Representations of Codeine Misuse on Instagram: Content Analysis

Background: Prescription opioid misuse has doubled over the past 10 years and is now a public health epidemic. Analysis of social media data may provide additional insights into opioid misuse to supplement the traditional approaches of data collection (eg, self-report on surveys). Objective: The aim of this study was to characterize representations of codeine misuse through analysis of public posts on Instagram to understand text phrases related to misuse. Methods: We identified hashtags and searchable text phrases associated with codeine misuse by analyzing 1156 sequential Instagram posts over the course of 2 weeks from May 2016 to July 2016. Content analysis of posts associated with these hashtags identified the most common themes arising in images, as well as culture around misuse, including how misuse is happening and being perpetuated through social media. Results: A majority of images (50/100; 50.0%) depicted codeine in its commonly misused form, combined with soda (lean). Codeine misuse was commonly represented with the ingestion of alcohol, cannabis, and benzodiazepines. Some images highlighted the previously noted affinity between codeine misuse and hip-hop culture or mainstream popular culture images. Conclusions: The prevalence of codeine misuse images, glamorizing of ingestion with soda and alcohol, and their integration with mainstream, popular culture imagery holds the potential to normalize and increase codeine misuse and overdose. To reduce harm and prevent misuse, immediate public health efforts are needed to better understand the relationship between the potential normalization, ritualization, and commercialization of codeine misuse.