Talking about pain plainly: authentic expression of pain management on Reddit

Pain Management & Opioid Use

The misuse of opioids started with chronic pain management in the U.S. healthcare system. In the 1970s, the American Pain Society declared pain as “the fifth vital sign” (Wailoo, 2015) and it became a medical norm to use opioids (Rosenblum et al., 2008). The rise of using pain medicine was aided by major marketing campaigns from companies like Purdue Pharma, which falsely claimed OxyContin was nonaddictive (Pezalla et al., 2017). Further, physicians who rely on incentives to treat pain were evaluated on patient satisfaction, leading to the “pill-mill” phenomenon (Currie & Schwandt, 2021).

In the late 1990’s, restrictions on prescribing opioids for chronic non-cancer pain were implemented to curb their overuse (Manchikanti et al., 2012), sparking a rise in illicit opioid use. Individuals who were addicted to opioids for pain treatment went through withdrawal symptoms when their prescriptions were no longer filled, which led many to look for alternatives like heroine and fentanyl (Dasgupta et al., 2018). Thus, even though the volume of opioid prescriptions has dropped since 2010, opioid-related deaths have continually increased due to the COVID-19 pandemic stress and the closure of treatment clinics (Gomes et al., 2021; Manchikanti et al., 2021). In addition, very few people with opioid use disorders (OUDs) will receive treatment, and those in treatment often relapse (Chih et al., 2014). New technologies and existing social networks support individuals struggling with or without professional mental health support.

Authentic Expression and Pain Management on Reddit

The reason why language production is informative for timely intervention derives from the “expressive writing” paradigm (Pennebaker, 1997; Donnelly & Murray, 1991). The core idea of the paradigm is that expression relieves mental inhibition, which is detrimental to our health. In online health communities, expressing one’s challenges often elicits social support from other users (Liu et al., 2017; Lapidot-Lefler & Barak, 2012). One study identified seven expression types prevalent in an online support forum: emotional support, informational support, insight disclosure, gratitude expression, change talk, universality, and negative affect (Yang et al., 2023). However, limited research explores the role of authenticity in expression for health benefits. A recent literature review found only 22 studies focused on understanding the credibility and authenticity of social content in health communication (Jenkins et al., 2020).

In addition, authentic expression on social media is notably biased towards positivity over negativity, known as the “positivity bias” on social media (Reinecke & Trepte, 2014). Namely, online users are likely to produce content that is true and positive, in comparison to that of true but negative (Reinecke & Trepte, 2014). Not only positive expression was more prevalent online (Utz, 2011), people with better offline well-being were more likely to express themselves in a positive and authentic way online, thus in turn harnessing the positive benefit of authentic expression (Reinecke & Trepte, 2014). The inclination of positive authentic expression hurdles social support seeking as users that are experiencing negative life events in the condition of necessity, such as striving for financial support, grieving for loss, or going through an emotional breakdown. The positivity norm of social media environment may restrict people who like to solicit support through expressing their negative experiences. In turn, the emotional inhibition may worsen their physical and mental health conditions (Pennebaker, 1997).

Online sources that promote anonymity circumvent many social pressures that exist in online networks tied to the offline environment. The present study focuses on Reddit, a community-based social media platform that allows participants to post, reply, upvote, downvote and share content in various modalities without connecting their online profiles with their offline identities (Widman, 2022). Compared to other social media platforms, Reddit is known for anonymous engagement that encourages the freedom of expression (De Choudhury & De, 2014). It is also known for user generated communities around specific topic forums known as “subreddits”, denoted by the prefix “r/”. For instance, “r/politics” is described as “for news and discussion about U.S. politics” (https://www.reddit.com/r/politics/) on its home page. Users who navigated in this forum can post, reply, and share content pertinent to the U.S. politics. Once users submit a post, it can be voted “up” or “down” by the community members. Posts with more upvotes are shown at the top of the subreddit forum. Thousands of subreddits exist on Reddit to facilitate users (“Redditors”) discussion interests. Internet sites similar to Reddit in other countries are Tianya in China, Daum Café in South Korea, and 5ch.net in Japan.

