Impact of recreational and medicinal marijuana on surgical patients: A review

Association Between Marijuana Use and Clinical Outcomes After Coronary Artery Bypass Grafting

INTRODUCTION

Though marijuana use has been linked to an increase in heart failure admissions, no prior study has explored the association between its use and outcomes after coronary artery bypass grafting (CABG). This study examines the relationship between marijuana use and postoperative outcomes in CABG patients.

METHODS

We utilized data from the National Inpatient Sample database from 2008 to 2018 for CABG patients ≥18 y old. Patients were divided into two groups based on marijuana use (abuse/dependency versus nonuse). Primary outcomes include in-hospital mortality, favorable discharge, and length of stay (LOS). Secondary outcomes include acute kidney injury (AKI), acute myocardial infarction (AMI), and transient ischemic attack (TIA)/stroke. A multivariable model, adjusted for confounding variables, was utilized for each outcome.

RESULTS

A total of 343,796 patients met inclusion criteria for the study, 590 of which were marijuana users. In both marijuana user and nonuser groups, most patients were male and White with an average age of 56.0 and 66.3 y, respectively. There was a nonsignificant decreased odds of in-hospital mortality among marijuana users (odds ratio [OR] = 0.41, [0.141-1.124]). Marijuana users exhibited significantly decreased odds of home discharge (OR = 1.50, [1.24-1.81]), and increased odds of longer LOS (mean 10.4 d versus 9.8 d; OR = 1.14, [1.09-1.20]), AKI (OR = 1.40, [1.11-1.78]), AMI (OR = 1.56, [1.32-1.84]), and TIA/stroke (OR = 1.64, [1.21-2.22]).

CONCLUSIONS

Marijuana use and dependency are associated with increased nonhome discharge, AKI, AMI, TIA/stroke, and longer LOS. Further studies are needed to delineate the pathophysiologic derangements that contribute to these unfavorable post-CABG outcomes.

Peri-Operative Impact of Cannabis Use in Conjunction With Elective Primary Breast Augmentation in a Private Practice

Background The consumption of recreational and medicinal cannabis in the United States continues to increase. Understanding the effects of cannabis in patients undergoing elective primary breast augmentation (EPBA) is of paramount importance with the expanding rates of reported cannabis consumption. Objectives This study aims to analyze the peri-operative impact of cannabis use in conjunction with EPBA in a single-surgeon practice in San Francisco, California. Methods A retrospective chart review was performed of 134 adult female patients undergoing EPBA from August 2018 to January 2022 within a single-surgeon practice plastic surgery office. Cannabis use was self-reported as current use or former use. Cohorts were grouped as cannabis users and cannabis non-users. Results Of the 134 patient charts identified for analysis, 58 (43.3%) reported cannabis use. Cannabis users were significantly younger than cannabis non-users (26.8 years versus 31.5 years, P<0.001). No significant differences were found between groups among intra-operative blood loss, post-operative complication rates, post-operative narcotic use, or intra-operative anesthetic requirements. The incidence of adverse events, including wound breakdown, skin necrosis, and capsular contracture requiring reoperation, did not differ significantly between cannabis users and cannabis non-user groups. Ninety-six percent of patients had their implants placed subpectorally, and all procedures were done using a Keller funnel. Eighty-three percent of patients had Sientra implants, and 96% of all implants were silicone gel implants. All procedures were done under general anesthesia. Patients were followed for up to two years. Discussion This review found no significant differences in peri-operative and post-operative outcomes between cannabis users and cannabis non-users.

Cannabis smoking and abdominal wall reconstruction outcomes: a propensity score-matched analysis

PURPOSE

Despite increasing use of cannabis, literature on perioperative effects is lagging. We compared active cannabis-smokers versus non-smokers and postoperative wound morbidity and reoperations following open abdominal wall reconstruction (AWR).

METHODS

Patients who underwent open, clean, AWR with transversus abdominis release and retromuscular synthetic mesh placement at our institution between January 2014 and May 2022 were identified using the Abdominal Core Health Quality Collaborative database. Active cannabis-smokers were 1:3 propensity matched to non-smokers based on demographics and comorbidities. Wound complications, 30 day morbidity, pain (PROMIS 3a-Pain Intensity), and hernia-specific quality of life (HerQles) were compared.

