-based information in drug abuse research and add new information well-nigh lay beliefs most buprenorphine that may help inform prevention and policy measures.
INTRODUCTION
Buprenorphine, a semi-synthetic opioid, has very high affinity, but low intrinsic activity at mu receptors, which makes information technology an effective medication in the treatment of opioid dependence.i–3 Buprenorphine'south use in substance abuse treatment in the U.S. has expanded essentially since its approval in 2002.four Simultaneously, U.S.-based reports about its illicit use have too increased.four–7 Enquiry suggests that the employ of illicit buprenorphine in the U.S. seldom represents an attempt to attain euphoria but is more commonly linked to cocky-treatment of opioid withdrawal symptoms.8–xiv For example, a study conducted with individuals inbound opioid habit treatment programs in New England plant that out of 51 interviewees, the majority (96%) had used buprenorphine illicitly to attune opiate withdrawal symptoms.x A study conducted in Providence, Rhode Island, with a community-recruited sample of 100 opioid users found that 74% reported lifetime utilise of diverted buprenorphine. Self-medication of withdrawal symptoms and inability to admission treatment services were cited as mutual motives for illicit buprenorphine use, specially amid injection drug users.11 To pattern constructive intervention and policy measures, more than inquiry is needed to understand lay attitudes near buprenorphine self-treatment practices.
In that location is a growing recognition that the Web provides unprecedented opportunities for drug abuse research.xv,16 Increasing numbers of users rely on the Web to share their experiences and opinions about different drugs. Such user-generated content provides a rich source of information well-nigh lay knowledge, attitudes and behaviors related to illicit drugs.18,19 Prior studies have utilized such sources to explore emerging trends of illicit drug utilize, including mega-dosing with loperamide (Imodium)20 and using Kratom21 to self-treat opioid withdrawal.
The written report builds on PREDOSE (PREscription Drug abuse Online Surveillance and Epidemiology) platform, a novel Semantic Web tool that was developed by our interdisciplinary research squad to facilitate information extraction from Web-forums on illicit drugs.22 The study aims to explore Spider web-forum discussions about the use of buprenorphine to self-care for opioid withdrawal. Kickoff, we draw trends in the frequency of buprenorphine mentions on a Web forum and compare them to ii of the most commonly abused pharmaceutical opioids—oxycodone and hydrocodone. Next, we conduct content analysis of Web-forum posts to describe user attitudes almost buprenorphine's effectiveness in self-treatment, dosing practices and concomitant drug apply.
METHODS
A Web forum that allows for the free discussion of recreational drug use and is accessible for public viewing was selected for the report. The selected Web forum was started in 2004, and focused primarily on illicit opioids and other drugs. It grew from 32 posts in 2004, to 1,356 in 2005, almost 10,000 in 2006, and almost l,000 posts per yr in 2011 and 2012.
Wright Land University IRB approved the study and determined that it meets the criteria for Human being Subjects Research exemption four, because information technology is limited to content analysis of publicly bachelor Web postings that are made anonymously and intended for public viewing. To safeguard anonymity, pseudonyms used past forum contributors were anonymized during the data collection; the actual name of the website is non mentioned to assure confidentiality.33 Direct quotes were edited slightly (without altering the content) to make sure that they cannot be used to identify the website using net search engines.33
The PREDOSE platform retrieved posts (data collected through 09/2013) using web crawlers and retained them in a text data base of operations. To examine the frequency of buprenorphine-related discussions on the web forum, PREDOSE extract data on the number of posts per year that mentioned buprenorphine, including relevant brand and slang terms (e.g., Suboxone, Subutex, bupe). For comparative purposes, data on the frequency of oxycodone and hydrocodone mentions were also extracted. To compare relative numbers of buprenorphine, hydrocodone and oxycodone mentions, occurrence ratios were calculated. An occurrence ratio is expressed as the proportion x/y where x is equal to the number of posts that mention selected drug (e.m., buprenorphine) over a gear up fourth dimension catamenia, while the denominator y is equal to the number of all posts on the same website and over the same time flow (e.thousand., year 2011).23
To clarify lay attitudes about buprenorphine apply for cocky-handling, we utilized data retrieval functions of PREDOSE and subsequent manual coding facilitated by NVivo. "Cocky-treatment" is divers as using buprenorphine in an effort to alleviate opiate withdrawal symptoms for oneself in the absence of authorization past a prescribing md. The analysis proceeded in the following stages:
Showtime, PREDOSE was used to extract posts mentioning "buprenorphine" and "withdrawal," including relevant brand and slang terms that are commonly used in the Web-based discussions ("Sub," "bupe," "WD," "W/D," etc.). The two terms co-occurring within a window of 20 word apart were treated as a possible association rule.24 The PREDOSE platform identified and extracted 1,217 posts containing discussions nearly buprenorphine and opioid withdrawal (covering from 01/2005 to 09/2013).
