If you smoke, vape, or ingest cannabis, your anesthesiologist should know before you undergo a surgical procedure, according to new medical guidelines.

All patients who undergo procedures that require regional or general anesthesia should be asked if, how often, and in what forms they use the drug, according to recommendations from the American Society of Regional Anesthesia and Pain Medicine (ASRA).

One reason: Patients who regularly use cannabis may experience worse pain and nausea after surgery and may require more opioid analgesia, the group said.

The society's recommendations ― published last week in Regional Anesthesia and Pain Medicine ― are the first guidelines in the United States to cover cannabis use as it relates to surgery, the group said.

Possible Interactions
Use of cannabis has increased in recent years, and researchers have been concerned that the drug may interact with anesthesia and complicate pain management. Few studies have evaluated interactions between cannabis and anesthetic agents, however, according to the authors of the new guidelines.

"With the rising prevalence of both medical and recreational cannabis use in the general population, anesthesiologists, surgeons, and perioperative physicians must have an understanding of the effects of cannabis on physiology in order to provide safe perioperative care," the guideline said.

"Before surgery, anesthesiologists should ask patients if they use cannabis ― whether medicinally or recreationally ― and be prepared to possibly change the anesthesia plan or delay the procedure in certain situations," Samer Narouze, MD, PhD, ASRA president and senior author of the guidelines, said in a news release about the recommendations.

Although some patients may use cannabis to relieve pain, research shows that "regular users may have more pain and nausea after surgery, not less, and may need more medications, including opioids, to manage the discomfort," Narouze, chairman of the Center for Pain Medicine at Western Reserve Hospital in Cuyahoga Falls, Ohio, said.

Risks for Vomiting, Heart Attack
The new recommendations were created by a committee of 13 experts, including anesthesiologists, chronic pain physicians, and a patient advocate. Shalini Shah, MD, vice chair of anesthesiology at the University of California at Irvine School of Medicine, was lead author of the document.

Four of 21 recommendations were classified as grade A, meaning that following them would be expected to provide substantial benefits. Those recommendations are to screen all patients before surgery; postpone elective surgery for patients who have altered mental status or impaired decision-making capacity at the time of surgery; counsel frequent, heavy users about the potential for cannabis use to impair postoperative pain control; and counsel pregnant patients about the risks of cannabis use to unborn children.

The authors cited studies to support their recommendations, including one showing that long-term cannabis use was associated with a 20% increase in the incidence of postoperative nausea and vomiting, a leading complaint of surgery patients. Other research has shown that cannabis use is linked to more pain and use of opioids after surgery.
Other recommendations include delaying elective surgery for at least 2 hours after a patient has smoked cannabis, owing to an increased risk for heart attack, and considering adjustment of ventilation settings during surgery for regular smokers of cannabis. Research has shown that smoking cannabis may be a rare trigger for myocardial infarction and is associated with airway inflammation and self-reported respiratory symptoms.

Nevertheless, doctors should not conduct universal toxicology screening, given a lack of evidence supporting this practice, the guideline stated.

The authors did not have enough information to make recommendations about reducing cannabis use before surgery or adjusting opioid prescriptions after surgery for patients who use cannabis, they said.

Kenneth Finn, MD, president of the American Board of Pain Medicine, welcomed the publication of the new guidelines. Finn, who practices at Springs Rehabilitation in Colorado Springs, Colorado, has edited a textbook about cannabis in medicine and founded the International Academy on the Science and Impact of Cannabis.

"The vast majority of medical providers really have no idea about cannabis and what its impacts are on the human body," Finn said.

For one, it can interact with numerous other drugs, including warfarin.

Guideline co-author Eugene R. Viscusi, MD, professor of anesthesiology at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, emphasized that while cannabis may be perceived as "natural," it should not be considered differently from manufactured drugs.

Cannabis and cannabinoids represent "a class of very potent and pharmacologically active compounds," Viscusi told Medscape Medical News. While researchers continue to assess possible medically beneficial effects of cannabis compounds, clinicians also need to be aware of the risks.

"The literature continues to emerge, and while we are always hopeful for good news, as physicians, we need to be very well versed on potential risks, especially in a high-risk situation like surgery," he said.

Shah has consulted for companies that develop medical devices and drugs. Finn is the editor of the textbook, "Cannabis in Medicine: An Evidence-Based Approach," (Springer), for which he receives royalties.


https://www.medscape.com/viewa...Y&impID=5073653#vp_2

An ER doc acquaintance of mine told me 10 years ago there was no point in screening anyone under 30 for cannabis as you could assume they would test positive. With legal adult use here in Michigan, I would add the same for anyone over 55 today. And a lot of folks between those ages as well.

