COVID-19 Pandemic Impact on Substance Misuse: A Social Media Listening, Mixed Method Analysis

The restrictive measures adopted during the COVID-19 pandemic modified some previously consolidated drug use patterns. A focus on social networks allowed drug users to discuss, share opinions and provide advice during a worldwide emergency context. In order to explore COVID-19-related implications on drug trends/behaviour and on most popular psychotropic substances debated, the focus here was on the constantly updated, very popular, Reddit social platform’s posts and comments. A quantitative and qualitative analysis of r/Drugs and related subreddits, using a social media listening netnographic approach, was carried out. The post/comments analysed covered the time-frame December 2019–May 2020. Between December 2019 and May 2020, the number of whole r/Drugs subreddit members increased from 619,563 to 676,581 members, respectively, thus increasing by 9.2% by the end of the data collection. Both the top-level r/Drugs subreddit and 92 related subreddits were quantitatively analysed, with posts/comments related to 12 drug categories. The drugs most frequently commented on included cannabinoids, psychedelics, opiates/opioids, alcohol, stimulants and prescribed medications. The qualitative analysis was carried out focussing on four subreddits, relating to some 1685 posts and 3263 comments. Four main themes of discussion (e.g., lockdown-associated immunity and drug intake issues; drug-related behaviour/after-quarantine plans’ issues; lockdown-related psychopathological issues; and peer-to-peer advice at the time of COVID-19) and four categories of Redditors (e.g., those continuing the use of drugs despite the pandemic; the “couch epidemiologists”; the conspirationists/pseudo-science influencers; and the recovery-focused users) were tentatively identified here. A mixed-methods, social network-based analysis provided a range of valuable information on Redditors’ drug use/behaviour during the first phase of the COVID-19 pandemic. Further studies should be carried out focusing on other social networks as well as later phases of the pandemic.


Introduction
Over the last 16 months, the SARS-CoV-2 contagion has spread worldwide, with a number of measures (e.g., social distancing and quarantine; [1]) having been taken as a result. In association with self-confinement at home, many users have increased their web access on a daily basis [2,3]. Users have turned to the internet for news, exchange of views and purchase of products, with increased levels of the associated risk of exposure to unverified sources of information [4][5][6][7]. Within the open web, in addition to common search engines, there are social networks/platforms. These include Twitter, Facebook, Telegram, Youtube, WhatsApp and Reddit [8][9][10][11][12][13].

Materials and Methods
A quantitative and qualitative analysis of Reddit subreddits was conducted from December 2019 to May 2020. In order to investigate drug use issues among e-psychonauts, other Reddit users and the related possible COVID-19 pandemic impact, a mixed-methods (MM) strategy was adopted. With this approach, a range of qualitative and quantitative data are analysed in parallel to provide a better understanding of a specific issue [58][59][60]. More specifically, the quantitative component was here the result of the manual screening of Reddit posts/threads, whilst for the qualitative analysis a netnographic  approach was adopted. In this study, original posts and comments were included. In Reddit, "post" means the first content shared by a user (e.g., questions, thoughts, tips, experiences, pictures) and "comment" defines any eventual reply to this specific post. Data were collected from both the Reddit website and the r/Drugs' related subreddits; conversely, the r/covid19stack and r/Opioid_RCs subreddits were located from dedicated links [62][63][64][65][66][67]. More precisely, D.A. carried out the initial posts/comments' extraction activity; the range of free texts identified were screened and their proper, initial coding/categorization was drafted by D.A., a psychiatrist with quantitative/qualitative research experience assessing web-based NPS drug discussions. The findings and categorizations were then independently reviewed by F.S., a senior academic with proper teaching and research experience on quantitative/qualitative recreational/NPS drug research, in order to achieve an agreement to be presented to the whole researchers' group for both resolving possible disagreements and final approval of the quantitative analysis.
The quantitative search, relating to the r/Drugs Reddit component and its related subreddits [66], was performed by inserting specific keywords into the search bar of each subreddit. This process included two phases. In the first phase, the latest/trendiest topics were explored, in order to obtain the keywords that were eventually used to refine further searches. The keywords first used here included "COVID", "coronavirus", "corona", "quarantine", "pandemic" and "lockdown". In the second phase, the titles/contents of the discussions were explored, whilst analysing the presence of the above mentioned COVID-19-related keywords in all the r/Drugs subreddits. The threads adopting the "New" posts order criteria were screened here to facilitate optimal temporal discrimination. The Reddit new/trendy topics can be explored by considering the ranking functions (e.g., Hot, New, Top, Rising). This option allowed the exclusion of those posts/comments that were clearly antecedent to the beginning of the pandemic. Irrelevant/not applicable posts (e.g., where the term "corona" referred to a brand of an alcoholic drink) were excluded. To facilitate the manual keyword search, an Application Programming Interface (API), developed by Reddit users and hosted in a distinct website [68] (GitHub, 2020), was used. The search was repeated several times, a thousand to a thousand items at a time, and, hence, the 1000 item limit imposed by the native Reddit API [67] was bypassed (see Table S1).

