Open Access Open Access  Restricted Access Subscription or Fee Access

Postoperative pain scores and opioid consumption in opioid-dependent patients with cancer after intraoperative remifentanil analgesia: A prospective case-controlled study

Cyrus Motamed, MD, Juliette Audibert, MD, Aline Albi-Feldzer, MD, Gaelle Bouroche, MD, Christian Jayr, MD, PhD


Background: Opioid dependency is becoming increasingly common among surgical patients with cancer, and can lead to inadequate pain relief during the initial postoperative period. No guidelines are currently available for the management of perioperative and postoperative morphine administration in these patients. As a first approach, the authors assessed the opioid requirements of these patients during the early postoperative period.

Methods: A group of 35 consecutive surgical patients with cancer on opioid therapy (opioid-dependent group) for cancer pain were compared to a matched group of 44 surgical opioid-naive patients (control group). All patients underwent major head and neck or abdominal surgery. The following parameters were recorded and compared: preoperative and postoperative morphine consumption, patient-controlled analgesia records and Visual Analog Scale scores, intraoperative remifentanil and desflurane consumption, Bispectral Index monitoring values, heart rate, and blood pressure.

Results: Remifentanil requirements were significantly higher (1.4-fold) in the opioid-dependent group compared to the control group (p < 0.05). On postoperative day 1, morphine requirements were significantly higher in the opioid-dependent group (2.3-fold) compared to the control group (p < 0.05). Baseline heart rate was significantly higher in the opioid-dependent group and this difference remained significant during surgery, no significant difference in blood pressure was observed between the two groups.

Conclusion: This study shows a 40 percent increase of intraoperative remifentanil requirements in opioid-dependent patients during cancer surgery. Morphine requirements during the postoperative period were increased by up to 140 percent.


opioid therapy, remifentanil, morphine

Full Text:



Chapman CR, Donaldson G, Davis J, et al.: Postoperative pain patterns in chronic pain patients: A pilot study. Pain Med. 2009; 10(3): 481-487.

Roullet S, Nouette-Gaulain K, Biais M, et al.: Preoperative opioid consumption increases morphine requirement after leg amputation. Can J Anaesth. 2009; 56(12): 908-913.

Brill S: Managing surgical pain in long-term opioid patients. J Pain Palliative Care Pharmacother. 2013; 27(2): 185-187.

Hayhurst CJ, Durieux ME: Differential opioid tolerance and opioid-induced hyperalgesia: A clinical reality. Anesthesiology 2016; 124(2): 483-488.

Chu LF, Clark DJ, Angst MS: Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: A preliminary prospective study. J Pain. 2006; 7(1): 43-48.

Kouyanou K, Pither CE, Wessely S: Medication misuse, abuse and dependence in chronic pain patients. J Psychosom Res. 1997; 43(5): 497-504.

Egan TD: Remifentanil pharmacokinetics and pharmacodynamics. A preliminary appraisal. Clin Pharmacokinet. 1995; 29(2): 80-94.

Michelsen LG, Hug CC, Jr: The pharmacokinetics of remifentanil. J Clin. Anesth. 1996; 8(8): 679-682.

Westmoreland CL, Hoke JF, Sebel PS, et al.: Pharmacokinetics of remifentanil (GI87084B) and its major metabolite (GI90291) in patients undergoing elective inpatient surgery. Anesthesiology. 1993; 79(5): 893-903.

Rozen D, Grass GW: Perioperative and intraoperative pain and anesthetic care of the chronic pain and cancer pain patient receiving chronic opioid therapy. Pain Practice. 2005; 5(1): 18-32.

Koo CH, Cho YJ, Hong DM, et al.: Influence of high-dose intraoperative remifentanil with intravenous ibuprofen on postoperative morphine consumption in patients undergoing pancreaticoduodenectomy: A randomized trial. J Clin. Anesth. 2016; 35: 47-53.

Yu EH, Tran DH, Lam SW, et al.: Remifentanil tolerance and hyperalgesia: Short-term gain, long-term pain? Anaesthesia. 2016; 71(11): 1347-1362.

Salengros JC, Huybrechts I, Ducart A, et al.: Different anesthetic techniques associated with different incidences of chronic post-thoracotomy pain: Low-dose remifentanil plus presurgical epidural analgesia is preferable to high-dose remifentanil with postsurgical epidural analgesia. J Cardiothorac Vasc Anesth. 2010; 24(4): 608-616.

Brill S, Ginosar Y, Davidson EM: Perioperative management of chronic pain patients with opioid dependency. Curr Opin Anaesthesiol. 2006; 19(3): 325-331.

Loftus RW, Yeager MP, Clark JA, et al.: Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology. 2010; 113(3): 639-646.

