Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

The State of Synthetic Cannabinoid Medications for the Treatment of Pain

Synthetic cannabinoids are compounds made in the laboratory to structurally and functionally mimic phytocannabinoids from the Cannabis sativa L. plant, including delta-9-tetrahydrocannabinol (THC). Synthetic cannabinoids (SCs) can signal via the classical endogenous cannabinoid system (ECS) and the greater endocannabidiome network, highlighting their signalling complexity and far-reaching effects. Dronabinol and nabilone, which mimic THC signalling, have been approved by the Food and Drug Administration (FDA) for treating nausea associated with cancer chemotherapy and/or acquired immunodeficiency syndrome (AIDS). However, there is ongoing interest in these two drugs as potential analgesics for a variety of other clinical conditions, including neuropathic pain, spasticity-related pain, and nociplastic pain syndromes including fibromyalgia, osteoarthritis, and postoperative pain, among others. In this review, we highlight the signalling mechanisms of FDA-approved synthetic cannabinoids, discuss key clinical trials that investigate their analgesic potential, and illustrate challenges faced when bringing synthetic cannabinoids to the clinic.

Potential perioperative cardiovascular outcomes in cannabis/cannabinoid users. A call for caution

Background

Cannabis is one of the most widely used psychoactive substances. Its components act through several pathways, producing a myriad of side effects, of which cardiovascular events are the most life-threatening. However, only a limited number of studies address cannabis's perioperative impact on patients during noncardiac surgery.

Methods

Studies were identified by searching the PubMed, Medline, EMBASE, and Google Scholar databases using relevant keyword combinations pertinent to the topic.

Results

Current evidence shows that cannabis use may cause several cardiovascular events, including abnormalities in cardiac rhythm, myocardial infarction, heart failure, and cerebrovascular events. Additionally, cannabis interacts with anticoagulants and antiplatelet agents, decreasing their efficacy. Finally, the interplay of cannabis with inhalational and intravenous anesthetic agents may lead to adverse perioperative cardiovascular outcomes.

Conclusions

The use of cannabis can trigger cardiovascular events that may depend on factors such as the duration of consumption, the route of administration of the drug, and the dose consumed, which places these patients at risk of drug-drug interactions with anesthetic agents. However, large prospective randomized clinical trials are needed to further elucidate gaps in the body of knowledge regarding which patient population has a greater risk of perioperative complications after cannabis consumption.

Cannabis use disorder and perioperative outcomes following complex cancer surgery

INTRODUCTION

Cannabis usage is increasing in the United States, especially among patients with cancer. We sought to evaluate whether cannabis use disorder (CUD) was associated with higher morbidity and mortality among patients undergoing complex cancer surgery.

METHODS

Patients who underwent complex cancer surgery between January 2016 and December 2019 were identified in the National Inpatient Sample database. CUD was defined according to ICD-10 codes. Propensity score matching was performed to create a 1:1 matched cohort that was well balanced with respect to covariates, which included patient comorbidities, sociodemographic factors, and procedure type. The primary composite outcome was in-hospital mortality and seven major perioperative complications (myocardial ischemia, acute kidney injury, stroke, respiratory failure, venous thromboembolism, hospital-acquired infection, and surgical procedure-related complications).

RESULTS

Among 15 014 patients who underwent a high-risk surgical procedure, a cohort of 7507 patients with CUD (median age; 43 years [IQR: 30-56 years]; n = 3078 [41.0%] female) were matched with 7507 patients who were not cannabis users (median age; 44 years [IQR: 30-58 years); n = 2997 [39.9%] female). CUD was associated with slight increased risk relative to postoperative kidney injury (CUD, 7.8% vs. no CUD, 6.1%); however, in-hospital mortality was slightly lower (CUD, 0.9% vs. no CUD, 1.6%) (both p < 0.001). On multivariable analysis, after controlling for other risk factors, CUD was not associated with higher morbidity and mortality (adjusted odds ratio: 1.06, 95% CI: 0.98-1.15; p = 0.158).

CONCLUSION

CUD was not associated with a higher risk of postoperative morbidity and mortality following complex cancer surgery.

