Medical cannabis: considerations for the anesthesiologist and pain physician

Cannabinoid Analgesia in Postoperative Pain Management: From Molecular Mechanisms to Clinical Reality

Postoperative pain (POP) is a challenging clinical phenomenon that affects the majority of surgical patients and demands effective management to mitigate adverse outcomes such as persistent pain. The primary goal of POP management is to alleviate suffering and facilitate a seamless return to normal function for the patient. Despite compelling evidence of its drawbacks, opioid analgesia remains the basis of POP treatment. Novel therapeutic approaches rely on multimodal analgesia, integrating different pharmacological strategies to optimize efficacy while minimizing adverse effects. The recognition of the imperative role of the endocannabinoid system in pain regulation has prompted the investigation of cannabinoid compounds as a new therapeutic avenue. Cannabinoids may serve as adjuvants, enhancing the analgesic effects of other drugs and potentially replacing or at least reducing the dependence on other long-term analgesics in pain management. This narrative review succinctly summarizes pertinent information on the molecular mechanisms, clinical therapeutic benefits, and considerations associated with the plausible use of various cannabinoid compounds in treating POP. According to the available evidence, cannabinoid compounds modulate specific molecular mechanisms intimately involved in POP. However, only two of the eleven clinical trials that evaluated the efficacy of different cannabinoid interventions showed positive results.

Overview: Chronic Pain and Cannabis-Based Medicines

Chronic pain is primarily conceptualized as a disease in its own right when it is associated with emotional distress and functional impairment. Pathophysiologically, dysfunction of the cortico-mesolimbic connectome is of major importance, with overlapping signals in the nociceptive and stress systems. The endocannabinoid system plays an important role in the central processing of nociceptive signals and regulates the central stress response. Clinically, there is moderate evidence that cannabis-based medicines (CBM) can contribute to a significant reduction in pain, especially the associated pain affect, and improvement in physical function and sleep quality in a proportion of patients with chronic pain. The analgesic effect appears to be largely independent of the cause of pain. In this context, CBM preferentially regulates stress-associated pain processing.

The Quebec Cannabis Registry: Investigating the Safety and Effectiveness of Medical Cannabis

Objective: To investigate the safety and effectiveness of medical cannabis (MC) in the real-world clinical practice setting. Design: A 4-year prospective noncomparative registry of adult patients who initiated MC for a variety of indications. This paper reports on patients followed for up to 12 months, with interim visits at 3, 6, and 9 months after enrollment. Setting: Public or private outpatient clinics certified to authorize MC in the province of Quebec, Canada. Participants: Overall, 2991 adult (age ≥18 years) patients (mean age 51 years; 50.2% women) were enrolled between May 2015 and October 2018, with the last follow-up ending in May 2019. Interventions/Exposures: Cannabis products (dried, oil, or other) purchased from a Canadian licensed cannabis producer as authorized by physicians. Main Outcome Measures: The primary outcomes were self-reported pain severity, interference and relief (Brief Pain Inventory [BPI]), symptoms using the Revised Edmonton Symptom Assessment System (ESAS-r) and health-related quality of life dimensions (EQ-5D-5L) at baseline and each follow-up visit. The secondary outcomes were self-reported adverse events (AEs) and characteristics of cannabis treatment. Results: All patient-reported outcomes (BPI, ESAS-r, and EQ-5D-5L) showed a statistically significant improvement at 3 months (all p<0.01), which was maintained or further improved (for pain interference, tiredness, and well-being) over the remainder of the 12-month follow-up. Results also revealed clinically significant improvements in pain interference and tiredness, anxiety, and well-being from baseline. There were 79 AE reports (77 patients), 16 met the regulatory definition of seriousness, in which only 8 AEs were certainly or probably related to MC. Conclusions: MC directed by physicians appears to be safe and effective within 3 months of initiation for a variety of medical indications.

