REVIEW

CURRENT
OPINION Anesthetic considerations in medical
cannabis patients
Elyad M. Davidson a, Noa Raz b, and Aharon M. Eyal b

Purpose of review
Growing numbers of patients, consuming cannabinoids admitted to surgery, create a challenge to
anesthesia providers. This review provides a summary of recent literature related to cannabis and
anesthesia, with specific recommendations to the anesthetic management of medical cannabis consumers.
Recent findings
At present, cannabis has found its way to public consensus in many countries and is penetrating slower to
different medical fields. We relate and discuss recent findings investigating effects of cannabis consumption
on the various aspects including perioperative measures, post-operative pain, PONV, cardiovascular
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stability, and anesthesia monitoring.

Summary
Recent surveys estimate that 10–20% of adult populations have consumed cannabis in the past year.
Medical cannabis consumers are a newer group of cannabis users. Anesthesia providers have to update
their knowledge on cannabis and possible anesthetic interaction. It is unreasonable to make
recommendations that apply to the whole heterogeneous group of cannabis users, but is easier with the
more homogenous group of Medical cannabis users, characterized by frequent use and relatively high
cannabis doses, combined with good knowledge of administered composition and protocol, as well as
adverse and withdrawal effects. Anesthesia providers have to know the effects and modify anesthetic plan
accordingly. We provide perioperative anesthetic recommendations related to medical cannabis
consumers. Collecting information of the effects of medical cannabis use in perioperative setting will further
create a highly useful database for anesthetics in the close future.
Keywords
cannabis, medical- cannabis, anesthesia, perioperative

INTRODUCTION compositions used, route of administration, and

The number of cannabis users among operated
patients is increasing and will continue to increase
in the coming years, particularly in the United
States, Canada, some Western European countries,
and in Israel, where medical cannabis has been
approved. Some recent surveys estimate that 10–
20% of adult populations have consumed cannabis
in the past year [1]. There are important implica-
tions for anesthesia providers, as cannabis may have
significant implications on every stage of anesthe-
sia, from induction to the postoperative period.
Guidelines are sought for treating patients consum-
ing cannabis in the perioperative setting. Several
articles were published recently with the purpose
& &&
of supporting anesthesia providers [2 ,3 ,4 ,5].
These publications offer recommendations but have
various shortcomings. There is still a strong and
unmet need for practical and accurate recommen-
dations that address variables such as amount and
user’s personal medical situation.
Here we focus on an area that to our understand-
ing did not receive sufficient attention – medical
cannabis users. In the United States, most states have
passed legislation authorizing medical cannabis. It is
estimated that in the coming years, 2–3% of the
population of states and countries that approve med-
ical cannabis will use it on a regular basis [6]. The
recent opioid crisis has also been a driving force, to
increased search for analgesic alternatives such as
a
Department of Anesthesiology, CCM and Pain Relief, Hadassah
Hebrew University Hospital and bBazelet Medical Cannabis Group, Israel
Correspondence to Elyad M. Davidson, Department of Anesthesiology,
&&
CCM and Pain Relief, Hadassah Hebrew University Hospital, POB
12000, Jerusalem 9112001, Israel. Tel: +972 50 7874098;
e-mail: edavidson@hadassah.org.il
Curr Opin Anesthesiol 2020, 33:832–840
DOI:10.1097/ACO.0000000000000932