The anonymity, interactivity, and openness of Reddit is notably advantageous to discussing opioid use and pain management issues, given that message creators have less concern when revealing the negative experiences. It is speculated that the option of being anonymous means participants can worry less about exposure of their potentially stigmatized social identity. The perception of safety to disclose may encourage authentic expression, allowing one to reflect the feelings and thoughts of the true self. Exploring the role of Reddit in facilitating authentic expression addresses a research gap in the expressive paradigm. Therefore, the first and primary goal of this study is to describe how authentic expression be observed on Reddit.

RQ1: What are the patterns of authentic expression when people talk about pain management and opioid use on Reddit?

The investment of personal time into a virtual community is associated with individuals’ intrinsic motivation to interact with members within the same digital space (Wang et al., 2012). A study for peer support forum also found that the longer the users engaged with expression, their shared feelings with other members – known as “universality” – increased over time (Yang et al., 2023). If recurrence of community engagement may to establish a sense of belonging regardless of being a message producer or receiver, it is reasonable to deduct that the more frequent Redditors produce messages in the chosen community, the more likely they will develop sense of sharing and attachment. However, it remains uncertain whether authentic expression will vary along with more message contributions. Plausibly, authentic expression will increase with community engagement since both the two factors are positively linked to improved psychosocial well-being (Rodgers & Chen, 2005). Therefore, we hypothesize that frequency of post and replies will predict authenticity.

H1: Greater volume of posts and replies for a user will positively predict indicators of authenticity in the user’s language.

Topic modeling is adopted to identify specific concerns when users discussed their health issues online, such as themes surrounding weight loss on Reddit (Liu & Yin, 2020), Covid-19 vaccination (Melton et al., 2021), and maternal health (Park & Conway, 2017). If authentic expression is to examine how we express ourselves in accordance with our inner mind, investigations on the topics of opioid use and pain management will capture what we expressed that led the online conversations in health communities. By grasping issues dominating online discourse, health interventions can be informed for content strategies pursuant to Redditors’ interest.

RQ2: Which topics can be identified in the posts and replies related to opioid use and pain management on Reddit?

User network structure in subreddit is formed through the post - reply interactions. Network structure derived from online community interactions has captivated scholarly attention given that health intervention projects often leverage social network features to provide social support, access information resources, and reshape social norms (Cobb et al., 2010; Kossinets & Watts, 2006). For example, research found that the smoking cessation forum QuitNet followed the core-periphery structure, in which smokers formed a large cluster at the inferior position of a network mapping while nonsmokers grouped together in the network center (Cobb et al., 2010). These discoveries informed health practitioners about subgroup attributes, especially for detecting community members who are in need of network-level interventions. For the present study, examining basic network features of Reddit discussion on opioid use and pain management subreddits will inform future health interventions. The differences between out-degree (i.e., post) and in-degree (i.e., reply) for Redditors can tell which subreddits have gathered more interactive users, an informative signal to understand where greater engagement could be encouraged, or to help individuals find the most well-connected subreddits.

RQ3: What are the network structures among users who explicitly talk about pain management and opioids in Reddit?

In addition to examining basic network structures, the present paper aims audience duplication across subreddits. Understanding audience duplication can uncover audience behaviors across platforms and facilitate content distribution based on audiences’ trajectories (Xu, 2021; Fletcher & Nielsen, 2017; Headen et al., 1977). The underlying reason to inspect audience duplication is to sort out the common users shared by two media platforms. In our study, the duplicated audiences are Redditors who posted across subreddits, indicating a pattern of users who actively posted messages related to pain management