Kopman AF, Yee PS, Neuman GG: Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997; 86(4): 765-771.

Minkowitz HS: Postoperative pain management in patients undergoing major surgery after remifentanil vs. fentanyl anesthesia. Multicentre Investigator Group. Can J Anaesth. 2000; 47(6): 522-528.

Chung F: Discharge criteria--a new trend. Can J Anaesth. 1995; 42(11): 1056-1058.

Angst MS, Clark JD: Ketamine for managing perioperative pain in opioid-dependent patients with chronic pain: A unique indication? Anesthesiology. 2010; 113(3): 514-515.

Gemes G, Rigaud M, Dean C, et al.: Baroreceptor reflex is suppressed in rats that develop hyperalgesia behavior after nerve injury. Pain. 2009; 146(3): 293-300.

Devys JM, Mora A, Plaud B, et al.: Intrathecal + PCA morphine improves analgesia during the first 24 hr after major abdominal surgery compared to PCA alone. Can J Anaesth. 2003; 50(4): 355-361.

Motamed C, Spencer A, Farhat F, et al.: Postoperative hypoxaemia: Continuous extradural infusion of bupivacaine and morphine vs patient-controlled analgesia with intravenous morphine. Br J Anaesth. 1998; 80(6): 742-747.

Chou R, Gordon DB, de Leon-Casasola OA, et al.: Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016; 17(2): 131-157.

Rapp SE, Ready LB, Nessly ML: Acute pain management in patients with prior opioid consumption: A case-controlled retrospective review. Pain. 1995; 61(2): 195-201.

Chapman CR, Davis J, Donaldson GW, et al.: Postoperative pain trajectories in chronic pain patients undergoing surgery: The effects of chronic opioid pharmacotherapy on acute pain. J Pain. 2011; 12(12): 1240-1246.

Derrode N, Lebrun F, Levron JC, et al.: Influence of peroperative opioid on postoperative pain after major abdominal surgery: Sufentanil TCI versus remifentanil TCI. A randomized, controlled study. Br J Anaesth. 2003; 91(6): 842-849.

Cortinas Saenz M, Geronimo Pardo M, Cortinas Saenz ML, et al.: Acute opiate tolerance and postoperative hyperalgesia after a brief infusion of remifentanil managed with multimodal analgesia. Revista Espanola Anestesiol Reanimacion. 2008; 55(1): 40-42.

Guignard B, Bossard AE, Coste C, et al.: Acute opioid tolerance: Intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology. 2000; 93(2): 409-417.

Hansen EG, Duedahl TH, Romsing J, et al.: Intra-operative remifentanil might influence pain levels in the immediate post-operative period after major abdominal surgery. Acta Anaesthesiol Scand. 2005; 49(10): 1464-1470.

Kim SH, Stoicea N, Soghomonyan S, et al.: Intraoperative use of remifentanil and opioid induced hyperalgesia/acute opioid tolerance: Systematic review. Front Pharmacol. 2014; 5: 108.

Lahtinen P, Kokki H, Hynynen M: Remifentanil infusion does not induce opioid tolerance after cardiac surgery. J Cardiothorac Vasc Anesth. 2008; 22(2): 225-229.

Lee LH, Irwin MG, Lui SK: Intraoperative remifentanil infusion does not increase postoperative opioid consumption compared with 70% nitrous oxide. Anesthesiology. 2005; 102(2): 398-402.

Fletcher D, Martinez V: Opioid-induced hyperalgesia in patients after surgery: A systematic review and a meta-analysis. Br J Anaesth. 2014; 112(6): 991-1004.

Vinik HR, Kissin I: Rapid development of tolerance to analgesia during remifentanil infusion in humans. Anesth Analg. 1998; 86(6): 1307-1311.

Larcher A, Laulin JP, Celerier E, et al.: Acute tolerance associated with a single opiate administration: Involvement of N-methyl-D-aspartate-dependent pain facilitatory systems. Neuroscience. 1998; 84(2): 583-589.

Celerier E, Laulin J, Larcher A, et al.: Evidence for opiate-activated NMDA processes masking opiate analgesia in rats. Brain Res. 1999; 847(1): 18-25.

de Leon-Casasola OA, Lema MJ: Epidural bupivacaine/sufentanil therapy for postoperative pain control in patients tolerant to opioid and unresponsive to epidural bupivacaine/morphine. Anesthesiology. 1994; 80(2): 303-309.

de Leon-Casasola OA, Myers DP, Donaparthi S, et al.: A comparison of postoperative epidural analgesia between patients with chronic cancer taking high doses of oral opioids versus opioid-naive patients. Anesth Analg. 1993; 76(2): 302-307.



  • There are currently no refbacks.