Cannabis use in liver transplant candidates and recipients

The increasing legality and acceptance of cannabis sale and consumption across the United States has led to a measurable increase in cannabis use nationwide, including in liver transplant (LT) candidates and recipients. With over 75% of liver transplant recipients transplanted in states with legalized use of medicinal and/or recreational cannabis, liver transplant clinicians must have expertise in the assessment of cannabis use given its potential impact on clinical care. In this review, the authors provide an understanding of nomenclature and tools to assess cannabis use, highlight essential components to guide clinical policy development and implementation, and discuss the potential impacts of cannabis use on patients' transplant course.

Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial

BACKGROUND

Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events.

RESULTS

The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly.

CONCLUSION

Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy.

REGISTRATION

NCT04610398 (ClinicalTrials.gov identifier).

Marijuana Use, Vaping, and Preoperative Anesthetic and Surgical Considerations in Clinical Practice

In recent years, marijuana and vaping have acquired widespread popularity, with millions of people using them for a variety of reasons, including recreational purposes. However, these practices have often overlooked the implications on surgery and the preoperative anesthesia considerations. Marijuana can influence a patient's response to anesthesia, alter postoperative pain management, and increase the risk of complications, whereas vaping can have negative effects on the respiratory system and hinder the body's ability to recover after surgery.

The Association of Cannabis Use After Discharge From Surgery With Opioid Consumption and Patient-reported Outcomes

OBJECTIVE

To compare outcomes of patients using versus not using cannabis as a treatment for pain after discharge from surgery.

BACKGROUND

Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes.

METHODS

Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing 16 procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included postdischarge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life, and regret to undergo surgery (secondary).

RESULTS

Of 11,314 included patients (58% females, mean age: 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI: 0.4-1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (adjusted odds ratio: 1.7, 95% CIL 1.4-2.1) and 1 month (adjusted odds ratio: 2.1, 95% CI: 1.7-2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs 82.6%), best quality of life (46.7% vs 63.0%), and no regret (87.6% vs 92.7%) (all P < 0.001).

CONCLUSIONS

Patient-reported cannabis use, to treat postoperative pain, was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes.

Medical Cannabis Use and Inflammatory Cytokines and Chemokines Among Adult Chronic Pain Patients

Background: Utilizing cannabis as a therapeutic option for chronic pain (CP) has increased significantly. However, data regarding the potential immunomodulatory effects of cannabis in CP patients remain scarce. We aimed at exploring the relationship between cannabis use and inflammatory cytokines and chemokines among a cohort of CP patients. Methods: Adult patients with a CP diagnosis and medical authorization of cannabis were enrolled. Patients completed validated clinical questionnaires and self-reported the effectiveness of cannabis for symptom management. Patients' blood and cannabis samples were analyzed for the presence of four major cannabinoids, two major cannabinoid metabolites, 29 different cytokines/chemokines, and cortisol. The multivariable linear regression model was used to identify cannabis and patient factors associated with immune markers. Results: Fifty-six patients (48±15 years; 64% females) were included, with dried cannabis (53%) being the most common type of cannabis consumed. Seventy percent of products were considered delta-9-tetrahydrocannabinol (Δ9-THC)-dominant. The majority of patients (96%) self-reported effective pain management, and 76% reported a significant decrease in analgesic medication usage (p≤0.001). Compared with males, female patients had higher plasma levels of cannabidiol (CBD), cannabidiolic acid, Δ9-THC, and 11-hydroxy-Δ9-tetrahydrocannabinol but lower concentrations of delta-9-tetrahydrocannabinolic acid and 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH). Females had significantly lower eotaxin levels (p=0.04) in comparison to male patients. The regression analysis indicated that high cannabis doses were related to increased levels of interleukin (IL)-12p40 (p=0.02) and IL-6 (p=0.01), whereas female sex was associated with decreased eotaxin (p≤0.01) concentrations. Blood CBD levels were associated with lower vascular endothelial growth factor (p=0.04) concentrations, and THC-COOH was a factor related to decreased tumor necrosis factor alpha (p=0.02) and IL-12p70 (p=0.03). Conclusion: This study provides further support for the patient-perceived effectiveness of cannabis in managing CP symptoms and reducing analgesic medication consumption. The results suggest a potential sex difference in metabolizing cannabinoids, and the varying immune marker concentrations may support a possible immunomodulatory effect associated with patient sex and cannabis product type. These preliminary findings provide grounds for further validation using larger, well-designed studies with longer follow-up periods.