RESULTS

Seventy-two cannabis-smokers were matched to 216 non-smokers. SSO (18% vs 17% p = 0.86), SSI (11.1% vs 9.3%, p = 0.65), SSOPI (12% vs 12%, p = 0.92), and all postoperative complications (46% vs 43%, p = 0.63) were similar between cannabis-smokers and non-smokers. Reoperations were more common in the cannabis-smoker group (8.3% vs 2.8%, p = 0.041), driven by major wound complications (6.9% vs 3.2%, p = 0.004). No mesh excisions occurred. HerQles scores were similar at baseline (22 [11, 41] vs 35 [14, 55], p = 0.06), and were worse for cannabis-smokers compared to non-smokers at 30 days (30 [12, 50] vs 38 [20, 67], p = 0.032), but not significantly different at 1 year postoperatively (72 [53, 90] vs 78 [57, 92], p = 0.39). Pain scores were worse for cannabis-smokers compared to non-smokers at 30 days postoperatively (52 [46, 58] vs 49 [44, 54], p = 0.01), but there were no differences at 6 months or 1 year postoperatively (p > 0.05 for all).

CONCLUSION

Cannabis smokers will likely experience similar complication rates after clean, open AWR, but should be counseled that despite similar wound complication rates, the severity of their wound complications may be greater than non-smokers.

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids

BACKGROUND

The past two decades have seen an increase in cannabis use due to both regulatory changes and an interest in potential therapeutic effects of the substance, yet many aspects of the substance and their health implications remain controversial or unclear.

METHODS

In November 2020, the American Society of Regional Anesthesia and Pain Medicine charged the Cannabis Working Group to develop guidelines for the perioperative use of cannabis. The Perioperative Use of Cannabis and Cannabinoids Guidelines Committee was charged with drafting responses to the nine key questions using a modified Delphi method with the overall goal of producing a document focused on the safe management of surgical patients using cannabinoids. A consensus recommendation required ≥75% agreement.

RESULTS

Nine questions were selected, with 100% consensus achieved on third-round voting. Topics addressed included perioperative screening, postponement of elective surgery, concomitant use of opioid and cannabis perioperatively, implications for parturients, adjustment in anesthetic and analgesics intraoperatively, postoperative monitoring, cannabis use disorder, and postoperative concerns. Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes.

CONCLUSIONS

Specific clinical recommendations for perioperative management of cannabis and cannabinoids were successfully created.

The Problem of Appetite Loss After Major Abdominal Surgery

Objective:

To systematically review the problem of appetite loss after major abdominal surgery.

Summary of Background Data:

Appetite loss is a common problem after major abdominal surgery. Understanding of etiology and treatment options is limited.

Methods:

We searched Medline, Cochrane Central Register of Controlled Trials, and Web of Science for studies describing postoperative appetite loss. Data were extracted to clarify definition, etiology, measurement, surgical influence, pharmacological, and nonpharmacological treatment. PROSPERO registration ID: CRD42021224489.

Results:

Out of 6144 articles, we included 165 studies, 121 of which were also analyzed quantitatively. A total of 19.8% were randomized, controlled trials (n = 24) and 80.2% were nonrandomized studies (n = 97). The studies included 20,506 patients undergoing the following surgeries: esophageal (n = 33 studies), gastric (n = 48), small bowel (n = 6), colon (n = 27), rectal (n = 20), hepatobiliary (n = 6), and pancreatic (n = 13). Appetite was mostly measured with the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ C30, n = 54). In a meta-analysis of 4 randomized controlled trials gum chewing reduced time to first hunger by 21.2 hours among patients who had bowel surgery. Other reported treatment options with positive effects on appetite but lower levels of evidence include, among others, intravenous ghrelin administration, the oral Japanese herbal medicine Rikkunshito, oral mosapride citrate, multidisciplin-ary-counseling, and watching cooking shows. No studies investigated the effect of well-known appetite stimulants such as cannabinoids, steroids, or megestrol acetate on surgical patients.

