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Tianeptine: a new frontier in surveillance and understanding through social media

Interest in the abuse of tianeptine in the United States has been increasing over the past decade (1). The xenobiotic, which is known under the trade name internationally as Stablon or Coaxil, was historically touted for its efficacy as an antidepressant (2). While the chemical structure is similar to tricyclic antidepressants, pharmacodynamic research indicates that the drug increases serotonin reuptake and beneficial effects may be secondary to neuronal remodeling, increased neuronal plasticity, and modulation of cerebral dopamine concentrations (3,4). More recently, tianeptine’s activity at the mu-opioid receptor has become an area of significant interest given its potential to lead to misuse (5). Experience with tianeptine in the United States is limited but has largely centered around its high propensity for abuse. Unlike therapeutic use encountered internationally, tianeptine is generally sold in convenience stores under the pseudonyms “Zaza” and “Tianna Red (6).” As such, nonmedical use predominates and can be difficult to characterize or track. Recent literature has illustrated the tolerance that rapidly develops and has provided information on clinical presentation and overall outcomes (1,6). Severe neurological effects from both acute intoxication (1) and withdrawal are particularly noteworthy, with several published cases necessitating admissions to intensive care units (6). Sporadic reports of death associated with tianeptine have even appeared (7). What has been glaringly absent in the available literature to date, however, is insight into individuals’ motivations for using tianeptine and practice patterns with regard to dosing or concomitant ingestions. These variables have been difficult to capture by traditional surveillance methods employed by other manuscripts that rely heavily on clinical symptoms and patient disposition once they report to a health-care facility. The manuscript authored by KE Smith et al. “When an obscurity becomes trend: Social-media descriptions of tianeptine use and associated atypical drug use” in this issue of the American Journal of Drug and Alcohol Abuse (8) brings a much more nuanced approach to individual perceptions of tianeptine that has previously eluded description in the scientific vernacular. In surveying Reddit, the authors have tapped into a database that may be unfamiliar to some practitioners but has wielded a wealth of valuable information from actual users of tianeptine. In fact, Reddit has been referred to as “the front page of the internet (9).” It is designed as a method for individuals to share information in an almost real-time manner. Following an extensive preliminary review of the social media themes, 210 unique posts were gleaned from Reddit. In contrast to previous research that has highlighted the clinical effects associated with tianeptine use, Smith et al. pivoted and focused on the front-end motivations that drive interest in tianeptine. Through the authors’ innovative efforts, individuals’ impulses for ongoing tianeptine use were illustrated through the descriptions of positive effects, negative effects, and reported withdrawal effects. Such an approach also allowed the authors to capture detailed dosing in 132 of the posts and to record concomitant ingestions, thereby yielding insights that had eluded previous works. Their comprehensive results have helped identify several valuable themes. The first of these is the realization of “polydrug use that included tianeptine” seen across posts. Cognitive enhancers, including phenibut and racetams, were most frequently used in combination with tianeptine to synergize the effects. Kratom was the second most frequently mentioned substance and appeared to correlate with both increased positive symptoms of tianeptine usage but also with the development of withdrawal symptoms. Another strong theme that permeates this work is the idea that users were not necessarily seeking a recreational high or euphoric