Perioperative Care Considerations for Patients with Cannabis Use

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Perioperative Care Considerations for Patients with Cannabis Use

Elizabeth M. Leimer, MD, PhD; Brandon Togioka, MD

Background

Cannabis use has increased substantially over the past 20 years, largely driven by increased availability and decreased cost. Currently, cannabis is recreationally legal in 21 states and medically legal in 38 states.1 Over the past 30 years, the potency of cannabis has increased 3-fold.2 It is likely that surgical teams will encounter patients who use cannabis.

In one study, 5.9% of surgical patients reported cannabis use in the month preceding surgery.3 Greater than 80% of patients believe cannabis provides effective postoperative analgesia,4 which is contrary to evidence that cannabis use makes postoperative pain management more difficult. It should be acknowledged that the relationship between cannabidiol (CBD) and tetrahydrocannabinol (THC) content of cannabis products and outcomes in the perioperative period are not fully elucidated. This brief is intended to help practitioners with preoperative risk assessment, intraoperative anesthetic planning, and postoperative pain management for patients using cannabis.

Perioperative Considerations by System

Neurological considerations

  • Chronic cannabis use may lead to deficits across several cognitive domains, including verbal learning and memory, executive functioning, working memory, and decision-making.8
  • Anesthetic induction and maintenance doses may need to be adjusted in chronic cannabis users.
    • One randomized, single-blind study found that chronic cannabis users required an increased propofol dose for successful laryngeal mask airway insertion compared to non-cannabis users.9
  • Acute cannabis intoxication may cause lethargy, ataxia (movement without coordination), hyperkinesis (excessive purposeless movement), tachypnea, tachycardia, and hypertension.5
  • THC is a central nervous system depressant, which may synergistically interact with anesthetic medications to depress consciousness and delay emergence.6,7

Post-operative pain considerations

  • Regular cannabis use may worsen pain and increase postoperative opioid requirements.
    • In one prospective study, cannabis users reported worse pain and greater functional impairment on the day of surgery and at 3- and 6-months post-surgery compared to non-cannabis users. The average daily oral morphine equivalents did not differ between groups at any timepoint.3
    • A retrospective study found that cannabis users had a higher opioid requirement in the 36 hours after hip or knee arthroplasty compared to non-cannabis users.10

Cardiovascular considerations

  • Regular active cannabis use at the time of surgery may be associated with an increased risk of postoperative myocardial infarction (MI), arrhythmias, cardiac arrest, cardiomyopathy, and stroke.3
    • A retrospective cohort study utilizing the Nationwide Inpatient Sample (NIS) demonstrated that the odds of postoperative MI are twice as high amongst patients with active chronic cannabis use compared to non-cannabis users. This study also showed that these patients may have a higher risk of experiencing a cerebrovascular event.11
    • Another retrospective cohort study utilizing the NIS demonstrated a higher incidence of perioperative MI and stroke in active cannabis users undergoing vascular surgery compared to non-cannabis users.12
  • Acute cannabis intoxication may increase risk for perioperative cardiac complications. Acute THC administration is associated with tachycardia and increased cardiac index.
    • Two prospective cohort studies demonstrated dose-related tachycardia after administration of THC intravenously13,14 with the highest dose leading to a heart rate 36% higher than that of the placebo group and which remained elevated compared to the placebo group after 100 minutes.14
    • A retrospective case-crossover analysis demonstrated that the risk of MI one hour after smoking marijuana is increased almost 5-fold compared to baseline.15

Respiratory considerations

  • Cannabis smoke contains many toxic substances including acetaldehyde, hydrogen cyanide, and nitrogen oxides.16
  • Smoking cannabis may increase the risk of postoperative respiratory complications and active use is associated with the development of obstructive respiratory pathology.
    • A prospective cohort study demonstrated that cannabis use is associated with reduced FEV1/FVC, increased lung capacity, wheezing, cough, chronic bronchitis, and asthma compared to non-cannabis users.17

Gastrointestinal considerations

  • Regular cannabis use may be associated with changes in the gastrointestinal tract, including delayed gastric emptying, delayed gastric motility, cyclical vomiting, and cannabis hyperemesis syndrome.
  • Cannabis is commonly used to treat chemotherapy induced nausea and vomiting,18 but the efficacy of cannabis for treating postoperative nausea and vomiting (PONV) has not been established.
    • One retrospective cohort study demonstrated an association between active chronic cannabis use and an increased incidence of postoperative nausea and vomiting.19

