Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

Abstract

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids

“…A recent consensus-based guideline recommended reducing cannabinoid use 7 days prior to surgery (to less than 1.5 g/day of smoked cannabis, 300 mg/day of CBD oil, 20 mg/day of THC oil) while cautioning not to attempt any tapering strategies within 6 days of elective surgery and not to attempt tapering a day prior to surgery. 115 Contrary to this recommendation, recent reviews of perioperative cannabinoids recommended cessation 72 hours prior to surgery. 84 94 An even more conservative recommendation was recently provided, in which the authors recommended up to 10 days of cessation of oral cannabis consumption.…”

“…Other human studies have found altered gamma neural oscillations in cannabis users, but it remains unclear how those changes would affect anesthetic management. 189 190 Finally, in their consensus recommendations on the perioperative management of cannabis, Ladha et al 115 suggested giving 'extra consideration to greater depth of anesthesia during induction and maintenance of anesthesia' in cannabis users. They also stated that acutely intoxicated cannabis users might have lower anesthetic requirements and recommended the use of intraoperative electroencephalogram (EEG) monitoring.…”

Illicit Drug Use and Endoscopy: When Do We Say No?

“…For patients whose procedure is scheduled in more than 7 days, cannabis tapering or cessation can be considered based on amount and frequency consumed. However for patients for which surgery will occur in less than 1 day, weaning or cessation is not recommended due to risk of cannabis withdrawal and/or increased anxiety or pain [ 73 ]. In cases of intermediate use (1–6 days) non-toxic patients may be able to proceed to endoscopy on a case-by-case basis while planning for the above-mentioned considerations associated with use.…”

Persistent Pain After Cardiac Surgery: Prevention and Management

“…67,68 Interestingly, patients on cannabinoids may have higher tolerance to opioids and NSAIDs, requiring higher doses. 69 Addressing patients' psychological comorbidities may also play a key role within a multifaceted approach to PPP prevention after cardiac surgery. Patients may present with preexisting psychological risk factors for the development of chronic pain including anxiety, depression, posttraumatic stress disorder, and pain catastrophizing.…”

“… 67 , 68 Interestingly, patients on cannabinoids may have higher tolerance to opioids and NSAIDs, requiring higher doses. 69 …”