Ksiazek (2011) categorized two types of audience duplication from the network perspectives: absolute duplication and primary duplication. Absolute duplication is the duplication shared by a pair of nodes without sequential orders whereas primary duplication implicates the directionality from one media to another (Ksiazek, 2011). Though primary duplication reveals more information about the directionality, the present study adopts the absolute duplication approach due to the inability to identify the sequential navigation of Redditors, as the engagement patterns can only be observed when timestamps from the log data are available. Moreover, adopting the absolute duplication matrix is sufficient to understand the relations between subreddits and their sharing of Redditors for authentic expression. By identifying subreddits with the largest group of common users, researchers are able to prioritize supportive health interventions for conversation focus of pain management. The present study also aims to find out how authentic expression is associated with the common users shared between two subreddits. Resolving this question will chart the course on which Reddit communities to prioritize for health interventions.

RQ4: Which subreddits have overlapping users discussing pain management issues? Does authentic expression differ between two subreddits with absolute duplications?

Data Collection

Data were collected from Reddit.com from 2010 to 2021 using the R package “RedditExtractoR”. Messages (i.e., posts and replies) mentioning the five key themes (“opiates”, “opioid”, “pain killer”, “pain medication”, and “pain reliever”) were crawled, along with respective a) user handles (i.e., Redditors), b) subreddit , c) upvote score, d) post score, e) reply score and f) URL. In total, 57, 564 messages were collected. Of the messages, 124 were initial posts and 57, 688 were replies .

Automated Text Analysis

Before having an integrated dataset for analysis, text from the posts and replies was processed by Linguistic Inquiry and Word Count (LIWC), a natural language processing tool that outputs linguistic scores corresponding to different social and psychological categories (Boyd et al., 2022) with high reliability (Kim et al., 2024). The LIWC authenticity score is calculated based on a series of words shown to predict individuals’ levels of honesty versus deception (Newman et al., 2003). Specifically, when people were lying, they tended to use less self-reference words (e.g., I, my, and mine) to disassociate themselves from their expression (Buller et al., 1996; Knapp & Comadena, 1979). The authenticity score generated by LIWC considered not only the self-reference words, but also the other two linguistic cues – negative affect and cognitive complexity (Newman et al., 2003). Instead of solely focusing on individual linguistic cues (i.e., “self-references or negative words or cognitive words”), the LIWC authenticity score accounts for all three features (i.e., “self-references and negative words and cognitive words”). The calculation integrating multiple linguistic cues was validated in a set of studies to understand social and psychological processing through words (Kim et al., 2024; Markowitz et al., 2022; Newman et al., 2003).

For example, in the present dataset, a message scoring high in authenticity was stating “Thank you for your post. You do a really great job of showing the complicated, non-black-and-white life we live” (Authentic score: 99). On the contrary, an example with low authenticity was “…I understand he’s grieving but I think I did the right thing for Baby Grinch. She was in so much pain…” (Authentic score: 14.44). The two differ on the proportional use of self-reference words such as “I”, negative emotion words (e.g., “grieving”, “pain”), and motion verbs (e.g., “do”, “did”). On the basis that deceptive verbal utterance often relates to fewer self-references, more negative affect words, and less cognitive complexity, the second message was graded lower in the authenticity category. More detailed explanations about which words are included in the index formula can be found in the LIWC coding book (https://www.liwc.app/help/liwc#Authenticity).

The zero-order correlations between authenticity and other relevant language categories were explored. Authenticity scores for replies were significantly related to several other linguistic features, including cognition and insight, but the effect size was moderate (refer to Figure 1). Similar findings were found for authentic expression in initial posts.

Figure 1.

Correlation Metrix among LIWC features

Data Analysis

We applied social network analysis (SNA) and regression models to address research questions and hypotheses. To have a comprehensive view of authentic expression not in quantitative format, we also add a supplementary analysis using Latent Dirichlet Allocation (LDA) topic modeling to see if there any topics are heavily discussed under the five key themes. Table 1 in the appendix lists all the statistic software used for analysis in this study.

Table 1.

