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Bal DS, Chung D, Urichuk M, Shah J, Fidel MG, Panchendrabose K, Sidhom K, Bard R, Nayak JG, Patel P. Utilizing Local Anesthesia Only for Penile and Scrotal Urologic Surgery: A Prospective Study on Patient Tolerability and Surgical Outcomes for a Sedation-free Option. Urology 2024:S0090-4295(24)00739-8. [PMID: 39208947 DOI: 10.1016/j.urology.2024.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 08/20/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE To prospectively assess surgical outcomes, complications, and patient-reported tolerability of invasive scrotal surgeries under local anesthesia (LA) alone, without sedation, compared to tolerability of penile procedures commonly performed in this manner. METHODS Adult patients undergoing penile and scrotal surgeries under LA only were enrolled from August 2022 to June 2023 (NCT05617261). Demographics, surgeon-perceived and patient-reported pain, and surgical variables were collected. Tolerability to the procedures and future anesthetic choice for a repeat procedure was assessed on follow-up. Complication data were collected, including recurrence, infection, excessive pain, and emergency room and family physician visits. RESULTS Hundred and seven patients were enrolled with a mean age ± SD of 42.2 ± 16.4 years. There was a 100% procedural success rate and no cases of perioperative complications or escalation of anesthetic. Around 92.4% (n = 97) of patients indicated they would opt for LA only for a hypothetical repeat procedure. Of the minority opting for general anesthetic, most indicated discomfort or preferring an element of amnesia. No differences between intraoperative pain or tolerability scores of invasive scrotal procedures compared to penile procedures were observed. On univariate analysis, longer procedure duration (P = .003), cannabis use (P = .01), and higher intra-operative pain (P = .005) was associated with lower tolerability. CONCLUSION LA alone in an office-based setting is promising for scrotal surgeries. It offers similarly high patient tolerability compared to procedures that are routinely performed under LA, with the preservation of outcomes. Adopting this method has the potential for substantial cost savings, reduced wait times, enhanced accessibility, and improved surgical efficiency.
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Affiliation(s)
- Dhiraj S Bal
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
| | - David Chung
- Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB
| | - Matthew Urichuk
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
| | - Jainik Shah
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
| | | | | | - Karim Sidhom
- Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB
| | - Robert Bard
- Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB; Men's Health Clinic Manitoba, Winnipeg, MB
| | - Jasmir G Nayak
- Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB; Men's Health Clinic Manitoba, Winnipeg, MB
| | - Premal Patel
- Section of Urology, Department of Surgery, University of Manitoba, Winnipeg, MB; Men's Health Clinic Manitoba, Winnipeg, MB.
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Nasser Y, Biala S, Chau M, Partridge ACR, Yang JY, Lethebe BC, Stinton LM, Cooray M, Cole MJ, Ma C, Chen YI, Andrews CN, Forbes N. Baseline Cannabinoid Use Is Associated with Increased Sedation Requirements for Outpatient Endoscopy. Cannabis Cannabinoid Res 2024; 9:310-319. [PMID: 36269560 DOI: 10.1089/can.2022.0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Given the underlying properties of cannabinoids, we aimed to assess associations between cannabinoid use and sedation requirements for esophagogastroduodenoscopy (EGD) and colonoscopy. Methods: A prospective cohort study was conducted at three endoscopy units. Adult outpatients undergoing EGD or colonoscopy with endoscopist-directed conscious sedation (EDCS) were given questionnaires on cannabinoid use and relevant parameters. Outcomes included intraprocedural midazolam, fentanyl, and diphenhydramine use, procedural tolerability, and adverse events. Multivariable logistic regression was performed to yield adjusted odds ratios (AORs) of outcomes. Results: A total of 419 patients were included. Baseline cannabinoid use was associated with high midazolam use, defined as ≥5 mg, during EGD (AOR 2.89, 95% confidence interval, CI: 1.19-7.50), but not during colonoscopy (AOR 0.89, 95% CI 0.41-1.91). Baseline cannabinoid use was associated with the administration of any diphenhydramine during EGD (AOR 3.04, 95% CI: 1.29-7.30) with a similar nonsignificant trend for colonoscopy (AOR 2.36, 95% CI: 0.81-7.04). Baseline cannabinoid use was associated with increased odds of requiring high total sedation, defined as any of midazolam ≥5 mg, fentanyl ≥100 mcg, or any diphenhydramine during EGD (AOR 3.72, 95% CI: 1.35-11.68). Cannabinoid use was not independently associated with fentanyl use, intraprocedural awareness, discomfort, or adverse events. Conclusions: Baseline cannabinoid use was associated with higher sedation use during endoscopy with EDCS, particularly with midazolam and diphenhydramine. Given increasingly widespread cannabinoid use, endoscopists should be equipped with optimal sedation strategies for this population. As part of the informed consent process, cannabis users should be counseled that they may require higher sedation doses to achieve the same effect.
