• Launette Marie Rieb, Wendy V Norman, Ruth Elwood Martin, Jonathan Berkowitz, Evan Wood, Ryan McNeil, and M-J Milloy.
• aDepartment of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada bBC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada cCollaborating Centre for Prison Health and Education, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada dSauder School of Business, University of British Columbia, Vancouver, BC, Canada eDivision of AIDS, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
• Pain. 2016 Dec 1; 157 (12): 2865-2874.

AbstractWithdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation-a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.

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