Preoperative Testing

  • Preoperative testing for the presence of THC can be accomplished with a urine sample. However, currently available urine metabolite tests are unable to determine the dose ingested, the timing of ingestion, or the degree of intoxication.20
  • The 8-item revised Cannabis Use Disorders Identification Test (CUDIT-R) screening tool has been validated and used to identify cannabis use disorder.21

Bottom Line

  • Perioperative physicians are likely to encounter patients with acute cannabis intoxication and patients engaging in frequent and prolonged cannabis use.
  • The American Society of Regional Anesthesia (ASRA) and Pain Medicine provides

guidelines for treating patients who use cannabis.

American Society of Regional Anesthesia (ASRA) and Pain Medicine recommendations:22

For patients with acute cannabis intoxication:

Grade A recommendation

  • Elective surgery should be postponed or cancelled when patients show evidence of acute intoxication such as altered mental status or impaired decision-making capacity.

For patients with chronic cannabis use:

Grade A recommendations

  • All preoperative patients should be queried for cannabis use, including product type, amount and frequency, time and route of last consumption.
  • Patients should be counseled on potential negative effects on postoperative pain control.
  • Pregnant patients should be counseled regarding the risks of maternal cannabis on the fetus/neonate.

Grade B recommendations

  • Preoperative patients should be counseled on the risks of continued cannabis use. These should be multidisciplinary risk-benefit discussions involving the surgeon, anesthesiologist, and patient.
  • Cannabis use during pregnancy and immediately postpartum should be discouraged.

Grade C recommendations

  • For patients with regular cannabis use that present for surgery without altered mental status, non-emergent surgery should be delayed a minimum of 2 hours after cannabis smoking due to increased risk of perioperative MI.
  • Medication doses for induction and maintenance of anesthesia may need to be adjusted based on clinical presentation and history of cannabis use including product type and time of last use.
  • Multimodal analgesia should be implemented and incorporate regional analgesia as appropriate.
  • Frequent cannabis users should be monitored for cannabis withdrawal in the postoperative period.
  • Postoperative cannabis withdrawal can be treated with low dose dronabinol, a cannabinoid agonist.

Suggested Citation: Leimer ME and Togioka B. Perioperative Care Considerations for Patients with Cannabis Use. The Systematically Testing the Evidence on Marijuana Project; November 2023. Accessed (Month DD, YYYY). https://www.cannabisevidence.org/clinician-resources/clinician-briefs/perioperative-care/

Author Affiliations: Both authors are affiliated with Oregon Health & Science University.

Acknowledgements: Thank you to Avital O’Glasser, MD, FACP, SFHM, DFPM and Esther Choo, MD MPH for critically reviewing this document.

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Citations

1. Report: State Medical Cannabis Laws. National Conference of State Legislatures. June 22, 2023. Accessed October 30, 2023. https://www.ncsl.org/health/state-medical-cannabis-laws.

2. Delta-9-tetrahydrocannabinol (THC) and Cannabidiol (CBD) Potency of Cannabis Samples Seized by the Drug Enforcement Administration (DEA), Percent Averages from 1995-2021. Potency Monitoring Program, Quarterly Report # 153, NIDA Contract Number: N01DA-15-7793.

3. McAfee J, Boehnke KF, Moser SM, Brummett CM, Waljee JF, Bonar EE. Perioperative cannabis use: a longitudinal study of associated clinical characteristics and surgical outcomes. Reg Anesth Pain Med. 2021;46(2):137-144. doi:10.1136/rapm-2020-101812

4. Khelemsky Y, Goldberg AT, Hurd YL, et al. Perioperative Patient Beliefs Regarding Potential Effectiveness of Marijuana (Cannabinoids) for Treatment of Pain: A Prospective Population Survey. Reg Anesth Pain Med. 2017;42(5):652-659. doi:10.1097/AAP.0000000000000654

5. AMES F. A clinical and metabolic study of acute intoxication with Cannabis sativa and its role in the model psychoses. J Ment Sci. 1958;104(437):972-999. doi:10.1192/bjp.104.437.972

6. Frizza J, Chesher GB, Jackson DM, Malor R, Starmer GA. The effect of delta 9-tetrahydrocannabinol, cannabidiol, and cannabinol on the anaesthesia induced by various anaesthetic agents in mice. Psychopharmacology (Berl). 1977;55(1):103-107. doi:10.1007/BF00432824