Perceptions and Preoccupations of Patients and Physicians Regarding Use of Medical Cannabis as an Intervention Against Chronic Musculoskeletal Pain: Results from a Qualitative Study

Objective

Explore perceptions and preoccupations regarding use of medical cannabis against chronic musculoskeletal pain, among patients and physicians.

Design

Qualitative study using interviews with patients and physicians, based on the Theory of Planned Behavior (TPB).

Setting

The study was conducted in Quebec, Canada, in spring 2020.

Subjects

We included 27 adult patients and 11 physicians (GPs, anesthesiologists, psychiatrists, and a rheumatologist); the mean age of patients was 48.2 years; 59.3% of patients and 36.4% of physicians were women; 59.3% of patients used no medical cannabis at the time of study; 45.5% of physicians had never authorized it.

Methods

Semi-structured interviews were conducted, transcribed and for the qualitative analysis codes were developed in a hybrid, inductive and deductive approach. Guided by the TPB, facilitators and barriers, perceived benefits and harms, and perceived norms that may influence cannabis use or authorization were documented.

Results

Although medical cannabis is an interesting avenue for the relief of chronic musculoskeletal pain, doctors and patients agreed that it remained a last line option, due to the lack of scientific evidence regarding its safety and efficacy. The norms surrounding medical cannabis also play an important role in the social and professional acceptance of this therapeutic option.

Conclusion

Medical cannabis is seen as a last line option among interventions in the management of chronic pain, and attitudes and prior experiences play a role in the decision to use it. Study results may contribute to improved shared decision making between patients and physicians regarding this option.

Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions

Background

Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians.

Objectives

Little is known about patients’ perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O’Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP.

Methods

Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients’ perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients’ demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies.

Results

Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being.

In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation.

Conclusion

MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-021-00096-8.

Impact of recreational cannabis legalization on patient self-reporting of cannabis use at a pharmacist-led primary care clinic

BACKGROUND

The Cannabis Act, introduced in Canada in 2018, legalized the use of recreational cannabis. The impact of the announcement and implementation of this act on patient self-reporting of cannabis use has not been explored.

OBJECTIVE

The study objective was to determine if patient self-reported cannabis use increased after the announcement and implementation of legislative changes to legalize recreational cannabis.

METHODS

A repeated cross-sectional design was used for a retrospective chart review of patients seen at a pharmacist-led primary care clinic. A convenience sample of patient records was divided into 3 panels, corresponding with the preannouncement (November 1, 2013-October 4, 2015), postannouncement (October 5, 2015-October 16, 2018), and postimplementation (October 17, 2018-October 17, 2019) stages of the legalization of recreational cannabis. Search terms used included cannabis, marijuana, marihuana, recreational drugs, natur∗, medicinal, pot, joint, oil, butter, brownies, edibles, cannabin∗, THC, tetrahydro∗, sativa, and indica (∗ = string wild card). The frequency of reporting use and the number of queries related to cannabis were assessed. The analysis of variance test and Pearson correlation (chi-square) were used to compare the 3 panels.

RESULTS

A total of 298 patient charts were included in the analysis. One hundred, 99, and 99 patient charts corresponded with panels 1, 2, and 3, respectively. At each time point, 6%, 8%, and 14% of the patients reported cannabis use (P = 0.03). A statistically significant increase in topical oil use and a decrease in prescription tablet or capsule use between panels 1 and 3 (P = 0.036) were identified.

CONCLUSION

This study found an increase in self-reporting of cannabis use across the 3 consecutive panels. The change in the product formulations used may reflect the various products available. Frontline pharmacists are encouraged to initiate conversations regarding cannabis use as part of routine practice.

