As knowledge of the ineffective and also harmful effects of cannabis accumulates, this commentary discusses the emerging evidence for cannabis use complicating perioperative management in causing an increase in pain and/or opioid use.
This statement looked at the definition, incidence and risk factors for persistent postoperative opioid use and how it might be dealt with.
“Patient characteristics associated with an increased risk of persistent postoperative opioid use included preoperative opioid use, depression, substance use disorder, preoperative pain conditions, and smoking.”
They discuss in the free full text how health policy may help to curtail persistent opioid use.
It is known that opioid use often stems from family or friend prescriptions.
“In this analysis, opioid prescriptions to family members were associated with overdose among individuals who do not receive opioid prescriptions”.
“Prior opioid dispensing to family members was associated with 2.89-fold higher odds of individual overdose, which persisted in young children and increased with greater quantities of opioid medications dispensed to family members.”
Increased education as to the risks, safe storage of opioids, and availability of opioid antagonists is suggested.
The risks from opioid and benzodiazepines may begin even earlier than the perioperative period. This retrospective analysis examined patients that received prescriptions for either in the year before surgery.
They found “opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption.”
It is suggested: “These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.”
A population study in Sweden raises concerns regarding the widespread use of gabapentinoids for pain, sometimes with poor evidence bases, and in an effort to curb opioid overuse. However they bring issues of their own in terms of adverse effects, drug interaction and even misuse (search this blog!).
“This study suggests that gabapentinoids are associated with an increased risk of suicidal behaviour, unintentional overdoses, head/body injuries, and road traffic incidents and offences. Pregabalin was associated with higher hazards of these outcomes than gabapentin.”
“When stratifying on age, increased hazards of all outcomes were associated with participants aged 15 to 24 years.”
This study examined the association between gabapentinoids on the day of surgery and adverse postoperative outcomes in patients undergoing colorectal surgery in the United States.
Their use was associated with only a slightly lower opioid use on the day of surgery but a higher odds of non-invasive ventilation and naloxone use after surgery.
It highlights the fact that before blindly implementing enhanced recovery protocols, a firm evidence base should be established, as opioid-phobia may paradoxically result in unintended adverse events.
Faced with the opioid epidemic, many have turned to postoperative use of Tramadol in the belief it has less misuse potential.
This observational study finds however that: “People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids”.
They advocate reclassifying Tramadol and urge caution in its prescription.
This study on those on long term opioid therapy found high variability in opioid dose was associated with a greater than 3-fold increased risk of opioid overdose even after controlling for dose.
This occurred even on low dose opioids. Several mechanisms are postulated, including tapering leading to withdrawal effects that precipitated recommencing higher doses, seeking other opioid prescriptions or sources etc.
Individuals with sustained opioid therapy discontinuation (defined as 3 continuous months with 0 mg of morphine equivalents before the index date) were 51% less likely to have experienced an overdose than individuals who had not discontinued opioid therapy
The authors warn that physicians should consider the risks that may be associated with dose variability when designing and implementing new policies to reduce opioid prescribing.
The results of a joint workshop provide guidance on all aspects of substance use in pregnancy. Issues discussed in the full free text include screening tests, biologic tests, management of pain in labor and after Cesarean, pain after discharge, and approaches to medication assisted therapy (Methadone and Buprenorphine are standards of care), and organizational issues to optimize care. Discussion around breast feeding and the common neonatal opioid withdrawal syndrome (NOWS) occurs.
A Colorado database may foretell events in Canada when legal cannabis edibles will probably hit the market more.
These products have variable constituents and concentrations and may be taken in excess or cumulate before they are absorbed fully and produce ill effects,
Significant side effects necessitating ER visits included intoxication, hyperemesis, psychiatric and cardiovascular effects including myocardial infarction and ventricular dysthymias.
Education, especially in teenagers, is needed on the nontrivial nature of cannabis adverse effects in many spheres.