CHRONIC AND INTERVENTIONAL PAIN
ORIGINAL ARTICLE
Perioperative Patient Beliefs Regarding Potential Effectiveness
of Marijuana (Cannabinoids) for Treatment of Pain
A Prospective Population Survey
Yury Khelemsky, MD,* Andrew T. Goldberg, MD,* Yasmin L. Hurd, PhD,† Gary Winkel, PhD,‡ Allen Ninh, BS,§
Lucia Qian, BS,§ Anna Oprescu, MPH,§ Jeffrey Ciccone, MD,* and Daniel J. Katz, MD*
Background and Objectives: Cannabinoids have an expanding pres-
ence in medicine. Perioperative patients' perceptions of the effectiveness of
these compounds, and acceptance if prescribed for pain, have not been pre-
viously described. Our primary objective was to describe patients' beliefs
regarding the potential effectiveness of cannabinoids for the treatment of
acute and chronic pain, as well as gauge patient acceptance of these com-
pounds if prescribed by a physician. In addition, demographic and pain his-
tory data were collected to elucidate the predictors of the aforementioned
patient attitudes. Secondarily, we sought to characterize the subgroup of pa-
tients who reported marijuana use. Predictors of marijuana use, effective-
ness, and adverse effects were also reported for this subgroup.
Methods: An anonymous questionnaire was administered to 501 patients
in the preoperative registration area at Mount Sinai Hospital, New York,
New York. The questionnaire was designed to collect data on patient demo-
graphics, presence of pain, pain severity, use of pain medication, history of
illicit-drug use, tobacco use, cannabis use, patient beliefs about the poten-
tial effectiveness of marijuana for acute and chronic pain and their willing-
ness to use cannabis for pain, if prescribed by a physician. Normality of
distributions for continuous variables was assessed with skewness and kur-
tosis measures. A logistic regression model was used to assess the demo-
graphic and medical characteristics of marijuana users compared with
nonusers. The effectiveness of marijuana in dealing with pain and adverse
effects associated with its use were examined using exploratory principal
component analysis.
Results: More than 80% of this cohort of preoperative patients believed
that marijuana could be at least somewhat effective for the treatment of pain
after surgery and would be willing to use cannabinoid compounds if pre-
scribed by their physician. Predictors of positive attitudes toward marijuana
included history of marijuana use, pain history, and being a marijuana non-
user of white race. Approximately 27% of the respondents reported a his-
tory of marijuana use. Younger patients, those with higher levels of pain
in the last 24 hours, and those who found standard therapies to be less ef-
fective for their pain were more likely to use marijuana.
From the Departments of *Anesthesiology, Perioperative and Pain Medicine,
†Neuroscience, and ‡Oncological Sciences, Icahn School of Medicine at Mount
Sinai, New York, NY; and §Icahn School of Medicine at Mount Sinai, New York, NY.
Accepted for publication April 12, 2017.
Address correspondence to: Yury Khelemsky, MD, Department of
Anesthesiology, Perioperative and Pain Medicine, Icahn School of
Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY
10029 (e‐mail: Yury.khelemsky@mountsinai.org).
The authors declare no conflict of interest.
Y.K., the principal investigator, and G.W., the statistician, had full access to all
data in the study and take responsibility for the integrity of the data and
accuracy of the data analysis.
No funding was received for this study.
This work has not been presented at any meetings.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal's Web site (www.rapm.org).
Copyright © 2017 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000654
652 Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Conclusions: Patients generally believe that marijuana could be at least
somewhat effective for the management of pain and are willing to use can-
nabinoid compounds for this indication, if prescribed by a physician.
(Reg Anesth Pain Med 2017;42: 652–659)
T he landscape of acute and chronic pain management has been
evolving rapidly because of the increased importance placed
by patients and government agencies on adequate analgesia, as
well as mounting concerns about the efficacy and safety of com-
monly used pain medications such as opioids and nonsteroidal
anti-inflammatory drugs.1 This, coupled with expanding social
and legal acceptance of cannabinoids in the United States for
medical indications as well as recreational use, has created a fa-
vorable environment for the integration of these compounds into
evidence-based medical practice.2 Although there is growing evi-
dence on the role of the endocannabinoid (EC) system in nocicep-
tive processing, clinical outcomes have been mixed.3
