Weeding Out the Problem: The Impact of Preoperative Cannabinoid Use on Pain in the Perioperative Period

Abstract

BACKGROUND: The recreational and medical use of cannabinoids has been increasing. While most studies and reviews have focused on the role of cannabinoids in the management of acute pain, no study has examined the postoperative outcomes of surgical candidates who are on cannabinoids preoperatively. This retrospective cohort study examined the impact of preoperative cannabinoid use on postoperative pain scores and pain-related outcomes in patients undergoing major orthopedic surgery. METHODS: Outcomes of patients who had major orthopedic surgery at our hospital between April 1, 2015 and June 30, 2017 were reviewed. Data were obtained from Networked Online Processing of Acute Pain Information, a locally developed database for our Acute Pain Service. Propensity score matching was used to balance baselines variables including age, sex, type of surgery, history of depression or anxiety, and perioperative use of regional anesthesia between patients who reported use of cannabinoids and those not on this substance. Intensity of pain with movement in the early postoperative period (defined as up to 36 hours after surgery) was the primary outcome of this study. The secondary outcomes (all in early postoperative period) were pain at rest, opioid consumption, incidence of pruritus, nausea and vomiting, sedation, delirium, constipation, impairment of sleep and physical activity, patient satisfaction with analgesia, and the length of Acute Pain Service follow-up. RESULTS: A total of 3793 patients were included in the study. Of these, 155 patients were identified as being on cannabinoids for recreational or medical indications in the preoperative period. After propensity score matching, we compared data from 155 patients who were on cannabinoids and 155 patients who were not on cannabinoids. Patients who were on preoperative cannabinoids had higher pain numerical rating score (median [25th, 75th percentiles]) at rest (5.0 [3.0, 6.1] vs 3.0 [2.0, 5.5], P = .010) and with movement (8.0 [6.0, 9.0] vs 7.0 [3.5, 8.5], P = .003), and a higher incidence of moderate-to-severe pain at rest (62.3% vs 45.5%, respectively, P = .004; odds ratio, 1.98; 95% CI, 1.25–3.14) and with movement (85.7% vs 75.2% respectively, P = .021; odds ratio, 1.98; 95% CI, 1.10–3.57) in the early postoperative period compared to patients who were not on cannabinoids. There was also a higher incidence of sleep interruption in the early postoperative period for patients who used cannabinoids. CONCLUSIONS: This retrospective study with propensity-matched cohorts showed that cannabinoid use was associated with higher pain scores and a poorer quality of sleep in the early postoperative period in patients undergoing major orthopedic surgery.

Perioperative pain and addiction interdisciplinary network (PAIN): protocol for the perioperative management of cannabis and cannabinoid-based medicines using a modified Delphi process

“…16 A similar finding was reported in a recent 2019 Canadian retrospective cohort study of patients who had undergone major orthopaedic surgery. 17 This study also noted higher rates of postoperative myocardial infarction and sleep disruption in cannabis using patients. A 2019 retrospective cohort review of 4 186 122 elective surgical patients found that those patients with an ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) code for cannabis dependence or cannabis abuse had an adjusted odds of postoperative myocardial infarction of 1.88 times higher (p<0.001) compared with those without an active cannabis use disorder.…”

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…Providers should actively engage patients in shared decision-making and education regarding the perioperative implications of chronic cannabinoid use (discussed comprehensively elsewhere [147,148]), including how postoperative pain is affected. Cannabinoid use is associated with significantly increased anesthetic requirements during surgery, higher postoperative pain scores, higher perioperative opioid consumption, and poorer postoperative sleep quality [149][150][151][152]. This may be due to cannabinoid receptor downregulation and the complex interactions of the endocannabinoid system with various neurotransmitters and pain modulation pathways [153,154].…”

A review of the anesthetic implications of marijuana use

“…There are no specific data regarding intraoperative analgesic use in cannabis users, but recent studies have shown that cannabis users report higher pain scores, have worse sleep, and require more rescue analgesics in the immediate postoperative phase of care. [62][63][64] It is possible that this population may require greater analgesic use in the intraoperative phase, but there are no data to support or refute this view. Nevertheless, the use of a multimodal perioperative analgesic approach utilizing acetaminophen and a nonsteroidal antiinflammatory drug or a cyclooxygenase-2-specific inhibitor combined with a local or regional analgesia technique, if possible, would be beneficial.…”

“…69 Recent trials have actually shown higher pain scores and greater analgesic use in the postoperative period among cannabis users. [62][63][64] Thus, though evidence seems to support the analgesic effects of cannabis in chronic pain conditions, it is possible that cannabis users may have augmented pain perception in the acute postoperative period.…”