What a Tangled Web We Weave- ASRA Guidelines on the Management of the Perioperative Patient on Cannabis and Cannabinoids.
Genevieve D’souza, MD, FASA, Rita Agarwal, MD, FAAP, and Myron Yaster MD
When I moved to Colorado in December 2016, I was immediately struck by the fact that in Denver there were as many cannabis dispensaries as Starbuck locations. At the time this was unusual. Not so much today. In 2023, legalization and decriminalization in 39 states (and counting) has made cannabis the most commonly used psychotropic substance after alcohol in America. Millions of Americans use cannabis regularly, many on a daily basis. Unfortunately, at the federal level, it remains a class I drug making it illegal to use as a medicinal for any purpose. The result is that despite its use by millions of Americans, as physicians, we really don’t know a lot about it. Indeed, because it is level 1 drug, it has not really been studied well by the medical/pharmaceutical industrial complex and wont be until the DEA, FDA, and the Federal government allow us to do it by changing its DEA classification.
Normally, I scan the various journals that I can access through the University of Colorado in preparing and deciding which articles to choose for the PAAD. Unfortunately, the library doesn’t have full access to the Journal Regional Anesthesia and Pain Medicine and I would have missed today’s article of the day by Shah et al.1 However, there has been so much lay press (Wall St Journal, NY Times, Washington Post) attention to it, I asked Rtia Agarwal, the PAAD’s primary pain reviewer, to not only review this article for us but to send me a PDF of the original article so I could read it in full.
I think you will find many issues discussed in the article to be controversial, particularly on the interactions of cannabis with acute and chronic pain, perioperative opioid requirements, and even the effects of cannabis on MAC. Should acute or chronic cannabis use delay of surgery or affect the drugs we use perioperatively? Can older patients give consent if cannabis is in their system? Rita and Genevieve have done an admirable job reviewing the article. I would love to hear your thoughts. Send to me and I will post in a reader response. Myron Yaster MD
Original article
Shah S, Schwenk ES, Sondekoppam RV, Clarke H, Zakowski M, Rzasa-Lynn RS, Yeung B, Nicholson K, Schwartz G, Hooten WM, Wallace M, Viscusi ER, Narouze S. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med. 2023 Mar;48(3):97-117. PMID: 36596580.
Charlotte’s web came to fame for seizure control in medically complex children after an interview by Dr. Sanjay Gupta on CNN in 2013 https://www.cnn.com/2013/08/07/health/charlotte-child-medical-marijuana/index.html (although those of us who lived in Colorado knew about it and Charlotte Figi the child who inspired the strain long before Dr Gupta’s interview). Dr. Gupta reported that the evidence for that particular strain of marijuana which was extremely high in CBD with minimal THC was compelling, leading to his change of opinion on the medical uses of marijuana. Based on his reporting he thought it could be of benefit for neurologically devastated children with intractable seizures. After that interview and additional national news coverage, almost 100 families moved to Colorado for easy access to Charlotte’s Web for their children suffering from intractable seizures. Since then, the use of cannabinoids and cannabis has exploded and like Pandora’s box is unlikely to fade away. Epidiolex (based on Charlotte’ web) has been FDA approved for treatment of intractable seizures, and entered the marketplace. CBD is now being advocated for other therapeutic reasons such as chronic pain, anxiety, inflammation, insomnia, Crohn’s disease, Parkinson’s disease, dystonia, Alzheimer’s, dementia, ALS, OCD, ADHD, depression and more. However, guidelines for its use in the perioperative period and its health implications have been not addressed formally for many years.
In 2019, Flannery et al.2 published an article in Anesthesia and Analgesia on Perioperative Management of the Pediatric Patient on Medicinal Marijuana: What Anesthesiologists Should Know. This article reviewed the literature regarding the use of each of the CBD compounds in the literature, with particular attention to data in children. The history, known pharmacology, data from non-medicinal use, current evidence, and anesthetic considerations are described. We also described the literature on the effects of cannabinoids and medical marijuana products on chronic pain in a previous PAAD
With the rising prevalence of both medical and recreational cannabis use in adults, adolescents and children, anesthesiologists, surgeons, pain and perioperative physicians must have an understanding of the effects of cannabis on physiology in order to provide safe perioperative care.
Chronic pain is one of the most common indications for medical cannabis prescriptions. Many patients, including children, use cannabinoid products for pain relief without the guidance of a knowledgeable clinician and therefore may use varying doses and formulations that can lead to greater adverse effects. All cannabinoids may lead to alterations in pain perception and responses to opioids in the perioperative period. It can be difficult to ascertain the quantity of cannabinoids (THC and CBD) consumed as package labeling may be wildly inaccurate, even when obtained from state-licensed dispensaries (we live in California, these things exist here). Medical Marijuana is legal in 39 states for adults, however children can receive cannabinoid products with the approval and a prescription from a licensed physician, and others may be obtaining it from illegal dispensaries or pot farms where the percentage of CBD/THC cannot be guaranteed or known.
The ASRA guidelines have summarized the existing cannabis literature in order to provide perioperative physicians and others with tools to address the challenges that arise from managing patients taking cannabis and cannabinoids.
Key recommendations include :
Universal screening for cannabinoids should be performed prior to surgery and should include type of cannabis or cannabinoid product, time of last consumption, route of administration, amount, and frequency of use. While the guidelines specifically address adults, these types of screenings should be considered in adolescents as well.
When considering whether to stop cannabinoids perioperatively, several factors come into play including:
· Medicinal versus recreational use.
· The dose, frequency and chronicity of use.
· The THC:CBD ratio of the product(s).
· The route of administration.
Given that cannabis smoking can negatively affect airway resistance, cardiovascular physiology, and cognition, anesthesiologists should discourage cannabis use prior to surgery and in the perioperative period (similar to tobacco smoking), unless its use is medically indicated. Medically sanctioned use of cannabinoid products in children are usually administered as an oral formulation, and almost never involves a product that can be smoked
Any decision to cancel or postpone an elective surgery/procedure in a cannabis-consuming patient may be further directed by any clinical concerns about underlying cardiorespiratory illnesses or problems with mentation consequent to cannabis use. Because acute cannabis consumption increases heart rate and blood pressure, delaying surgery for a minimum of 2 hours is recommended after acute cannabis smoking because of increased perioperative risk of acute MI in adults. There is no guidance in minors. With other cannabinoids routes (non-smoking) of administration, consider risks and benefits before proceeding with elective surgery given the temporal association of cannabis usage and adverse cardiovascular effects. Further acute consumption by altering cognition makes consenting for procedures problematic and is no different than acute alcohol intoxication.
How cannabis interacts with opioid and pain postoperatively is discussed in detail. Shah et al.1 state repeatedly that pain and opioid needs increase dramatically following chronic and acute cannabis consumption. Has this been your clinical experience? Further, they underline the effects of smoking cannabis on the airway, pulmonary function, and the development of reactive airway disease. Bronchospasm and perioperative wheezing are common and the authors suggest cannabis cessation prior to surgery as a good idea, much like it is for tobacco.
These are well written consensus guidelines of ASRA society in helping guide perioperative clinicians in taking care of patients taking cannabis products safely.
References
1. 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. Mar 2023;48(3):97-117. doi:10.1136/rapm-2022-104013
2. Flannery KM, D'Souza G, Agarwal R. Perioperative Management of the Pediatric Patient on Medicinal Marijuana: What Anesthesiologists Should Know. Anesthesia and analgesia. Nov 2019;129(5):1339-1343. doi:10.1213/ane.0000000000003956