Further research is needed to legitimize the use of cannabi-
noids as analgesics in the scheme of evidence-based medicine.
Strikingly, patient views regarding the use of cannabinoid com-
pounds for acute and chronic pain have not been meaningfully re-
ported in the literature. As groundwork for the much needed
clinical outcomes research, we believe it is imperative to assess pa-
tients' belief structures regarding the medical use of cannabinoids,
as it is likely that patients have been exposed to this issue because
of the ubiquitous presence of these compounds in the fabric of
our culture.
This study sought to prospectively elucidate via an anony-
mous survey of patients presenting for elective surgery at a large
metropolitan hospital both their perceptions of potential effective-
ness and acceptance, if prescribed, of cannabinoid compounds for
analgesic indications.
METHODS
The study protocol was approved by the institutional review
board of Icahn School of Medicine at Mount Sinai. An anony-
mous questionnaire (survey) was designed to collect data on pa-
tient demographics, presence of pain, pain severity, use of pain
medication, history of illicit-drug use, tobacco use, and cannabis
use. Using a 4-point Likert scale, all patients were asked to de-
scribe their beliefs about the potential effectiveness of marijuana
for acute and chronic pain and their willingness to use cannabis
for pain if prescribed by a physician. A Likert scale was used be-
cause it is the standard instrument for assessing attitudes about a
particular topic.
Self-identified cannabis users were further asked to describe
the route of administration, the amount and frequency of use,
whether the cannabis was prescribed, its efficacy, and adverse ef-
fects. The survey form is displayed in Appendix 1 (Supplemental
Digital Content 1, http://links.lww.com/AAP/A223).
Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
The questionnaire was administered to patients in the preop-
erative registration area prior to surgery at Mount Sinai Hospital,
New York, New York, from May 2016 until July 2016. All patients
in the preoperative registration area were scheduled to undergo
elective surgery. Types of surgeries included those typically per-
formed at a major academic center main operating room complex
including general, neurologic, orthopedic, and gynecologic, among
others. The survey was not administered during each day of this
2-month interval; the survey days were subject to availability of
the 2 medical students tasked with administering the question-
naire. The 2 medical students trained for the project advised sub-
jects of the anonymous nature of the study, and institutional
review board–approved information sheets were made available
prior to survey administration. The medical students were asked
to cease survey administration once 500 surveys were completed.
Survey acceptance rate was 100% because there were no patients
who refused to participate in the survey after being asked to do so.
Patients were given ample time to complete the surveys in private.
Study data were managed with a secure REDCap (Research
Electronic Data Capture) electronic data capture tool housed on a
secure institutional server.
Statistical Analysis
Descriptive information for the sample's study measures in-
cluded both frequency distributions and, where appropriate,
means and SDs. Normality of distributions for continuous vari-
ables was assessed with skewness and kurtosis measures. Once
sample descriptive information was generated, a logistic regres-
sion model was used to assess the demographic and medical char-
acteristics of marijuana users compared with nonusers. In the
initial univariate model building, we adopted a somewhat liberal
P value (P < 0.15) for potential predictor variables and included
only those variables in the final multivariate model that met that
initial criterion. Once included in the final model, only those pre-
dictors whose P < 0.05 were retained.
Because there were study questions about sample attitudes
toward marijuana and, for marijuana users, questions about the ef-
fectiveness of marijuana in dealing with pain and adverse effects
associated with its use, we examined the interrelationships among
these questions using exploratory principal component analysis
(PCA). In the PCA analyses, the principal components were
obliquely rotated, which allowed them to be correlated with one
another. If the data supported a 3-component solution, demo-
graphic, medical, and pain variables as predictors of each compo-
nent cluster were assessed using a general linear model approach
(analysis of variance). All analyses were conducted using version
9.4 of the Statistical Analysis System (SAS).
Details of PCA Analysis