Cannabis and Cannabinoids in the Perioperative Period

Cannabis use is increasingly common, and with a growing number of jurisdictions implementing legalization frameworks, it is likely that providers will encounter more patients who use cannabis. Therefore, it is important for providers to understand the implications of cannabis use and practical considerations for the perioperative period. Cannabis affects multiple organ systems and may influence intraoperative anesthesia, as well as postoperative pain management. The effects of cannabis and key anesthetic considerations are reviewed here.

Cannabis Users Require More Anesthetic Agents for General Anesthesia in Ambulatory Oral and Maxillofacial Surgery Procedures

BACKGROUND

The use of cannabis in the general population has steadily increased over recent years and there is limited literature regarding the anesthetic implications of chronic cannabis use, particularly in the setting of outpatient anesthesia.

PURPOSE

To determine whether chronic cannabis users undergoing deep sedation or general anesthesia during ambulatory procedures require more anesthetic agents than nonusers.

STUDY DESIGN, SETTING, AND SAMPLE

A retrospective cohort study of subjects undergoing deep sedation or general anesthesia at the Oklahoma University Oral and Maxillofacial Surgery Clinic from January to December 2022 was performed. The inclusion criteria were duration of anesthetic procedure between 15 to 40 minutes, use of propofol, fentanyl, ketamine, and midazolam, and extraction of at least 2 teeth. The exclusion criterion was patients undergoing adjunctive procedures other than extractions during sedation.

PREDICTOR VARIABLE

Cannabis use status was grouped as users and nonusers. A user was defined as a subject who self-reported any regular use of cannabis.

OUTCOME VARIABLE

The primary outcome variable was the amount of intravenous anesthetic agents administered. Secondary outcome variables included the length of the procedure and the number of teeth extracted.

COVARIATES

Age, sex, and the senior-most resident involved in the sedation.

ANALYSES

IBM SPSS was utilized to perform descriptive statistics, paired t-tests, ANOVA, and multivariate linear regression. A level of significance of 5% (P < .05) was used for all analyses.

RESULTS

Four hundred and ninety nine subjects were identified, 189 met the inclusion criteria, and 57 reported using cannabis. The mean age of nonusers was 28.2 ± 7.8 years and that of users was 26.6 ± 6.4 years (P = .09). Females represented 71.9% of nonusers and 72.7% of users. Cannabis users received significantly more propofol (117.5 mg ± 71.3 vs 152.5 mg ± 101.8; P = .004), midazolam (4.7 mg ± 1.0 vs 5.1 mg ± 1.5; P = .01), ketamine (40.2 mg ± 15.7 vs 46.1 mg ± 16.9; P = .01), and fentanyl (75.2 μg ± 26.3 vs 88.6 μg ± 32.8; P = .002) than nonusers, despite extracting a similar number of teeth (4.5 ± 3.1 vs 4.4 ± 3.5; P = .37) in a similar amount of time (25.5 ± 7.3 vs 27.3 ± 7.8; P = .06).

CONCLUSION AND RELEVANCE

Cannabis users required more propofol, midazolam, ketamine, and fentanyl than non-cannabis users during outpatient oral and maxillofacial surgery procedures.

[Does medicinal cannabis or cannabis consumption have an influence on the perioperative anesthesiological management?]