I see some really janky rhythms in the back of my ambulance due to edibles. Enough that if a person tells me they are using them, I'm expecting to see disarrhythmia on the monitor. .

Brad, I assume you are not a doc but could the use of the gummies have a severe adverse effect on someone 84 years old. Concerned for a neighbor who has been using them, not prescribed by a doc.

My (layman) understanding is that the same is, more or less, true for regular or heavy alcohol use as well. Several years ago, while in a doctor's office, and a couple days prior to a serious procedure that would require a hospital stay, I was required to be screened and fill out a separate anasthesia consent form. When I expressed mild surprise about filling out the form a few days prior to the procedure it was explained to me that those who drank alcohol regularly/heavily or used certain drugs, may require more anasthesia and/ or expect more side effects.

quote:

...

"The vast majority of medical providers really have no idea about cannabis and what its impacts are on the human body," Finn said.

For one, it can interact with numerous other drugs, including warfarin.

Guideline co-author Eugene R. Viscusi, MD, professor of anesthesiology at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, emphasized that while cannabis may be perceived as "natural," it should not be considered differently from manufactured drugs.

Cannabis and cannabinoids represent "a class of very potent and pharmacologically active compounds," Viscusi told Medscape Medical News. While researchers continue to assess possible medically beneficial effects of cannabis compounds, clinicians also need to be aware of the risks.

"The literature continues to emerge, and while we are always hopeful for good news, as physicians, we need to be very well versed on potential risks, especially in a high-risk situation like surgery," he said.

...

A family member was once pre-med, before later switching majors, but he remains a medical nerd and frustrated wannabe doctor. To this day he does a credible job of staying on top of the state of medicine, and sort of serves as our extended family's medical consultant. Several years ago he had two families of medical doctors move into his neighborhood and he was excited for the opportunity to geek out with these doctors whenever he could.

One of his neighbor doctors was trained at a service academy, and later went into private practice after serving her commitment. She worked for various practices, but now has her own small practice in a state with both legalized medicinal and recreational marijuana use, and recently legalized psychedelics.

I don't know what her current position is, or whether it's changed, but as of several years ago, she would NOT prescribe pain medications to her patients that used marijuana regularly. She said that while in medical school, her class simply didn't receive any science-based training on either how to prescribe medicinal marijuana for the treatment of various ailments, and they also didn't receive training on how marijuana might interact with other prescription pain meds.

She told any of her patients that did admit to using marijuana that she would continue to see them, but would not prescribe any pain relief medications to them while they were using marijuana. For those she suspected lied to her about marijuana use, and continued to complain of pain and request prescription pain meds, she would first require them to get a drug screening and wait for their results to come back clean.

This appears to be widely practiced. For recent hernia surgery, I was asked by the surgeon at my first consultation if I consumed marijuana, the day before surgery during a phone call from the hospital staff for routine health questions, and by the anesthesiologist about 15 minutes before the procedure. It is also in the pre-op literature packet I received.

All indications were that for a user, the procedure would occur, but the type and amount of anesthesia would be affected. Also that post-op pain could be more severe and the chance for breathing related problems increased for smokers in general.

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Originally posted by Appliance Brad:
An ER doc acquaintance of mine told me 10 years ago there was no point in screening anyone under 30 for cannabis as you could assume they would test positive. With legal adult use here in Michigan, I would add the same for anyone over 55 today. And a lot of folks between those ages as well.

I see some really janky rhythms in the back of my ambulance due to edibles. Enough that if a person tells me they are using them, I'm expecting to see disarrhythmia on the monitor. .

I've got a bunch of friends over 55 and not one of them uses MJ in any form. I don't believe it's that widespread in older people based on what I see.

quote:

Originally posted by Appliance Brad:
An ER doc acquaintance of mine told me 10 years ago there was no point in screening anyone under 30 for cannabis as you could assume they would test positive. ...

Is there any danger in that assumption?

The same “everyone” who use marijuana are the same “everyone” who says it has no ill effects.

One friend is researching the effects of marijuana vaping on 12-14 year olds.

Admittedly, lots of substances are very harmful at that stage, but frankly, selling to children that age should probably be 25-life.

Their bodies are wrecked.

I was asked the cannabis question on a sleepy-time procedure a couple of weeks ago so at least some anesthesiologists are already with the program.

I can see why an anesthesiologist would want to know everything you're putting in your body. One of Sigforum's pharmacists said a memorable quote that applies here.

quote:

Everything strong enough to cause an action is strong enough to cause a reaction.