Qualitative Analysis
The qualitative component of the research was carried out employing the netnographic approach. The qualitative analysis of both the whole r/Drugs subreddit and some related, most popular subreddits (r/HPPD; r/StackAdvice; r/Supplements) was conducted (see details in Table 1 and Table S2). The themes of these subreddits revolved around (a) general issues related to the range of available psychotropics; (b) the specific psychopathological consequences of drug intake; (c) the range of remedies considered by Reddit users in coping with untoward consequences of drug intake; and (d) peer-to-peer advice and social media sharing issues. Free texts (e.g., posts/comments) containing the selected keywords were examined; some representative quotes were then identified and grouped in the "main themes" Results section. A similar procedure was carried out to identify and group the different "types of users". In line with previous suggestions [69,70], the posts were selected whilst applying different and multiple sampling strategies. More precisely, the Palinkas et al. [7] theoretical sampling criteria were considered here to group the different types of users, whilst multistage (e.g., opportunistic or emergent) sampling criteria were considered to identify the main themes. The iterative process made it possible to refine and classify the posts/comments as representative for putative categories, until their screening was completed. The groups' classification was carried out taking into account the contents' variety of COVID-19 keyword-related posts using an inductive approach (e.g., generation of new theory emerging from the data; [71,72]

Data Collection and Privacy Disclaimer
The current overall screening focussed on Redditors' COVID-19-related activities running from 01 December 2019 to 31 May 2020, in order to include the first six months of the COVID-19 outbreak [73]. The precise number of members made available by Reddit related only to the date in which the social platform was being accessed; conversely, no historical data of members' figures were made available from the Reddit platform. Hence, to better assess the possible levels of numerical fluctuations relating to both selected subreddits' members and posts/comments, the quantitative analysis was carried on the 11th day of each month, using 11th March 2020 as a time-point reference, with this date having been the date on which the WHO declared COVID-19 to be a pandemic ( [74]; see Table S1).
Each subreddit content was freely accessible on the open web. In line with previous studies [27], full anonymity was guaranteed and no usernames or references to the Redditors were collected, used or analysed. The raw data were imported into Word and Microsoft Excel spreadsheets. Furthermore, according to the unobtrusive and naturalistic methods of conducting netnographic studies [48][49][50][51][52][53][54][55][56][57][58][59][60][61], no posts or other contributions to private/public forum discussions were made.

Ethics
The study was carried out within the framework of the University of Hertfordshire Ethics' Committee (code: aLMS/SF/UH/02951(2) approval).

Number of Subreddits and Their Classification
On 11 December 2019 and 11 May 2020, 619,563 and 676,581 members were counted on the whole r/Drugs subreddit, respectively, with a 9.2% overall increase overtime.