The greatly increasing use of medicinal cannabis products as well as the upcoming legalization of cannabis not only require a general re-evaluation of how these substances might be classified as illegal drugs, but also enforce a critical view on the possible consequences that cannabis consumption might have on the anesthesiological strategies applied for surgical procedures. Although high-quality clinical studies are still lacking, several clinical studies meanwhile indicate that an active preoperative cannabis consumption seems to be associated with relevant pathophysiological aspects. Patients who regularly consume high doses of cannabis show an increased risk of cardiovascular and respiratory complications as well as the postoperative nausea and vomitting (PONV) associated with anesthesia. This also applies to relatively young patients. Moreover, the requirements for general anesthetics and analgesics seem to be increased in the context of cannabis consumption, e.g., these patients may require additional efforts when it comes to monitoring the depth of anesthesia and providing a personalized multimodal postoperative pain therapy. It therefore appears to be meaningful to carefully assess and document the extent and duration of the preoperative cannabis consumption during the preoperative assessment. Furthermore, the possibility to perform a preoperative dose reduction of cannabis products in cases with high doses should at least be considered. As the consumption of cannabis is not only increasing in Germany but also worldwide, important future insights will offer a guide towards a safe handling of cannabis in perioperative medicine in the coming years.

Cannabis Use Disorder and Perioperative Complications

Importance

Cannabis use is growing in the US and is increasingly perceived as harmless. However, the perioperative impact of cannabis use remains uncertain.

Objective

To assess whether cannabis use disorder is associated with increased morbidity and mortality after major elective, inpatient, noncardiac surgery.

Design, Setting, and Participants

This retrospective, population-based, matched cohort study used data from the National Inpatient Sample for adult patients aged 18 to 65 years who underwent major elective inpatient surgery (including cholecystectomy, colectomy, inguinal hernia repair, femoral hernia repair, mastectomy, lumpectomy, hip arthroplasty, knee arthroplasty, hysterectomy, spinal fusion, and vertebral discectomy) from January 2016 to December 2019. Data were analyzed from February to August 2022.

Exposure

Cannabis use disorder, as defined by the presence of specific International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes.

Main Outcome and Measures

The primary composite outcome was in-hospital mortality and 7 major perioperative complications (myocardial ischemia, acute kidney injury, stroke, respiratory failure, venous thromboembolism, hospital-acquired infection, and surgical procedure-related complications) based on ICD-10 discharge diagnosis codes. Propensity score matching was performed to create a 1:1 matched cohort that was well balanced with respect to covariates, which included patient comorbidities, sociodemographic factors, and procedure type.

Results

Among 12 422 hospitalizations, a cohort of 6211 patients with cannabis use disorder (median age, 53 years [IQR, 44-59 years]; 3498 [56.32%] male) were matched with 6211 patients without cannabis use disorder for analysis. Cannabis use disorder was associated with an increased risk of perioperative morbidity and mortality compared with hospitalizations without cannabis use disorder in adjusted analysis (adjusted odds ratio, 1.19; 95% CI, 1.04-1.37; P = .01). The outcome occurred more frequently in the group with cannabis use disorder (480 [7.73%]) compared with the unexposed group (408 [6.57%]).

Conclusions and Relevance

In this cohort study, cannabis use disorder was associated with a modest increased risk of perioperative morbidity and mortality after major elective, inpatient, noncardiac surgery. In the context of increasing cannabis use rates, our findings support preoperative screening for cannabis use disorder as a component of perioperative risk stratification. However, further research is needed to quantify the perioperative impact of cannabis use by route and dosage and to inform recommendations for preoperative cannabis cessation.

Cannabis Use Does Not Increase Risk of Perioperative Complications Following Primary Total Hip Arthroplasty: A Cohort-Matched Comparison

Introduction: Cannabis use among arthroplasty patients has dramatically increased throughout the United States. Despite this trend, knowledge remains particularly limited regarding the effects of cannabis use on perioperative outcomes in total hip arthroplasty (THA). Therefore, the goal of this research was to investigate how cannabis use affects risk of perioperative outcomes, cost and length of stay (LOS) after THA. Materials and Methods: The National Inpatient Sample was used to identify 331,825 patients who underwent primary THA between 2010 and 2014 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) procedure code 81.51. Patients with an ICD-9 diagnosis code correlating to history of thromboembolic events, cardiac events, or active substance use other than cannabis were eliminated. The ICD-9 diagnosis codes for cannabis use (304.3-304.32, 305.2-305.22) were used to identify 538 patients with active use. Cannabis users were matched 1:1 to nonusers on age, sex, tobacco use, and comorbidities. The chi-square test was used to determine risk of major and minor complications, whereas the Kruskal-Wallis H test was used to compare hospital charges and LOS. Results: A total of 534 (99.3%) patients with cannabis use were successfully matched with 534 patients without cannabis use. Risk of major complications among cannabis users (25, 4.68%) was similar to that of nonusers (20, 3.74%, p=0.446). Minor complications also occurred at similar rates between cannabis users (77, 14.4%) and nonusers (87, 16.3%, p=0.396). LOS for cannabis users (3.07±2.40) did not differ from nonusers (3.10±1.45, p=0.488). Mean hospital charges were higher for cannabis users ($17,847±10,024) compared with nonusers ($16,284±7025, p<0.001). Conclusion: Utilizing statistically matched cohorts within a nationally representative database demonstrated that cannabis use is not associated with increased risk of complications or prolonged LOS after primary THA. However, cannabis use is associated with higher hospital charges.