2nd, a random sample of 404 posts (the numbers of posts by yr--2005: two; 2006: nine; 2007: nineteen; 2008: 18; 2009: 31; 2010: thirty; 2011: 109; 2012: 114; 2013: 72) was selected for manual coding. The sample represented 33% of the total number of posts that independent mentions of both buprenorphine and withdrawal.
Third, the random sample (n=404) was manually coded using the Complementary Explorative Data Analysis framework, which integrates qualitative and quantitative methods in content analysis of media communications.25 Using a qualitative approach and preliminary "open" coding of a subset of posts, a coding scheme was developed.25 The coding scheme focused on the post-obit key elements: if the post discussed buprenorphine to self-care for withdrawal (since co-occurrence of the two terms could exist linked to other issues, such as withdrawal from buprenorphine); if information technology expressed views about buprenorphine'southward efficacy in withdrawal management (positive/negative views and reasons for lack of efficacy); if it reported buprenorphine dosing practices (reported amount in mg in cocky-treatment of withdrawal); and concomitant buprenorphine and other drug use (Table 1). The coding scheme was then consistently applied to the entire body of 404 posts. Qualitative and quantitative approaches were used to analyze coded data.
Table 1
Content analysis of Web forum posts that mention buprenorphine and opioid withdrawal symptoms (N=404).
| Buprenorphine Cocky-Treatment Related Themes | Number of posts | Percentage |
|---|---|---|
| | ||
| Buprenorphine effectiveness in self-treatment of opioid withdrawal | 95 | 24% |
| Positive views | 72 | 76% |
| Negative views | 66 | 69% |
| | ||
| Mention of buprenorphine dose to self-treat opioid withdrawal | 82 | 20% |
| 2mg or less | 58 | 71% |
| More than than 2 mg simply less than 8 mg | 23 | 28% |
| More than 8mg | 8 | x% |
| | ||
| Buprenorphine employ in combination with other drugs when self-treating withdrawal | 50 | 12% |
| Other Illicit opioids | 31 | 62% |
| Benzodiazepines | xv | 30% |
| Dextromethorphan | ii | 4% |
| Loperamide | 2 | iv% |
| Tramadol | 2 | 4% |
| Cannabis | ii | 4% |
| Alcohol | 2 | 4% |
Inter-coder reliability analyses using Cohen's Kappa statistic were performed to assess coding consistency among coders.26 Three samples of posts were selected to appraise inter-coder reliability in relation to the three central themes. The first subsample was randomly selected to exam for coding reliability to identify positive and/or negative opinions about buprenorphine's effectiveness. It included 52 posts representing over l% of posts that contained discussions related to buprenorphine'southward efficacy. The other two subsamples were selected to assess coding reliability in relation to buprenorphine'southward dosing (n=50), and concomitant drug use (n=35). These sub-samples were purposefully selected to ensure that sufficient numbers of key characteristics were included in the reliability check. Afterward reviewing, clarifying and pre-testing coding rules, the reliability sub-samples were independently coded by two coders (the first author and a inquiry associate). SPSS was used to calculate Cohen'southward Kappa. Kappa scores of 0.6–0.viii indicate moderate, and higher up 0.8, substantial agreement.26, 35
RESULTS
Trends in buprenorphine-related posts
The overall number of buprenorphine-related posts increased from 46 in 2005 to 1,012 in 2009, 4,376 in 2011, and 3,546 in 2012. These numbers include all posts that incorporate at least ane mention of buprenorphine or its slang/brand names, without taking into account that the aforementioned private might have authored more than one posting. Figure i displays changes in the occurrence ratio of buprenorphine-related posts over time in comparison to two other commonly abused pharmaceutical opioids—oxycodone and hydrocodone. Equally shown in the figure, initially buprenorphine was less ordinarily discussed than hydrocodone or oxycodone. Even so, the frequency of buprenorphine-related postal service increased essentially over time, overtaking not only hydrocodone, only also oxycodone-related posts in 2012 (Figure 1).