The questionnaire included a total of 13 items asking about
attitudes toward marijuana (6 questions), marijuana effectiveness
(3 items), and marijuana adverse effects (4 items). It was expected
that the interrelationships between and among these questions
would reveal 3 correlated principal components. These compo-
nents would include the 6 attitudinal questions (component I) as
a group, a cluster of the 3 effectiveness items (component II), and
a third component comprising the 4 adverse effects items (compo-
nent III). However, although all patients responded to the attitude
questions, only the marijuana users were asked about the effec-
tiveness and adverse effects because these questions would not
be relevant to nonusers. To test the expectation that there were 3
principal components, we first conducted a PCA of the 13 items
for the marijuana users only. Next, a PCA of the 6 attitudinal items
for the nonuser group was conducted for comparison purposes.
© 2017 American Society of Regional Anesthesia and Pain Medicine
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Patient Views on Marijuana for Pain
RESULTS
Sample Characteristics
Five hundred one surveys were distributed, with all surveys
collected. A summary of the patient demographics can be seen
in Table 1. A minority of patients did not respond to all survey
items; however, the items to which they did respond were included
in the analysis.
There were an approximately equal number of men and
women, although there were more white participants (52%),
followed by Latino and African Americans. Approximately 62%
of the participants were older than 45 years, and most had com-
pleted either high school or college. There was a considerable in-
come spread, with more than 35% reporting annual incomes
greater than $100,000 and 12% reporting incomes less than
$25,000 per year.
With regard to the pain variables, approximately 46% of the
patients reported having pain that exceeded everyday kinds of
pain, and most reported that the pain in the last 24 hours was mod-
erate. Twenty-four percent were taking prescription pain medica-
tions; however, only 10% reported using opioids for pain relief.
A plurality (43%) reported that there was less than a 25% reduc-
tion in their current pain, and less than 6% reported their medica-
tions were 75% to 100% effective. A summary of the pain-related
variables can be seen in Table 2.
Slightly more than a quarter of the sample (27.4%) reported
being marijuana users, whereas a smaller percentage smoked
tobacco (approximately 10%). The percentage of those reporting
the use of different types of illicit drugs (eg, amphetamines, co-
caine, heroin, phencyclidine, synthetic cannabinoids [K2/Spice],
methamphetamines, and/or 3,4-methylenedioxymethamphetamine
[Ecstasy]) within the last year was exceptionally small (≤1%) ex-
cept for amphetamines (3%) and cocaine (2.2%). A summary
of tobacco and drug use is shown in Table 1.
PCA Analysis
To determine the appropriateness of the PCA for both sam-
ples, the Kaiser-Meyer-Olkin (KMO) index was used.4 Values be-
tween 0.80 and 0.99 indicate that PCA is appropriate. For the
marijuana user sample, the KMO index was 0.85. Appendix 2
(Supplemental Digital Content 2, http://links.lww.com/AAP/
A224) summarizes the resulting obliquely rotated PCA. It can
be seen that the 3-component structure appears to characterize
the data adequately. The first component represents attitudes
toward marijuana, the second component describes marijuana
effectiveness, and the third component focuses on adverse ef-
fects. As expected, there was a positive correlation (r = 0.50)
between marijuana attitudes (component I) and reports of its
effectiveness in dealing with pain, sleep, and mood (compo-
nent II). Increases in reported effectiveness were associated
with increases in positive attitudes toward marijuana. There
was a weak negative relationship (r = − 0.25) between effec-
tiveness and adverse effects. Not surprisingly, increases in re-
ports of negative adverse effects were associated with
decreases in reported effectiveness. Finally, there was essen-
tially no relationship between marijuana attitudes and reports
of its adverse effects (r = −0.09).
In addition to the PCAs, the reliabilities of each of the scales
representing each of the principal components were assessed
using Cronbach α, an index that ranges between 0 and 1.0 (higher
values indicate greater reliability). The reliability values of the
marijuana attitudes scale were 0.91, 0.92 for the effectiveness
scale, and 0.76 for the adverse effects scale. All α measures would
indicate that the scales were sufficiently reliable.
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Khelemsky et al Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017

