Guidelines recommend universal screening for cannabinoids prior to surgery

Universal screening for cannabinoids should be performed prior to surgery, according to new guidelines from the American Society of Regional Anesthesia and Pain Medicine.

The consensus guidelines, in development since November 2020, were published Jan. 3 by Regional Anesthesia & Pain Medicine. They cover preoperative, intraoperative, and acute postoperative care considerations regarding patients who use cannabis and cannabinoids. For each recommendation, the guideline authors assigned grades based on the U.S. Preventive Services Task Force definitions of evidence strength, which specifies Grades A to D or I for insufficient evidence.

The recommendations include the following:

• 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)
• Patients should be counseled on the potential risks of continued perioperative cannabinoids. (Grade B)
• Elective surgery should be postponed in patients who have altered mental status or impairment of decision-making capacity due to acute cannabis intoxication. (Grade A)
• Elective surgery should be delayed for a minimum of two hours after smoking cannabis because of increased perioperative risk of acute myocardial infarction. (Grade C)
• Patients who frequently use cannabis should be counseled on the potentially negative effects on postoperative pain control. “Low-dose, medically supervised use likely has a lower risk of negative effects,” the guidelines said. (Grade A)
• While the guidelines did not recommend the routine use of additional postoperative monitoring for cardiac or neurological adverse events, they did recommend increased vigilance, given that cardiac and neurovascular events frequently occur in the postoperative period. (Grade C)
• Multimodal analgesia incorporating regional analgesia should be used, if appropriate, and opioids should be used as rescue medication. “Patients may need additional follow-up for adequacy of analgesia and the need for adjusting postoperative pain medications accordingly,” the guidelines said. (Grade C)
• Opioids may be administered, with increased vigilance, when indicated for the management of perioperative pain in patients who use cannabis. (Grade C)
• Patients using cannabis should be counseled regarding the risk of cannabis withdrawal symptoms, and those who consume cannabis routinely should be postoperatively monitored for them using a validated and reliable scale. (Grade C)

There was insufficient evidence to recommend for or against adjusting postoperative opioid prescriptions in surgical patients who consume cannabinoids or the routine tapering of cannabis and cannabinoids in the perioperative period, the guidelines noted. There was also not enough data to recommend a specific duration for delaying elective surgery after nonsmoking routes of cannabis administration; clinicians should consider weighing the risks and benefits before proceeding, the authors said.

“Cannabinoid use in the perioperative setting has significant potential negative medical implications. We hope these guidelines will help both clinicians and researchers in their pursuit of optimal patient care,” they concluded, adding that the guidelines may be revised if new evidence warrants updated recommendations.