Cannabis Use Disorder and Postoperative Complications
Rita Agarwal MD
Original article
Willer BL, Mpody C, Nafiu OO. Trends in Adolescent Comorbid Cannabis Use Disorder and Postoperative Complications. Pediatrics. 2024 Jun 1;153(6):e2024065757. doi: 10.1542/peds.2024-065757. PMID: 38708543.
In the U.S., marijuana (cannabis) is one of the most commonly used psychoactive substances by adolescents and teenagers. With the increasing legalization and acceptance across the nation, there continues to be a perception that it is safe, “natural”, and a better alternative for a host of medical complaints. Until a few years ago, the idea of addiction to marijuana or cannabis products was looked at skeptically. However, with increased use there is now recognition of this problem. Approximately 40% of high school students report having tried marijuana and approximately 20% reported using it the previous month.1 In today’s PAAD, Willer et al. report that approximately 7 % of high school students report smoking marijuana daily or almost daily.2 So yep, you will have patients in your practice who are exposed to cannabis or who are using it regularly. What is the difference between regular use of cannabis and cannabis use disorder (CUD)? The DSM–5, defines cannabis use disorder as “the presence of clinically significant impairment or distress in 12 months, manifested by at least 2 of the following:3
· Cannabis is taken in larger amounts or used over a longer period than intended
· Persistent desire to cut down with unsuccessful attempts
· Excessive time spent acquiring cannabis, using cannabis, or recovering from its effects
· Cravings for cannabis use
· Recurrent use resulting in neglect of social obligations
· Continued use despite social or interpersonal problems
· Important social, occupational, or recreational activities foregone to be able to use cannabis
· Continued use despite physical harm
· Continued use despite physical or psychological problems associated with cannabis use
· Tolerance
· Withdrawal symptoms when not using cannabis
SAMHSA estimates that 1 in 10 people who use cannabis will become addicted; when they start before the age of 18, the rate of addiction rises to 1 in 6.4 Of-course CUD is probably underdiagnosed and definitely undertreated.
Cannabis is known to have multiple potentially deleterious physiologic effects and drug-drug interactions.5 Acute and chronic use can lead to neurologic, cardiovascular and immunosuppressive effects. Smoked or vaped cannabis product can cause respiratory problems and reactive airway disease.
Today’s PAAD article is by the outstanding group at Nationwide Children’s Hospital and looks at the incidence of post-operative complications in children diagnosed with CUD. The authors used a large database from the Pediatric Health Information System (PHIS), that is managed by the Children’s Hospital Association. This database provides deidentified information from 50 non-profit hospital systems and includes data from the inpatient, emergency department, and ambulatory care settings. They looked at children aged 10-17 who underwent inpatient surgery between 2009-2022 and identified patients with a diagnosis of CUD by using ICD codes. Over ½ million children underwent inpatient surgery during this time at one of the participating hospitals. Of those 2504 (0.5%) had a comorbid ICD-9 or 10 code diagnosis of CUD. Before propensity matching, the patients with a CUD diagnosis tended to be older (16 vs 14), were more likely to be male, Black, and come from lower income zip codes. These patients were also more likely to have a history of alcohol or smoking dependence, and more likely to be undergoing urgent or emergent operations. For the purposes of this article patients were propensity matched to minimize these covariates. Over the time period studied the prevalence of the diagnosis of CUD increased from 0.4% to 0.6%.
The overall incidence of postoperative complications was 2.6% and mortality was 0.58% with a higher incidence of both in the patients diagnosed with CUD. This is consistent with the majority of research in adults.6,7 Some of the statistics that really struck me about this paper was the incidence of mortality in children with CUD was 1.5%. The incidence of stroke was 0.9% and postoperative respiratory complications occurred in 5.2% ( versus 2.4% in patients with no diagnosis of CUD). These seem like high numbers, especially the mortality rate, but the types of surgery in this study included all inpatient surgery including cardiac, and major thoracic, abdominal and orthopedic.
The downside of these types of studies is the lack of detail and granularity of the patients, their other diseases, the type of anesthetic or airway used and what if any interventions were being used to treat the CUD. However, the strength is that it identifies a problem that many of us don’t think about, and that is almost certainly underdiagnosed. The paper by Flannery et al5 gives a nice summary of perioperative considerations for children undergoing anesthesia who are using medicinal marijuana and the ASRA consensus guidelines are an excellent review of the perioperative care of patients ( primarily adults ) using cannabis or cannabinoid products.4
How many of you screen or ask your patients about cannabis use in your practice? How many ask specifically about CUD? This is a sobering article that should prompt those of us who are not already doing so, to start asking! Send your thoughts and comments to Myron who will post in a Friday Reader response.
References
1. Willer BL, Mpody C, Nafiu OO. Trends in Adolescent Comorbid Cannabis Use Disorder and Postoperative Complications. Pediatrics 2024;153(6) (In eng). DOI: 10.1542/peds.2024-065757.
2. Hashemi D, Gray K. Cannabis Use Disorder in Adolescents. The Psychiatric clinics of North America 2023;46(4):647-654. (In eng). DOI: 10.1016/j.psc.2023.03.013.
3. Hasin DS, O'Brien CP, Auriacombe M, et al. DSM-5 criteria for substance use disorders: recommendations and rationale. Am J Psychiatry 2013;170(8):834-51. (In eng). DOI: 10.1176/appi.ajp.2013.12060782.
4. Shah S, Schwenk ES, Sondekoppam RV, et al. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Regional anesthesia and pain medicine 2023;48(3):97-117. (In eng). DOI: 10.1136/rapm-2022-104013.
5. Flannery KM, D'Souza G, Agarwal R. Perioperative Management of the Pediatric Patient on Medicinal Marijuana: What Anesthesiologists Should Know. Anesthesia and analgesia 2019;129(5):1339-1343. (In eng). DOI: 10.1213/ane.0000000000003956.
6. Potnuru PP, Jonna S, Williams GW, 2nd. Cannabis Use Disorder and Perioperative Complications. JAMA surgery 2023;158(9):935-944. (In eng). DOI: 10.1001/jamasurg.2023.2403.
7. Ding C, Xu D, Cheng T. Cannabis Use Disorder Associated With Increased Risk of Postoperative Complications After Hip or Knee Arthroplasties: A Meta-analysis of Observational Studies. The Journal of the American Academy of Orthopaedic Surgeons 2024 (In eng). DOI: 10.5435/jaaos-d-23-00407.