TABLE 1. Summary of Demographic Variables and Tobacco and Drug Use

Demographic Variables n % Mean (SD)

Age, y
18–25 32 6.8
25–30 29 6.1
30–45 98 20.7 43.6 (11.6)
45–60 135 28.5
60–75 143 30.2
>75 36 7.6
Sex
Female 266 55.5
Male 213 44.5
Race/ethnicity
White 263 55.1
Hispanic/Latino 86 18
African American 71 15
Asian/Pacific Islander 36 6
Other 19 4
Native American 2 0.4
Minimum level of education
None 4 0.9
Less than high school 13 2.8
High school 163 34.5
Bachelor's degree 160 33.9
Master's degree 93 19.7
Doctorate degree 39 8.3
Income
<$25,000 62 14.3
$25,000–$49,999 83 19.2
$50,000–$99,999 108 24.9
≥$100,000 180 41.6
n %
Current tobacco use
Yes 49 10.6
No 415 89.4
History of marijuana use
Yes 137 27.4
No 364 72.7
Last Use of Drug
Never >1 y Ago <1 y Ago
Illicit-Drug Use n % n % n %
Amphetamine use 460 91.8 26 5.2 15 3
Cocaine use 432 86.2 58 11.6 11 2.2
Heroin use 482 96.2 17 3.4 2 0.4
Phencyclidine use 496 99 5 1 0 0
Synthetic cannabinoid use (K2/Spice) 494 98.6 7 1.4 0 0
Methamphetamine use 495 98.8 3 0.6 3 0.6
3,4-Methylenedioxymethamphetamine (Ecstasy) use 472 94.2 24 4.8 5 1

As noted previously, a PCA analysis of marijuana attitudes marijuana attitude items clustered together as a single component
for patients who are not marijuana users was also conducted. (Appendix 3, Supplemental Digital Content 3, http://links.lww.
The KMO index for this sample was 0.89. As expected, all the com/AAP/A225). As was the case for marijuana users, increased

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Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
TABLE 2. Pain-Related Variables
Pain-Related Variables
Pain other than everyday kinds of pain
Yes
No
Average pain in the last 24 h (from 0 = none to
10 = pain as bad as you can imagine)
Taking prescribed medications for pain
Yes
No
Taking chronic opioid medications for pain
Yes
No
% Pain relief (decrease in pain) from treatments
or medications over last 24 h
0%–25%
25%–50%
50%–75%
75%–100%
agreement with any 1 attitudinal item was associated with in-
creased agreement with the remaining items. The scale's reliability
was 0.94.
Marijuana Attitudes and Perception of
Effectiveness in All Patients
Eighty-one percent of patients expressed the belief that mar-
ijuana could be at least somewhat effective for pain after surgery,
and 81.5% reported that they would use it if prescribed by a phy-
sician for pain after surgery or acute injury. Eighty-three percent
of patients expressed the belief that marijuana could be at least
somewhat effective for chronic pain, and 82% indicated that they
would use it if prescribed by a physician for chronic pain. Eighty-
nine percent of the cohort affirmed that marijuana should be legal-
ized for medical use, whereas only 60% believed that it should be
legalized for recreational use. Data regarding marijuana attitudes
of the total cohort are depicted in Figure 1.
Predictors of Marijuana Attitudes in All Patients
Because the PCAs for marijuana attitudes for both marijuana
users and nonusers yielded the same results, the information from
both groups was used in the identification of possible demo-
graphic, medical, and pain relief predictors of attitudes. An analy-
sis of variance was used for this purpose. The resulting analysis
FIGURE 1. Marijuana attitudes of the total cohort.
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Patient Views on Marijuana for Pain
n % Mean (SD)
230 47.4
255 52.6
3.2 (3.3)
122 25.3
361 74.7
47 10
424 90
216 63.7
49 14.4
45 13.3
29 8.6
suggested that whether the patient was a marijuana user, the pa-
tient's race, and whether they experienced pain other than every-
day kinds of pain were significant predictors. The overall model
was statistically significant (F4,445 = 39.00, P < 0.01, R2 = 0.26).
Patients reporting having pain other than everyday pain had signif-
icantly (F1,445 = 3.87, P = 0.05) more positive attitudes toward
marijuana (mean, 2.98) compared with those not reporting any
pain beyond everyday pain (mean, 2.83). Compared with pa-
tients of other races/ethnicities, whites reported significantly
(F1,445 = 6.02, P = 0.01) more positive attitudes toward marijuana
(mean, 3.01) compared with nonwhites (mean, 2.80). Not
completely surprisingly, marijuana users were significantly
(F1,445 = 135.84, P < 0.01) more positive (mean, 3.41) compared
with nonusers (mean, 2.40). The significant findings for whites
and marijuana users should be interpreted cautiously because
there was a significant (F1,445 = 6.17, P = 0.01) interaction be-
tween white race and marijuana use. White marijuana users were
significantly more positive (mean, 3.41) compared with white
nonusers (mean, 2.62). The same pattern held for nonwhite respon-
dents (meannonwhite users = 3.41 vs meannonwhite nonusers = 2.19). Both
white and nonwhite marijuana users were almost equally positive
toward marijuana (meanwhite users = 3.41 vs meannonwhite users = 3.41).
However, when comparing nonusers with one another, race/
ethnicity did make a difference. White nonusers were signifi-
cantly more positive to marijuana (mean, 2.62) than nonwhites
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Khelemsky et al Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017

