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SCREEN ALL PATIENTS FOR CANNABIS USE BEFORE SURGERY: GUIDELINE

Jake Remaly

January 09, 2023

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If you smoke, vape, or ingest cannabis, your anesthesiologist should know before
you undergo a surgical procedure, according to new medical guidelines.

All patients who undergo procedures that require regional or general anesthesia
should be asked if, how often, and in what forms they use the drug, according to
recommendations from the American Society of Regional Anesthesia and Pain
Medicine (ASRA).



One reason: Patients who regularly use cannabis may experience worse pain and
nausea after surgery and may require more opioid analgesia, the group said.

The society's recommendations ― published last week in Regional Anesthesia and
Pain Medicine ― are the first guidelines in the United States to cover cannabis
use as it relates to surgery, the group said.




POSSIBLE INTERACTIONS

Use of cannabis has increased in recent years, and researchers have been
concerned that the drug may interact with anesthesia and complicate pain
management. Few studies have evaluated interactions between cannabis and
anesthetic agents, however, according to the authors of the new guidelines.

SUGGESTED for you




"With the rising prevalence of both medical and recreational cannabis use in the
general population, anesthesiologists, surgeons, and perioperative physicians
must have an understanding of the effects of cannabis on physiology in order to
provide safe perioperative care," the guideline said.

"Before surgery, anesthesiologists should ask patients if they use cannabis ―
whether medicinally or recreationally ― and be prepared to possibly change the
anesthesia plan or delay the procedure in certain situations," Samer Narouze,
MD, PhD, ASRA president and senior author of the guidelines, said in a news
release about the recommendations.



Although some patients may use cannabis to relieve pain, research shows that
"regular users may have more pain and nausea after surgery, not less, and may
need more medications, including opioids, to manage the discomfort," Narouze,
chairman of the Center for Pain Medicine at Western Reserve Hospital in Cuyahoga
Falls, Ohio, said.


RISKS FOR VOMITING, HEART ATTACK

The new recommendations were created by a committee of 13 experts, including
anesthesiologists, chronic pain physicians, and a patient advocate. Shalini
Shah, MD, vice chair of anesthesiology at the University of California at Irvine
School of Medicine, was lead author of the document.

Four of 21 recommendations were classified as grade A, meaning that following
them would be expected to provide substantial benefits. Those recommendations
are to screen all patients before surgery; postpone elective surgery for
patients who have altered mental status or impaired decision-making capacity at
the time of surgery; counsel frequent, heavy users about the potential for
cannabis use to impair postoperative pain control; and counsel pregnant patients
about the risks of cannabis use to unborn children.



The authors cited studies to support their recommendations, including one
showing that long-term cannabis use was associated with a 20% increase in the
incidence of postoperative nausea and vomiting, a leading complaint of surgery
patients. Other research has shown that cannabis use is linked to more pain and
use of opioids after surgery.



Other recommendations include delaying elective surgery for at least 2 hours
after a patient has smoked cannabis, owing to an increased risk for heart
attack, and considering adjustment of ventilation settings during surgery for
regular smokers of cannabis. Research has shown that smoking cannabis may be a
rare trigger for myocardial infarction and is associated with airway
inflammation and self-reported respiratory symptoms.



Nevertheless, doctors should not conduct universal toxicology screening, given a
lack of evidence supporting this practice, the guideline stated.



The authors did not have enough information to make recommendations about
reducing cannabis use before surgery or adjusting opioid prescriptions after
surgery for patients who use cannabis, they said.



Kenneth Finn, MD, president of the American Board of Pain Medicine, welcomed the
publication of the new guidelines. Finn, who practices at Springs Rehabilitation
in Colorado Springs, Colorado, has edited a textbook about cannabis in medicine
and founded the International Academy on the Science and Impact of Cannabis.



"The vast majority of medical providers really have no idea about cannabis and
what its impacts are on the human body," Finn said.



For one, it can interact with numerous other drugs, including warfarin.



Guideline co-author Eugene R. Viscusi, MD, professor of anesthesiology at the
Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia,
emphasized that while cannabis may be perceived as "natural," it should not be
considered differently from manufactured drugs.



Cannabis and cannabinoids represent "a class of very potent and
pharmacologically active compounds," Viscusi told Medscape Medical News. While
researchers continue to assess possible medically beneficial effects of cannabis
compounds, clinicians also need to be aware of the risks.



"The literature continues to emerge, and while we are always hopeful for good
news, as physicians, we need to be very well versed on potential risks,
especially in a high-risk situation like surgery," he said.



Shah has consulted for companies that develop medical devices and drugs. Finn is
the editor of the textbook, "Cannabis in Medicine: An Evidence-Based Approach,"
(Springer), for which he receives royalties.



Reg Anesth Pain Med. Published online January 3, 2023. Full text



For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.


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Cite this: Screen All Patients for Cannabis Use Before Surgery:
Guideline - Medscape - Jan 09, 2023.

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