Included and Excluded Subreddits
Some 217 subreddits related to r/Drugs [66] were identified. However, some 127 subreddits, including Pics & Videos, Music, Youtube, Festivals, Misc, Regions/Languages, Memes, 18+ & NSFW were excluded from the analysis because they were deemed not relevant. Most typically, in fact, these subreddits focussed on a range of issues including pornography, sexmate searches, pictures, videos, memes and music festivals. Quantitative data regarding the remaining 90 subreddits were collected. Two further subreddits, albeit not explicitly listed within the macro r/Drugs subreddit itself but considered here as relevant (r/Opioid_RCs; r/covid19stack), were added, taking the total to 92 subreddits being analysed.
Those drug categories that, in terms of posts' numbers, received more attention included the following: CA, PS, OP, AC, ST; and, in terms of comments, the categories in-cluded the following: CA, OP, CS, PS, GM. Overall, the largest numbers of posts/comments were identified from the "Drugs & Activities" group.
Among the "Drugs A-Z" group, the largest number (n = 1,553,229) of Redditors related here to r/trees. Considering an arbitrary cut-off of 100 K members, in terms of popularity it was followed in decreasing order by r/LSD, r/Nootropics, r/shrooms, r/DMT and r/Supplements. Within the "Discussion" group, the largest number of members belonged to r/Psychonaut (n = 282,864), followed, with about/more than 100 K members, by r/vaporents and r/DrugNerds. Within the above-mentioned timeframe, the largest members' number (e.g., in excess of 100%) increase was observed in the following subreddits: r/covid19stack, r/Opioid_RCs, r/mescaline and r/MephHeads.

Supplements and Remedies
Some 87 supplements (e.g., vitamins, minerals, herb/botanical/plant extracts, aminoacids, traditional medicine products) and 7 remaining non-chemical remedies were identified as modalities to boost the immune system (See Table 2). The supplements' and remedies' list was extracted from three subreddits included in the "Therapeutic use" section of "cognitive enhancers/PIEDS" group (r/covid19stack, r/StackAdvice and r/Supplements) (See Table S3). Table 2.
Supplements and remedies in alphabetical order discussed in r/covid19stack, r/Supplements and r/StackAdvice. According to the current keyword criteria search, the first COVID-19-related posts/comments were dated 22 January 2020 (r/steroids) and 23 January 2020 (r/ketamine; r/researchchemicals) (See Table S1); users commented about the related health/sanitizing concerns (e.g., ( . . . ) So a lot of street K is coming from China and I d say its safe to say sanitation is probably not a criminal operation s main priority ( . . . ) So, I wonder if its poasible to get contaiminated drugs from the area? ( . . . )-Yeah I heard about the coronavirus. Scary shit! ( . . . )).

A. Vitamins, Plants and Supplements
For further details on members and individual keyword data on posts/comments, see Tables S1-S3.

Main Themes Being Discussed
Regarding cannabinoids, the focus was most typically on cultivation issues, whilst for psychedelics, cognitive enhancers and GABAergics/prescribed/over the counter (OTC) medications, the discussion revolved around the large range of related molecules. Conversely, NPS/EPS were typically listed in the "research chemicals" group, and, in particular, r/researchchemicals and r/Opioid_RCs. Finally, addiction recovery issues were identified from virtually all the analysed drug groups (for further details, see Table S1). Most typically, subredditors discussed a large range of themes, but four main themes were tentatively identified (see Table 2 and Table S2).
A total of four subreddits (relating to a total of 1685 posts and 3263 comments, as shown in Table 2) were screened for the qualitative analysis. From the whole list (see Table S2), they were selected according to the following criteria: r/Drugs, the main subreddit, since focussing on cross-cutting themes and general discussions; r/HPPD, the only r/Drugs related subreddit focussing on drug-induced disorders (Reddit, 2020 g); r/StackAdvice, dealing with the best drug stacking advice; r/Supplements, debating the different supplements and remedies to use to cope with possible drug/COVID-19-related untoward consequences. Due to the large volume of raw data generated, irrelevant posts/comments were excluded and manually removed from the data set. Following the removal of post/comments, the most relevant posts/comments (n = 190) were listed in Table S2: 69 on main theme one; 73 on main theme two; 16 on main theme three and 21 on main theme four. A brief summary of the issues debated within the four main themes is provided here (see also Table 3).