who were not users (mean, 2.19). Significant predictors of posi-
tive marijuana attitudes in the total cohort are summarized
in Table 3.
Cannabis Use Detail
Of the marijuana users, the majority (77%) said it was for
recreational purposes, and most said they smoked it rather than
vaped or ate it. Most reported they took between 1 to 2 and several
puffs when smoking. Of the 53% who reported rare use of mari-
juana, 83% said they last used it either 1 month to a year ago or
more than 1 year ago. Details regarding marijuana users, effective-
ness, and adverse effects are shown in Table 4.
Characteristics of Marijuana Users
A logistic regression model was used to determine the demo-
graphic, pain, and pain treatment relief variables that were associ-
ated with marijuana use. The overall model that was developed
was highly significant (Wald χ24 = 30.4, P < 0.01, R2 = 0.11).
Higher levels of average pain within the last 24 hours were associ-
ated with an increase in the odds of marijuana use (Wald
χ21 = 4.90, P = 0.03; odds ratio [OR], 1.10; 95% confidence inter-
val [CI], 1.01–1.19). Increased age was associated with a decrease
in the odds of reported marijuana use (Wald χ21 = 15.36, P < 0.01;
OR, 0.66; 95% CI, 0.54–0.82), whereas reported tobacco use was
significantly associated with an increase in the odds of marijuana
use (Wald χ21 = 8.32, P < 0.01; OR, 3.22; 95% CI, 1.45–7.11). Fi-
nally, decreased levels of relief from the pain treatment or medica-
tions provided within the last 24 hours were associated with a
decrease in the odds of marijuana use (Wald χ21 = 3.27,
P = 0.07; OR, 0.76; 95% CI, 0.57–1.02). A summary of patient
factors predictive of marijuana use, effectiveness, and adverse ef-
fects is shown in Table 3.
Marijuana Effectiveness in Marijuana Users
Approximately half of marijuana users believed that it is very
effective in decreasing pain and improving both sleep and mood.
There was only a single variable that was predictive of marijuana
effectiveness for marijuana users—average pain in the last
24 hours. As pain in the last 24 hours increased, there was a signif-
icant (F1,112 = 15.99, P < 0.01, R2 = 0.13) increase in reported
marijuana effectiveness. A summary of marijuana effectiveness
is shown in Table 4, with factors predictive of effectiveness found
in Table 3.
Marijuana Adverse Effects in Marijuana Users
Most marijuana users did not report any adverse effects. We
queried patients regarding 4 common adverse effects that include
anxiety, dizziness, dry mouth, and paranoia. When reported,
adverse effects were generally classified as mild, with dry
mouth reported as the most frequent untoward effect. As was
the case for marijuana effectiveness, there was only a single
variable that predicted marijuana adverse effects—patient in-
come. Higher patient income levels were significantly associ-
ated (F1,111 = 4.80, P = 0.03, R2 = 0.04) with an increase in
reported marijuana adverse effects. A summary of marijuana ad-
verse effects is shown in Table 4, with factors predictive of ad-
verse effects shown in Table 3.
DISCUSSION
Despite a general willingness by health care providers to con-
sider the use of cannabinoids in clinical care, significant knowledge
gaps and lack of comfort, both clinically and medicolegally, among
practitioners with recommending cannabinoid compounds likely
hinder both research and clinical practice.5–7 In addition, the per-
ception of a large cohort of patients regarding the potential effi-
cacy of cannabinoids and willingness to take such compounds if
prescribed for the treatment of postoperative and chronic pain
have not been previously described. Smaller surveys have been
done on the prevalence of cannabis use and analgesic effective-
ness in patient populations with underlying pain conditions, but
these are less representative of the broader demographic that our
study aimed to describe.8–10 Overall, we have found that more

