Withdrawal-associated injury site pain (WISP): a descriptive case series of an opioid cessation phenomenon

Rieb, Launette; Norman, Wendy V.; Martin, Ruth Elwood; Berkowitz, Jonathan; Wood, Evan; McNeil, Ryan; Milloy, M.‐J.

doi:10.1097/j.pain.0000000000000710

Cited by 17 publications

(17 citation statements)

References 147 publications

(158 reference statements)

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“…Thereby, research can give support for clinicians to understand factors that perpetuate opioid use and barriers to detoxification (Volkow and McLellan, 2016). Aligned with this perspective the tDCS and other neuromodulatory approaches can help in the management of pain with lower risk of producing addiction, while it could reduce the suffering when starting opioids dose reduction protocols (Rieb et al, 2016).…”

Section: Introductionmentioning

confidence: 99%

Transcranial Direct Current Stimulation to Improve the Dysfunction of Descending Pain Modulatory System Related to Opioids in Chronic Non-cancer Pain: An Integrative Review of Neurobiology and Meta-Analysis

et al. 2019

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Background: Opioid long-term therapy can produce tolerance, opioid-induced hyperalgesia (OIH), and it induces dysfunction in pain descending pain inhibitory system (DPIS).Objectives: This integrative review with meta-analysis aimed: (i) To discuss the potential mechanisms involved in analgesic tolerance and opioid-induced hyperalgesia (OIH). (ii) To examine how the opioid can affect the function of DPIS. (ii) To show evidence about the tDCS as an approach to treat acute and chronic pain. (iii) To discuss the effect of tDCS on DPIS and how it can counter-regulate the OIH. (iv) To draw perspectives for the future about the tDCS effects as an approach to improve the dysfunction in the DPIS in chronic non-cancer pain.Methods: Relevant published randomized clinical trials (RCT) comparing active (irrespective of the stimulation protocol) to sham tDCS for treating chronic non-cancer pain were identified, and risk of bias was assessed. We searched trials in PubMed, EMBASE and Cochrane trials databases. tDCS protocols accepted were application in areas of the primary motor cortex (M1), dorsolateral prefrontal cortex (DLPFC), or occipital area.Results: Fifty-nine studies were fully reviewed, and 24 with moderate to the high-quality methodology were included. tDCS improved chronic pain with a moderate effect size [pooled standardized mean difference; −0.66; 95% confidence interval (CI) −0.91 to −0.41]. On average, active protocols led to 27.26% less pain at the end of treatment compared to sham [95% CI; 15.89–32.90%]. Protocol varied in terms of anodal or cathodal stimulation, areas of stimulation (M1 and DLPFC the most common), number of sessions (from 5 to 20) and current intensity (from 1 to 2 mA). The time of application was 20 min in 92% of protocols.Conclusion: In comparison with sham stimulation, tDCS demonstrated a superior effect in reducing chronic pain conditions. They give perspectives that the top-down neuromodulator effects of tDCS are a promising approach to improve management in refractory chronic not-cancer related pain and to enhance dysfunctional neuronal circuitries involved in the DPIS and other pain dimensions and improve pain control with a therapeutic opioid-free. However, further studies are needed to determine individualized protocols according to a biopsychosocial perspective.

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Section: Introductionmentioning

confidence: 99%

Transcranial Direct Current Stimulation to Improve the Dysfunction of Descending Pain Modulatory System Related to Opioids in Chronic Non-cancer Pain: An Integrative Review of Neurobiology and Meta-Analysis

et al. 2019

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“… 1 , 3 , 20 Nonsteroidal anti-inflammatories and gabapentin were among the medications that subjectively helped relieve her symptoms of WISP consistent with medications found to relieve WISP and OIH in other studies. 1 , 3 , 8 , 27 Pain during and immediately after opioid detoxification has been shown by other authors to be a risk factor for reinitiation of opioid use. 24 …”

Section: Discussionmentioning

confidence: 93%

“…It is possible that this pain-sensitive state then uncovered peripheral or central sensitization that resulted from the original injury but was quiescent under normal circumstances. 27 , 35 Given that Alice experienced occasional clicking in her knee, it is possible that she had underlying pathology that was pain free under normal circumstances.…”

Section: Discussionmentioning

confidence: 99%

“…This case study was extracted from our mixed methods study that characterized WISP. 27 The participant was recruited in 2014 from a primary care clinic providing methadone treatment in Vancouver, Canada. She provided written informed consent.…”

