Your anesthesiologist needs to know if you smoke pot
When Colorado legalized marijuana, it became a pioneer in creating new policies to deal with the drug.
Now the state’s surgeons, nurses, and anesthesiologists are becoming pioneers of a different sort in understanding what weed may do to patients who go under the knife.
Their observations and initial research show that marijuana use may affect patients’ responses to anesthesia on the operating table — and, depending on the patient’s history of using the drug, either help or hinder their symptoms afterward in the recovery room.
Colorado makes for an interesting laboratory. Since the state legalized marijuana for medicine in 2000 and allowed for its recreational sale in 2014, more Coloradans are using it — and they may also be more willing to tell their doctors about it.
Roughly 17% of Coloradans said they used marijuana in the previous 30 days in 2017, according to the National Survey on Drug Use and Health, more than double the 8% who reported doing so in 2006. By comparison, just 9% of U.S. residents said they used marijuana in 2017.
“It has been destigmatized here in Colorado,” said Dr. Andrew Monte, an associate professor of emergency medicine and medical toxicology at the University of Colorado School of Medicine and UCHealth. “We’re ahead of the game in terms of our ability to talk to patients about it. We’re also ahead of the game in identifying complications associated with use.”
One small study of Colorado patients published in May found marijuana users required more than triple the amount of one common sedation medicine, propofol, as did nonusers.
Those findings and anecdotal reports are prompting additional questions from the study’s author, Dr. Mark Twardowski, and others in the state’s medical field: If pot users indeed need more anesthesia, are there increased risks for breathing problems during minor procedures? Are there higher costs with the use of more medication, if a second or third bottle of anesthesia must be routinely opened? And what does regular cannabis use mean for recovery post-surgery?
But much is still unknown about marijuana’s impact on patients because it remains illegal on the federal level, making studies difficult to fund or undertake.
It’s even difficult to quantify how many of the estimated 800,000 to 1 million anesthesia procedures that are performed in Colorado each year involve marijuana users, according to Dr. Joy Hawkins, a professor of anesthesiology at the University of Colorado School of Medicine and president of the Colorado Society of Anesthesiologists. The Colorado Hospital Association said it doesn’t track anesthesia needs or costs specific to marijuana users.
As more states legalize cannabis to varying degrees, discussions about the drug are happening elsewhere, too. On a national level, the American Association of Nurse Anesthetists recently updated its clinical guidelines to highlight potential risks for and needs of marijuana users. American Society of Anesthesiologists spokeswoman Theresa Hill said that the use of marijuana in managing pain is a topic under discussion but that more research is needed. This year, it endorsed a federal bill calling for fewer regulatory barriers on marijuana research.
Why should patients disclose marijuana use?
No matter where patients live, though, many nurses and doctors from around the country agree: Patients should disclose marijuana use before any surgery or procedure. Linda Stone, a certified registered nurse anesthetist in Raleigh, N.C., acknowledged that patients in states where marijuana is illegal might be more hesitant.
“We really don’t want patients to feel like there’s stigma. They really do need to divulge that information,” Stone said. “We are just trying to make sure that we provide the safest care.”
In Colorado, Hawkins said, anesthesiologists have noticed that patients who use marijuana are more tolerant of some common anesthesia drugs, such as propofol, which helps people fall asleep during general anesthesia or stay relaxed during conscious “twilight” sedation. But higher doses can increase potentially serious side effects such as low blood pressure and depressed heart function.
Limited airway flow is another issue for people who smoke marijuana. “It acts very much like cigarettes, so it makes your airway irritated,” she said.
To be sure, anesthesia must be adjusted to accommodate patients of all sorts, apart from cannabis use. Anesthesiologists are prepared to adapt and make procedures safe for all patients, Hawkins said. And in some emergency surgeries, patients might not be in a position to disclose their cannabis use ahead of time.
Even when they do, a big challenge for medical professionals is gauging the amounts of marijuana consumed, as the potency varies widely from one joint to the next or when ingested through marijuana edibles. And levels of THC, the chemical with psychoactive effects in marijuana, have been increasing in the past few decades.
“For marijuana, it’s a bit of the Wild West,” Hawkins said. “We just don’t know what’s in these products that they’re using.”
Marijuana’s effects on pain after surgery
Colorado health providers are also observing how marijuana changes patients’ symptoms after they leave the operating suite — particularly relevant amid the ongoing opioid epidemic.
“We’ve been hearing reports about patients using cannabis, instead of opioids, to treat their postoperative pain,” said Dr. Mark Steven Wallace, chair of the pain medicine division in the anesthesiology department at the University of California-San Diego, in a state that also has legalized marijuana. “I have a lot of patients who say they prefer it.”