Anesthesia for Patients Who Self-Report Cannabis (Marijuana) Use Before Esophagogastroduodenoscopy: A Retrospective Review

Increasing numbers of patients are using cannabis before procedures that require anesthesia. This study set out to examine the impact of cannabis use on anesthetic agent requirements, associated cardiac and respiratory morbidity, and overall satisfaction levels in patients undergoing esophagogastroduodenoscopy (EGD). This involved a retrospective review of patients undergoing EGD at a single center. Fortyseven, self-reported cannabis users were identified and 23 were successfully cross-matched with control participants for comparison purposes. The Wilcoxon signed rank test was used to evaluate differences in propofol administration between the 2 groups, and the McNemar test was used to test for differences in fentanyl and ketamine administration. No statistically significant differences were observed in propofol, fentanyl, or ketamine administration in the cannabis group compared with the control group. No adverse cardiac or respiratory events were reported within 30 days for either group. This study was specific to EGD procedures of short duration, and larger studies are needed to confirm results of no consequence in cannabis users undergoing anesthesia. Future studies should consider cannabis users who undergo anesthesia for diverse procedure types of various durations.

The model of care at a leading medical cannabis clinic in Canada

Medical cannabis access has been legalized in more than 30 countries worldwide and popularity among patients is increasing rapidly. Cannabinoid-based treatments have been shown to be beneficial for several symptoms such as chemotherapy-induced nausea and vomiting, spasticity, chronic pain, intractable seizures and insomnia, yet high-quality clinical trials are still limited. As millions of patients now have legal access to medical cannabis, little information is available about the development of best clinical practices and an effective medical cannabis clinic model. A medical cannabis clinic is an innovative and emergent practice model that may be necessary to bridge the gap between patient and healthcare provider interest and existing barriers to the prescription of medical cannabis treatments, such as limited medical education, lack of high-quality clinical research and challenging or evolving regulatory frameworks. In this paper, we describe the model of care and organization of a dedicated medical cannabis clinic operating in Quebec, Canada since 2014. We share the principles of medical cannabis practice, including the structure of its medical and support team, clinic organisation and procedure guidelines. Key clinic statistics and patient demographics are shared with year by year comparison. Operating since 2014, the clinic has endured a rapidly changing regulatory landscape in Canada, overcoming numerous challenges including medical and social stigma, limited funding, resources and institutional support combined with a high demand for services. To support medical cannabis leaders globally, an important knowledge-sharing is required. The clinic has expanded to a network of four clinic sites across Quebec and offers continuing education and preceptorships to health care providers and trainees as well as research services to both academic and industry partners. The description of the clinic offers guidance on medical cannabis treatment and care and discusses possible solutions to associated challenges. The clinic model of care can be adapted to different healthcare settings and regulatory frameworks; it may assist physicians and health care providers in the development of medical cannabis clinics or the implementation of best practices as medical cannabis access continues to evolve.

Evolving Global Perspectives of Pharmacists: Dispensing Medical Cannabis

Introduction: Different countries have employed a variety of methods for their populace to access medical cannabis. Objectives: The purpose of this literature review was to assess the international literature on pharmacists' beliefs and attitudes towards medical cannabis. Methodology: This literature review summarized the various countries that utilize pharmacies and pharmacists to dispense medical cannabis. The countries included in this review were: Australia, Canada, Denmark, Finland, Germany, Israel, Italy, Netherlands, Poland, Serbia, Switzerland, USA, and Uruguay. Discussion: The pharmacist perspective has been of key importance within the medical landscape, as they are the ones who not only dispense medication but also counsel and monitor patients and it is this perspective that is lacking. Conclusion: Overall, this review found that even though pharmacists are generally comfortable with dispensing medical cannabis; they still require further education to do so as safely and effectively as possible.