TABLE 3. Patient Factors Predictive of Marijuana Attitudes, Use, Effectiveness, and Adverse Effects

Significant Predictors of Positive Marijuana Attitudes in Total Cohort

Variables Means P
Pain other than everyday type of pain Yes 2.98 0.05
No 2.83
Race White nonusers 2.62 <0.01
Other nonusers 2.19
History of marijuana use Yes 3.41 <0.01
No 2.4
Factors Predictive of Use, Effectiveness, and Adverse Effects in Marijuana Users
Factors Predictive of Marijuana Use OR 95% CI P
Higher levels of average pain within the last 24 h 1.1 1.01–1.19 0.03
Increased age 0.66 0.54–0.82 <0.01
Tobacco use 3.22 1.45–7.11 <0.01
Decreased level of relief from pain treatments within last 24 h 0.76 0.57–1.02 0.07
Factors Predictive of Marijuana Effectiveness P/R2
Increased levels of average pain within the last 24 h <0.01/0.13
Factors Predictive of Marijuana Adverse Effects P/R2
Higher patient income levels 0.03/0.04

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Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017 Patient Views on Marijuana for Pain

TABLE 4. Detail of Marijuana Use, Effectiveness and Adverse Effects in Marijuana Users (n = 137)

Smoking Vaping Eating

Route of Use n % n % n %
109 79.6 27 19.7 29 21.1
1–2 Puffs Several Puffs Entire Joint
Dose n % n % n %
44 33.2 51 37.2 30 21.9
Medical (Prescribed) Recreational (Not Prescribed)
Reason for Use n % n %
31 22.6 106 77.4
Rare Weekly Daily Multiple Times Daily
Frequency of Use n % n % n % n %
68 52.7 33 25.6 19 14.7 9 7
>1 y Ago 1 mo to 1 y Ago 1 wk to 1 mo Ago <1 wk Ago <24 h Ago
Last Used n % n % n % n % n %
61 48.8 22 17.6 11 8.8 13 10.4 18 14.4
Very Effective Somewhat Effective Slightly Effective No Effect
Symptom Relief n % n % n % n %
Decreasing pain 47 46.5 23 22.8 4 4 27 26.7
Improving sleep 63 55.7 15 13.3 10 8.9 25 22.1
Improving mood 72 64.2 15 13.4 5 4.5 20 17.9
Severe Moderate Mild None
Adverse Effects n % n % n % n %
Anxiety 3 2.6 6 5.2 20 17.2 87 75
Dizziness 0 0 6 5.2 16 13.9 93 80.9
Dry mouth 2 1.7 26 22 35 29.7 55 46.6
Paranoia 3 2.5 3 2.5 29 24.6 83 70.3