Categories/Types of Users
In analysing all of the posts and comments, four types of users were tentatively identified. Indeed, the COVID-19 pandemic seemed to have impacted the drug supply chain, drug choice and users' behavioural changes in various ways. One could argue that there are differences in reacting to the pandemic due to individual characteristics, place of living and personality traits. Those topics most typically debated revolved around COVID-19 health-related concerns, reliable psychological/psychiatric indicators of distress, loneliness, the desire to obtain an altered state of mind to better cope with boredom and troubles in accessing proper medical prescriptions. Some examples are provided here, with further clinical vignettes available in Table 4. e.g., Sorry, imma gonna keep doing drugs as usual. e.g., If I'm on lockdown for 2 weeks I'm most certainly not staying sober.; Do acid first, then go sober! I don't give af about the coronavirus; WH can fuck off (WH = White House).

Type 2. Couch
Epidemiologists e.g., ( . . . ) I realized the other day that the early warning symptoms of coronavirus are basically identical to mild heroin withdrawals so . . . now I've just been kinda uncertain as to whether I actually have coronavirus or if ( . . . ) I just feel better when I hit the black cause it's getting me well lmao yikes. e.g., MDMA weakens your immun system. And I'm not sure how it is with amphetamine. The chance of dying by using mdma and getting Corona virus in 1-2 days after is bigger than 0.2%.

Type 3. Conspirationists/Pseudo-Science Influencers
e.g., The seed code is CORONA. Enjoy, psychonauts; Don't worry, the CIA will continue to funnel in all yalls drugs . . . e.g., Can you ask the DMT entities to help us solve this COVID-19 situation? e.g., Psychedelics are the cure. e.g., A theory for everything. e.g., memento mori corona . . . drawn under the influence of psychic tv and coil.