Phytocannabinoid Pharmacology: Medicinal Properties of Cannabis sativa Constituents Aside from the "Big Two"

Plant-based therapies date back centuries. Cannabis sativa is one such plant that was used medicinally up until the early part of the 20th century. Although rich in diverse and interesting phytochemicals, cannabis was largely ignored by the modern scientific community due to its designation as a schedule 1 narcotic and restrictions on access for research purposes. There was renewed interest in the early 1990s when the endocannabinoid system (ECS) was discovered, a complex network of signaling pathways responsible for physiological homeostasis. Two key components of the ECS, cannabinoid receptor 1 (CB1) and cannabinoid receptor 2 (CB2), were identified as the molecular targets of the phytocannabinoid Δ⁹-tetrahydrocannabinol (Δ⁹-THC). Restrictions on access to cannabis have eased worldwide, leading to a resurgence in interest in the therapeutic potential of cannabis. Much of the focus has been on the two major constituents, Δ⁹-THC and cannabidiol (CBD). Cannabis contains over 140 phytocannabinoids, although only a handful have been tested for pharmacological activity. Many of these minor cannabinoids potently modulate receptors, ionotropic channels, and enzymes associated with the ECS and show therapeutic potential individually or synergistically with other phytocannabinoids. The following review will focus on the pharmacological developments of the next generation of phytocannabinoid therapeutics.

Delta-9-Tetrahydrocannabinol and Cannabidiol Drug-Drug Interactions

Although prescribing information (PI) is often the initial source of information when identifying potential drug-drug interactions, it may only provide a limited number of exemplars or only reference a class of medications without providing any specific medication examples. In the case of medical cannabis and medicinal cannabinoids, this is further complicated by the fact that the increased therapeutic use of marijuana extracts and cannabidiol oil will not have regulatory agency approved PI. The objective of this study was to provide a detailed and comprehensive drug-drug interaction list that is aligned with cannabinoid manufacturer PI. The cannabinoid drug-drug interaction information is listed in this article and online supplementary material as a PRECIPITANT (cannabinoid) medication that either INHIBITS/INDUCES the metabolism or competes for the same SUBSTRATE target (metabolic enzyme) of an OBJECT (OTHER) medication. In addition to a comprehensive list of drug-drug interactions, we also provide a list of 57 prescription medications displaying a narrow therapeutic index that are potentially impacted by concomitant cannabinoid use (whether through prescription use of cannabinoid medications or therapeutic/recreational use of cannabis and its extracts).

High Doses of Δ9-Tetrahydrocannabinol Might Impair Irinotecan Chemotherapy: A Review of Potentially Harmful Interactions

This review proposes the hypothesis that the effectiveness of irinotecan chemotherapy might be impaired by high doses of concomitantly administered Δ⁹-tetrahydrocannabinol (THC). The most important features shared by irinotecan and THC, which might represent sources of potentially harmful interactions are: first-pass hepatic metabolism mediated by cytochrome P450 (CYP) enzyme CYP3A4; glucuronidation mediated by uridine diphosphate glycosyltransferase (UGT) enzymes, isoforms 1A1 and 1A9; transport of parent compounds and their metabolites via canalicular ATP-binding cassette (ABC) transporters ABCB1 and ABCG2; enterohepatic recirculation of both parent compounds, which leads to an extended duration of their pharmacological effects; possible competition for binding to albumin; butyrylcholinesterase (BChE) inhibition by THC, which might impair the conversion of parent irinotecan into the SN-38 metabolite; mutual effects on mitochondrial dysfunction and induction of oxidative stress; potentiation of hepatotoxicity; potentiation of genotoxicity and cytogenetic effects leading to genome instability; possible neurotoxicity; and effects on bilirubin. The controversies associated with the use of highly concentrated THC preparations with irinotecan chemotherapy are also discussed. Despite all of the limitations, the body of evidence provided here could be considered relevant for human-risk assessments and calls for concern in cases when irinotecan chemotherapy is accompanied by preparations rich in THC.

Medical cannabis in supportive cancer care: lessons from Canada

Medical cannabis, or cannabinoid-based products, continues to grow in popularity globally, driving the evolution of regulatory access frameworks; cancer patients and caregivers often rely on guidance from their physicians regarding cannabinoid-based treatments. But the majority of healthcare practitioners still feel unprepared and insufficiently informed to make reasonable, evidence-based recommendations about medical cannabis. More than 30 countries worldwide have now legalized access to medical cannabis; yet various nations still face arduous regulatory challenges to fulfill the needs of patients, healthcare practitioners, and other medical stakeholders. This has affected the deployment of comprehensive medical cannabis access programs adapted to cultural and social realities. With a 20-year history of legal medical cannabis access and nearly 400,000 registered patients under its federal access program, Canada serves as a model for countries which are developing their regulatory frameworks. The Canadian clinical experience in cannabinoid-based treatments is also a valuable source of lessons for healthcare professionals who wish to better understand the current evidence examining medical cannabis for oncology patients.