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Affiliation(s)
- Yasmin Nasser
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Soliman Biala
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Millie Chau
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Jeong Yun Yang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B Cord Lethebe
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Laura M Stinton
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mohan Cooray
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Martin J Cole
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Ma
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Yen-I Chen
- Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Moon AS, LeRoy TE, Yacoubian V, Gedman M, Aidlen JP, Rogerson A. Cannabis Use Is Associated With Increased Use of Prescription Opioids Following Posterior Lumbar Spinal Fusion Surgery. Global Spine J 2024; 14:204-210. [PMID: 35536563 PMCID: PMC10676165 DOI: 10.1177/21925682221099857] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVES Cannabis is an antinociceptive which has been evaluated as a possible adjunct or substitute for opioid use in the treatment of acute pain. The aim of this study was to evaluate the association between preoperative cannabis usage and consumption of opioids for postoperative analgesia. METHODS Patients who underwent one- or two-level posterior lumbar fusion surgery were categorized as cannabis users or non-cannabis users based on preoperative diagnoses of cannabis use. Total morphine equivalent dose was calculated for both in-house opioid consumption and postoperative prescription opioid usage. Age, ASA, BMI, depression, tobacco use, estimated blood loss, OR time, LOS, disposition to rehab, 30-day readmission, in-house opioid consumption and postoperative prescription opioid usage were compared between groups using t-tests. RESULTS Of the 220 opioid naïve patients, 29 (13%) patients were identified as cannabis users while 191 (87%) were non-cannabis users. There were no significant associations between opioid naïve cannabis usage and ASA, BMI, tobacco use, EBL, OR time, LOS, disposition to rehab, or readmission. Opioid naïve cannabis users had greater association with depression (31.3% vs 13.7%, P=.017) and younger age (56.37 years vs 65.37 years, P<.001). Interestingly, cannabis use was associated with a lower Charlson Comorbidity Index (CCI), with 1.38 vs 2.49 (P=.002). Cannabis users were found to have increased postoperative prescription opioid usage (2545.41 POST-MED vs 1379.72 POST-MED, P=.019). CONCLUSIONS Cannabis usage is associated with increased usage of opioids postoperatively, both while in-patient and post-discharge, after posterior lumbar spinal fusion surgery.
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Affiliation(s)
- Andrew S. Moon
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Taryn E. LeRoy
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
| | | | | | - Jessica P. Aidlen
- Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Ashley Rogerson
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
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Ripperger D, Atte A, Ritto F. Cannabis Users Require More Anesthetic Agents for General Anesthesia in Ambulatory Oral and Maxillofacial Surgery Procedures. J Oral Maxillofac Surg 2023; 81:1460-1465. [PMID: 37783364 DOI: 10.1016/j.joms.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/10/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
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.
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Affiliation(s)
- Daniel Ripperger
- Chief Resident, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK
| | - Antonio Atte
- Resident, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK
| | - Fabio Ritto
- Professor & Program Director, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK.
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Lee N, Le EL, Constantine R, Iorio ML. Patterns of Opioid Demand after Operative Treatment of Distal Radius Fractures. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4901. [PMID: 37020989 PMCID: PMC10069858 DOI: 10.1097/gox.0000000000004901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/07/2023] [Indexed: 04/05/2023]
Abstract
The purpose of this study was to evaluate opioid demand after open reduction and internal fixation of distal radius fractures in patients with and without a diagnosis of cannabis use.