Distribution of Average Authentic Expression Score across Subreddits for Pain Management

Authentic Expression Patterns (RQ1)

There were 46 subreddits included in our dataset and Table 1 displays the discussion topics and the average authenticity score in each community. The top three subreddits with highest authenticity scores are r/AskReddit, r/AskDoc, and r/Superstonks. The first two are the subsidy of the popular feature “Ask Me Anything” Reddit affords. The r/Superstonks is a community that labels itself as “A place for theoretical discussions about business and stocks - specifically GameStop Stock ($GME).” The bottom of the table 1 are subreddits with the lowest authentic score, the last three of which were r/politics, r/marvelstudios, r/RedditSessions. The RedditSessions is a content sharing community that creates streamed musical performances (https://www.reddit.com/r/RedditSessions/).

If taking the size of community (i.e., the number of subredditors) into consideration, among those with large number of users (i.e., number of messages over 1000 or number of Redditors over 1000), r/AskReddit still had the highest authentic score, implying messages produced in this community had less filtered/construed expression. In comparison, large subreddits like r/AmItheAsshole and r/politics scored the lowest authentic grading, 34.03 and 32.14 out of 100 scale separately.

Relationship between the Frequency of Expression and Authenticity (Hypothesis 1)

OLS regression was applied to test the H1 for the authenticity of initial posts and replies separately by each Redditor. Authenticity score was averaged by each Redditor, and the closeness centrality was created as the covariate in the model. The reason of controlling closeness centrality is to sort out the influence of a Redditor’s prior engagement in the community. The closeness centrality is an index that measures the multidirectional interactions of a participant in a network (Ganley & Lampe, 2009). In our study, it represents the extent of interactions a Redditors conversed with other participants on Reddit. The higher closeness centrality a Redditor has, the more likely he/she had interacted with the other Redditors on the same platform. We then added the number of posts and the number of replies each Redditor produced in the model for the authenticity score outcomes. Table 2 presents the results.

Table 2.

OLS Regression on the Authenticity Score of Redditors (N = 32, 175)

As Table 2 suggests, authentic expression was associated with the frequency of message production activities on Reddit. Specifically, authenticity in posting expression was significantly related to the number of posts (β = 14.85, p < 0.001), the number of replies (β = 0.001, p < 0.001), and the closeness centrality (β = 0.005, p < 0.001). If Redditors regularly posted and replied on Reddit, as well interacted across subreddits, they were likely to express their inner thoughts and feelings for post writing in a truthful way. However, as for the reply authenticity, a directional difference was observed. The frequency of replying behaviors was not necessarily related to authenticity expression for replies. Instead, they were negatively tied to authenticity expression in reply production (β = - 0.56, p < 0.01). It is noteworthy to observe a divergent pattern between post and reply authenticity in association of message production frequency on Reddit, which may imply that the initiation of posting, rather than the initiation of replies, encourages more authentic expression in the anonymous platform.

Dominant Topics of Pain Management on Reddit (RQ2)

To better understand what was discussed related to pain management on Reddit, Latent Dirichlet Allocation (LDA) topic modeling was applied for the 46 selected subreddits . Though no clear patterns emerged for “opioid” and “opiates,” there was a common theme for replies related to “pain reliever”, “pain management”, and “pain killer”. The shared topic is about relationship management that mentions social roles such as father, mother, daughter, husband, and, more broadly, people. Table 6 lists out the five themes for the three pain-related discussion.

Table 6.

Audience Duplication across Subreddits and the Average Authentic Score

Network Description among Redditors (RQ3)

First, message production at the post and reply levels for each user (i.e., node) was separated. Table 3 shows the average network statistics for the user and user network when their messages contained one of the five key terms. An active node is a user who produced at least seven messages, including posts and replies. Among the five terms, there are more Redditors who actively posted or replied using “opiates” than rather than other pain-related categories. They also have larger number of degree (i.e., posts and replies). However, Redditors who talked about “opiates” did not often engage with multiple subreddits based on its lowest closeness centrality. Instead, they tended to possess higher betweenness centrality, suggesting that Redditors discussing “opiates” was either an authority figure in their communities or they were on the periphery between two subreddits (e.g., participation at occasional levels across subreddits). The interpretation of the above network statistics was derived from Abbasi’s research (2012) for our study context.