Medicinal cannabis for psychiatric disorders: a clinically-focused systematic review

BACKGROUND

Medicinal cannabis has received increased research attention over recent years due to loosening global regulatory changes. Medicinal cannabis has been reported to have potential efficacy in reducing pain, muscle spasticity, chemotherapy-induced nausea and vomiting, and intractable childhood epilepsy. Yet its potential application in the field of psychiatry is lesser known.

METHODS

The first clinically-focused systematic review on the emerging medical application of cannabis across all major psychiatric disorders was conducted. Current evidence regarding whole plant formulations and plant-derived cannabinoid isolates in mood, anxiety, sleep, psychotic disorders and attention deficit/hyperactivity disorder (ADHD) is discussed; while also detailing clinical prescription considerations (including pharmacogenomics), occupational and public health elements, and future research recommendations. The systematic review of the literature was conducted during 2019, assessing the data from all case studies and clinical trials involving medicinal cannabis or plant-derived isolates for all major psychiatric disorders (neurological conditions and pain were omitted).

RESULTS

The present evidence in the emerging field of cannabinoid therapeutics in psychiatry is nascent, and thereby it is currently premature to recommend cannabinoid-based interventions. Isolated positive studies have, however, revealed tentative support for cannabinoids (namely cannabidiol; CBD) for reducing social anxiety; with mixed (mainly positive) evidence for adjunctive use in schizophrenia. Case studies suggest that medicinal cannabis may be beneficial for improving sleep and post-traumatic stress disorder, however evidence is currently weak. Preliminary research findings indicate no benefit for depression from high delta-9 tetrahydrocannabinol (THC) therapeutics, or for CBD in mania. One isolated study indicates some potential efficacy for an oral cannabinoid/terpene combination in ADHD. Clinical prescriptive consideration involves caution in the use of high-THC formulations (avoidance in youth, and in people with anxiety or psychotic disorders), gradual titration, regular assessment, and caution in cardiovascular and respiratory disorders, pregnancy and breast-feeding.

CONCLUSIONS

There is currently encouraging, albeit embryonic, evidence for medicinal cannabis in the treatment of a range of psychiatric disorders. Supportive findings are emerging for some key isolates, however, clinicians need to be mindful of a range of prescriptive and occupational safety considerations, especially if initiating higher dose THC formulas.

Cannabis-based medicines and the perioperative physician

The increasing availability of cannabis for both recreational and medicinal purposes means that anaesthetists will encounter an increasing number of patients taking cannabis-based medications. The existing evidence base is conflicted and incomplete regarding the indications, interactions and long-term effects of these substances. Globally, most doctors have had little education regarding the pharmacology of cannabis-based medicines, despite the endocannabinoid system being one of the most widespread in the human body. Much is unknown, and much is to be decided, including clarifying definitions and nomenclature, and therapeutic indications and dosing. Anaesthetists, Intensivists, Pain and Perioperative physicians will want to contribute to this evidence base and attempt to harness such therapeutic benefits in terms of pain relief and opiate-avoidance, anti-emesis and seizure control. We present a summary of the pharmacology of cannabis-based medicines including anaesthetic interactions and implications, to assist colleagues encountering these medicines in clinical practice.

Medication Use and Pain Management in Pregnancy: A Critical Review

BACKGROUND

Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence-based recommendations for managing pain in pregnancy.

METHODS

A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases.

RESULTS

Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues.

CONCLUSIONS

Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.