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Affiliation(s)
- Nayun Lee
- From the University of Colorado School of Medicine, Aurora, Colo
| | - Elliot L.H. Le
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colo
| | - Ryan Constantine
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colo
| | - Matthew L. Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colo
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Hussain N, Boulos R, Malik TM, Abd-Elsayed A, Essandoh MK, Khan S, Nguyen A, Weaver TE. Identifying Predictors for Early Percutaneous Spinal Cord Stimulator Explant at One and Two Years: A Retrospective Database Analysis. Neuromodulation 2023; 26:124-130. [PMID: 35367127 DOI: 10.1016/j.neurom.2022.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/06/2021] [Accepted: 01/11/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Placement of percutaneous spinal cord stimulator (SCS) implant has become a therapeutic option for various chronic pain conditions; however, early surgical explant still occurs. Unfortunately, evidence regarding the incidence of early surgical explant, and patient-specific factors and comorbidities associated with such, is limited and mixed. The objective of this retrospective analysis was to elucidate the incidence and predictors of percutaneous SCS explant within the first two years of device placement. MATERIALS AND METHODS The PearlDiver-Mariner Patient Record Database of all payer claims was used to identify patients who underwent percutaneous lead SCS implant (leads and generator) with subsequent explant within two years of initial device implant. The primary outcome was to determine the incidence of SCS explant within the first two years of device placement. Secondary outcomes included evaluating the effects of several patient-specific comorbidities on explant rates using univariate regression analysis. RESULTS Across the database, a total of 52,070 patients who underwent percutaneous lead SCS implant were included, of whom 3104 (5.96%) had SCS explant within the first two years. Most explants occurred within the first-year time interval at 72.8% (2260 patients), whereas only 27.2% (844 patients) had SCS explant between years one and two. At the one-year time interval, covariates associated with an increased odds ratio (OR) (95% CI) of SCS explant were 1) depression (1.39 [1.26, 1.52]), 2) chronic preoperative (1.27 [1.16, 1.39]) or postoperative (1.23 [1,13, 1.36]) opioid use, 3) cannabis abuse (1.58 [1.20, 2.02]), 4) tobacco use (1.13 [1.04, 1.23]), and 5) coagulopathy (1.22 [1.07, 1.38]). In contrast, the OR of explant was lower in patients who were older, men, or had diabetes (complicated or uncomplicated). All associated covariates became nonsignificant after the first year of SCS implant (ie, between the first and second years), and only depression and tobacco use remained as associated factors for device explant. CONCLUSIONS Our retrospective analysis highlights that the rate of percutaneous SCS explant appears to considerably decrease after the first year of device implant. Furthermore, this analysis sheds additional insights into patients who may be at risk of early percutaneous SCS explant, especially within the first year of device placement, and underscores the importance of a continued multidimensional/biopsychologic assessment in patients with chronic pain.
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Affiliation(s)
- Nasir Hussain
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Racha Boulos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tarik M Malik
- Department of Pain Medicine, University of Chicago, Chicago, IL, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar Khan
- Department of Orthopedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anthony Nguyen
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tristan E Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Muacevic A, Adler JR, Lindsey W, Ramos O, Cheng W, Danisa O. Preoperative Cannabis Use Associated With an Increased Rate of Reoperation and Postoperative Opioid Use Following Anterior Cervical Decompression and Fusion. Cureus 2022; 14:e31285. [PMID: 36514630 PMCID: PMC9733193 DOI: 10.7759/cureus.31285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/10/2022] Open
Abstract
Objectives The objective of this retrospective cohort study was to evaluate the associations among preoperative cannabis use, postoperative opioid use, and postoperative outcomes following elective anterior cervical decompression and fusion (ACDF). Methods Patients who underwent one- or two-level ACDF were characterized preoperatively as active cannabis users, former users, or nonusers. Patients were also classified based on history of preoperative opioid use as chronic users, acute users, or nonusers. Groups were compared based on outcomes including the rate of emergency department visits six months postoperatively, rate of readmissions one year postoperatively, rate of reoperation two years postoperatively, and daily postoperative opioid use measured in milligram morphine equivalents (MMEs) at 0-6 months and 6-12 months postoperatively. Results Of the 198 patients included in this study, 13 (6.6%) were active cannabis users, 11 (5.6%) were former users, and 174 (87.8%) were nonusers. The rate of reoperation within two years was 23.1% for active cannabis users, 0% for former users, and 4.0% for nonusers (p=0.0075). The average daily opioid use in MMEs 6-12 months postoperatively was 49.4 for active cannabis users, 4.1 for former users, and 13.3 for nonusers (p=0.0014). For chronic opioid users, acute users, and nonusers, the average daily opioid use in MMEs 6-12 months postoperatively was 39.9, 18.4, and 5.7, respectively (p<.0001). Conclusions History of cannabis use is associated with increased postoperative opioid use and increased rate of reoperation following elective ACDF.
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Wiseman LK, Mahu IT, Mukhida K. The Effect of Preoperative Cannabis Use on Postoperative Pain Following Gynaecologic Oncology Surgery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:750-756. [DOI: 10.1016/j.jogc.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/27/2022]
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Bulat E, Jotwani R, Weinberg R, Akerman MA, White RS. Cannabis, anesthesia and acute postoperative pain: known and unknown. Pain Manag 2021; 11:341-346. [PMID: 33648349 DOI: 10.2217/pmt-2020-0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Tweetable abstract Cannabis use may significantly affect anesthetic, perioperative and acute pain management care; but research needs to be standardized, expanded and more inclusive.
