Management of the Perioperative Patient on Cannabis and Cannabinoids

Publication Date: January 2, 2023
Last Updated: January 31, 2023

Question 1: Should all surgical and procedural patients requiring anesthesia be screened for cannabinoids preoperatively and if so, what information should be obtained?

  • Statement: Cannabinoids are the most commonly used recreational drugs in the USA and other countries, and the use of cannabinoids, both recreational and medicinal, may result in physiologic derangements. They may have interactions with other medications and treatments in the perioperative period. Level of Certainty: Moderate
  • Recommendation 1: 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. Grade A
  • Recommendation 2: Universal toxicology screening for cannabinoids is not currently indicated based on insufficient available evidence. Grade D

Question 2: What evidence exists to guide the decision to continue or stop cannabinoids perioperatively and/or postpone elective surgery?

  • Statement 1: Acute effects of cannabis use can result in altered mental status and impairment of decision-making capacity. Hence, the frequency and the timing of the last dose of cannabis usage are important. Level of Certainty: High
  • Statement 2: Smoking cannabis can cause increases in heart rate and blood pressure that is prominent within the first 1–2 hours of usage. Level of certainty: High
  • Statement 3: Smoking cannabis may lead to a higher risk of perioperative acute MI within the first 1–2 hours. Level of certainty: Moderate
  • Statement 4: Smoking cannabis may have deleterious effects on airway resistance and respiratory adverse events. Level of certainty: Moderate
  • Statement 5: There is a lack of published data on the perioperative cardiovascular effects following other routes of cannabinoid administration. Level of certainty: Moderate
  • Recommendation 1: Patients should be counseled on the potential risks of continued perioperative cannabinoids. Grade B
  • Recommendation 2: We recommend postponing elective surgery in patients who have altered mental status or impairment of decision-making capacity due to acute cannabis intoxication. Grade A
  • Recommendation 3: We recommend delaying elective surgery for a minimum of 2 hours after cannabis smoking because of increased perioperative risk of acute MI . Grade C
  • Recommendation 4: With other cannabinoids routes (non-smoking) of administration, consider weighing the risks and benefits before proceeding with elective surgery given the temporal association of cannabis usage and adverse cardiovascular effects. There is a lack of published data to recommend a specific duration. Grade I

Question 3: For patients on concomitant cannabis and opioid use preoperatively, does existing evidence provide guidance on tapering of cannabinoids prior to surgery?

  • Statement 1: Chronic use of THC may worsen postoperative pain, increase postoperative opioid use and precipitate the development of postoperative hyperalgesia. Level of certainty: Moderate
  • Statement 2: There is a lack of high-quality evidence describing the risks of concomitant opioids and cannabinoids in the perioperative period and in addition few studies have addressed the benefits and risks of preoperative cannabinoid tapering. We are uncertain of the overall benefit of preoperative cannabinoid tapering. Level of certainty: Low
  • Recommendation 1: We recommend that the frequent cannabis user be counseled on the potentially negative effects on postoperative pain control. Low-dose, medically supervised use likely has a lower risk of negative effects. Grade A
  • Recommendation 2: We cannot recommend for or against the routine tapering of cannabis and cannabinoids in the perioperative period. Grade I

Question 4: What are the specific concerns of chronic cannabinoid use in a parturient presenting for labor or cesarean section?

  • Statement 1: While cannabis use during pregnancy and in the postpartum period has the potential for adverse maternal and fetal physiological complications, there is currently no evidence to suggest that there are any specific implications with neuraxial anesthesia for labor or cesarean section. Level of certainty: Moderate
  • Recommendation 1: Pregnant patients should be educated and counseled about the risks of maternal cannabis use on the fetus/neonate. Grade A
  • Recommendation 2: Cannabis use during pregnancy and immediate postpartum period should be discouraged. Grade B

Question 5: Should the intraoperative doses of anesthetics and analgesics be adjusted in patients who have taken cannabinoids preoperatively?

  • Recommendation 1: Consideration should be given to adjusting induction and maintenance doses of anesthetic agents based on clinical presentation and timing of the last consumption of cannabis in surgical and procedural patients. Grade C
  • Recommendation 2: There is insufficient evidence to recommend for or against the use of intraoperative EEG monitoring in patients who have taken cannabinoids. Grade I

Question 6: Does acute or chronic cannabis exposure require any adjustment of ventilator settings to accommodate for possible V/Q mismatch, smoke inhalation injury, or other lung pathology?