Conclusions:

Appetite loss after major abdominal surgery is common and associated with increased morbidity and reduced quality of life. Recent studies demonstrate the influence of reduced gastric volume and ghrelin secretion, and increased satiety hormone secretion. There are various treatment options available including level IA evidence for postoperative gum chewing. In the future, surgical trials should include the assessment of appetite loss as a relevant outcome measure.

Rates of self-directed perioperative cannabidiol use in patients undergoing total hip or knee arthroplasty

Aim: To evaluate the prevalence of self-directed cannabidiol (CBD) use in patients with end-stage degenerative hip and knee arthritis who underwent total hip arthroplasty and total knee arthroplasty. Materials & methods: Anonymous surveys for 109 patients were completed at 6 weeks follow-up after either total hip arthroplasty or total knee arthroplasty at a single tertiary care US orthopedic hospital. Results: Within the perioperative window encompassing both preoperative and postoperative periods, 22% (95% CI: 14-30%) of patients used CBD. Conclusion: There was no difference in pain satisfaction between patients who used CBD and patients who did not. Given high rates of self-directed perioperative CBD use and the mixed body of evidence, further research is needed to better understand whether CBD is safe and effective.

The Effects of Cannabis: Implications for the Surgical Patient

Background:

Cannabis use is increasingly prevalent. Cannabinoid receptors regulate pro-inflammatory cytokines, and compounds in marijuana exert diverse physiologic effects. As more patients use cannabis, clinicians should recognize implications of perioperative cannabis use. Although the role of cannabis use in perioperative pain control has been explored, little is known about its effect on perioperative wound healing or on hematologic, pulmonary, and cardiovascular physiology.

Methods:

We searched PubMed for English-language articles related to cannabis (ie, marijuana, cannabidiol oil, and tetrahydrocannabinol) and wound healing, cardiovascular, pulmonary, or hematologic outcomes, and surgery. Titles and abstracts were reviewed, and relevant articles were analyzed. Human, animal, and pathology studies were included. Editorials, case reports, and review articles were excluded.

Results:

In total, 2549 wound healing articles were identified; 5 human studies and 8 animal/pathology studies were included. Results were conflicting. An estimated 2900 articles related to cardiovascular effects were identified, of which 2 human studies were included, which showed tetrahydrocannabinol and marijuana caused tachycardia. A total of 142 studies regarding pulmonary effects were identified. Three human studies were included, which found no difference in respiratory complications. In total, 114 studies regarding hematologic effects were identified. The 3 included human studies found conflicting venous thromboembolism risks. The overall study quality was poor. Information about dose/duration, administration route, and follow-up was reported with variable completeness.

Conclusions:

Surgeons should consider effects of cannabis in the perioperative setting. Little is known about its perioperative effects on wound healing, or on cardiovascular, pulmonary, and hematologic physiology. Further research should elucidate the effects of administration route, dose, and timing of cannabis use among surgical patients.

The Quality of Online Resources Available to Patients Regarding Cannabidiol for Symptomatic Relief of Hip or Knee Arthritis is Poor

INTRODUCTION

This study aimed to assess the quality of online resources pertaining to cannabidiol (CBD) for the nonoperative management of hip and knee arthritis.

METHODS

Websites were identified on the three most popular global search engines using terms relevant to CBD, hip or knee pain, and arthritis. Websites were scored based on a 25-point scale regarding diagnosis, evaluation, and treatment of hip and knee pathologies.

RESULTS

The initial search yielded 287 results, and 94 websites were analyzed after meeting inclusion criteria. The average Flesch-Kincaid reading level was 48, corresponding to a college education level. Mean website score was poor at 7.46 (SD 3.51) of 25 (29.8%). Websites published by physicians had statistically higher scores (P = 0.03).

CONCLUSIONS

Many online resources regarding CBD use for hip and knee arthritis are available; however, the readability is more advanced than recommended by the National Institutes of Health. Very few resources are sponsored by physicians or professional organizations, and many are overtly sales oriented. Patients should be counseled that the information available online on this topic is generally unreliable. Surgeons and professional health organizations should play a stronger role in providing balanced resources to patients regarding CBD use for hip and knee arthritis.