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Affiliation(s)
- Evgeny Bulat
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Rohan Jotwani
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY 10065, USA
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Michael A Akerman
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY 10065, USA
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McAfee J, Boehnke KF, Moser SM, Brummett CM, Waljee JF, Bonar EE. Perioperative cannabis use: a longitudinal study of associated clinical characteristics and surgical outcomes. Reg Anesth Pain Med 2020; 46:137-144. [PMID: 33208521 DOI: 10.1136/rapm-2020-101812] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite increases in cannabis use generally and for pain management, data regarding cannabis use in patients undergoing surgery are lacking. This study examined the prevalence of cannabis use among patients undergoing elective surgery and explored differences in clinical characteristics and surgical outcomes between cannabis users and non-cannabis users. METHODS This prospective study included 1335 adults undergoing elective surgery. Participants completed self-report questionnaires preoperative and at 3-month and 6-month postsurgery to assess clinical characteristics and surgical outcomes. RESULTS Overall, 5.9% (n=79) of patients reported cannabis use (53.2% medical, 19.0% recreational and 25.3% medical and recreational). On the day of surgery, cannabis users reported worse pain, more centralized pain symptoms, greater functional impairment, higher fatigue, greater sleep disturbances and more symptoms of anxiety and depression versus non-cannabis users (all p<0.01). Additionally, a larger proportion of cannabis users reported opioid (27.9%) and benzodiazepine use (19.0%) compared with non-cannabis users (17.5% and 9.2%, respectively). At 3 and 6 months, cannabis users continued to report worse clinical symptoms; however, both groups showed improvement across most domains (p≤0.05). At 6 months, the groups did not differ on surgical outcomes, including surgical site pain (p=0.93) or treatment efficacy (p=0.88). CONCLUSIONS Cannabis use is relatively low in this surgical population, yet cannabis users have higher clinical pain, poorer scores on quality of life indicators, and higher opioid use before and after surgery. Cannabis users reported similar surgical outcomes, suggesting that cannabis use did not impede recovery.
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Affiliation(s)
- Jenna McAfee
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin F Boehnke
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephanie M Moser
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin E Bonar
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.,Injury Prevention Center, University of Michigan, Ann Arbor, Michigan, USA
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Ladha KS, McLaren-Blades A, Goel A, Buys MJ, Farquhar-Smith P, Haroutounian S, Kotteeswaran Y, Kwofie K, Le Foll B, Lightfoot NJ, Loiselle J, Mace H, Nicholls J, Regev A, Rosseland LA, Shanthanna H, Sinha A, Sutherland A, Tanguay R, Yafai S, Glenny M, Choi P, Ladak SSJ, Leroux TS, Kawpeng I, Samman B, Singh R, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process. Br J Anaesth 2020; 126:304-318. [PMID: 33129489 DOI: 10.1016/j.bja.2020.09.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.
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Affiliation(s)
- Karim S Ladha
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Alexander McLaren-Blades
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Akash Goel
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Michael J Buys
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Paul Farquhar-Smith
- Department of Anaesthetics, The Royal Marsden NHS Foundation Trust, London, UK
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Yuvaraj Kotteeswaran
- Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, Thunder Bay, ON, Canada
| | - Kwesi Kwofie
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Division of Brain and Therapeutics, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Nicholas J Lightfoot
- Department of Anaesthesia and Pain Medicine, Counties Manukau Health, Auckland, New Zealand
| | - Joel Loiselle
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hamish Mace
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Fremantle Hospital Group, Melville, Australia; University of Western Australia, Perth, Australia
| | - Judith Nicholls
- Department of Anaesthesia, Intensive Care and Pain, Cayman Islands Health Services Authority, George Town, Cayman Islands
| | | | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, University of Oslo, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Avinash Sinha
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | | | - Rob Tanguay
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Sherry Yafai
- Releaf Institute, Santa Monica, CA, USA; John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Martha Glenny
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Paul Choi
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Salima S J Ladak
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Ian Kawpeng
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Bana Samman
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Rajbir Singh
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada; Centre for Cannabinoid Therapeutics, Toronto, ON, Canada.