Cannabis and Pregnancy: A Review

Importance

Prenatal cannabis use is rising and is a major public health issue. Cannabis use in pregnancy and during lactation has been associated with increased maternal and offspring morbidity and mortality.

Objective

This review aims to summarize the existing literature and current recommendations for cannabis use during pregnancy or lactation.

Evidence Acquisition

A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "cannabis," "cannabinoid," "delta-9-tetrahydrocannabinol," "THC," "cannabidiol," "fetal outcomes," "perinatal outcomes," "pregnancy," and "lactation."

Results

Available studies on cannabis use in pregnancy and during lactation were reviewed and support an association with increased risk of preterm birth, neonatal intensive care unit admission, low birth weight, and small-for-gestational-age infants.

Conclusion and Relevance

There is a critical need for research on the effects of cannabis use in pregnancy and during lactation. This is a necessary first step before furthering patient education, developing interventions, and targeting antenatal surveillance to ameliorate the adverse impacts on maternal and fetal health.

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.

Approach and Management of Alcohol Withdrawal Syndrome in Operative Head and Neck Cancer Patients

Postoperative head and neck cancer patients are at increased risk for alcohol withdrawal syndrome. Literature has shown that in this patient population, alcohol withdrawal is associated with an increase in postoperative medical and surgical complications, length of hospitalization, and hospital-related costs. Harm reduction and addiction medicine philosophies can reduce morbidity and mortality, but have not been fully validated in perioperative surgical management for head and neck cancer. This commentary synthesizes key principles of addiction medicine and current strategies that Otolaryngology-Head and Neck Surgery surgeons can consider in their perioperative assessment and management of alcohol withdrawal syndrome in their patients.

Directive clinique no 425b : Le cannabis aux différentes périodes de la vie des femmes - Partie 2 : Grossesse, période postnatale et allaitement

OBJECTIF

Fournir aux fournisseurs de soins les meilleures données probantes sur l'utilisation de cannabis et la santé des femmes. Les domaines d'intérêt sont le dépistage, la dépendance et le sevrage; la communication et la tenue de dossier; la grossesse (y compris les issues fœtales et maternelles); la gestion de la douleur maternelle; les soins postnataux (y compris la fumée secondaire et la parentalité); et l'allaitement.

POPULATION CIBLE

Femmes enceintes, allaitantes ou qui planifient une grossesse. BéNéFICES, RISQUES ET COûTS: Discuter de l'utilisation de cannabis avec les femmes enceintes, allaitantes ou qui planifient une grossesse les aide à faire des choix éclairés. D'après des données probantes limitées, il faut éviter l'utilisation de cannabis pendant la grossesse ou l'allaitement, ou réduire la consommation au maximum si l'abstention n'est pas un objectif atteignable, étant donné l'absence de données sur l'innocuité et le suivi à long terme des grossesses et nourrissons exposés au cannabis. DONNéES PROBANTES: Les auteurs ont interrogé les bases de données PubMed et Cochrane Library pour extraire des articles sur l'utilisation de cannabis pendant la grossesse et l'allaitement publiés entre le 1^er janvier 2018 et le 5 février 2021. Les termes de recherche ont été déterminés à partir de termes de recherche MeSH, de mots clés et de leurs variantes : cannabis, cannabinoids, cannabidiol, CBD, THC, marijuana, edible, pregnancy, pregnant, prenatal, perinatal, postnatal, breastfeed, breastfed, lactation, nursing, fetus, fetal, neonatal, newborn et child. Les auteurs ont inclus toutes les publications des types suivants : essais cliniques, études observationnelles, revues (y compris les revues systématiques et les méta-analyses), directives cliniques et déclarations de conférences de consensus. Les principaux critères d'inclusion étaient les femmes enceintes et allaitantes, comme population cible, et l'exposition au cannabis, comme intervention d'intérêt. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé qui prodiguent des soins aux femmes en âge de procréer. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Directive clinique no 425a : Le cannabis aux différentes périodes de la vie des femmes - Partie 1 : Fertilité, contraception, ménopause et douleur pelvienne