Discussion
The present research has been conducted on a major and very popular social network, covering a time-period of six months, aiming at exploring the relationship between COVID-19 and substance misuse through a social media listening approach. In order to outline a comprehensive picture of the phenomenon, a large number of posts/comments, using a netnographic approach, were analysed here. At present, although the pandemic has been going on for several months, the attention of both the scientific literature and the media has mostly been directed to its medical/virological aspects. Conversely, only a few efforts have been made to clarify the impact of the COVID-19-related lockdown on both mental health and patterns/styles of recreational drug intake. For this reason, the current research focus was on the first six months of the pandemic, months that have been characterized by the strongest levels of self-isolation. From this point of view, for some vulnerable individuals, the only possible travel at that time was a "trip", whilst being connected with peers through social media.
With the very best of our understanding, the current paper is likely to represent the first mixed-methods, large sample size, empirical investigation focussing on behavioural changes in drug intake during the first six months of the COVID-19 pandemic using a social media listening approach. Other studies have aimed at describing the trends in substance use during the current pandemic [43,44,[76][77][78][79][80][81], without considering the need to carry out large-scale, social media mining, research activities [82][83][84]. Per definition, lockdown has been, and for some countries still is, characterised by both social confinement and human isolation. In parallel, the use of both the web and social media has increased considerably to maintain human contacts, hence the importance of assessing the drug enthusiasts' online entries [54]. As previously highlighted, the online and offline worlds influence each other [85,86], although the directionality and the extent of these phenomena are not always clear. For social listening, Reddit was chosen here as the platform to be investigated. Although the Reddit platform does not provide precise data relating to its total members during the period December 2019-May 2020, anecdotal data have suggested that Reddit, as a social platform, recorded a spike in engagement during the pandemic [87]. The interest in social media during the pandemic has been explored by recent remaining studies as well [88].
Different from other social networks such as Facebook, Twitter, etc., Reddit promotes anonymity, with some Redditors describing themselves in different fantasy ways (e.g., "friendly faces" in r/Drugs; "tryptonaut" in r/tryptonaut; "bartards" in r/benzodiazepines; "dextronauts" in r/dxm; "opiate enthusiasts" in r/opiates; "ents" in r/trees; "salvia people" in r/Salvia, "Vaporists" in r/vaporents, etc.). Indeed, these nicknames may emphasise the importance of the sense of belonging to a sub-culture, different from the remaining sub-tribes and, indeed, from the "druggies" as well.
Overall, Redditors showed a strong tendency to share with their peers a range of materials (e.g., pictures, links, trip reports), to facilitate mutual help activities ("sharing for caring, sharing for drugging"). Users posts and comments focussed on a range of COVID-19-related issues; health and sanitising issues were frequently mentioned, including the quality/possible contamination of drug products and the risks of health consequences [80,89] in those with underlying chronic medical conditions. Many users asked for some advice about the possible of use of specific supplements to boost their immune system [90][91][92][93][94] and, indeed, the current pandemic stimulated the search for a range of psychotropics with only limited levels of potential harm on both the respiratory and the immune systems. In line with this, more attention was given to oral, as opposed to inhaled, modes of intake. Furthermore, there were a large number of posts related to both the indoor cultivation (e.g., of cannabis) and intake of edible products (see Table 2).
The recent literature has highlighted the dramatic impact of COVID-19 on mental health [95][96][97][98]. In line with this, various posts related to a range of possible concerns (e.g., anxiety, depressive, psychotic, hypochondriac, obsessive-compulsive), although this was not necessarily associated with a modification of Redditors' drug consumption patterns. A special focus of the debate was here on the Hallucinogen Persisting Perception Disorder (HPPD) [99,100], with users asking for remedies to treat the problem, due to the impossibility of visiting clinicians/specialists. COVID-19 affected drug markets in various ways, with sudden changes in drug purity/potency, price and supply/availability levels [80,101,102]. These issues were hotly debated here, especially in some subreddit groups (e.g., r/Addiction; r/Recovery). Al-though no obvious drug exchange elements were reported here, likely because these activities are explicitly discouraged by Reddit moderators with a penalty consisting of being banned, characteristics of drug delivery activities were reported, with specific reference to some dealers' optimal "customer care" approach.
Overall, the quarantine regime seemed to have encouraged Redditors to develop a range of consumption coping strategies, including conservative (e.g., continuing with drug intake using stocks of purchased drugs); a switch to NPS, which can be bought online and delivered by the postman whilst avoiding legal issues; abandoning drug use and looking for new alternative activities (e.g., studying, doing physical exercise/workout) to be put in place to cope with the lack of psychoactive drugs. Interestingly, whilst some users tried to minimise the risks related to the modified lifestyle scenario, others showed relative levels of carelessness, with several comments having been related here to a range of conspiracy theories, otherwise widely disseminated in social media [103,104].
Whilst all the drug categories attracted Redditors' attention, cannabis, alcohol, psychedelics, opioids and cognitive enhancers were the most popular drugs [105]. Due to their availability levels, alcohol and cannabis were often cited as replacement, "comfort", psychotropics. Conversely alcohol polydrug use [106], to obtain an intense dissociative/detachment from the current contingency, was noted as having increased during lockdown.
Although some users seemed to be cautious about using substances at home during the pandemic, for others (e.g., "psychonauts"; [43,44,47,107,108]), the confinement experience triggered the use of NPS and/or psychedelics to facilitate insight and mental exploration issues. Indeed, some r/DrugNerds and r/researchchemicals Redditors seemed to focus on a compulsive search for new molecules to be tried. The availability of such posts and comments may have contributed to both the spread of "infodemia" [109] and to the related risks associated with the intake of NPS presenting with only little, or none at all, clinical pharmacological knowledge [75,[110][111][112].
Consistent with previous research [54,113], significant at home, lockdown-related levels of use of both prescribed and OTC sedative drugs during the COVID-19 pandemic were identified. One could speculate that this was carried out to obtain an ad hoc, cloudy/obtunded ("four walls' daze"; Yan et al., 2020), state of mind to best cope with both boredom and loneliness. In other cases, the switch to the psychotropics available at home, such as the prescribed/OTC medications, was carried out because of the lack of access to the preferred recreational drugs(s). On the other hand, many users complained that they were unable to renew their prescriptions, for the impossibility of going outside/visiting a doctor.
Whilst pre-COVID-19, web-based drug enthusiasts' categorisations had already been made available [81], an attempt at categorizing Redditors with respect to their approach to drug use at the time of COVID-19 is proposed. Although the importance of personality traits is, indeed, relevant in deriving categories of drug users, assessing the Redditors' personality dimensions was not the aim of the current study [114][115][116][117][118][119]. Specific personality issues could well have influenced the single subjects' drug use intake/related behaviour during the pandemic itself. Indeed, reference to specific temperament and character traits, including the four dimensions of temperament (e.g., novelty seeking, harm avoidance, reward dependence and persistence); and the three dimensions of character (e.g., selfdirectedness, cooperativeness and self-transcendence; [120][121][122][123][124][125][126]) could have been of help here in interpreting the range of different drug-related behaviour described. These behaviours included persisting in careless drug use, arguably suggesting low levels of harm avoidance; high novelty seeking levels, possibly characterising those attracted by NPS; high self-transcendence levels in those looking for NPS/novel psychedelics; antisocial personality traits in those allegedly refusing to wear a face mask whilst in others' presence [127]; with neuroticism, hypochondria and "coronaphobia" in those in need to be reassured whilst still using drugs [128][129][130][131][132]. Furthermore, the different attitudes described here could have been associated as well with the subject's environmental/social context, family/work background, age [48], attachment styles and cognitive biases [116,133,134].