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McLaren-Blades A, Ladha K, Goel A, Manoo V, Kotteeswaran Y, Gee YY, Fiorellino J, Clarke H. Perioperative pain and addiction interdisciplinary network (PAIN): protocol for the perioperative management of cannabis and cannabinoid-based medicines using a modified Delphi process. BMJ Open 2020; 10:e036472. [PMID: 32690522 PMCID: PMC7371125 DOI: 10.1136/bmjopen-2019-036472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION At the conception of this study (January 2019), a literature search by the authors found no evidence-based or consensus perioperative guidelines for patients consuming cannabis products, or for those patients in whom a cannabinoid medication could be considered for perioperative treatment. Currently, there is a large global population that consumes cannabis. The availability of cannabis has also increased this decade with greater legal access to cannabis products in some countries such as USA, Canada, Uruguay, Israel, Australia and Germany. There are recognised possible therapeutic benefits for the use of cannabis in patients with chronic pain, chronic neuropathic pain and chemotherapy-induced nausea and vomiting. There are also potential side effects from cannabis use such as psychosis, cannabis hyperemesis syndrome, misuse disorder and cannabis withdrawal syndrome. There is evidence that cannabis may also affect factors in the perioperative period such as monitoring, quality of analgesia, sleep and opioid consumption. Given the large population of persons using cannabis, the heterogeneity of cannabis products and the paucity (and heterogeneity) of perioperative literature surrounding it, perioperative guidelines for cannabis consuming patients are both lacking and necessary. In this paper, we present the design for a modified Delphi technique that has been started with the intent of deriving cannabis perioperative guidelines from the available medical literature and the consensus of multidisciplinary experts. MATERIALS, METHODS AND ANALYSIS This study will use a scoping narrative literature review and modified Delphi process to generate cannabis perioperative guidelines. A scoping narrative review of cannabis in the perioperative period by the authors of this proposal was completed and provided to a panel of 17 experts. These experts were recruited for their knowledge and expertise regarding cannabis and/or perioperative medicine. They were asked to rate a series of indications and clinical scenarios in two rounds. During the first round, the expert panel was blinded to each other's participation. During the second round of this process, the expert panel met after being provided with an analysis of the first round's submissions so they could be discussed further and, if possible, reach a further consensus regarding them. Using the results obtained from the Delphi review process, a draft of proposed cannabis perioperative guidelines will be generated. These proposed guidelines will be returned to the expert panel for critiquing prior to their finalisation. ETHICS AND DISSEMINATION Study and panellist data will be deidentified and stored as per institutional (Toronto General Hospital) guidelines. Institutional research ethics board provided a waiver for this modified Delphi protocol. Findings will be presented and published in peer-reviewed publications and conferences.
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Affiliation(s)
| | - Karim Ladha
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Akash Goel
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Varuna Manoo
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Yuvaraj Kotteeswaran
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Yen-Yen Gee
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Joseph Fiorellino
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Hance Clarke
- Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
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Ladha KS, Manoo V, Virji AF, Hanlon JG, Mclaren-Blades A, Goel A, Wijeysundera DN, Kotra LP, Ibarra C, Englesakis M, Clarke H. The Impact of Perioperative Cannabis Use: A Narrative Scoping Review. Cannabis Cannabinoid Res 2019; 4:219-230. [PMID: 31872058 PMCID: PMC6922064 DOI: 10.1089/can.2019.0054] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
As countries progressively embrace the legalization of both medicinal and recreational cannabis, there remains a significant knowledge gap when it comes to the perioperative uses of cannabis, as well as the management of cannabis users. This review summarizes the information available on the subject based on existing published studies. Articles outlining the physiological changes occurring in the human body during acute and chronic use of cannabis (outside the context of anesthesia) are also taken into consideration as understanding these changes allows a more calculated approach to better anticipate patients' needs in the perioperative setting. Common questions facing the anesthesiologist at each phase of the perioperative period will be addressed and a systematic approach to the effect of cannabinoids on various organ systems will also be presented. Issues unique to cannabis use such as cannabis withdrawal syndrome and alterations in post-operative pain processing will also be discussed. To date, the number of studies available for guidance is small and study designs are markedly heterogenous, if not limited, making conclusions challenging. While the currently available information can assist in making decisions, further studies of larger scale are eagerly anticipated to help guide future patient care.
