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Background and Aims The perioperative pain management of patients in a drug rehabilitation program is a challenge, as trying to meet their needs in analgesia without bypassing the rehabilitation program. The opioid free anesthesia is gaining ground for these patients lately. The recent entry of the NOL index (Nociception Level Index) may constitute valuable aid in the intraoperative assessment of analgesia.

Methods A 60-year-old man, with history of IV heroin dependence, in a methadone(70mg daily) rehabilitation program, ASA II, attended our hospital for cholecystectomy and bile duct exploration. Opioid free anesthesia was administered (according to Mulier protocol-Mullimix: 50μg dexmedetomidine, 500mg lidocaine, 50mg ketamine diluted in 100ml NS). Loading was done with 1μg/kg dexdemetomidine in 15 min and MgSO4 40mg/kg. Also parecoxib and dexamethasone were administered. Induction in anesthesia was carried out with Mullimix 0.2 ml/kg, propofol 2 mg/kg and rocuronium 0.6 mg/kg. The maintenance was done with desflurane and mullimix 0.2ml/kg/h initially, and the dose was titrated with maintaining the NOL ratio at values of 10-25. 2g of paracetamol were administered 30 min before the end of the operation and the wound was infiltrated with 40 ml of ropivacaine 0.375%. Methadone intake was continued throughout the perioperative period. Postoperative analgesia included paracetamol 4g and parecoxib 80mg daily.

Results Pain assessment was performed in the PACU, and every 4 hours for the first 48 hours with NRS values (numerical rate scale) < 4. The patient received no other opioids.

Conclusions Guided by analgesia monitoring, opioid free anesthesia can be an efficient method for patients in rehabilitation programs.