"I couldn't even be in my own skin": Examining the role of withdrawal pain in the treatment journeys of people who use opioids.

INTRODUCTION

Withdrawal is a common and debilitating experience among people who use opioids (PWUO) yet the role it plays in treatment journeys is under-represented in the literature. The scant literature on withdrawal experiences focuses primarily on illicit opioid use with less attention paid to experiences across a variety of opioid usage, including withdrawal that occurs with medication for opioid use disorder (MOUD). This study examined PWUO's experiences of withdrawal across their treatment journeys to better understand the role of withdrawal in care engagement.

METHODS

We analyzed transcripts from 34 telephone interviews conducted with participants who had an opioid use disorder (OUD) diagnosis. All participants had a clinical encounter in 1 of 4 outpatient addiction medicine clinics in a large integrated health system that serves central and northeast Pennsylvania. Approximately half of the participants were receiving MOUD at the time of the interview. Over half (54%) were female and ages ranged from 22 to 70 years. The interview guide focused on barriers and facilitators to MOUD retention but allowed for participants to share other aspects of their treatment journey. An inductive narrative analysis was conducted, allowing participants' treatment journeys to be examined holistically.

RESULTS

Comparison of treatment journeys within and across participants revealed the centrality of the withdrawal experience in treatment decisions. The lived experience of pain and distress was illustrated along with an explication of how withdrawal occurs, including instances of "forced withdrawal." Withdrawal pain influenced decisions both to seek and avoid MOUD, shaping choices regarding MOUD type and whether to taper off MOUD, and the use of other withdrawal management approaches, such as buying MOUD off "the street."

CONCLUSION

Findings support the need for increasing understanding of withdrawal from the perspective of PWUO among healthcare personnel and public health professionals. Underestimating the impact of withdrawal experiences across the treatment continuum may compromise the delivery of effective care, potentially reducing treatment engagement and increasing the likelihood of risky behaviors by PWUO. Future studies should examine the role of individual agency in treatment decisions that may cause withdrawal symptoms as well as experiences of withdrawal with newer clinical practices.