Interview with Dr. Ekrami: Does Cannabis Use Increase Pain After Surgery?
There have been dozens of clinical studies and anecdotal cases documenting the efficacy of cannabis use for treating various kinds of pain. It has also been touted to be safe for post-operative care, helping patients speed up their recovery time after undergoing surgery.
However, many studies recommend against using cannabis before surgery. While some may find it beneficial for calming nerves, the risk could be greater than the reward. Some studies have found that using cannabis before surgery increases the anesthetic dose, which can be dangerous for some patients.
Meanwhile, new research by lead study author Elyad Ekrami, MD, a clinical research fellow at the Outcomes Research Department at the Cleveland Clinic’s Anesthesiology Institute, found that cannabis users tend to experience more pain after surgery, resulting in a higher opioid intake. They analyzed the medical records of 34,521 adult patients, 1,681 of whom were cannabis consumers. These patients had elective surgeries done at the Cleveland Clinic from January 2010 through December 2020.
Those who consumed marijuana 30 days prior to surgery were found to suffer from 14% more pain within the first 24 hours after their operation, compared to those who never consumed marijuana. Additionally, cannabis consumers were found to need 7% more opioids following surgery. According to the study’s authors, 7% is not statistically significant though it is clinically relevant.
“Cannabis is the most commonly used illicit drug in the United States and increasingly used as an alternative treatment for chronic pain, but there is limited data that shows how it affects patient outcomes after surgery,” Ekrami explained in a press release. “Our study shows that adults who use cannabis are having more – not less – postoperative pain. Consequently, they have higher opioid consumption after surgery,” he added.
Opioids are powerful pain killers that are prescribed for patients who suffer from extreme cases of pain. Some of the most widely used opioids in hospital settings include fentanyl, morphine, tramadol, oxymorphone, and oxycodone. Some patients, not all, find relief from opioids though they have been notorious over the last few years for its addictive properties and fatal side effects.
“The association between cannabis use, pain scores and opioid consumption has been reported before in smaller studies, but they’ve had conflicting results,” says Dr. Ekrami. “Our study has a much larger sample size and does not include patients with chronic pain diagnosis or those who received regional anesthesia, which would have seriously conflicted our results. Furthermore, our study groups were balanced by confounding factors including age, sex, tobacco and other illicit drug use, as well as depression and psychological disorders,” he said.
Dr. Ekrami makes it clear that more research is done to properly evaluate the effect of marijuana use on surgical outcomes. “Physicians should consider that patients using cannabis may have more pain and require slightly higher doses of opioids after surgery, emphasizing the need to continue exploring a multimodal approach to post-surgical pain control,” he says.
Dr. Ekrami was kind enough to answer a few questions from us at Cannabis.net:
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Do you recommend that cannabis users abstain from cannabis use before surgery? If yes, how long should they abstain?
Data we received from our study suggests that cannabis use before surgery might cause higher pain scores and also higher opioid consumption after surgery. With this data we cannot make a clear statement that abstaining from cannabis before surgery would help their pain. But possibly giving a break before surgery might be helpful. More data and studies are needed to make a clear statement on this.
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Is it possible that cannabis use impacts how we perceive pain post operatively because of the anesthesia used?
Chronic cannabis use can cause desensitization and down regulation of CB1, 2 and Mu opioid receptors. These receptors are also target of opioid medications which are used during surgery. This can be one of the possible reasons. And the other reason which we think, is the fact regular cannabis users do not usually have access to their cannabis during their stay in the hospital and cannabis is effective in managing pain in short term. So, they feel more pain at the hospital.
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Some studies have shown that THC has a biphasic effect, meaning that it increases pain sensitivity in the beginning though this is followed by sedation. Could this play a role in these results?
Cannabis has biphasic effect, meaning that at lower loses it causes wakefulness and alertness while at higher doses it has a sedating effect. But this seems not to be related with the concept of our study which is more about postoperative pain. The study which you mentioned is probably the study by Hill and colleagues (1974) which I could not find any new articles in literature supporting this.
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What non-opioid alternatives could doctors recommend for patients who experience more pain after surgery?
Regional anesthesia including regional nerve blocks can be considered more for these patients. Also, they can use non-opioids medications like Tylenol or Ibuprofen to control their pain. Opioids need to be used at right dose for right amount of time since they have serious side effects at higher doses, and they are addictive potential.
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What safety protocols do you advise cannabis-using patients to do prior to surgery?
I would suggest patients to be honest with their physicians about any drugs or tobacco that they regularly use. This will help the caregivers to have a better understanding and expectation of their pain management.
Conclusion
Cannabis users who may need to undergo surgery in the near future should disclose their use to their physician. Based on the data we have so far, together with Dr. Ekrami’s findings, these suggest that it’s for your own health to abstain from marijuana until after your surgery has healed.
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