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Data visualization with prescription opioid hashtags demonstrated terms related to codeinemisuse (Figure 2) and to other activities that co-occurred with these hashtags (Figure 3). Among the terms related to codeine misuse, we came across a number of terms related to processing codeine into the form commonly used in nonmedical consumption, such as lean. Lean, also known as sizzurp or purple drank, is a concoction consisting of promethazine or codeine cough syrup, ice cubes, and soda, with the optional addition of hard candy [22,26]. Nonopioid hashtags that frequently occurred with codeine-related hashtags revealed a robust relationship between codeine misuse and polysubstance use, especially cannabis use (eg, weed, cannabis, and kush), Additionally, there was a less common association with hip-hop culture (eg, hip hop and rap; Figure 3).

Definitions and examples of emergent themes are in Multimedia Appendix 2. The greatest proportion of posts were limited to images of codeine or lean in everyday places (use-behavior). Posts grouped under use-behavior contained images or videos of consuming in their homes, cars, or public places such as the beach. The preparation of codeine from a liquid, cough-syrup formulation into its misused form (ie, lean) was its own theme (preparation). Similar to use-behavior, posts grouped under preparation depicted the preparation, but not consumption, of lean in an array of common venues. The next most common type of post represented co-occurrence of codeine misuse with recreational alcohol, cannabis, and benzodiazepine consumption (polysubstance use). Posts grouped under polysubstance use depicted codeine alongside other intoxicants, concurrent consumption, and hashtagged (eg, #cannabis) in the caption. In our thematic framework, use-behavior is distinct from polysubstance use, in that we only applied the former to posts that showed codeine misuse exclusively, whereas we applied the latter to posts where users represented codeine misuse alongside alcohol or other drugs.

Although further large-scale exploration is needed, our preliminary analyses of Instagram posts suggests that codeine misuse may be becoming normalized, commercialized, and ritualized. The most common theme uncovered was a simple visual depiction of lean, which is codeine cough syrup mixed with ice, soda, and occasionally hard candies (ie, Jolly Ranchers). Other prominent themes included depictions of codeine with other substances such as alcohol and cannabis and the preparation of lean.

The specificity of the narratives (eg, chopped and screwed or trap music) and paraphernalia (eg, double Styrofoam cups) associated with codeine misuse could speak to ritualized or performative activity [36]. Though apparently contradictory, ritualization does not necessarily proscribe normalization. Rather, ritualization is better understood as a process representing initiation into a particular social group that has its own unique sets of norms, practices, and aesthetics [37]. Correctly performing ritualized preparation of codeine cough syrup into the form of lean seems to signify participation or membership in a particular subculture. Similarly, references to trap and chopped and screwed in these representations of misuse speak to these as dominant narratives for codeine misuse. Novel populations of misusers may adopt these images to identify with this particular subculture, perpetuating its use over time [37].

Patients with COPD report variability in the frequency and severity of cough and sputum symptoms throughout the day, with greatest impact first thing in the morning and at night-time.101139 The prevalence and severity of cough symptoms at the start of the day may relate to periods of increased activity associated with getting washed and dressed, whereas the night-time cough and sputum symptoms may be a consequence of mucus hypersecretion or reduced ciliary activity. In the analyses reported here, treatment with aclidinium significantly reduced the percentage of days and nights with symptoms of coughing and bringing up phlegm or mucus. The severity of morning and night-time cough and sputum symptoms was also found to be reduced. Treatment approaches that impact on cough and sputum symptoms throughout the whole 24-hour day may provide clinical benefits to some patients in terms of their overall well-being, particularly in the morning and night-time when patients report that these symptoms are most troublesome. 781b155fdc