Last time I went under anesthesia (colonscopy) there was a laundry list of things I couldn't take x days out such as prescriptions, over the counter, supplements, and alcohol. Seems reasonable to add cannabis.

Considering you're supposed to disclose to your doctor (which would include your surgeon/anesthesiologist/etc.) all medication and supplements you're taking so that they can make fully informed decisions about prescriptions and treatments, it tracks that they need to know if you're using marijuana too.

Mrs.BurtonRW, who presently works at an outpatient endoscopy clinic, encounters this all the time. Patients with chronic N/V complaints wondering why they feel so bad after coming out of their propofol/fentanyl naps...

Maybe you should stop chain-smoking weed? Idiots.

Yes. The CRNAs she works with are very aware.

-Rob

Weed smokers will need opioids? LMAO. I had shoulder surgery, bankart repair of the labrum, a few years ago. I took those prescribed opioids from my Ortho for 24 hours then chunked them in the trash and just dealt with the pain. I felt awful with those in my system.

quote:

Originally posted by McGregor:
Brad, I assume you are not a doc but could the use of the gummies have a severe adverse effect on someone 84 years old. Concerned for a neighbor who has been using them, not prescribed by a doc.

I'm a NREMT AEMT.

Based on what I've seen on monitors in the back of my bus (at my license level I'm out of my scope to interpret 12 leads but I'm trained in them), there seems to be a correlation to disarrythmia and gummie use. There are several peer reviewed papers available on the topic.

I would suggest they discuss the use with either their PCP or their cardiologist. That said, when I get to be 84, I'm gonna do whatever I damn well please and be happy I made it that far

quote:

Originally posted by Flash-LB:
I've got a bunch of friends over 55 and not one of them uses MJ in any form. I don't believe it's that widespread in older people based on what I see.

Is cannabis legal in your state? It is here for recreational use and there are tons....TONS of people 55 and over using it. Trust me, I'm in and out of dozens of houses every week eithe fixing appliances or doing EMS and pot is literally everywhere.

quote:

Originally posted by mark123:

quote:

Originally posted by Appliance Brad:
An ER doc acquaintance of mine told me 10 years ago there was no point in screening anyone under 30 for cannabis as you could assume they would test positive. ...

Is there any danger in that assumption?

Not really because they are still testing everyone for it. It's just another line on their chart from the ER. He was just saying that you expect a positive on people under 30

quote:

Originally posted by Flash-LB:

quote:

Originally posted by Appliance Brad:
An ER doc acquaintance of mine told me 10 years ago there was no point in screening anyone under 30 for cannabis as you could assume they would test positive. With legal adult use here in Michigan, I would add the same for anyone over 55 today. And a lot of folks between those ages as well.

I see some really janky rhythms in the back of my ambulance due to edibles. Enough that if a person tells me they are using them, I'm expecting to see disarrhythmia on the monitor. .

I've got a bunch of friends over 55 and not one of them uses MJ in any form. I don't believe it's that widespread in older people based on what I see.

I guess I'm really an outlier since I've never used cannabis in any form during my 85 years on Earth, and won't even stay around anyone who's smoking it. I don't think I would test positive. (I have used anesthesia recently and don't recall having been asked about it.)

flashguy

Few years ago went to a national conference of United States Attorney on the subject on MJ. One speaker said in Denver there are more MJ stores in that city than McDonalds and Starbucks combined.

quote:

Originally posted by Appliance Brad:

quote:

Originally posted by mark123:

quote:

Originally posted by Appliance Brad:
An ER doc acquaintance of mine told me 10 years ago there was no point in screening anyone under 30 for cannabis as you could assume they would test positive. ...

Is there any danger in that assumption?

Not really because they are still testing everyone for it. It's just another line on their chart from the ER. He was just saying that you expect a positive on people under 30

I don’t think drug screens are done as a standard pre-procedure test; I looked my pre-op orders pretty thoroughly to see what they looked for in my recent orders and it was not present. Maybe because I’m not a twenty something person saying “dude” instead of “sir”, but it’s probably because it’s an unnecessary invasion of privacy. That would explain why I was asked repeatedly if I used any substances including aspirin, vitamins, etc. They want to make it clear that using anything could affect anesthesia and that it is completely on the person, not medical staff if there are complications as a result.

I did the same after a dental procedure. I took 1 hit had had immediate bed spins. The other 29 pills went down the drain.

quote:

Originally posted by Prefontaine:
I took those prescribed opioids from my Ortho for 24 hours then chunked them in the trash and just dealt with the pain. I felt awful with those in my system.