Open Access Open Access  Restricted Access Subscription or Fee Access

Postsurgical patient-controlled opioid self-administration is greater in hospitalized abstinent smokers than nonsmokers

Caren L. Steinmiller, PhD, Christina Diederichs, BS, Timothy A. Roehrs, PhD, Maren Hyde-Nolan, MS, Thomas Roth, PhD, Mark K. Greenwald, PhD


Objective: To compare 24-hour postsurgical patient-controlled analgesia (PCA) in smokers and nonsmokers.

Design: Patients completed a presurgical questionnaire inquiring about sleep, nicotine and other substance use, and comorbid disorders. Nicotine use was discontinued on hospital admission on the day of surgery. After morning surgery and (spinal) anesthesia recovery, each patient began opioid PCA with a device that limited dose frequency (morphine 1 mg equivalent units) using a lockout period (range, 6-10 minutes).

Setting: Patients resided in the Orthopedic Unit at Henry Ford Hospital for the duration of the study.

Patients: Cigarette smokers (n = 13) and healthy nonsmokers (n = 13) who completed the presurgical questionnaire were matched for age, gender, and type of surgery (hip vs knee replacement).

Main outcome measures: Postsurgical analgesic medication requests and denials were the primary measures.

Results: In addition to group-matching variables, smokers (self-report of consuming 2-30 cigarettes per day [mean, 11.7]) and nonsmokers did not significantly differ in average weight, height, body mass index, surgery start time (about 9:45 AM), PCA start time (about 4 PM), or lockout interval (8.6 minutes). More smokers (n = 11) than nonsmokers (n = 5) received opioids during recovery before PCA (χ2 = 5.85, p < 0.05). During PCA, smokers had significantly more injection denials [F(1,24) = 4.65, p < 0.05] and fewer infusions per request [F(1,24) = 6.74, p < 0.05] than nonsmokers. During nighttime hours, smokers had significantly more infusion requests [F(1,24) = 4.41, p < 0.05] and more injection denials [F(1,24) = 5.67, p < 0.03] than nonsmokers.

Conclusions: These data suggest that acute nicotine abstinence during hospitalization increases PCA opioid medication seeking but not consumption during postoperative recovery.


patient-controlled analgesia, smoking abstinent, pain medication seeking

Full Text:



Substance Abuse and Mental Health Services Administration: Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. Rockville, MD: Office of Applied Studies, 2010; NSDUH Series H-38A, HHS Publication No. SMA 10-4586 Findings.

Kurtz S, Ong K, Lau E, et al.: Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg. 2007; 89: 780-785.

Phillips DM: JCAHO pain management standards are unveiled. JAMA. 2000; 284: 4-5.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Facts about pain management. 2011. Available at Accessed May 8, 2012.

John U, Meyer C, Rumpf HJ, et al.: Nicotine dependence criteria and nicotine withdrawal symptoms in relation to pain among an adult general population sample. Eur J Pain. 2009; 13(1): 82-88.

Weingarten TN, Moeschler SM, Ptaszynski AE, et al.: An assessment of the association between smoking status, pain intensity, and functional interference in patients with chronic pain. Pain Physician. 2008; 11(5): 643-653.

Fertig JB, Pomerleau OF, Sanders B: Nicotine-produced antinociception in minimally deprived smokers and ex-smokers. Addict Behav. 1986; 11(3): 239-248.

Jamner LD, Girdler SS, Shapiro D, et al.: Pain inhibition, nicotine, and gender. Exp Clin Psychopharmacol. 1998; 6(1): 96-106.

Creekmore FM, Lugo RA, Weiland KJ: Postoperative opiate analgesia requirements of smokers and nonsmokers. Ann Pharmacother. 2004; 38: 949-1053.

Glasson JC, Sawyer WT, Lindley CM, et al.: Patient-specific factors affecting patient-controlled analgesia dosing. J Pain Palliat Care Pharmacother. 2002; 16(2): 5-21.

Woodside JR: Female smokers have increased postoperative narcotic requirements. J Addict Dis. 2000; 19(4): 1-10.

Marco AP, Greenwald MK, Higgins MS: A preliminary study of 24-hour post-cesarean patient controlled analgesia: Postoperative pain reports and morphine requests/utilization are greater in abstaining smokers than non-smokers. Med Sci Monit. 2005; 11(6): CR255-CR261.

