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Comment & Response
June 16, 2021

Concerns About Recommendations for Perioperative Cannabis Use—Reply

Author Affiliations
  • 1Department of Surgery, University of Colorado School of Medicine, Aurora
  • 2Department of Surgery, City of Hope National Medical Center, Duarte, California
JAMA Surg. 2021;156(10):989. doi:10.1001/jamasurg.2021.2265

In Reply We thank Ladha et al and Davidson et al for their Letters to the Editor regarding our Review article on perioperative cannabis1 and for bringing some additional published research to the forefront. This includes a recent retrospective study demonstrating the association of cannabis use disorder with perioperative myocardial infarction.2 It should be noted that regular cannabis use is not synonymous with cannabis use disorder and that 42% of these patients were also tobacco smokers,2 potentially confounding examination of perioperative cardiac events. However, we agree that given the known association of cannabis use with tachycardia, caution should be used in patients with a predisposition to cardiac disorders. Such warnings exist in the package inserts for dronabinol and nabilone. Ladha et al and Davidson et al also cite a retrospective study from a center that used dronabinol off label for pain control primarily in patients with prehospitalization cannabis use.3 The authors of this study found a decrease in opioid use in the first 48 hours after initiation of treatment, which is encouraging, but did not find a difference in overall opioid use or pain scores. In our Review article, we attempted to focus on level 1 data when available and agree that more data are needed to render final conclusions regarding efficacy of cannabis as an analgesic. Ladha et al and Davidson et al also raised concerns regarding our recommendation to hold cannabis use 10 days prior to surgery. This recommendation was made based on our current poor understanding of its perioperative effects and the known half-lives of cannabidiol and delta-9-tetrahydrocannabinol (THC) analogues to enable significant clearance from the patient. We recognize that cannabis withdrawal syndrome is a described entity characterizing the psychiatric adverse events experienced by approximately 12% of long-term frequent cannabis users after abrupt reduction or cessation of use.4 These effects primarily consist of nervousness/anxiety, sleep difficulty, and depressed mood.4 We were unable to find data regarding how withdrawal from cannabis might affect perioperative outcomes, but we agree that support should be offered if cannabis withdrawal syndrome is a clinical concern. We acknowledge that others may have different practice patterns but noted that in the panel of experts assembled for the referenced consensus,5 only 1 author was a surgeon. We would be happy to participate in future consensus panels to increase surgeon participation.

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