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Affiliation(s)
- Karim S. Ladha
- Department of Anesthesia and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Varuna Manoo
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Ali-Faizan Virji
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - John G. Hanlon
- Department of Anesthesia and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Alexander Mclaren-Blades
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Akash Goel
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Duminda N. Wijeysundera
- Department of Anesthesia and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
- Department of Anesthesia and the Institute of Health Policy, Management and Evaluation, Toronto, Canada
| | - Lakshmi P. Kotra
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
| | - Carlos Ibarra
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
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Tapley P, Kellett S. Cannabis-based medicines and the perioperative physician. Perioper Med (Lond) 2019; 8:19. [PMID: 31827774 PMCID: PMC6898917 DOI: 10.1186/s13741-019-0127-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/16/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Patrick Tapley
- Department of Anaesthesia, Sunnybrook Health Sciences Centre, Bayview Avenue, Toronto, Canada
| | - Suzanne Kellett
- Shackleton Department of Anaesthesia, University Hospital Southampton, Tremona Road, Southampton, UK
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Echeverria-Villalobos M, Todeschini AB, Stoicea N, Fiorda-Diaz J, Weaver T, Bergese SD. Perioperative care of cannabis users: A comprehensive review of pharmacological and anesthetic considerations. J Clin Anesth 2019; 57:41-49. [DOI: 10.1016/j.jclinane.2019.03.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/16/2019] [Accepted: 03/03/2019] [Indexed: 12/23/2022]
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Abstract
Since March 2017, the prescription of medical cannabis at the expense of the statutory health insurance is possible after approval by the respective medical services. Chronic pain is the most common indication, as health claims data and the accompanying survey show. From the point of view of the law, a prescription is indicated in cases of serious illness, missing or not indicated established therapeutic approaches and a not entirely remote prospect of improvement of the illness or its symptoms. This describes a broader indication spectrum than can currently be based on randomised controlled clinical trials. There is weak evidence of low efficacy for neuropathic pain. For pain related to spasticity and cancer-related pain there is evidence of improvements in quality of life, but effects on pain are of little relevance. For all other indications, only an individual therapeutic trial can be justified based on the available external evidence. However, this usually corresponds to the demand of "a not entirely remote prospect" of a noticeably positive effect of medical cannabis. It is also problematic that almost no long-term studies for the application and efficacy of flowers and extracts are available.Current knowledge on the use of cannabis-based drugs and, more clearly, medical cannabis for chronic pain is insufficient. The increase in the number of countries with marketing authorisations or exemptions for medicinal cannabis or cannabis-based drugs for chronic pain will also pave the way for larger empirical and population-based studies that will further improve the evidence base of research and clinical use.
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Effects of pre-operative recreational smoked cannabis use on opioid consumption following inflammatory bowel disease surgery. Eur J Anaesthesiol 2019; 36:705-706. [DOI: 10.1097/eja.0000000000001044] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alexander JC, Joshi GP. A review of the anesthetic implications of marijuana use. Proc (Bayl Univ Med Cent) 2019; 32:364-371. [PMID: 31384188 DOI: 10.1080/08998280.2019.1603034] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/22/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- John C Alexander
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical CenterDallasTexas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical CenterDallasTexas
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Bauer FL, Donahoo WT, Hollis HW, Tsai AG, Pottorf BJ, Johnson JM, Silveira LJ, Husain FA. Marijuana's Influence on Pain Scores, Initial Weight Loss, and Other Bariatric Surgical Outcomes. Perm J 2018; 22:18-002. [PMID: 30010532 DOI: 10.7812/tpp/18-002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pain management can be challenging following bariatric surgery, and patients with obesity tend to increase opioid use after undergoing surgery. This report quantifies marijuana (MJ) use and its relationship to pain and other surgery-related outcomes in a population from a state that has legalized MJ. METHODS Data were collected for consecutive patients undergoing weight reduction surgeries between May 1, 2014 and July 31, 2015. Demographics, preoperative comorbidities, medications, and perioperative opioid use were analyzed. The primary outcome evaluated was inpatient opioid pain medication use quantified using natural log morphine equivalents. Secondary outcomes included percentage of total body weight loss after three months, postoperative complications, and changes in medical comorbidities. RESULTS A total of 434 patients, among whom 36 (8.3%) reported MJ use, comprised the study population. Perioperative opioid requirements were significantly higher in the MJ-user group (natural log morphine equivalents of 3.92 vs 3.52, p = 0.0015) despite lower subjective pain scores (3.70 vs 4.24, p = 0.07). MJ use did not affect percentage of 90-day total body weight loss, development of postoperative complications, or improvement in medical comorbidities. CONCLUSION Perioperative opioid use was significantly higher in the MJ-user group despite lower subjective pain scores. The difference in opioid requirements suggests an interaction between MJ use and opioid tolerance or pain threshold. The percentage of total body weight loss, improvement in medical comorbidity, and incidence of postoperative complications at 90-day follow-up were not affected by MJ use in this cohort analysis.
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Affiliation(s)
- Frank L Bauer
- At the time of this study a Surgeon in the Department of Graduate Medical Education General Surgery at Saint Joseph Hospital in Denver, CO.
| | - William T Donahoo
- At the time of this study an Attending Physician in the Department of Metabolic-Surgical Weight Management at Kaiser Permanente Colorado, and a Clinical Associate Professor of Medicine in the Division of Endocrinology, Diabetes & Metabolism at the University of Florida in Gainesville.
| | - Harris W Hollis
- At the time of this study a Senior Research Advisor in the Department of Graduate Medical Education General Surgery at Saint Joseph Hospital in Denver, CO.
| | - Adam G Tsai
- Attending Physician in the Department of Metabolic-Surgical Weight Management at Kaiser Permanente Colorado.
| | - Brian J Pottorf
- Attending General Surgeon at Longmont United Hospital in Longmont, CO.
| | - Jason M Johnson
- Program Director of the General Surgery Residency in the Department of Graduate Medical Education General Surgery at Saint Joseph Hospital in Denver, CO.
| | | | - Farah A Husain
- At the time of this study an Attending Physician in the Department of Metabolic-Surgical Weight Management at Kaiser Permanente Colorado, and an Assistant Professor of Surgery in the Bariatric Surgery Division in the Department of Surgery at Oregon Health and Science University in Portland.