A review of the anesthetic implications of marijuana use

Marijuana, derived from plants of the genus Cannabis, is the most commonly used illicit drug in the United States. Marijuana is illegal at the federal level and remains a Drug Enforcement Agency Schedule 1 substance. Nevertheless, most states have passed less stringent legislation related to its use, ranging from decriminalization of possession to allowing medical or even recreational use, and some county and municipal law enforcement agencies have refrained from prosecuting personal possession and/or use even when statute would require such action. Therefore, as use of marijuana becomes more common in the larger population, more patients who are chronic and/or heavy users of marijuana present for surgical procedures, raising the question of best practices to care for these patients in the perioperative period. This review summarizes the known physiologic effects of marijuana in humans, discusses potential implications of marijuana use that the anesthesiologist should consider at each phase of the perioperative period, and outlines recommendations for future study.

Should Cannabinoids Be Added to Multimodal Pain Regimens After Total Hip and Knee Arthroplasty?

BACKGROUND

This study investigated the effects of dronabinol on pain, nausea, and length of stay following total joint arthroplasty (TJA).

METHODS

We retrospectively compared 81 consecutive primary TJA patients who received 5 mg of dronabinol twice daily in addition to a standard multimodal pain regimen with a matched cohort of 162 TJA patients who received only the standard regimen. A single surgeon performed all surgeries. Patient demographics, length of stay, opioid morphine equivalents (MEs) consumed, reports of nausea/vomiting, discharge destination, distance walked in physical therapy, and visual analog scale pain scores were collected for both groups. Student's t-tests as well as chi-square or Mann-Whitney U-tests were used for statistical comparisons.

RESULTS

There were no significant differences between the 2 groups for age, gender, body mass index, American Society of Anesthesiologists score, anesthesia type, visual analog scale scores, distance walked with physical therapy, discharge disposition, or episodes of nausea/vomiting. The mean length of stay in the dronabinol group was significantly shorter at 2.3 ± 0.9 days versus 3.0 ± 1.2 days in the control group (P = .02). In the context of a shorter stay, the dronabinol group consumed significantly fewer total MEs (252.5 ± 131.5 vs 313.3 ± 185.4 mg, P = .0088). Although the dronabinol group consumed fewer MEs per day and per length of stay on average, neither of these achieved statistical significance. No side effects of dronabinol were reported.

CONCLUSION

These findings suggest that further investigation into the role of cannabinoid medications for non-opioid pain control in the post-arthroplasty patient may hold merit.

Perioperative Patient Beliefs Regarding Potential Effectiveness of Marijuana (Cannabinoids) for Treatment of Pain: A Prospective Population Survey

BACKGROUND AND OBJECTIVES

Cannabinoids have an expanding presence in medicine. Perioperative patients' perceptions of the effectiveness of these compounds, and acceptance if prescribed for pain, have not been previously described. Our primary objective was to describe patients' beliefs regarding the potential effectiveness of cannabinoids for the treatment of acute and chronic pain, as well as gauge patient acceptance of these compounds if prescribed by a physician. In addition, demographic and pain history data were collected to elucidate the predictors of the aforementioned patient attitudes. Secondarily, we sought to characterize the subgroup of patients who reported marijuana use. Predictors of marijuana use, effectiveness, and adverse effects were also reported for this subgroup.

METHODS

An anonymous questionnaire was administered to 501 patients in the preoperative registration area at Mount Sinai Hospital, New York, New York. The questionnaire was designed to collect data on patient demographics, presence of pain, pain severity, use of pain medication, history of illicit-drug use, tobacco use, cannabis use, patient beliefs about the potential effectiveness of marijuana for acute and chronic pain and their willingness to use cannabis for pain, if prescribed by a physician. Normality of distributions for continuous variables was assessed with skewness and kurtosis measures. A logistic regression model was used to assess the demographic and medical characteristics of marijuana users compared with nonusers. The effectiveness of marijuana in dealing with pain and adverse effects associated with its use were examined using exploratory principal component analysis.