Medicinal and Recreational Marijuana: Review of the Literature and Recommendations for the Plastic Surgeon

Supplemental Digital Content is available in the text.

With the shift in public opinion and legalization of cannabis for therapeutic and recreational use, cannabis consumption has become more common. This trend will likely continue as decriminalization and legalization of marijuana and associated cannabinoids expand. Despite this increase in use, our familiarity with this drug and its associated effects remains incomplete. The aim of this review is to describe the physiologic effects of marijuana and its related compounds, review current literature related to therapeutic applications and consequences, discuss potential side effects of marijuana in surgical patients, and provide recommendations for the practicing plastic surgeon. Special attention is given to areas that directly impact plastic surgery patients, including postoperative pain, nausea and vomiting and wound healing. Although the literature demonstrates substantial support for marijuana in areas such as chronic pain and nausea and vomiting associated with chemotherapy, the data supporting its use for common perioperative problems are lacking. Its use for treating perioperative problems, such as pain and nausea, is poorly supported and requires further research.

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).

Cannabis Abuse or Dependence and Post-operative Outcomes After Appendectomy and Cholecystectomy

BACKGROUND

Though cannabis is gaining broader acceptance among society and a noted increase in legalization, little is known regarding its impact on post-operative outcomes. We conducted this study to quantify the relationship between cannabis abuse or dependence (CbAD) on post-operative outcomes after cholecystectomy and appendectomy.

METHODS

Using the 2013-2015 Nationwide Readmissions Database, we identified discharges associated with cholecystectomy or appendectomy from January 2013-August 2015. Patients were grouped by CbAD history. The primary outcomes were length of stay, serious adverse events, home discharge, and 30-day readmission. Propensity-score matching was used to account for differences between groups and all statistics accounted for the matched sample.

RESULTS

The final sample included 3288 patients with a CbAD history matched 1:1 to patients without a CbAD history (total sample = 6576). After matching, acceptable balance was achieved in clinical characteristics between groups. In the cholecystectomy cohort (n = 1707 pairs), CbAD patients had longer hospitalizations (3.5 versus 3.2 d, P 0.003) and similar rates of serious adverse events (6.1 versus 4.8, P 0.092), home discharge (96.1 vs 96.2, P 0.855), and readmission (8.3 versus 6.9, P 0.137). In the appendectomy cohort (n = 1581 pairs), CbAD patients had longer hospital stays (2.7 versus 2.5 d, P 0.024); more frequent serious adverse events (5.0 versus 3.5, P 0.041); and similar home discharge (96.8 vs 97.3, P 0.404) and readmission (5.4 versus 5.1, P 0.639) rates.

CONCLUSIONS

Patients with a history of CbAD in the cholecystectomy and appendectomy cohorts had slightly longer hospital stays, and patients with a history of CbAD in the appendectomy group displayed a slight increase in adverse events, but otherwise similar clinical outcomes without clinically significant increases in complications compared to patients without this history.

Analgesic efficacy of cannabinoids for acute pain management after surgery: a systematic review and meta-analysis

Background

Evidence regarding the role of cannabinoids in managing acute postoperative pain is conflicting. The purpose of this systematic review and meta-analysis was to determine the analgesic efficacy of perioperative cannabinoid compounds for acute pain management after surgery.

Methods

Original research articles evaluating the addition of cannabinoids to standard opioid-based systemic analgesia (Control) in the postoperative period were sought. Our primary outcomes were cumulative oral morphine equivalent consumption and rest pain severity at 24 hours postoperatively. We also assessed analgesic consumption in the postanesthesia care unit (PACU), pain scores in PACU, 6 and 12 hours postoperatively, and opioid-related and cannabinoid-related side effects, patient satisfaction, and quality of recovery as secondary outcomes.