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Häuser W, Finn DP, Kalso E, Krcevski-Skvarc N, Kress HG, Morlion B, Perrot S, Schäfer M, Wells C, Brill S. European Pain Federation (EFIC) position paper on appropriate use of cannabis-based medicines and medical cannabis for chronic pain management. Eur J Pain 2018; 22:1547-1564. [PMID: 30074291 DOI: 10.1002/ejp.1297] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/24/2018] [Indexed: 01/30/2023]
Abstract
Cannabis-based medicines are being approved for pain management in an increasing number of European countries. There are uncertainties and controversies on the role and appropriate use of cannabis-based medicines for the management of chronic pain. EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper to empower and inform specialist and nonspecialist prescribers on appropriate use of cannabis-based medicines for chronic pain. The expert panel reviewed the available literature and harnessed the clinical experience to produce these series of recommendations. Therapy with cannabis-based medicines should only be considered by experienced clinicians as part of a multidisciplinary treatment and preferably as adjunctive medication if guideline-recommended first- and second-line therapies have not provided sufficient efficacy or tolerability. The quantity and quality of evidence are such that cannabis-based medicines may be reasonably considered for chronic neuropathic pain. For all other chronic pain conditions (cancer, non-neuropathic noncancer pain), the use of cannabis-based medicines should be regarded as an individual therapeutic trial. Realistic goals of therapy have to be defined. All patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to reach the predefined goals and/or the patient is additionally burdened by an unacceptable level of adverse effects and/or there are signs of abuse and misuse of the drug by the patient, therapy with cannabis-based medicines should be terminated. SIGNIFICANCE This position paper provides expert recommendations for nonspecialist and specialist healthcare professionals in Europe, on the importance and the appropriate use of cannabis-based medicines as part of a multidisciplinary approach to pain management, in properly selected and supervised patients.
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Affiliation(s)
- Winfried Häuser
- Department Internal Medicine 1, Klinikum Saarbrücken gGmbH, Saarbrücken, Germany.,Department Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany
| | - David P Finn
- Pharmacology and Therapeutics, School of Medicine, Galway Neuroscience Centre and Centre for Pain Research, NCBES, National University of Ireland Galway, Galway, Ireland
| | - Eija Kalso
- Department of Perioperative Medicine, Intensive Care and Pain Medicine, Pain Clinic, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Nevenka Krcevski-Skvarc
- Department of Anesthesiology, Intensive Care and Pain Treatment, Faculty of Medicine of University Maribor, University Medical Center Maribor and Institute for Palliative Medicine and Care, Maribor, Slovenia
| | - Hans-Georg Kress
- Department of Special Anaesthesia and Pain Therapy, Medical University of Vienne/AKH, Vienna, Austria
| | - Bart Morlion
- Leuven Centre for Algology and Pain Management, University Hospital Leuven, Leuven, Belgium
| | - Serge Perrot
- Department of Pain Center and INSERM U987, Cochin Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Michael Schäfer
- Department of Anaesthesiology and Intensive Care Medicine, Charité University Berlin, Berlin, Germany
| | | | - Silviu Brill
- Pain Center, Sourasky Medical Center, Tel Aviv, Israel
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Abstract
The growing popularity of medical and recreational consumption of cannabis, especially among the youth, raises immediate concerns regarding its safety and long-terms effects. The cardiovascular effects of cannabis are not well known. Cannabis consumption has been shown to cause arrhythmia including ventricular tachycardia, and potentially sudden death, and to increase the risk of myocardial infarction (MI). These effects appear to be compounded by cigarette smoking and precipitated by excessive physical activity, especially during the first few hours of consumption. Cannabinoids, or the active compounds of cannabis, have been shown to have heterogeneous effects on central and peripheral circulation. Acute cannabis consumption has been shown to cause an increase in blood pressure, specifically systolic blood pressure (SBP), and orthostatic hypotension. Cannabis use has been reported to increase risk of ischemic stroke, particularly in the healthy young patients. The endocannabinoid system (ECS) is currently considered as a promising therapeutic target in the management of several disease conditions. Synthetic cannabinoids (SCs) are being increasingly investigated for their therapeutic effects; however, the value of their benefits over possible complications remains controversial. Despite the considerable research in this field, the benefits of cannabis and its synthetic derivatives remains questionable even in the face of an increasingly tolerating attitude towards recreational consumption and promotion of the therapeutic complications. More efforts are needed to increase awareness among the public, especially youth, about the cardiovascular risks associated with cannabis use and to disseminate the accumulated knowledge regarding its ill effects.