Limitations
The current study presented with a few limitations. First, the current approach was adopted whilst considering both the empirical phenomenology model [135] and grounded theory principles [136,137], although one could argue the investigation was not fully in line with these approaches. Furthermore, the quantitative/qualitative posts/comments' assessment was carried out manually, whilst ad hoc software to analyse specific subreddits was used before [34,[138][139][140]. Conversely, the manual searching approach likely enhanced the value of the entries' qualitative assessment here, fully in line with netnographic analysis principles [35,141]. On social media, people tend to speak freely and that by itself is an advantage, unlike other methods of obtaining data such as focus groups or interviews. On the other side, social data analysis may imply biases, methodological pitfalls and ethic boundaries [142]; for, e.g., it could be argued that Redditors represent an extremely varied population, potentially including a large plethora of users such as e-psychonauts, academics/researchers, curious people, trolls and trend influencers. Moreover, social media/Reddit users are only partially representative of people who use drugs in general; for, e.g., as recently highlighted, not all persons with drug-related problems have access to PCs/smartphones [143]. Finally, only the first few months of the COVID-19 pandemic were analysed here, and, at the time of writing, this pandemic is not over yet.

Conclusions
The current mixed-methods, qualitative and quantitative, focus on Reddit entries provided a range of valuable information relating to drug use at the time of COVID-19, thus confirming that social media analysis allows both trend and real-time data to be obtained. This approach is potentially useful for a wide range of researchers, clinicians and stakeholders, e.g., psychiatrists, psychologists, pharmacologists, sociologists, harm reduction projects. A tentative Redditors' categorisation has also been proposed. Personality traits/cognitive bias, attachment styles, health/psychiatric worries, medical access issues, living/consumption settings and pressure to expose contents/thoughts could probably explain the different detected reactions. The Reddit community seems to auto-regulate itself with harm reduction advice, but various drug users' trending patterns could worry clinicians and institutions. Further studies should be carried out by adding country-specific keywords, more subreddits/drug themes and focusing on other social networks as well. More studies should expand the potential of this approach in systematically exploring social networks in order to offer ideas for further investigations. Understanding the cultural, behavioural and psychological nuances/patterns related to the multi-faceted world of drug consumption, could help in designing new drug treatment/management and prevention strategies tailored to peculiar/new/changing contexts such as the COVID-19 pandemic.
Author Contributions: D.A. and F.S. conceived the idea of this paper; data were extracted by D.A., whilst F.S. supervised all stages of the process and was consulted to resolve any possible issues. D.A. drafted the first version of the manuscript and revised it after contributions from J.M.C., A.G., N.S. and F.S. All authors have read and agreed to the published version of the manuscript.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We acknowledge support by the Open Access Publication Fund of the University of Duisburg-Essen.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki, and it was carried out within the framework of the University of Hertfordshire Ethics' Committee (code: aLMS/SF/UH/02951(2) approval).

Informed Consent Statement:
Data were mined from a publicly available social media platform (Reddit), without interacting with, intervening, or manipulating/changing the website's environments; no registration was required to read the threads/posts/comments online. Being common and ethically tenable in research activities using online forums/platforms, forum users were not informed about their posts being used for research purposes. We read MDPI's position on ethical publication issues.

Data Availability Statement:
The sources from which the data presented in this study are derived are properly mentioned within the article and supplementary material.