Percentage of buprenoprhine, oxycodone, and hydrocodone-related posts on a Spider web-forum discussing illicit drug use
Lay attitudes about buprenorphine cocky-treatment
Manual coding of 404 posts determined that 68% (249) of those posts discussed using buprenorphine to self-treat opioid withdrawal. The remaining 32% discussed other bug, most commonly, withdrawal from buprenorphine ("I am taking kratom to save Suboxone withdrawal symptoms....").
Buprenorphine'south effectiveness
Out of 404 coded posts, we identified 95 that contained discussions related to buprenorphine's efficacy in alleviating opiate withdrawal symptoms (Table 1). They comprised 25% of the full sample of coded posts (N=404), and almost 40% of those that discussed buprenorphine apply to self-treat withdrawal (due north=249). The coder reliability assessment indicated moderate agreement between coders in identifying positive (kappa= 0.70, p<0.001) and negative opinions (a kappa=0.64, p<0.001) regarding buprenorphine'due south effectiveness. About 76% of these posts expressed positive views and 69% expressed negative views most buprenorphine's effectiveness in helping to relieve withdrawal symptoms (Tabular array 1). For instance, a positive opinion was expressed in the following fashion: "Buprenorphine has saved my ass from the sufferings of heroin withdrawal many times. It has been swell to me during my breaks from heroin. It is my life jacket when I begin to drown." In contrast, some other person shared a negative stance: "If I'm in severe withdrawal, coming off a 3 g per day heroin habit, I'd rather accept nothing, than bupe. That shit is awful …." About 45% of the coded posts contained accounts of both positive and negative experiences in terms of buprenorphine's effectiveness in self-treatment: "First fourth dimension I took a sub information technology worked very well, but my tolerance was very low. Every time since... ugh, much rather bargain with information technology cold turkey, because that shit sent me into horrible pain."
Those who expressed negative attitudes about buprenorphine's effectiveness typically complained that buprenorphine is not fully effective in alleviating all physical withdrawal symptoms and/or that "switch over" periods are besides long, and information technology takes several days for buprenorphine to "kick in." Equally one person stated, "Now, when I end doing dope and have subs, they hardly accept away any of my withdrawal symptoms for at least 4 days…." A third negative theme indicated that buprenorphine is non very constructive in controlling cravings: "Sub keeps me out of withdrawal. But my god! All I tin think about is putting a needle in my arm and getting off. It drives me insane! Non-stop cravings!"
Many posts expressed a belief that buprenorphine might be ineffective because of the "size of a person's habit." For case: "If you've been using full agonists for years and years, especially potent ones similar heroin, the sub merely doesn't practice it for you." Others emphasized that buprenorphine is a "weird" drug and its effectiveness declines when users repeatedly switch dorsum and forth betwixt buprenorphine and heroin or other opioids:
I concord that Suboxone is a life saver, but be conscientious! I had the attitude that because I had Suboxone, I could do as much dope as I wanted, because if I was gonna get sick, I could just take my subs… . What I didn't realize is the more times you lot switch between full agonists and subs, the less effective the subs get.
I spent a few years going back and forth from subs to heroin. This worked well for some fourth dimension. About a year ago, I tried to become stable on Subutex again. It just wasn't working! I tried high doses, I tried low doses…. It was exactly like cold turkey WD. I mean the subs did aught for me. I believe with the all switching back and forth from subs to dope, information technology somehow made the subs completely ineffective for me.
Dosing
Out of 404 coded posts, 82 (xx%) contained information about the specific amounts of the daily dose of buprenorphine used in self-treatment (Table 1). They comprised almost 33% of the posts that contained discussion of buprenorphine use to cocky-treat withdrawal (n=249). The coder reliability cess indicated moderate agreement between coders in identifying reports of dosing at or beneath ii mg/solar day (kappa=0.75, p<0.001) and in a higher place 2 mg per mean solar day (kappa=0.79, p<0.001). Over 70% of coded posts advocated use of very low doses—2 mg and lower per day--when cocky-treating opioid withdrawal symptoms, and but 10% mentioned daily doses of 8 mg or greater (Tabular array 1). In Web-forum discussions virtually "depression dosing," buprenorphine was described as "a horse of dissimilar colour at dosages two mg," every bit a "counterintuitive" drug that may be more effective at lower doses than at higher doses. For example:
Ordinarily, I would endeavor 6 mg+ of bupe for an attempt at relief of WD, just since I heard less is more, I decided to start depression and add more if I needed information technology. Lucky me! two mg put me to sleep the commencement night, and it simply got progressively better each twenty-four hours.
