New guidelines suggest reporting heavy marijuana use before surgery

January 22, 2023

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New guidance from the National Industry Council suggests anesthesiologists Ask patients about cannabis and marijuana Use before surgery to have local contact.

The new guidelines were released this month by the American Society of Regional Anesthesia and Pain Medicine. Dr. Samer Narrows, MD, chief of the Center for Pain Medicine at Western Reserve Hospital in Cuyahoga Falls, is the chair of that organization.

The guidelines recommend that anesthesiologists ask patients if they use cannabis, how often, how often, what type of marijuana and if it has been smoked or ingested. The guidelines also call for postponing elective surgery if a patient reaches a high and for pregnant patients to be educated about the risks of marijuana use for their babies.

more:New guidelines say heavy marijuana use should be disclosed before surgery

Narrows joins us for this month’s Health Actions column, a monthly look at a medical topic of interest with a local expert.

Below is an edited transcript of our interview. There too The podcast is available to meet us.

What are the new guidelines for marijuana use and surgery?

This was a consensus report from a panel of experts we established from a variety of anesthesia practice backgrounds and patient advocates. We thought it was time to give directions to anesthesiologists and surgeons on how to handle a patient who shows up for a surgical procedure and they are using cannabis, whether it is medicinal or marijuana in its recreational form.

Why are pre-operative cannabis usage guidelines needed?

We’re seeing more patients using cannabis, especially for recreational use and most states now have some form of legalization of cannabis in general. So there is an increasing number of patients who smoke cannabis and go for surgery.

We’ve also noticed that in the past few years, the potency of THC in the available cannabis market has been much higher than we used to be a decade ago, and we don’t fully understand all of the potential interactions with THC, the drug, and other drugs. So this raised a red flag that there could be serious interactions.

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We also obtained a lot of observations from the CPs of the interactions during anesthesia. Some patients, not knowing which of them are using cannabis, have different results in the recovery room. This could be more pain, more violence, more vomiting.

All these factors prompted us to create a working group to develop guidelines as a road map on how to deal with these situations.

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When will anesthesiologists start using these guidelines?

My understanding is that some institutions already have some form of local guidelines. These are the first US guidelines on preoperative cannabis administration. I hope it will be implemented as soon as it is released. I expect widespread adoption. (The American Society of Anesthesiologists has revised the guidelines and agreed with the recommendations.)

How were you involved in creating these Guidelines?

These particular guidelines took nearly two years to develop. Most of the literature available is basic science or animal science. Unfortunately clinical data is still mostly observational data. As there are more accepted applications for cannabis, I expect there will be more research. As we get more data, we may update the guidelines.

Personally, I started to gain more interest about five or six years ago as states, including Ohio, started looking into medical cannabis.

She has published a textbook on cannabis and pain. The majority of medical practitioners in this country don’t know much about cannabis, and the legalization of cannabis really trumps the science we know. Only recently have some medical schools added cannabis pharmacology to the curriculum.

What are some of the problems that can occur with excessive cannabis use and surgery?

I’m not saying that every patient who uses cannabis will have a bad outcome. There are some patients who did not tell their surgeon and they had no problem. However, we identified three subgroups of patients who may not have the best outcome from anesthesia in surgery.

The first group are those who show up at the time of surgery in an acute intoxicated state. If you have just smoked cannabis at a high dose, especially with the high strength of TCH and you may have changed dispensaries and you do not know what it contains. In this case, you may come to the hospital with some delusions or paranoia or you may not be able to get good, informed consent. In these cases we recommend postponing surgery until the patient is re-evaluated.

The second group are patients with cannabis use disorder, which means they are heavy users. These patients can develop a tolerance to cannabis from chronic use so we know from the literature that if you develop a tolerance to cannabis, you may have more pain in the recovery room, even for a minor procedure. We recommend a multimodal approach in trying different medications or even nerve blocks or local anesthetics.

The third group are heavy smokers. There is data showing that in the first two hours after smoking a joint, the incidence of an increased heart rate will increase. An irregular heartbeat and high blood pressure are known risk factors for a heart attack. There is a risk to you during the stress of the surgery. We recommend that the surgery be delayed for at least two hours.

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Do the new guidelines recommend drug testing to screen patients before surgery?

That’s a very good question. We recommend screening by questioning, but we recommend direct questions. Most surveys will ask if someone is using an illegal (or illegal) drug and most patients in states where they allow recreational cannabis use do not consider that to be an illegal substance and in states where it is not legalized, the patient does not want to disclose and get in trouble.

We recommend direct questions in a confidential manner.

We did not find sufficient evidence to recommend a comprehensive urine test for the patient at this time. Many may not be accurate about levels or marijuana use can still show up after weeks of use.

You don’t want a patient high on medical or recreational marijuana before surgery, right?

yes. Usually with medical marijuana, it is a small or controlled dose and is closely monitored. Most are eaten as food rather than smoked or vaped.

We recommend that the patient speak with their treating physician to see if you can stop them or if there are any alternatives to using them prior to surgery.

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When should patients be screened for marijuana use before surgery?

The patient is evaluated at most institutions a few days before surgery, so the anesthesiologist or doctor can discuss these questions afterwards.

Are these guidelines for the days leading up to surgery or could there be any levels of marijuana the patient had at the time of surgery?

We haven’t established guidance about weaning before or stopping because clinical evidence is just beginning to accumulate in the literature over the past few years. We may update the guidelines. But for now, if the patient is very intoxicated, the elective surgery should not be performed.

What are other potential complications from heavy cannabis surgery?

There can be a cross-talk between cannabis users and some anesthetics, which means they may not work or you may need more. There are also some interactions between THC and blood thinners. The patient may be at increased risk of bleeding, although this is rare. There may also be cases of severe hypotension in the recovery room.

Can you explain what excessive vomiting is?

yes. It is persistent vomiting from excessive cannabis use. In small doses, THC is a remedy for nausea and vomiting, but in higher doses, especially quickly, more vomiting occurs.

In states where there is legalization of recreational marijuana, emergency room physicians notice this more often.

This is a good reason to discuss the difference between smoking marijuana and eating marijuana. This excessive vomiting is usually caused by eating and not smoking because with smoking, you usually get the effect within a minute.

For foods, which are often preferred over smoking, especially by prescription doctors, food items take a few hours to get started.

What usually happens is that young patients take a small dose and feel nothing. So they keep eating and don’t feel the fuss. They think they are safe to eat more and in a matter of hours, it all kicks in and they go to the emergency room with a bad result.

There is decent evidence that medical marijuana is here to stay. Our role is to educate doctors and patients about its safe use.

To read about previous health procedures topics, go to www.tinyurl.com/BettyHealthyActions

Beacon Journal reporter Betty Lynn Fisher can be reached at 330-996-3724 or blinfisher@thebeaconjournal.com. Follow her at @blinfisherABJ on Twitter or www.facebook.com/BettyLinFisherABJ. For her most recent articles and columns, go to www.tinyurl.com/bettylinfisher

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