Matthew Sheahan, 25, of Denver, said he used marijuana to relieve pain after the removal of his wisdom teeth four years ago. After surgery, he smoked marijuana rather than using the ibuprofen prescribed but didn’t disclose this to his doctor because pot was illegal in Ohio, where he had the procedure. He said his doctor told him his swelling was greatly reduced. “I didn’t experience the pain that I thought I would,” Sheahan said.
In a study underway, Wallace is working with patients who’ve recently had surgery for joint replacement to see whether marijuana can be used to treat pain and reduce the need for opioids.
But this may be a Catch-22 for regular marijuana users. They reported feeling greater pain and consumed more opioids in the hospital after vehicle crash injuries compared with nonusers, according to a study published last year in the journal Patient Safety in Surgery.
“The hypothesis is that chronic marijuana users develop a tolerance to pain medications, and since they do not receive marijuana while in the hospital, they require a higher replacement dose of opioids,” said Dr. David Bar-Or, who directs trauma research at Swedish Medical Center in Englewood, Colo., and several other hospitals in Colorado, Texas, Missouri and Kansas. He is studying a synthetic form of THC called dronabinol as a potential substitute for opioids in the hospital.
Again, much more research is needed.
“We know very little about marijuana because we’ve not been allowed to study it in the way we study any other drug,” Hawkins said. “We’re all wishing we had a little more data to rely on.”
When Colorado legalized marijuana, it became a pioneer in creating new policies to deal with the drug.
How to Talk to Your Doctor About Cannabis Use
Have you had a bad experience disclosing cannabis use to a doctor? Did a doctor’s attitude toward cannabis impact the quality of care you received? You’re not alone.
Unfortunately, a prevailing stigma, lack of exposure to current marijuana research , and confusion about the legality of discussing cannabis with patients are still barriers within the medical community that keep doctors from treating their cannabis-using patients accurately and fairly.
One thing medical and non-medical cannabis users have in common with the rest of the world is that all need access to medical care. So what is a cannabis user to do?
To answer this question, Weedmaps News spoke with two experts on the subject. Dr. Bonni Goldstein is a Medical Director of Canna-Centers, a medical marijuana evaluation service in Lawndale, California, and a medical adviser to Weedmaps. Ted Chan is the CEO of CareDash , a fast-growing healthcare review website.
Both Goldstein and Chan have consulted with thousands of patients, many of whom report a variety of poor experiences disclosing cannabis use to doctors. Based on their respective years of research, and field experience in the subject, here are some key words of advice to keep in mind when talking to your doctor about weed.
Be Transparent (and Prepare for a Negative Response)
The first thing both adult users and medical cannabis patients should realize when disclosing to a physician is that they’re likely to be met with either prejudice, ignorance, or both.
Goldstein has seen thousands of medical cannabis patients, many of whom have reported frustrating conversations with their doctors about using cannabis as medicine.
“Unfortunately, most doctors know nothing about cannabis as medicine or about the endocannabinoid system (ECS). There is no formal education about these topics in the majority of medical school or residency programs.” Goldstein said. “Only about 9% of medical schools even mention cannabis as medicine in their curriculum. And the reality is that we as doctors are taught that cannabis is a drug of abuse.”
Goldstein added that those who disclose non-medical cannabis use to doctors are likely to be lectured or even diagnosed with cannabis use disorder , a clinical impairment of control over cannabis use despite harmful or adverse effects.
Even with these systemic biases within the medical community, it’s ultimately better to err on the side of full disclosure with a physician.
For all of marijuana’s potentially therapeutic properties, there are risks involved in mixing it with other medications . Drug.com lists 612 drugs that interact with cannabis, 129 of which have major interactions. Recent findings suggest that cannabis users need more than twice the usual amount of anesthesia before undergoing endoscopic surgery. It’s also possible to be allergic to cannabis , and experience symptoms typical of other food, skin, or airborne allergies. The more your doctors know, the better chance they have of giving you proper care.
That’s why Chan recommends being completely transparent about your patterns of cannabis use. “If you use a little, say that,” Chan said. “If it’s daily, recreational, or to manage a specific symptom, don’t be afraid to say it.”
According to Chan, full transparency is not only a way to increase your chances of getting the medical care you need, but also a quicker route to finding out the doctor’s attitude toward cannabis. Just be prepared to find out you know more than your doctor about cannabis and how it affects your body.