than 80% of patients presenting for elective surgery believe that
marijuana may be at least somewhat useful for the treatment of
pain and are willing to take cannabinoid compounds for analgesia,
if prescribed by a physician.
Various forms of cannabis have been used for thousands of
years to treat a variety of conditions, and modern research efforts
have recently identified the endogenous system involved in medi-
ating its actions. The EC system is composed of 2 major receptors,
CB1 and CB2, with the former found at presynaptic sites in the
peripheral and central nervous systems and the latter mostly on
immune cells. The signaling via these receptor subtypes has been
implicated in normal nociceptive processing, acute pain, and
chronic pain states in both clinical and preclinical models.3 Ongo-
ing research of this system has yielded the concept of the
“endocannabinoidome,” a complex system of receptors, ligands,
EC-like mediators, and specific metabolic enzymes, with each
presenting potential areas for pharmacological targets.11
A recent systematic review and meta-analysis found that
there was moderate quality evidence to support the use of cannabi-
noids for the treatment of chronic pain and spasticity, with other re-
cent systematic reviews supporting this assertion.12 In addition to
pain, exogenous cannabis compounds and formulations, such as
ajulemic acid, cannabidiol, cannabis, dronabinol, levonantradol,
nabilone, nabiximols, cannibadiol, ECP002A, tetrahydrocan-
nabinol, and tetrahydrocannabinol/cannabidiol combinations,
have been studied for the treatment of multiple conditions such
as psychosis, anxiety, depression, nausea and vomiting, spas-
ticity, and insomnia.12
Marijuana Attitudes and Perception of
Effectiveness in All Patients
Although overall the majority of patients in this study be-
lieved that marijuana could be effective for treating pain and
would use it if prescribed by a physician, a more detailed look at
the data in Table 5 reveals some ambiguity in patients' views, as
approximately 1 in 4 patients only “somewhat agreed” with these
premises. In addition, approximately 1 in 5 patients did not believe
that marijuana could be an effective analgesic and may not be
comfortable with taking cannabinoid compounds for pain relief,
even if prescribed by a physician. This, coupled with the fact that
the majority (72.3%) of the patients in this cohort have never used
marijuana, signals the need for careful patient selection, consent,
and education in both trials and clinical practice because a signif-
icant number of patients may have reservations regarding the util-
ity of cannabinoids in medical practice.

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Khelemsky et al Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017

TABLE 5. Marijuana Attitudes of Total Cohort

Strongly Agree Agree Somewhat Agree Disagree

Statement n % n % n % n %
Believe marijuana is effective for chronic pain 132 29.6 137 30.7 103 23.1 74 16.6
Would use marijuana for chronic pain if prescribed by a physician 168 35.5 139 29.5 80 17 85 18
Believe that marijuana is effective for pain after surgery or acute injury 119 27 116 26.3 121 27.4 85 19.3
Use marijuana for pain after surgery or acute injury if prescribed by a physician 163 35.1 131 28.1 85 18.3 86 18.5
Marijuana should be legalized for medical use 204 43 137 28.8 82 17.2 52 11
Marijuana should be legalized for recreational use 109 23.4 72 15.4 99 21.2 186 40