RESULTS

More than 80% of this cohort of preoperative patients believed that marijuana could be at least somewhat effective for the treatment of pain after surgery and would be willing to use cannabinoid compounds if prescribed by their physician. Predictors of positive attitudes toward marijuana included history of marijuana use, pain history, and being a marijuana nonuser of white race. Approximately 27% of the respondents reported a history of marijuana use. Younger patients, those with higher levels of pain in the last 24 hours, and those who found standard therapies to be less effective for their pain were more likely to use marijuana.

CONCLUSIONS

Patients generally believe that marijuana could be at least somewhat effective for the management of pain and are willing to use cannabinoid compounds for this indication, if prescribed by a physician.

Medical Marijuana: Current Concepts, Pharmacological Actions of Cannabinoid Receptor Mediated Activation, and Societal Implications

PURPOSE OF REVIEW

The purpose of the following review is to summarize the history and current policies related to marijuana use and prevalence, basic and clinical science pharmacological literature regarding efficacy, subpopulations of concern, and varying policies regarding its use at present.

RECENT FINDINGS

With the increasingly widespread utilization of marijuana, there is also a growing complexity of public health policy, regulation, and necessity to further assess the medical indications and adverse long-term effects of marijuana use. Health care providers as well as the general public must be prepared to become familiar and up-to-date with medical literature, legislation, and educational material regarding medical marijuana.

Anesthetic implications of recreational drug use

PURPOSE

As the use of recreational drugs increases, the likelihood of an anesthesiologist perioperatively encountering patients using or addicted to these drugs will also increase.

PRINCIPAL FINDINGS

Addicted patients may present for anesthetic care in a variety of circumstances in everyday elective surgeries or in acute or life-saving situations, such as emergency Cesarean delivery or trauma surgery. Therefore, it is important for anesthesiologists to know about the most common illicit drugs being used, their clinical presentation and side effects, and the anesthetic options that are beneficial or detrimental to these patients. The most frequently used illicit substances, apart from alcohol and tobacco, are cannabis, cocaine, heroin, prescription opioids, methamphetamine, and hallucinogens. When planning anesthetic care, it is important for anesthesiologists to understand the effects of these agents, including various drug interactions, to predict tolerance to some anesthetic agents, to recognize drug withdrawal signs and symptoms, and to be prepared to manage all these factors in the perioperative period.

CONCLUSIONS

For optimal patient care through the perioperative period, it is critical to obtain information about patient drug use and other associated treatment in order to construct an appropriate anesthetic plan, including specific considerations during surgery, emergence, and in the postanesthesia care unit.

A user's guide to cannabinoid therapies in oncology

"Cannabinoid" is the collective term for a group of chemical compounds that either are derived from the Cannabis plant, are synthetic analogues, or occur endogenously. Although cannabinoids interact mostly at the level of the currently recognized cannabinoid receptors, they might have cross reactivity, such as at opioid receptors. Patients with malignant disease represent a cohort within health care that have some of the greatest unmet needs despite the availability of a plethora of guideline-driven disease-modulating treatments and pain and symptom management options. Cannabinoid therapies are varied and versatile, and can be offered as pharmaceuticals (nabilone, dronabinol, and nabiximols), dried botanical material, and edible organic oils infused with cannabis extracts. Cannabinoid therapy regimens can be creative, involving combinations of all of the aforementioned modalities. Patients with malignant disease, at all points of their disease trajectory, could be candidates for cannabinoid therapies whether as monotherapies or as adjuvants. The most studied and established roles for cannabinoid therapies include pain, chemotherapy-induced nausea and vomiting, and anorexia. Moreover, given their breadth of activity, cannabinoids could be used to concurrently optimize the management of multiple symptoms, thereby reducing overall polypharmacy. The use of cannabinoid therapies could be effective in improving quality of life and possibly modifying malignancy by virtue of direct effects and in improving compliance or adherence with disease-modulating treatments such as chemotherapy and radiation therapy.