Results

Eight randomized controlled trials (924 patients) and four observational studies (4259 patients) were analyzed and included. There were insufficient data to pool for quantification of differences in cumulative oral morphine equivalent consumption and rest pain severity at 24 hours postoperatively with the addition of cannabinoids in comparison to Control. Qualitative synthesis revealed no differences in cumulative oral opioid consumption or pain at rest 24 hours postoperatively with the addition of cannabinoids in comparison to Control. Patients receiving cannabinoids appeared to have an increased weighted mean difference 95% CI of pain at 12 hours by 0.83 cm (0.04 to 1.63) (p=0.04). Patients receiving cannabinoids also appeared to have 3.24 times increased odds of developing hypotension postoperatively (95% CI 1.12 to 9.36) (p=0.03). Qualitative and quantitative synthesis revealed no differences in any other secondary outcomes.

Conclusions

Our quantitative and qualitative review of the literature suggests that the analgesic role of perioperative cannabinoid compounds is limited, with no clinically important benefits detected when cannabinoids are added to traditional systemic analgesics compared with traditional systemic analgesics alone. Notably, there appears to be a signal towards increased postoperative pain and hypotension associated with the addition of perioperative cannabinoids to traditional systemic analgesics. These results do not support the routine use of cannabinoids to manage acute postoperative pain at the present time.

The Effects of Marijuana Use on Lumbar Spinal Fusion

MINI: This study compared clinical and patient-reported outcomes following transforaminal lumbar interbody fusion between patients who use or do not use marijuana. We found that patients who use marijuana are younger, but do not demonstrate any differences in preoperative or postoperative Oswestry disability index scores or rates of fusion.

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The purpose of this study was to evaluate marijuana usage and its effect on outcomes following transforaminal lumbar interbody fusion (TLIF).

SUMMARY OF BACKGROUND DATA

As marijuana becomes legalized throughout the United States, its medicinal and recreational usage is becoming more mainstream. Clinicians currently have little guidance regarding both short-term and long-term effects of marijuana usage on surgical interventions. While the rate of lumbar spinal fusion in the United States continues to grow, the effect of marijuana usage on fusion remains uncertain.

METHODS

One hundred two patients who underwent TLIF performed by the same surgeon were followed for 12 months. Patients were self-reported for marijuana usage (n = 36). Patient reported outcome measures included preoperative Oswestry disability index (ODI), 6-month ODI, and 12-month ODI, as well as length of stay (LOS), complications, return to operating room (OR), revision surgery, and confirmed fusion. Continuous variables were compared using the independent two-sample t test or analysis of variance (ANOVA), whereas categorical variables were analyzed using the chi-square or Fischer exact tests. Adjusted analysis was performed using a multivariate logistic regression model.

RESULTS

Marijuana usage was associated with a younger population (P < 0.001), but showed no difference regarding sex or body mass index compared with the non-usage group. There was no statistically significant difference in complications, return to OR, or revision surgery between groups. When controlling for factors such as age and preoperative ODI, multivariate analysis demonstrated that marijuana usage did not limit postoperative ODI reduction. The marijuana usage group demonstrated shorter LOS (2.42 vs. 3.00 d, P = 0.020). Fusion rates at 12 months were similar between groups (96% vs. 92.3%, P = 0.678). ODI was similar between groups at all time points.

CONCLUSION

Perioperative outcomes were similar in patients who underwent TLIF regardless of marijuana usage.

LEVEL OF EVIDENCE

3.

Marijuana, Lower Urinary Tract Symptoms, and Pain in the Urologic Patient

OBJECTIVE

To describe marijuana's clinical role for urologic symptoms.

METHODS

Studies related to marijuana, voiding dysfunction, lower urinary tract symptoms (LUTS), and pain through January 2019 from PubMed were evaluated for relevance and quality.

RESULTS

Forty-eight studies were reviewed. Cannabinoids have mixed efficacy for neurogenic LUTS and little evidence for non-neurogenic LUTS, chronic non-cancer-related and perioperative pain. For cancer-related pain, high-level studies demonstrate cannabinoids are well-tolerated with unclear benefit.

CONCLUSION

Cannabinoids appear well-tolerated in the short-term, but their efficacy and long-term impact is unproven and unknown in urologic discomfort. Cannabinoids for urologic symptoms should be further explored with well-designed randomized controlled trials.