OBJECTIF

Fournir aux fournisseurs de soins de santé les meilleures données probantes sur l'utilisation de cannabis et la santé des femmes. Les domaines d'intérêt sont : les profils généraux d'utilisation du cannabis ainsi que la sécurité de la consommation; les soins aux femmes qui utilisent le cannabis; la stigmatisation; le dépistage, l'intervention brève et l'orientation vers le traitement; les effets sur la régulation hormonale; la santé reproductive, y compris la contraception et la fertilité; la fonction sexuelle; les effets sur les symptômes périménopausiques et postménopausiques; et l'utilisation dans le traitement des syndromes de douleur pelvienne chronique.

POPULATION CIBLE

La population cible comprend toutes les femmes qui consomment ou utilisent du cannabis ou qui envisagent de le faire. RéSULTATS: Un dialogue ouvert et fondé sur des données probantes relativement à l'utilisation et la consommation de cannabis, dialogue qui mènera à l'amélioration des soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation et de la consommation de cannabis par une approche basée sur la connaissance des traumatismes donne l'occasion au fournisseur de soins et à la patiente de créer une solide alliance thérapeutique collaborative. Cette alliance permet aux femmes de faire des choix éclairés sur leurs propres soins. Elle facilite également le diagnostic et le traitement possible des troubles de l'usage du cannabis. Il ne faut pas stigmatiser la consommation, car la stigmatisation nuit à l'alliance thérapeutique (c'est-à-dire le partenariat entre la patiente et le fournisseur de soins). Plusieurs effets indésirables de la consommation de cannabis peuvent être confondus avec d'autres problèmes de santé. À l'heure actuelle, l'utilisation du cannabis pour traiter les problèmes de santé féminine n'est pas financée par le secteur public; par conséquent, les utilisatrices doivent assumer les coûts directs. Les coûts indirects de l'utilisation de cannabis sont inconnus. Ainsi, les fournisseurs de soins et les patientes doivent comprendre le rôle du cannabis dans les problèmes de santé féminine de sorte que les femmes puissent prendre des décisions éclairées. DONNéES PROBANTES: Des recherches ont été effectuées dans PubMed, Embase et la littérature grise pour recenser des études publiées entre le 1^er janvier 2018 et le 18 février 2021 concernant l'utilisation du cannabis et ses effets sur l'infertilité, la contraception, les symptômes périménopausiques et postménopausiques et la douleur pelvienne. Toutes les publications des types suivants ont été incluses : essais cliniques, études observationnelles, revues (y compris les revues systématiques et les méta-analyses), directives cliniques et déclarations de conférences de consensus. Un survol des publications a été effectué pour en confirmer la pertinence. Les termes de recherche ont été définis à l'aide des termes MeSH (Medical Subject Headings) et mots clés (et variantes) suivants : cannabis, cannabinoids, marijuana, dexanabinol, dronabinol et tetrahydrocannabinol. À ces termes ont été combinés les termes suivants afin de cerner la santé des femmes : estrogen, estradiol, medroxyprogesterone acetate, vaginal contraception, oral contraceptives, fertilization, amenorrhea, oligomenorrhea, pelvic pain, dysmenorrhea, endometriosis, interstitial cystitis, vulvodynia et menopause. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant l'approche d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les fournisseurs de soins de santé qui prodiguent des soins aux femmes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 425a: Cannabis Use Throughout Women's Lifespans - Part 1: Fertility, Contraception, Menopause, and Pelvic Pain

OBJECTIVE

To provide health care providers with the best evidence on cannabis use with respect to women's health. Areas of focus include general patterns of cannabis use as well as safety of use; care for women who use cannabis; stigma; screening, brief intervention, and referral to treatment; impact on hormonal regulation; reproductive health, including contraception and fertility; sexual function; effects on perimenopausal and menopausal symptoms; and use in chronic pelvic pain syndromes.

