Robert C. Juniewicz, BA
Sidney Kimmel Medical College- Thomas Jefferson University
SUMMARY POINTS
Cannabis use is increasing in the United States adult population.
Cannabis has been shown to alter pain signaling and promote bone healing.
The effects of pre-op cannabis use of post-op pain and opioid use is unclear.
Advocacy for changing the schedule 1 status of cannabis will allow for more robust evidence on the effects of cannabis on orthopedic patients.
ANALYSIS
Background
Orthopedics is a rapidly growing field commonly utilizing opioid pain medication post operatively. It is one of the major prescribers of opioids for pain and, amidst an opioid epidemic, it is necessary to study factors that impact opioid use (1). Cannabis use and its effects on the human body is an emerging topic especially with its effects on pain management. Currently, there are three known cannabinoid receptors: CB1, CB2 and GPR55 (2,3). Two of these receptors, CB1 and CB2, are known to dampen nociceptive pain signaling and all three have been shown to affect bone healing by altering the function of osteoblasts and osteoclasts (2-4). Additionally, animal models used to study the effects of cannabinoids have shown that they have an opioid sparing effect, with a 3.6x reduction in opioid use when co-administered with cannabis (5). Due to these effects, the impact of cannabis use on post-operative pain, opioid use, and surgical outcomes has become a topic worth investigating.
Figure 1. Biochemical Effects of Cannabinoids
Cannabis use in the United states is rapidly growing with a 13.8% increase in cannabis product users from 2002 to 2019 (6-8). In 2023, there was an estimated 55 million adults (18 and older) that used cannabis (9). Currently, 38 states and the District of Columbia have legalized medical use and 23 states have legalized recreational use of cannabis products (10,11). This rise in cannabis use is of specific interest in the orthopedic community as chronic lower back pain and arthritis related pain are some of the most common reasons for prescribing medicinal cannabis products (12,13). The number of orthopedics patients using cannabis is increasing and provides more motivation to study its impact on orthopedic procedures. Thus, the purpose of this analysis is to explore the current literature on cannabis and its effects on orthopedic post-op pain, opioid use, and outcomes.
Figure 2. Map of states where medical and recreational cannabis is legal. See Link from Delaware just became the latest state to legalize recreational marijuana. See a list of every state where cannabis is legal. Business Insider.com. Updated April 27, 2023. Accessed June 28, 2023. https://www.businessinsider.com/legal-marijuana-states-2018-1
Analysis
To date, there is a limited number of studies focusing on the effects of pre-op cannabis use on orthopedic procedure outcomes. However, there are studies on this topic within other surgical fields. Some studies found associations between cannabis and the cardiovascular and hematological systems. Two of the studies found that surgical patients with pre-op cannabis use (PCU) had a significantly increased risk of arrhythmias and myocardial infarction (MI) (15,16). Furthermore, there was a significantly increased incidence of venous thromboembolism, deep vein thrombosis, and pulmonary embolism in patients with PCU compared to cannabis naive patients (CNP) (17,18). Furthermore, an in vitro study examining the effects of cannabis found increased pulmonary edema and inflammation, significant tachycardia related to MI, and mixed anti and pro-coagulant effects (3). Furthermore, in two studies focusing on orthopedic procedures the only significant difference between PCU and CNP were PCU experienced significantly greater rates of reoperation and 90-day readmission (16,22).
Studies focused on measuring the effects of PCU on patient pain and opioid use had contrasting results. Three studies investigating numerous surgical fields, including orthopedics, found that patients with PCU experienced greater pain and worse reported function up to 6 months post-op compared to CNP (3,19-21). Wiseman et al. was the only study that investigated the possible opioid sparing effects and found that pre-op cannabis users used significantly more opioids compared to naive patients at 12 and 36 hours post-op (20 vs 10 and 40 vs 40 morphine milligram equivalent, respectively) (19). However, this study only looked at gynecological surgery. Alternatively, one study that focused on spine orthopedic procedures found no difference in pain or function (22).
Overall, the evidence is unclear as to the effects of cannabis on post-op pain and opioid use as clinical studies are mixed and not aligning with preclinical basic science data. However, there is evidence that cannabis may have negative outcomes such as increased incidence of 90-day readmission, reoperation, hypercoagulable state, and greater cardiovascular risk.
Discussion
The landscape of current research on the effects of pre-op cannabis on orthopedic post-op pain, opioid use, and outcomes has a mixed picture without clear findings. Many studies examining this topic have called for more robust studies to elucidate clearer associations. However, this will prove challenging due to the current schedule one status of cannabis that limits the study of cannabis without special permission (23). Due to this limitation, it becomes difficult to accurately characterize the amount of cannabis use, strain of cannabis, method of use, and duration of use in patients. Additionally, with the legalization of recreational cannabis, future studies need to further delineate between those using cannabis for medical or recreational use to those requiring cannabis use for medical reasons (19). As the prevalence of both medical and recreational cannabis use increases, it becomes necessary to accurately study the drug's safety profile. In order to achieve this goal more robust studies need to be conducted.
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Delaware just became the latest state to legalize recreational marijuana. See a list of every state where cannabis is legal. Business Insider.com. Updated April 27, 2023. Accessed June 28, 2023. https://www.businessinsider.com/legal-marijuana-states-2018-1
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