From the Guidelines
The correct answer is "All of the above." Regular cannabis use places this 50-year-old woman at increased perioperative risk for higher pain levels, PONV (postoperative nausea and vomiting), and multiple drug interactions, as highlighted in the perioperative pain and addiction interdisciplinary network (PAIN) consensus recommendations 1. Cannabis users often develop tolerance requiring higher doses of analgesics postoperatively. Cannabis affects the chemoreceptor trigger zone and can worsen PONV when combined with anesthetics and opioids. Additionally, cannabis interacts with multiple medications through cytochrome P450 pathways, potentially affecting the metabolism of her numerous medications including tramadol, escitalopram, amlodipine, and apixaban.
These risks are in addition to cannabis withdrawal syndrome (CWS), which can manifest as irritability, anxiety, insomnia, and decreased appetite when cannabis use is abruptly stopped during hospitalization. Her complex medication regimen and multiple comorbidities further increase her vulnerability to these complications during the perioperative period. The importance of considering perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth is emphasized in the PAIN consensus recommendations 1.
Key considerations for her management include:
- Anticipating increased postoperative analgesic requirements
- Maintaining vigilance for cannabis withdrawal syndrome
- Implementing a multimodal approach to PONV prophylaxis, as suggested in the ERAS society recommendations 1
- Carefully monitoring and managing her multiple medications to minimize potential drug interactions.
From the Research
Perioperative Risks Associated with Regular Cannabis Use
The patient's regular use of cannabis edibles places her at increased risk for several perioperative complications. The potential risks include:
- Higher pain levels: While cannabis is often used for pain management, its chronic use can lead to increased pain sensitivity and decreased efficacy of opioid-based pain medications 2.
- PONV (Postoperative Nausea and Vomiting): Cannabis use has been linked to an increased risk of PONV, although the exact mechanisms are not fully understood 3.
- Multiple drug interactions: Cannabis, particularly cannabidiol, can interact with various medications, including anticoagulants, antiplatelet agents, and other substances, potentially leading to harmful drug-drug interactions 4, 5.
Summary of Risks
Given the patient's medical history and regular cannabis use, it is essential to consider the potential perioperative risks associated with cannabis use. The patient's use of cannabis edibles may increase her risk for higher pain levels, PONV, and multiple drug interactions, making it crucial to closely monitor her condition and adjust her medication regimen accordingly.
All of the above options are correct, as regular cannabis use can increase the risk of higher pain levels, PONV, and multiple drug interactions perioperatively 2, 4, 5, 3.