TARGET POPULATION

The target population includes all women currently using or contemplating using cannabis.

OUTCOMES

Open, evidence-informed dialogue about cannabis use, which will lead to improvement in patient care.

BENEFITS, HARMS, AND COSTS

Exploring cannabis use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of cannabis use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Multiple side effects of cannabis use may be mistaken for other disorders. Currently, use of cannabis to treat women's health issues is not covered by public funding; as a result, individual users must pay the direct cost. The indirect costs of cannabis use are unknown. Thus, health care providers and patients must understand the role of cannabis in women's health issues, so that women can make knowledgeable decisions.

EVIDENCE

PubMed, EMBASE, and grey literature were searched to identify studies of "cannabis use and effect on infertility, contraception, perimenopause and menopausal symptoms, and pelvic pain" published between January 1, 2018 and February 18, 2021. All clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. Publications were screened for relevance. The search terms were developed using the Medical Subject Headings (MeSH) terms and keywords (and variants), including cannabis, cannabinoids, marijuana, dexanabinol, dronabinol, tetrahydrocannabinol; the specific terms to capture women's health were estrogen, estradiol, medroxyprogesterone acetate, vaginal contraception, oral contraceptives, fertilization, amenorrhea, oligomenorrhea, pelvic pain, dysmenorrhea, endometriosis, interstitial cystitis, vulvodynia, and menopause.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All heath care providers who care for women.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Guideline No. 425b: Cannabis Use Throughout Women's Lifespans - Part 2: Pregnancy, the Postnatal Period, and Breastfeeding

OBJECTIVE

To provide health care providers with the best evidence on cannabis use and women's health. Areas of focus include screening, dependence, and withdrawal; communication and documentation; pregnancy (including maternal and fetal outcomes); maternal pain control; postpartum care (including second-hand smoking and parenting); and breastfeeding.

TARGET POPULATION

The target population includes women who are planning a pregnancy, pregnant, or breastfeeding.

BENEFITS, HARMS, AND COSTS

Discussing cannabis use with women who are planning a pregnancy, pregnant, or breastfeeding allows them to make informed choices about their cannabis use. Based on the limited evidence, cannabis use in pregnancy or while breastfeeding should be avoided, or reduced as much as possible if abstaining is not feasible, given the absence of safety and long-term follow up data on cannabis-exposed pregnancies and infants.

EVIDENCE

PubMed and Cochrane Library databases were searched for articles relevant to cannabis use during pregnancy and breastfeeding published between January 1, 2018, and February 5, 2021. The search terms were developed using the MeSH terms and keywords and their variants, including cannabis, cannabinoids, cannabidiol, CBD, THC, marijuana, edible, pregnancy, pregnant, prenatal, perinatal, postnatal, breastfeed, breastfed, lactation, nursing, fetus, fetal, neonatal, newborn, and child. In terms of publication type, all clinical trials, observational studies, reviews (including systematic reviews and meta-analyses), guidelines, and conference consensus statements were included. The main inclusion criteria were pregnant and breastfeeding women as the target population, and exposure to cannabis as the intervention of interest.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care providers who care for women of reproductive age.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Illicit Drug Use and Endoscopy: When Do We Say No?

BACKGROUND

Illicit drug use (IDU) is often encountered in patients undergoing elective ambulatory surgical procedures such as endoscopy. Given the variety of systemic effects of these drugs, sedation and anesthetics are believed to increase the risk of cardiopulmonary complications during procedures. Procedural cancelations are common, regardless of the drug type, recency of use, and total dosage consumed. There is a lack of institutional and society recommendations regarding the optimal approach to performing outpatient endoscopy on patients with IDU.

AIM

To review the literature for current recommendations regarding the optimal management of outpatient elective endoscopic procedures in patients with IDU. Secondary aim is to provide guidance for clinicians who encounter IDU in endoscopic practice.