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 Anesthetic considerations in medical cannabis patients Davidson et al.
KEY POINTS
 The number of cannabis users among patients admitted
for surgery increases and will continue to increase in
the coming years.
 There are important implications for anesthesia
providers, as cannabis may have significant
implications on all stages of anesthesia, from induction
to the postoperative period.
 Medical cannabis consumers are a newer group of
cannabis users and in comparison to recreational users,
possess a more homogenous group, characterized by
frequent use and relatively high cannabis doses,
combined with good knowledge of administered
composition.
 Anesthesia providers have to relate these concerns and
modify anesthetic plan accordingly.
 We provide perioperative anesthetic recommendations
related to medical cannabis consumers.
cannabis [7–9]. Given the rising proportion of medi-
cal cannabis users among adults, especially among
the elderly population and given the more vulnerable
medical situation of medical cannabis users, it is rea-
sonable to assume that in the coming years 5% of the
operated patients may be using medical cannabis.
Recent articles based their recommendations on
physiological effects observed in general studies of
cannabis use, studies that may have only limited
relevance to daily medical cannabis users. Many of
them were studies based on recreational users, con-
suming nonanalyzed cannabis compositions, some-
times contaminated with pesticides or fungal toxins
and/or blended with tobacco. Most of the clinical
research to date has focused on tetrahydrocannabi-
nol (THC), the cannabinoid receptor type 1 (CB1)
agonist overlooking effects of several other receptors
that also play an important role. Frequently, there is
confusion between cannabinoids concentrations
(potency) and actually consumed dose. Many of
the trials have used compositions that do not repre-
sent products on the market. Additionally, much of
the research report effects observed in populations
that do not represent the majority of adult daily
medical users (e.g., adolescent recreational users or
volunteers naı̈ve to cannabis). Finally, many of the
conclusions were based on animal trials, whereas
there are substantial interspecies differences.
Anesthesia providers may find prior literature
information and recommendation not specific
enough or confusing. The following deals with a
subset of the cannabis users group – ones who
consume cannabis daily and have good knowledge
of the composition and dose they use. The majority
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of this group is the medical cannabis users, where
recently more extensive and higher clarity data exist
and where the authors have hands-on experience.
This article deals with the effect of cannabis use
on the perioperative anesthetic period of medical
cannabis users. We will review recent publications
and will summarize with practical recommenda-
tions for the working anesthesiologist encountering
patients consuming medical cannabis.
CHARACTERIZATION OF MEDICAL
CANNABIS USE AND USERS
There are several key aspects in mapping out the
cannabis use and users.
EXPERIENCE, ADVERSE EFFECTS, AND
ADMINISTRATION FORM
Typically, medical cannabis patients are guided to
begin with a low THC concentration at the lowest
possible dose, which should be increased gradually to
find the composition dose, and administration form
that works best for them, that is, optimally balancing
between maximal medical result and minimal adverse
effects. If patients beginning medical cannabis follow
guidance of slow titration, they experience less adverse
effects than described in the literature for naı̈ve, non-
experienced recreational users [9]. In most cases, med-
ical cannabis users consume cannabis frequently, that
is, at least once a day, often four times a day or more.
Smoking or vaporizing is most likely the popular
consumption method of medical cannabis. An
increasing fraction of medical cannabis users are
treated with cannabis extracts, typically diluted in a
vegetable oil to be administered sublingually (often
named cannabis oils). Others receive tablets, capsules,
or edibles.
COMPOSITION, CONCENTRATION/
POTENCY, AND DOSE
In the majority of the medical cannabis prepara-
tions, cannabinoid concentrations range between 3
and about 25% by weight. Typically, each cannabi-
noids dose contained in one consumption ranges
between 1 and 50 mg.
An important anesthetic consideration is the com-
position of the consumed cannabis, as different com-
ponents have major different physiological effects.
The term ‘cannabis’ is commonly used as an umbrella
term that refers to a broad range of compositions made
from the cannabis plant and from its synthetic deriv-
atives. One distinction is between users of drugs con-
taining an isolated cannabis component, typically
THC or cannabidiol (CBD), or their synthetic form,
www.co-anesthesiology.com 833
Pain medicine
on the other hand, and ones that use a whole-plant
preparation extract. The whole plant users consume
over 400 compounds, including cannabinoids and
other cannabis-plant components such as terpenes
and flavonoids. Differently from most recreational
inflorescence (bud) products, most medical cannabis
products are provided with a reliable analysis, at least
that of the main cannabinoids content. The labeled
composition for oils and ground cannabis is more
accurate than that for inflorescence, because of the
large variance in the latter, even if coming from the
same stem, as opposed to oils and ground cannabis
that can be homogenized.
Given the relatively limited scientific knowl-
edge currently available to users and care providers,
it is practical to focus on the contents of THC and
CBD, keeping in mind that minor cannabinoids and
other noncannabinoid components, for example
terpenes and flavonoids, may also have a major
effect on the potency of cannabis (which is referred
to as the entourage effect).
A high concentration of THC is most common
in recreational products and in some medical ones,
but there are a significant fraction of medical
users who consume low THC concentrations com-
bined with a high proportion of CBD. Government
regulations in Israel have approved for both inflo-
rescence and oils the following compositions
(where T stands of THC, C for CBD and figures are