I cut the sub strip [2 mg] into virtually 24 tiny pieces, which is 1/12 of 1 mg each dose. I used 1 piece well-nigh every 4 to 6 hours, and it kept me well for about a week. I was amazed!
Many of the dose-related discussions endorsed a view that physician-prescribed doses, typically averaging 16–24 mg per solar day, are as well high for adequate management of opioid withdrawal symptoms, and thus, they tin can be "conserved" or shared with others. For example, one person stated: "You can conserve your Suboxone by taking ane pill or even half a pill. I do not know why doctors insist on prescribing 16 mg, even 32 mg per day of bupe...."
Concomitant drug use
Manual coding identified 50 posts that independent discussions about the use of buprenorphine in conjunction with other psychoactive drugs, nearly commonly opioid agonists and benzodiazepines (Table one). They comprised near 12% of the total sample of posts (n=404) that were manually analyzed, and xx% of the posts that discussed buprenorphine use to self-treat withdrawal (n=249). The coder reliability assessment indicated moderate to substantial level of agreement betwixt coders in identifying reports of concomitant use of other opioids (kappa=0.77, p<0.001) and benzodiazepines (kappa=0.92, p<0.001). The timing of buprenorphine dosing in relation to the opioid of choice was i of the central give-and-take points on the Web forum. Typically, buprenorphine, when taken as well presently after an opioid agonist, may precipitate a withdrawal syndrome. Information technology may too cake the furnishings of other opioids if they are consumed as well soon after using buprenorphine.ii
Avoiding the pain of withdrawal and getting the most out of the drug of choice were the main motivators for spacing out buprenorphine and other opioid dosing. Even so, many Web forum participants advocated utilize of a depression corporeality of buprenorphine in conjunction with an opioid agonist to make the transitions from a full agonist to buprenorphine easier and less painful. Such recommendations were especially relevant for those who tended to switch back and forth betwixt buprenorphine and their opioid of choice. For example:
I've low dosed bupe for months at a time and used huge amounts of heroin on top of it. As long as I kept a tiny daily dose of bupe in me, information technology was an insurance policy that I would never get dope sick, and could re-induct into full bupe maintenance without having to plunge into WD.
I take establish the first day or two of induction it'south ofttimes easier to employ a bit of drug of choice on top of bupe to ease the transition, i.eastward., 9 am: wake up in WD, take 1 mg bupe; 12 pm: do 0.two heroin; vi pm: 1 mg bupe; 12 am: 0.1 heroin; nine am: 1 mg bupe…. Plain you demand to be in WD before y'all induct, but once you have bupe in your system, you can take a total agonist then dose bupe once more even immediately afterward that without PWD [precipitated withdrawal]…Simply make sure it is consistently in your arrangement!
Benzodiazepines were too commonly endorsed drugs for use in combination with buprenorphine to help with slumber, anxiety or cravings. For example:
I would personally consider a benzodiazepine or some kind of sleeping or anxiety pill a must. Subs may take withdrawal away, but the cravings remain and you will still experience similar shit.
Taking Xanax 15 minutes before yous dose your bupe helps IMMENSELY. If I am on a 2 week run, my transition dorsum to bupe is hell … even without the PWs [precipitated withdrawals] I nevertheless have nausea and terrible cold sweats on twenty-four hours 1, but if I take a few bars [Xanax], it makes such a departure! Hell, I'll leave and consume at a restaurant vs. laying in a pile of my own sweat and puke.
Some other posts suggested the employ of dextromethorphan, tramadol, loperamide or cannabis to increment buprenorphine's effectiveness: "I observe subs help with WD, but volition non help me with the chills. For that, I use nearly 150 mg of DXM ... really does wonders…"; "Accept loperamide almost 90 minutes subsequently your bupe dose.... I did information technology and information technology took away all the WD symptoms the sub did not cuz of my huge tolerance to opiates…."
Discussion
Our findings indicate that frequency of buprenorphine-related posts increased over time, peaking in 2011 and overtaking oxycodone-related posts in 2012. These changes coincided with the release of tamper-resistant formulation of OxyContin in late 2010,27 which contributed to decreases in OxyContin abuse, but was linked to the increases in abuse of other opioids.27 Increases in Spider web-based mentions of buprenorphine are consequent with other information sources showing rising rates of illicit buprenorphine employ.vii They too indicate that due to buprenorphine's complex pharmacological profile, or every bit Web-forum participants suggested, "weird" properties, individuals may have more than questions and concerns about how to use information technology to increase its effectiveness and minimize unpleasant side furnishings.