The incidence of marijuana use in our study is similar to that
reported in previous surveys.8 Age, sex, level of education, and
income did not seem to effect patient beliefs regarding potential
effectiveness or acceptance of marijuana. This signifies that can-
nabinoids may be accepted as analgesics by patients across a
broad range of demographic and socioeconomic backgrounds.
Patients with a history of significant pain and those who re-
ported marijuana use had more positive views toward marijuana.
This is likely due to the fact that patients with ongoing pain have
failed other analgesic therapies and are more open to exploring al-
ternative options with a desire for these options to be effective. It is
also encouraging to see that patients with a history of marijuana
use have had an overall positive experience. This is likely due to
the overall effectiveness and low rates of adverse effects reported
by marijuana users in this study. Acceptance was more pro-
nounced in white patients without a history of marijuana use (vs
nonwhite patients without a history of marijuana use). Although
this difference is statistically significant, it is unclear if the pres-
ence of racial disparity, which has been documented in the perceived
effectiveness of other treatments, in acceptance of marijuana effec-
tiveness for pain, should be a factor to consider when presenting
cannabinoids as an analgesic option to patients without history
of marijuana use.13–15
Eighty-nine percent of the cohort responded affirmatively to
the idea of having marijuana being legalized for medical use, only
60% thought it should be legalized for recreational use. These
numbers are strikingly similar to a recent national Quinnipiac Uni-
versity Poll and may support the generalizability of our overall
findings to larger patient populations.16 The findings signal that
a significant proportion of the population believes that marijuana
is a medication and therefore should be taken only under physi-
cian supervision. Overall, the prevalence of illicit-drug use was
lower than previously reported in perioperative patient popula-
tions. This may have been related to our cohort being older be-
cause increasing age is known to be correlated with a decrease
in illicit-drug use.17
Predictors of Marijuana Use
Younger patients who use tobacco with higher levels of pain
in the last 24 hours were more likely to be marijuana users in our
cohort. Preexisting pain has been previously found to be signifi-
cantly associated with marijuana use.18 As younger age and
preexisting pain are well-known risk factors for difficult-to-
control pain, these patients were likely searching for alternative
methods of analgesia after finding typical methods of pain control
to be inadequate.19 The inadequacy of existing analgesic strategies
for many patients is supported by our findings, which revealed
that 43% of the overall cohort reported less than a 25% reduction
in their pain with medications, and less than 6% reported their
medications were 75% to 100% effective. Inadequacy of analgesia
with use of typically available modalities is an unfortunately
common occurrence in clinical pain practice and a strong impe-
tus for the introduction of novel analgesic agents into the
clinical arena.20–22
Cannabis Use Detail
Of the marijuana users, the majority (77%) said it was for
recreational purposes mostly by smoking. In other surveys, pa-
tients were more likely to identify their marijuana use as medicinal
(vs recreational); however, our cohort was less restrictive than the
previously studied pain clinic population perhaps because of the
anonymity of our study and the changing landscape today regard-
ing the use of marijuana in society.8 Among patients who admitted
to marijuana use, most found it to be effective in decreasing pain
and improving both sleep and mood. These findings are consistent
with a recently published study of patients using cannabis for ther-
apeutic purposes.23 Adverse effects of marijuana use were gener-
ally mild and corresponded to those described in similar reports.8
The only variable significantly associated with an increase in re-
ported adverse effects was higher income. The relationship be-
tween patient income and clinical outcomes likewise has been
supported by other studies.24–26 Overall, it seems that marijuana
smokers in this cohort report a generally favorable effect on their
symptoms and experienced mostly no or mild adverse effects.
There were several limitations of our study. First, sample se-
lection may have been biased because patients were not selected at
random, but only patients approached in the preoperative registra-
tion area by 2 medical students during certain days within a spe-
cific 2-month interval were surveyed. Because of the large
sample size, however, and the stability of the surgical case volume
and mix, it is likely that the sample is representative of our center's
overall ambulatory surgical population. Our cohort consisted en-
tirely of preoperative patients and therefore may not be represen-
tative of the general population. This was not a major concern of
the present study because we purposefully sought to categorize
this specific population as groundwork for planned future clinical
trials of cannabinoids during the perioperative period. However,
the overall demographics of the group, as well as the close corre-
spondence of the sample's opinions to existing data on legaliza-
tion, suggest that our findings in fact may be relevant to broader
patient populations. The survey queried personal information re-
garding illicit-drug use, which may have resulted in underreporting
of this dimension. Great care was taken to explain to the patients
that the surveys were completely anonymous, as well as to demon-
strate anonymity by the method of survey distribution and collec-
tion processes. Ideally, a postoperative survey would have been
administered to track patient views after experiencing postopera-
tive pain. Unfortunately, the completely deidentified nature of this
survey made correlation of the preoperative and postoperative co-
horts prohibitive. Overall, the exceptionally high participation rate
signals patients' confidence regarding the anonymity of the sur-
vey. It should be noted that for both the linear and logistic

658 © 2017 American Society of Regional Anesthesia and Pain Medicine

Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
regression models the R2's are quite modest. This result suggests
that there are unmeasured explanatory variables that could have
increased the predictive value of the models considered in this
study and that their identification is a task for future research.
In conclusion, the results of this novel survey reveal that most
patients believe that marijuana may be potentially effective for the
management of pain and exhibit a willingness to have cannabinoid
compounds incorporated into their care, thus underlining the need
for further research to responsibly allow such integration. It is our
hope that the acceptance by patients of cannabinoids for the man-
agement of pain will empower the medical community to engage
in the considerable effort required to properly define the appropri-
ate roles, efficacy, and safety of these compounds in legitimate
medical practice.
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