  • Statement 1: There is low-quality evidence that patients taking only oral cannabinoids do not experience significant changes in pulmonary function. Level of certainty: Low
  • Statement 2: There is conflicting evidence as to whether any ventilatory changes should be made for patients with chronic or acute cannabis exposure via inhalation. Acute cannabis inhalation may result in bronchodilation but may also cause airway irritation and bronchoconstriction in susceptible individuals. Long-term use of inhaled cannabis is likely associated with the development of obstructive lung disease-like patterns such as chronic bronchitis. Level of Certainty: Low
  • Recommendation 1: Based on the studies reviewed, patients taking only oral cannabis do not need any adjustments in ventilatory settings. Grade C
  • Recommendation 2: Adjustment of ventilatory settings should be considered since obstructive lung disease-like patterns may be associated with chronic cannabis consumption by inhalation, particularly in patients with comorbid conditions that are associated with an increased risk of pulmonary pathology. Grade C
  • Recommendation 3: Evidence is insufficient to guide ventilation settings following acute cannabis use via inhalation. Grade I

Question 7: Do patients taking perioperative cannabinoids require any special postoperative considerations? If so, for how long?

  • Statement 1: Acute cannabis intoxication and active CUD may be associated with increased risk for acute postoperative MI and cerebrovascular morbidity. Level of certainty: Moderate
  • Statement 2: A cannabis-using patient may have delayed gastrointestinal motility and may also be at a higher risk for PONV. Level of certainty: Moderate
  • Statement 3: Cannabis users and patients with CUD may be associated with higher postoperative pain scores and opioids use. Level of certainty: Moderate
  • Recommendation 1: Based on the currently available evidence, we do not recommend the routine use of additional postoperative monitoring for cardiac or neurological adverse events. However, we do recommend increased vigilance given that cardiac and neurovascular events do frequently occur in the postoperative period. Grade C
  • Recommendation 2: Based on the currently available evidence, we recommend using multimodal analgesia incorporating regional analgesia if appropriate and using opioids as rescue medication. Patients may need additional follow-up for adequacy of analgesia and the need for adjusting postoperative pain medications accordingly. Grade C

Question 8: Are there special considerations for concomitant opioid and cannabinoid use and should postoperative opioid prescriptions be adjusted prior to discharge?

  • Statement 1: Cannabinoid studies in patients taking opioids for chronic pain suggest that there may be a therapeutic benefit of low-dose THC on pain and opioid use, but the opioid-sparing effect is not apparent in the setting of acute pain. Level of certainty: Low
  • Statement 2: None of the studies reviewed identified any increase in significant adverse events (moderate to severe respiratory depression or nausea/vomiting) with the co-administration of THC and an opioid in experimental studies with healthy volunteers, and few studies reported on these outcomes in the clinical setting. Level of certainty: Low
  • Statement 3: There is evidence of increased pain and opioid requirements postoperatively among patients who use cannabis. Level of certainty: Low
  • Recommendation 1: Opioids may be administered when indicated for the management of perioperative pain in patients who use cannabis with increased vigilance. Grade C
  • Recommendation 2: There is insufficient evidence to recommend for or against adjusting postoperative opioid prescriptions in surgical patients who consume cannabinoids. Grade I

Question 9: How do cannabis withdrawal symptoms present in the postoperative period and is there evidence for specific treatment?

  • Statement: CWS may present in the postoperative period. Highest risk patients are those consuming high quantities or unknown amounts of THC containing products. The risk is considered to be less with individuals consuming CBD dominant (>10:1 CBD to THC ratio) products. Level of certainty: Moderate
  • Recommendation 1: Patients using cannabis should be counseled regarding the risk of CWS. Postoperatively, patients that consume cannabis routinely should be monitored for CWS using a validated and reliable scale. Grade C
  • Recommendation 2: The expert panel came to the consensus that initiating a cannabinoid agonist such as dronabinol at a low dose is the best choice to treat severe CWS postoperatively. Grade C

Recommendation Grading

Overview

Title

Management of the Perioperative Patient on Cannabis and Cannabinoids

Authoring Organization

American Society of Regional Anesthesia and Pain Medicine

Publication Month/Year

January 2, 2023

Last Updated Month/Year

October 23, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Prevention

Diseases/Conditions (MeSH)

D019990 - Perioperative Care, D002188 - Cannabis, D002186 - Cannabinoids

Keywords

perioperative, perioperative care, cannabis, perioperative management, cannabinoids, marijuana, CBD

Source Citation

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 Jan 3:rapm-2022-104013. doi: 10.1136/rapm-2022-104013. Epub ahead of print. PMID: 36596580.