Olson LC, Hong D, Conell-Price JS, et al.: A transdermal nicotine patch is not effective for postoperative pain management in smokers: A pilot dose-ranging study. Anesth Analg. 2009; 109(6): 1987-1991.

Johns MW: A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep. 1991; 14(6): 540-545. 15. Johns MW: Sleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep. 1994; 17(8): 703-710.

Tsui SL, Tong WN, Irwin M: The efficacy, applicability and side-effects of postoperative intravenous patient-controlled morphine analgesia: An audit of 1233 Chinese patients. Anaesth Intensive Care. 1996; 24: 658-664.

Gentile DA, Woodhouse J, Lynch P, et al.: Reliability and validity of the Global Pain Scale with chronic pain sufferers. Pain Physician. 2011; 14(1): 1-70.

Melby V, McBride C, McAfee A: Acute pain relief in children: Use of rating scales and analgesia. Emerg Nurs. 2011; 19(6): 32-37.

Smith MT, Quartana PJ, Okonkwo RM, et al.: Mechanisms by which sleep disturbance contributes to osteoarthritis pain: a conceptual model. Curr Pain Headache Rep. 2009; 13: 447-454.

McCracken LM, Iverson GL: Disrupted sleep patterns and daily functioning in patients with chronic pain. Pain Res Manag. 2002; 7: 75-79.

Cremeans-Smith JK, Millington K, Sledjeski E, et al.: Sleep disruptions mediate the relationship between early postoperative pain and later functioning following total knee replacement. J Behav Med. 2006; 29(2): 215-222.

Wylde V, Rooker J, Halliday L, et al.: Acute postoperative pain at rest after hip and knee arthroplasty: Severity, sensory qualities and impact on sleep. Orthop Traumatol: Surg Res. 2011; 97: 139-144.

Roehrs T, Hyde M, Blaisdell B, et al.: Sleep loss and REM sleep loss are hyperalgesic. Sleep. 2006; 29(2): 145-151.

Merlotti L, Roehrs T, Koshorek G, et al.: The dose effects of zolpidem on the sleep of healthy normal. J Clin Psychopharmacol. 1989; 9(1): 9-14.

Hadjiconstantinou M, Neff NH: Nicotine and endogenous opioids: Neurochemical and pharmacological evidence. Neuropharmacology. 2011; 60: 1209-1220.

Malin DH, Lake JR, Carter VA: The nicotinic antagonist mecamylamine precipitates nicotine abstinence syndrome in the rat. Psychopharmacology (Berl). 1994; 115(1-2): 180-184.

Ise Y, Narite M, Nagase H, et al.: Modulation of opioidergic system on mecamylamine-precipitated nicotine-withdrawal aversion in rats. Psychopharmacology (Berl). 2000; 151(1): 49-54.

Biala G, Staniak N: Varenicline and mecamylamine attenuate locomotor sensitization and cross-sensitization induced by nicotine and morphine in mice. Pharmacol Biochem Behav. 2010; 96: 141-147.

Trigo JM, Zimmer A, Maldonado R: Nicotine anxiogenic and rewarding effects are decreased in mice lacking _-endorphin. Neuropharmacology. 2009; 56: 1147-1153.

Holtman JR Jr, Crooks PA, Johnson-Hardy JK, et al.: The analgesic and toxic effects of nornicotine enantiomers alone and in interaction with morphine in rodent models of acute and persistent pain. Pharmacol Biochem Behav. 2010; 94: 352-362.

Rowley TJ, Payappilly J, Lu J, et al.: The antinociceptive response to nicotine agonists in a mouse model of postoperative pain. Anesth Analg. 2008; 107(3): 1052-1057.

Flood P, Daniel D: Intranasal nicotine for postoperative pain treatment. Anesthesiology. 2004; 101: 1417-1421.

Damaj MG, Glassco W, Aceto MD, et al.: Antinociceptive and pharmacological effects of metanicotine, a selective nicotinic agonist. J Pharmacol Exp Therap. 1999; 291: 390-398.

Bannon AW, Decker MW, Holladay MW, et al.: Broad-spectrum, non-opioid analgesic activity by selective modulation of neuronal nicotinic acetylcholine receptors. Science. 1998; 279: 77-81.



  • There are currently no refbacks.