Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

Karim S Ladha¹, Alexander McLaren-Blades², Akash Goel³, Michael J Buys⁴, Paul Farquhar-Smith⁵, Simon Haroutounian⁶, Yuvaraj Kotteeswaran⁷, Kwesi Kwofie⁸, Bernard Le Foll⁹, Nicholas J Lightfoot¹⁰, Joel Loiselle¹¹, Hamish Mace¹², Judith Nicholls¹³, Aviva Regev¹⁴, Leiv Arne Rosseland¹⁵, Harsha Shanthanna¹⁶, Avinash Sinha¹⁷, Ainsley Sutherland¹⁸, Rob Tanguay¹⁹, Sherry Yafai²⁰, Martha Glenny², Paul Choi², Salima S J Ladak², Timothy Sean Leroux²¹, Ian Kawpeng², Bana Samman², Rajbir Singh², Hance Clarke²²

Affiliations

¹ Department of Anesthesia and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
² Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada.
³ Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA.
⁴ Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA.
⁵ Department of Anaesthetics, The Royal Marsden NHS Foundation Trust, London, UK.
⁶ Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA.
⁷ Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, Thunder Bay, ON, Canada.
⁸ Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁹ Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Division of Brain and Therapeutics, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Anaesthesia and Pain Medicine, Counties Manukau Health, Auckland, New Zealand.
¹¹ Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
¹² Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Fremantle Hospital Group, Melville, Australia; University of Western Australia, Perth, Australia.
¹³ Department of Anaesthesia, Intensive Care and Pain, Cayman Islands Health Services Authority, George Town, Cayman Islands.
¹⁴ PureForm Global, Los Angeles, CA, USA.
¹⁵ Department of Research and Development, Division of Emergencies and Critical Care, University of Oslo, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
¹⁶ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
¹⁷ Department of Anesthesia, McGill University, Montreal, QC, Canada.
¹⁸ Department of Anesthesiology, St Paul's Hospital, Vancouver, BC, Canada.
¹⁹ Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
²⁰ Releaf Institute, Santa Monica, CA, USA; John Wayne Cancer Institute, Santa Monica, CA, USA.
²¹ The Arthritis Program, University Health Network, Toronto, ON, Canada.
²² Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada; Centre for Cannabinoid Therapeutics, Toronto, ON, Canada. Electronic address: hance.clarke@uhn.ca.

PMID: 33129489
DOI: 10.1016/j.bja.2020.09.026

Free article

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

Karim S Ladha et al. Br J Anaesth. 2021 Jan.

Free article

. 2021 Jan;126(1):304-318.

doi: 10.1016/j.bja.2020.09.026. Epub 2020 Oct 29.

Authors

Affiliations

¹ Department of Anesthesia and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
² Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada.
³ Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA.
⁴ Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA.
⁵ Department of Anaesthetics, The Royal Marsden NHS Foundation Trust, London, UK.
⁶ Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA.
⁷ Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, Thunder Bay, ON, Canada.
⁸ Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
⁹ Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Division of Brain and Therapeutics, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
¹⁰ Department of Anaesthesia and Pain Medicine, Counties Manukau Health, Auckland, New Zealand.
¹¹ Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
¹² Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Fremantle Hospital Group, Melville, Australia; University of Western Australia, Perth, Australia.
¹³ Department of Anaesthesia, Intensive Care and Pain, Cayman Islands Health Services Authority, George Town, Cayman Islands.
¹⁴ PureForm Global, Los Angeles, CA, USA.
¹⁵ Department of Research and Development, Division of Emergencies and Critical Care, University of Oslo, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
¹⁶ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
¹⁷ Department of Anesthesia, McGill University, Montreal, QC, Canada.
¹⁸ Department of Anesthesiology, St Paul's Hospital, Vancouver, BC, Canada.
¹⁹ Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
²⁰ Releaf Institute, Santa Monica, CA, USA; John Wayne Cancer Institute, Santa Monica, CA, USA.
²¹ The Arthritis Program, University Health Network, Toronto, ON, Canada.
²² Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada; Centre for Cannabinoid Therapeutics, Toronto, ON, Canada. Electronic address: hance.clarke@uhn.ca.

PMID: 33129489
DOI: 10.1016/j.bja.2020.09.026

Abstract

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

Keywords: anaesthesiology; cannabinoids; cannabis; pain; perioperative care; postoperative nausea and vomiting.

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Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

Affiliations

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

Authors

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Abstract

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LinkOut - more resources

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Medical

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