7. Chesher GB, Jackson DM, Starmer GA. Interaction of cannabis and general anaesthetic agents in mice. Br J Pharmacol. 1974;50(4):593-599. doi:10.1111/j.1476-5381.1974.tb08594

8. Dellazizzo L, Potvin S, Giguère S, Dumais A. Evidence on the acute and residual neurocognitive effects of cannabis use in adolescents and adults: a systematic meta-review of meta-analyses. Addiction. 2022;117(7):1857-1870. doi:10.1111/add.15764

9. Flisberg P, Paech MJ, Shah T, Ledowski T, Kurowski I, Parsons R. Induction dose of propofol in patients using cannabis. Eur J Anaesthesiol. 2009;26(3):192-195. doi:10.1097/EJA.0b013e328319be59

10. Liu CW, Bhatia A, Buzon-Tan A, et al. Weeding Out the Problem: The Impact of Preoperative Cannabinoid Use on Pain in the Perioperative Period. Anesth Analg. 2019;129(3):874-881. doi:10.1213/ANE.0000000000003963

11. Goel A, McGuinness B, Jivraj NK, et al. Cannabis Use Disorder and Perioperative Outcomes in Major Elective Surgeries: A Retrospective Cohort Analysis. Anesthesiology. 2020;132(4):625-635. doi:10.1097/ALN.0000000000003067

12. McGuinness B, Goel A, Elias F, Rapanos T, Mittleman MA, Ladha KS. Cannabis use disorder and perioperative outcomes in vascular surgery. J Vasc Surg. 2021;73(4):1376-1387.e3. doi:10.1016/j.jvs.2020.07.094

13. Malit LA, Johnstone RE, Bourke DI, Kulp RA, Klein V, Smith TC. Intravenous delta9-Tetrahydrocannabinol: Effects of ventilatory control and cardiovascular dynamics. Anesthesiology. 1975;42(6):666-673

14. Gregg JM, Campbell RL, Levin KJ, Ghia J, Elliott RA. Cardiovascular effects of cannabinol during oral surgery. Anesth Analg. 1976;55(2):203-213. doi:10.1213/00000539-197603000-00017

15. Mittleman MA, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering myocardial infarction by marijuana. Circulation. 2001;103(23):2805-2809. doi:10.1161/01.cir.103.23.2805

16. Moir D, Rickert WS, Levasseur G, et al. A comparison of mainstream and sidestream marijuana and tobacco cigarette smoke produced under two machine smoking conditions. Chem Res Toxicol. 2008;21(2):494-502. doi:10.1021/tx700275p

17. Aldington S, Williams M, Nowitz M, et al. Effects of cannabis on pulmonary structure, function and symptoms [published correction appears in Thorax. 2008 Apr;63(4):385]. Thorax. 2007;62(12):1058-1063. doi:10.1136/thx.2006.077081

18. Smith LA, Azariah F, Lavender VT, Stoner NS, Bettiol S. Cannabinoids for nausea and vomiting in adults with cancer receiving chemotherapy. Cochrane Database Syst Rev. 2015;2015(11):CD009464. Published 2015 Nov 12. doi:10.1002/14651858.CD009464.pub2

19. Suhre W, O’Reilly-Shah V, Van Cleve W. Cannabis use is associated with a small increase in the risk of postoperative nausea and vomiting: a retrospective machine-learning causal analysis. BMC Anesthesiol. 2020;20(1):115. Published 2020 May 18. doi:10.1186/s12871-020-01036-4

20. Connors N, Kosnett MJ, Kulig K, Nelson LS, Stolbach AI. ACMT Position Statement: Interpretation of Urine for Tetrahydrocannabinol Metabolites. J Med Toxicol. 2020;16(2):240-242. doi:10.1007/s13181-019-00753-8

21. Adamson SJ, Kay-Lambkin FJ, Baker AL, et al. An improved brief measure of cannabis misuse: the Cannabis Use Disorders Identification Test-Revised (CUDIT-R). Drug Alcohol Depend. 2010;110(1-2):137-143. doi:10.1016/j.drugalcdep.2010.02.017

22. Shah S, Schwenk ES, Sondekoppam RV, et al. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med. 2023;48(3):97-117. doi:10.1136/rapm-2022-104013

Page Last Reviewed:  December 2023