Table 3.

LDA Topic Models

Table 4.

Description of Network Features for the Pain Management Discussion

In order to decide whether the network feature differences of the five keywords are significant, we applied one-way ANOVA for degree and closeness centrality. As presented in Table 5, the significant results only occurred to the closeness centrality, meaning that the closeness centrality was construed differently by Redditors talking about the five themes. However, as the η2 only equals 0.008 in terms of effect size, the differences between the five pain talk networks were not large, indicating that disclosure network surrounding the five key words was different at a small scale.

Table 5.

ANOVA Results of Comparing Degree and Closeness Centrality for the Pain Management Discussion

Shared Users between Subreddits (RQ4)

Table 6 shows the summary of audience duplication between subreddits for shared users over or equal ten. The results provide insight into which subreddits to be prioritized. Among messages that contained one of the opioid and pain related keywords, subreddits “news” and “science” shared the most common users (n = 47), followed by “AmItheAsshole” with “TwoXChromosomes” (n = 27), and “TwoXChromosomes” with “science” (n = 21). Reflecting upon the description of the three paired in Table 1, it is interesting to notice that both “AmItheAsshole” and “TwoXChromosomes” are the Reddit communities built for disclosing life challenges. “AmItheAsshole” described itself as a forum encouraging personal stories to seek judgement and justification, while “TwoXChromosomes” welcomed discussion related to women and the rights of all genders. The results may indicate that Redditors discussing pain management issues can diverge in their motivations for information support (e.g., news and science) versus emotional support (e.g., justification and judgment).

In terms of authentic expression, there were five pairs of subreddits with duplicated audience having the highest score above 50 on average. They were the “AmItheAsshole” and “TwoXChromosomes”, “news” and “technology”, “TwoX-Chromosomes” and “science”, “IAmA” and “news”, “Music” and “science”. The higher authentic score may mean that users had a trust in the online community and might be willing to disclose their true feelings when dealing with opioid use and pain management in daily life. The overlapping audience between subreddits provides knowledge about where to reach the audience who can encounter the intervention multiple times.

Limitations

Albeit the aforementioned contributions to academics, the study has two limitations. Firstly, the package “RedditExtractoR” for data collection is not inclusive, meaning not all the messages mentioning the five key words were gathered. Particularly, the tool limited the number of threads and replies according to the Reddit API rule (Package ‘RedditExtractoR’, 2023). As “RedditExtractoR” still remains one of the main tools for Reddit data collection (Hintz & Betts, 2022), results generated from the current study can pave the way for further research such as studying specific subreddits with significant high or low authentic expression scores via other available data collection methods. The second limitation is that we solely used LIWC to measure the authentic expression score, which excluded other coding methods, such as human coding and machine learning approach. Though LIWC is widely recognized and well established for gauging verbal authenticity (Kim et al., 2024; Markowitz et al., 2022), the results can be substantiated via a triangulation approach for verbal authenticity measurement. Future research can introduce more diverse but consistent operationalizations to explore the conceptual dimensions of verbal authenticity in other platforms such TikTok (Yang et al., 2023).

In conclusion, the present study delves into Reddit, a popular anonymous social media platform for support seeking and provision, to disentangle the extent of authentic expression in the context of pain management and opioid use. The revelation of authenticity differences and findings about duplicated audiences across subreddits provided evidence about which subgroups need to be attended to (e.g., forums related to justice for personal situations like AmItheAsshole and rights of all genders like TwoXChromosomes). Findings from the present study will set the stage for researching authentic expression on comparable platforms in other countries where anonymous online media is widely used for social support.