METHODS

Systematic review of PubMed, CINAHL, Embase, and Google Scholar for articles presenting data on outcomes of elective procedures in patients using illicit drugs.

RESULTS

There are no clinically relevant differences in periprocedural complications or mortality in cannabis users compared to non-users. Endoscopy in patients with remote cocaine use was also found to have similar outcomes to recent use.

CONCLUSIONS

Canceling endoscopic procedures in patients with recent IDU without consideration of the type of drug, dosage, and chronicity may lead to unnecessary delays in care and increased patient morbidity. Healthcare systems would benefit from additional guidelines for evaluating the patient with recent illicit drug use for acute intoxication and consider proceeding with procedures in the non-toxic population.

Persistent Pain After Cardiac Surgery: Prevention and Management

Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.

Effect of preoperative cannabis use on perioperative outcomes: a retrospective cohort study

INTRODUCTION

The reported use of cannabis within surgical population is increasing. Cannabis use is potentially associated with increased harms and varied effects on pain control. These have important implications to perioperative care.

METHODS

We conducted a retrospective cohort study comparing surgical patients reporting cannabis use preoperatively to control patients with no cannabis exposure, in a 1:2 ratio. To control for confounding, we used a propensity score-matched analysis to assess the adjusted association between cannabis use and study outcomes. Our primary outcome was a composite of (1) respiratory arrest or cardiac arrest, (2) intensive care admission, (3) stroke, (4) myocardial infarction and (5) mortality during this hospital stay. Secondarily, we assessed the effects on pain control, opioid usage, induction agent dose and nausea-vomiting.

RESULTS

Between January 2018 and March 2019, we captured 1818 patients consisting of cannabis users (606) and controls (1212). For propensity score-matched analyses, 524 cannabis patients were compared with 1152 control patients. No difference in the incidence of composite outcome was observed (OR 1.06, 95% CI 0.23 to 3.98). Although a higher incidence of arrhythmias (2.7% vs 1.6%) and decreased incidence of nausea-vomiting needing treatment (9.6% vs 12.6%) was observed with cannabis users vs controls, results were not statistically significant. No significant differences were observed with other secondary outcomes.

CONCLUSION

Our results do not demonstrate a convincing association between self-reported cannabis use and major surgical outcomes or pain management. Perioperative decisions should be made based on considerations of dose, duration, and indication.

State of the science: cannabis and cannabinoids in palliative medicine-the potential

Cannabinoids are chemicals derived naturally from the cannabis plant or are synthetically manufactured. They interact directly with cannabinoid receptors or share chemical similarity with endocannabinoids (or both). Within palliative medicine, cannabinoid receptors (CB1 and CB2) may modulate some cancer symptoms: appetite, chemotherapy-induced nausea and vomiting, and mood, pain and sleep disorders. Opioid and cannabinoid receptors have overlapping neuroanatomical receptor distribution, particularly at the dorsal horn, dorsal striatum and locus coeruleus. They have a favourable safety profile compared with opioids, and cannabis-based medicines help chronic pain. While cannabidiol (CBD) has anti-inflammatory properties, tetrahydrocannabinol (THC) is the psychoactive substance for issues such as mood and sleep. Nabiximols (Sativex), a CBD:THC combination, is Food and Drug Administration approved for some multiple sclerosis symptoms and epilepsy. There has been a swift societal evolution in attitudes about use of cannabis and cannabinoid medicines for chronic pain. In the USA, 33 states have now legalised prescription-based medical cannabis for several medical conditions; Canada has had legislation since 2001 authorising medical use. The European Union (EU) recently declared all EU citizens must have access to medical cannabis over the next 4 years. The integration into medicine and routine clinical use of cannabis is fraught with information gaps, regulatory issues and scarcity of research. Each patient should have a comprehensive assessment and risk-benefit discussion before any cannabis-based intervention to avoid possible complications such as hallucinations, psychosis and potential cardiac harm.

Cannabis, anesthesia and acute postoperative pain: known and unknown

Tweetable abstract Cannabis use may significantly affect anesthetic, perioperative and acute pain management care; but research needs to be standardized, expanded and more inclusive.