Be Proactive in Gauging Your Doctor’s Reaction
Since most doctors you’re likely to encounter either know nothing or have a professional bias against cannabis, it’s important to be proactive and gauge how your doctor responds when you disclose cannabis use.
As CEO of CareDash, Chan has read thousands of reviews of doctors made by their patients, and talks to many patients personally. He considers patient advocacy a central role at CareDash. There’s no shortage of reviews on the site describing incidents where a patient was either misdiagnosed or denied the care they needed based on physicians’ bias against cannabis as a drug of abuse.
“ We have 160,000 reviews on the site, and I’d say about 100 involve negative experiences around marijuana impacting patient experience,” Chan said.
In states where medical cannabis is legal, CareDash reviewers have described incidents where doctors seem convinced that the patient is trying to scam them for a medical marijuana recommendation. Reviewers often express surprise that their physician seemed to have no working knowledge of medical cannabis research.
A New York patient reported seeing a neurologist who immediately dismissed her for “ seeking medical marijuana ” after the woman expressed a desire to use cannabidiol (CBD) oil for her foot neuropathy instead of a pharmaceutical prescription. A patient in Nebraska who went to an emergency room with the flu reported being misdiagnosed as having a rare disease the doctor claimed was from smoking too much marijuana. According to the patient, the visit was during flu season, and the doctor refused to test the patient for the flu, and made the diagnosis only after the patient had disclosed cannabis use to the nurse.
If your doctor has an overtly negative reaction when you tell them you use cannabis, Chan recommends seeking a second opinion.
You may also encounter a physician who seems reluctant to even address the subject of cannabis use when you disclose. According to Goldstein, most physicians don’t know they are free to discuss medical cannabis with their patients. Many think that because it is federally illegal, they can get in trouble for speaking to patients about it.
“In 2002, the 9th U.S. Circuit Court of Appeals held that the federal government could not punish or threaten to punish a doctor for telling a patient that his or her use of medical marijuana use is proper,” Goldstein noted. “The relationship between physician and patient is special and protected, so physicians have free speech as long as they tell the truth about the science. No physician has been punished federally due to this protection.”
Ask Your Doctor How They Feel About Cannabis
If you find an appropriate time to do so, Goldstein recommends that medical patients ask their doctor how they feel about cannabis as medicine.
“I tell patients who are nervous about bringing up medical cannabis use with their physician to first ask ‘What do you think about the use of medical cannabis for . (Insert ailment)?’ This way you are not sharing info that you may not be ready to share and you are feeling out the physician’s attitude toward cannabis.”
If You Have a Good Relationship with Your Doctor, Consider Sharing Medical Information
If you find your physician negative or dismissing of medical cannabis, Dr. Goldstein recommends following up via email or in person with a scientific article or two about medical cannabis for the ailment in question, or about the ECS.
“Everyone says there is not enough research [about medical cannabis] and this is true, but there is lots of research on medical cannabis for the more common ailments. And it can be accessed easily on the internet through Google Scholar or PubMed,” Goldstein said. “Giving your physicians published research in a non-threatening way is a good way to start the conversation.”
According to Chan, an overwhelming majority of doctors are quite averse to accepting medical research from patients. So if you’re going to try sharing cannabis information with your doctor, it might be best to wait until you’ve established an amicable relationship with them. Both Chan and Goldstein highly recommend elevating the conversation with technical and scientific terms (saying “cannabis” instead of “weed,” for example). If you’re a medical cannabis patient, refer to cannabis as medicine and emphasize how it helps you.
Don’t Be Afraid to Switch Doctors
According to Chan, there’s a growing pool of weed-friendly doctors who understand the science and respect medical and responsible adult use of cannabis. Though they may still be few and far between, Chan says their ranks are growing, and cannabis users should seek them out when possible.
“Patients have a choice. It is their right to have a primary care physician who is understanding and supportive of their lifestyle choices,” Chan said. “It is in the interest of both the doctor and the patient to be aligned.
“I view it as more of a dating situation. As you might be on a date that doesn’t work out,” Chan continued, “be friendly, but don’t be afraid to shop around the next time you need a checkup and find a physician who is more aligned with your choice to use marijuana.”
If one is available in your area, Goldstein recommends seeing a cannabis specialist in addition to your doctor visits. “ If you are asking your physician for medical cannabis advice, you will likely be disappointed as, again, most don’t know anything. Seeing a cannabis specialist is likely going to be much more beneficial if you are looking for specific advice about cannabinoids , product, and dosing .”
How to Talk to Your Doctor About Cannabis Use Have you had a bad experience disclosing cannabis use to a doctor? Did a doctor’s attitude toward cannabis impact the quality of care you received?