Section: Methodsmentioning

confidence: 99%

“… 13 , 20 , 21 , 28 When regular opioid use is stopped, some people experience a temporary return of pain at old healed injury sites, a phenomenon that we have documented and termed withdrawal-associated injury site pain (WISP). 27 The current case study is the first to detail one individual's pain experience with opioid use and withdrawal to shed light on the possible relationship between OIH and WISP, as well as to provide a case example to assist in the identification of this phenomenon.…”

Section: Introductionmentioning

confidence: 99%

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Linking opioid-induced hyperalgesia and withdrawal-associated injury site pain: a case report

Rieb

Norman

Martin

et al. 2018

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Introduction and objectives:Understanding the details of one individual's experience with pain, opioid use and withdrawal may generate insights into possible relationships between opioid-induced hyperalgesia and withdrawal-associated injury site pain (WISP).Methods:This case study was extracted from a mixed methods study that characterized WISP. In 2014, the individual was recruited from a primary care clinic that prescribes opioid agonist therapy. In an interview, she completed a 35-item survey and elaborated on her own experience. Follow-up contact was made in June of 2017.Results:This 34-year-old white woman had several twisting injuries of her right knee between ages 13 and 15. The pain resolved each time in a few days, and she was pain free for 15 years. Around age 30, she initiated illicit oxycodone recreationally (not for pain) and developed an opioid use disorder. On detoxification, she experienced severe knee pain for 6 weeks that resolved postdetoxification but returned after subsequent oxycodone use and withdrawal episodes along with generalized skin sensitivity. This experience of WISP became a barrier to opioid cessation. Although nonsteroidal anti-inflammatories and gabapentin relieved WISP and methadone therapy assisted her opioid use disorder, an eventual change to sublingual buprenorphine/naloxone provided superior control of both.Conclusion:This case report illustrates that both opioid use and withdrawal can reactivate injury site pain, which can increase with dose escalation and repeated withdrawal events. The timing, trajectory, and neuropathic features of WISP reported here are consistent with those previously reported for the development of opioid-induced hyperalgesia, possibly linking these phenomena.

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Oxycodone self-administration and withdrawal behaviors in male and female Wistar rats

et al. 2020

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Over the last decade oxycodone has become one of the most widely abused drugs. The emergence of oxycodone dependence as a serious health crisis has prompted a major need for animal models of oxycodone dependence with face and predictive validity. Oxycodone use in humans is more prevalent in women (Administration, 2014) and leads to pronounced hyperalgesia and irritability. However, it is unclear if the current animal model of oxycodone self-administration recapitulates these characteristics. We assessed the face validity of an extended access oxycodone self-administration model in rats by examining escalation of oxycodone intake and behavioral symptoms of withdrawal including irritability like behavior and mechanical nociception in male and female rats. We found that male and female rats escalated oxycodone intake over the course of 14 self-administration sessions, however, female rats escalated took more drug than male rats once escalated. When we assessed irritability-like behavior we found no differences between baseline or withdrawal, however when tested immediately after a 12-h self-administration session rats showed a decreased number of aggressive responses and a increased number of defensive responses. When tested for mechanical threshold during withdrawal rats showed pronounced hyperalgesia that was only partially reversed by oxycodone self-administration. The results of the present study demonstrate the face validity of the extended access model of oxycodone self-administration by identifying sex differences in the escalation of oxycodone intake and demonstrating pronounced changes to pain and affective states.

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Withdrawal-associated injury site pain (WISP): a descriptive case series of an opioid cessation phenomenon

Abstract: Supplemental Digital Content is Available in the Text.This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal.

Cited by 17 publications

References 147 publications

Transcranial Direct Current Stimulation to Improve the Dysfunction of Descending Pain Modulatory System Related to Opioids in Chronic Non-cancer Pain: An Integrative Review of Neurobiology and Meta-Analysis

Transcranial Direct Current Stimulation to Improve the Dysfunction of Descending Pain Modulatory System Related to Opioids in Chronic Non-cancer Pain: An Integrative Review of Neurobiology and Meta-Analysis

Linking opioid-induced hyperalgesia and withdrawal-associated injury site pain: a case report

Oxycodone self-administration and withdrawal behaviors in male and female Wistar rats

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