Our results revealed some similarities and differences between the medical recommendations and lay views about buprenorphine. Prior inquiry has shown that understanding the variation in lay and professional interpretations of drug use and other health-related behaviors and conditions is crucial for the evolution of effective interventions.17,34
Consequent with the medical model, many Web-forum participants agreed that because of its "ceiling effect" buprenorphine may be less constructive for people who are dependent on very loftier doses of opioids.1,2 Even so, many posts also linked its bereft or decreased effectiveness to an unintended issue of repeated "jumping" back and along between buprenorphine and their opioids of choice.
The need for coincident medications to assist with withdrawal symptoms, particularly during the induction and early stabilization period of buprenorphine therapy, has been recognized in the medical literature.28 However, lay beliefs about the employ of buprenorphine with other illicit opioids and benzodiazepines contrast with medical recommendations and may put users at increased risk for adverse wellness effects and overdose.i At that place is a need of further inquiry too as educational interventions for wellness care providers to accost such lay attitudes and beliefs.
Web-forum participants endorsed apply of significantly lower amounts of buprenorphine than conventional doses averaging between 16 and 24 mg per 24-hour interval. Lay attitudes that buprenorphine is more effective in lower doses contradict medical treatment protocols and prior research findings.1,2,29 The "less is more than" approach to buprenorphine dosing, every bit advocated on a Web forum, is linked to the complex pharmacological properties of buprenorphine.two In add-on, these findings are meaningful in the context of patient-controlled analgesia research. Some studies suggested that when people are in control of their own dose, they may be able to tolerate lower doses and/or report better pain control.30 Our findings indicate that the "less is more than" approach to buprenorphine dosing was normally discussed by spider web forum participants, although we currently don't have data on the prevalence of such beliefs in the customs-recruited samples. Such conflicting behavior about buprenorphine dosing may undermine effective treatment and contribute to buprenorphine diversion.
Although web-based data provide new opportunities for drug abuse research, we recognize at that place are several limitations inherent in analyzing Web data: 1) It is difficult to determine how representative Web information are of full general drug user population. It has been noted that individuals who share drug-related information online are more likely to be young adults,31 and may stand for trend-setters,xviii a group that is very important for early identification of emerging trends. 2) Demographic and geographic metadata were unavailable or incommunicable to extract from Web forums. iii) Our arroyo focused on the raw numbers of posts with specific drug mentions, without adjusting for multiple posts by the same poster. Although similar limitations are shared by other epidemiological sources (e.thousand., Treatment Episode Data Set), nosotros also recognize that future inquiry should accept into business relationship repeat contributions by the aforementioned poster. 4) Our technical capabilities of automatically extracting complex themes are still in the developmental stages, and our arroyo might have missed relevant posts that would accept been identified using manual, "open" coding (due east.g., apply of different colloquial expression or mention of specific symptoms of withdrawal). In addition, Web-based information present meaning challenges for automated analyses and even for human coders considering of the high level of ambiguity, as illustrated by only moderate-levels of inter-coder understanding on some of the themes. 5) The number of posts that contained mentions of concomitant drug use or buprenorphine dosing were relatively small. Further enhancement of the data extraction techniques should help generate more robust findings. Validity and generalizability of Web-based findings tin be improved by including a greater number Web-based sources, and past triangulating Web-based findings with data obtained from other sources, such as reports past clinical toxicologists, Web-based surveys and research with community recruited samples.33
Our results add together new information nigh utilise of diverted buprenorphine that may aid inform prevention, intervention, and policy measures (e.yard., improved patient educational activity and physician training) and warrant farther research with community-recruited samples to sympathise longitudinal patterns and consequences of illicit buprenorphine use. Information technology is clear that Web- forums are condign an important source of information for illicit drug users. Active monitoring of such sources is needed to identify lay knowledge, attitudes, and behaviors that may lead to negative health outcomes.
Acknowledgments
This study was supported by the National Found on Drug Corruption (NIDA), Grant No. R21 DA030571 (Daniulaityte, PI; Sheth, PI) and the Department of Customs Health Grant, Boonshoft School of Medicine, Wright Land University. The funding source had no further office in the study blueprint, in the collection, analysis and estimation of the data, in the writing of the study, or in the decision to submit the newspaper for publication.
The authors would like to express their gratitude to research acquaintance Timothy Lane, G.Ed. for his help to conduct coder reliability assessment, and to students at Kno.e.sister for their help in development of PREDOSE platform.
Footnotes
Announcement of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527156/
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