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Affiliation(s)
- Hemant Goyal
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Hamza H Awad
- Department of community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Jalal K Ghali
- Division of Cardiology, Mercer University School of Medicine, Macon, GA, USA
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Kreling MCGD, Mattos-Pimenta CAD. Opioid analgesic administration in patients with suspected drug use. Rev Bras Enferm 2017; 70:626-632. [DOI: 10.1590/0034-7167-2016-0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/18/2017] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: To identify the prevalence of patients suspected of drug use according to the nursing professionals' judgement, and compare the behavior of these professionals in opioid administration when there is or there is no suspicion that patient is a drug user. Method: A cross-sectional study with 507 patients and 199 nursing professionals responsible for administering drugs to these patients. The Chi-Square test, Fisher's Exact and a significance level of 5% were used for the analyzes. Results: The prevalence of suspected patients was 6.7%. The prevalence ratio of administration of opioid analgesics 'if necessary' is twice higher among patients suspected of drug use compared to patients not suspected of drug use (p = 0.037). Conclusion: The prevalence of patients suspected of drug use was similar to that of studies performed in emergency departments. Patients suspected of drug use receive more opioids than patients not suspected of drug use.
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Beaulieu P, Boulanger A, Desroches J, Clark AJ. Medical cannabis: considerations for the anesthesiologist and pain physician. Can J Anaesth 2016; 63:608-24. [PMID: 26850063 DOI: 10.1007/s12630-016-0598-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/21/2015] [Accepted: 01/25/2016] [Indexed: 02/02/2023] Open
Abstract
PURPOSE New regulations are in place at the federal and provincial levels in Canada regarding the way medical cannabis is to be controlled. We present them together with guidance for the safe use of medical cannabis and recent clinical trials on cannabis and pain. SOURCE The new Canadian regulations on the use of medical cannabis, the provincial regulations, and the various cannabis products available from the Canadian Licensed Producers were reviewed from Health Canada, provincial licensing authorities, and the licensed producers website, respectively. Recent clinical trials on cannabis and pain were reviewed from the existing literature. PRINCIPAL FINDINGS Health Canada has approved a new regulation on medical marijuana/cannabis, the Marihuana for Medical Purposes Regulations: The production of medical cannabis by individuals is illegal. Health Canada, however, has licensed authorized producers across the country, limiting the production to specific licenses of certain cannabis products. There are currently 26 authorized licensed producers from seven Canadian provinces offering more than 200 strains of marijuana. We provide guidance for the safe use of medical cannabis. The recent literature indicates that currently available cannabinoids are modestly effective analgesics that provide a safe, reasonable therapeutic option for managing chronic non-cancer-related pain. CONCLUSION The science of medical cannabis and the need for education of healthcare professionals and patients require continued effort. Although cannabinoids work to decrease pain, there is still a need to confirm these beneficial effects clinically and to exploit them with acceptable benefit-to-risk ratios.
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Affiliation(s)
- Pierre Beaulieu
- Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada. .,Department of Anesthesiology, CHUM, 3840 rue St Urbain, Montreal, QC, H2W 1T8, Canada.
| | - Aline Boulanger
- Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.,Pain Clinic, CHUM, Montréal, QC, Canada
| | - Julie Desroches
- Department of Anesthesiology, CHUM, 3840 rue St Urbain, Montreal, QC, H2W 1T8, Canada
| | - Alexander J Clark
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University and Central Zone, Nova Scotia Health Authority - QEII HSC, Halifax, NS, Canada
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Cawich SO, Hassranah D, Pooran S, Dan D, Narayansingh V. Complicated acute appendicitis? An unusual differential. Trop Doct 2014; 45:49-51. [PMID: 25253669 DOI: 10.1177/0049475514550064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Acute appendicitis is a common surgical diagnosis but several differential diagnoses exist and should be considered. Internal concealment is one such diagnosis. We present a case of a young man taken to the operating room with a preoperative diagnosis of complicated acute appendicitis. A ruptured caecum was encountered and several free-floating drug pellets were present. Attending doctors should consider this differential in the high prevalence areas and, whenever encountered, they should strongly consider early reporting.
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Affiliation(s)
- Shamir O Cawich
- Hepatobiliary Surgeon, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago
| | - Dale Hassranah
- Consultant Surgeon, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago
| | - Suresh Pooran
- Consultant Surgeon, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago
| | - Dilip Dan
- Consultant Surgeon, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago
| | - Vijay Narayansingh
- Professor of Surgery, Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago
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