percentage concentration): T20C4, T15C3, T10C2,
T5C5, T10C10, T3C15, T1C20, and T0C24. Recom-
mendations were issued for the most suitable com-
position for each indication (the ‘green book’) [10].
According to the author’s experience in Israel
(unpublished Bazelet company data), T20C4,
T15C3, and T10C10, the high concentration THC
compositions, are most common for patients diag-
nosed with various chronic pain types, T10C10,
T5C5, and T3C15 are most common for the elderly
populations, whereas children with uncontrolled
epilepsy and autism mainly use high CBD products.
MEDICAL VERSUS RECREATIONAL
CANNABIS USERS
Recreational cannabis users frequently lack accurate
information as to their cannabis content and might
not be open to admit cannabis use. On the contrary,
medical cannabis users can provide much useful
information to their anesthesia providers. This
includes the actual compositions used (sometimes
differing between day and night), delivered dose,
use frequency, delivery method, efficacy, adverse/
side-effect and in many cases extent of withdrawal
symptoms (as in-end of dose or when traveling,
where it is illegal to carry cannabis).
834 www.co-anesthesiology.com
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MECHANISM OF ACTION,
PHARMACOLOGY, PHARMACOKINETICS,
AND PHARMACODYNAMICS
Detailed information is beyond the scope of this
article. The information below is limited to aspects
essential for understanding the breadth of the effect,
on the one hand, and the importance of specific use
details on the other.
Cannabis compounds exert their effect mainly
via the endocannabinoid system (ECS), a wide-
spread neuromodulatory system engaged in multi-
ple physiological systems and processes, and having
a significant role in homeostasis. The ECS is consists
of cannabinoid receptors, endogenous cannabi-
noids (endocannabinoids), and the enzymes respon-
sible for cannabinoid synthesis and degradation.
Known ECS receptors include cannabinoid type
1(CB1) and type 2 (CB2) receptors, peroxisome pro-
liferator-activated receptors (PPARs), and transient
receptor potential (TRP) ion channels. CB1 receptors
are widely distributed in the central and peripheral
nervous systems, especially in the hippocampus,
cortex, olfactory areas, basal ganglia, cerebellum,
and dorsal horn of the spinal cord, but less so in
the brainstem. This distribution may account for
cannabinoid effects on nociception, anxiolysis,
memory, cognition, emotion, and movement with
relative sparing of respiratory depression. The CB2
receptors are distributed primarily in peripheral
lymphoid and hematopoietic cells, suggesting an
immunomodulatory function [11,12].
Cannabinoid receptors are modulated by endog-
enous as well as exogenous cannabinoids (including
phytocannabinoids, the cannabis-plant derived
ones, and their synthetic equivalents). THC, the
main psychoactive cannabinoid, is a CB1 and CB2
partial agonist, whereas CBD is not an agonist to
these receptors, but causes allosteric modulation of
both. Cannabinoids, and particularly CBD, have
additional effects within the nervous system
through signaling at a multitude of other receptors.
Those include actions related to adenosine, seroto-
nergic, glycine, nuclear PPARs, and transient recep-
tor potential channels, of the vanilloid subtype ion
channels (capsaicin target). Anesthetists should also
note the cannabinoids’ interaction with the opioid,
N-methyl-D-aspartate receptor, and g-amino butyric
acid [GABA] systems [13,14].
Pharmacokinetic
The absorption of inhaled cannabinoids is rapid,
with peak plasma concentrations observed within
10 min, compared with about 30 min in sublingual
administration, 0.5–2 h in oral administration, and
2 h transdermally [15]. THC and CBD bioavailability
Volume 33  Number 6  December 2020
 Anesthetic considerations in medical cannabis patients Davidson et al.
on inhalation ranges from 10 to 35%, whereas the
oral one is lower, 2–20% for both CBD and THC
[16,17].
Metabolism
The cannabinoids are mainly hydroxylated and glu-
curonidated in the liver by the cytochrome P450
family of isoenzymes. THC and CBD are metabo-
lized to more than 80 metabolites, each.
Elimination/Excretion
Main effects of inhaled cannabis persist for 2–4 h
and those of oral consumption last 4–6 h. Elimina-
tion of metabolites occurs via urine, bile, and feces.
The plasma half-life ranges from 20 to 30 h, but the
tissue half-life may be as long as 30 days depending
on frequency and chronicity of use due to fat accu-
mulation. Urinary metabolites are measurable 14–
30 days postexposure [18].
In the next sections, we briefly discuss, phar-
macological and physiological aspects related to
cannabis which support the perioperative anes-
thetic practical recommendations for treating med-
ical cannabis users admitted for elective surgery
(Table 1).
EFFECT OF CHRONIC CANNABIS USE ON
Airway
Laboratory studies consistently show Broncho dila-
tation and decreased airway resistance with either
inhaled or ingested THC [19]. Despite this, cannabis
smoking may result in airway hyperactivity, edema,
obstruction, chronic cough, bronchitis, emphysema
and bronchospasm as seen with tobacco smoking. In
fact, some authors have expressed concern that
cannabis may be more irritating to airways given
that it burns at a higher temperature than tobacco
[20–22].
Induction dose of anesthesia – anesthetic
dose
An early 2009 prospective study compared the
required induction dose of propofol in 30 patients
using cannabis (more than once a week) and 30 non-
cannabis users [23]. The research concluded that
chronic cannabis use increases the propofol dose
required for satisfactory clinical induction when
inserting a laryngeal mask.
A recent retrospective cohort in 250 patients
demonstrated that regular cannabis use has a signif-
icant effect on the amount of sedation required to
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perform a gastric endoscopic procedure. In this
study, the cannabis group (n ¼ 25) were regular can-
nabis users (daily or weekly) compared with
(n ¼ 225) nonusers. Cannabis users required 14%
more fentanyl, 19.6% more midazolam, and
220.5% more propofol for the duration of the endo-
scopic procedure. Thus, a strong association appears
to exist between the regular use of cannabis and the
required doses of the sedative medications fentanyl,
midazolam, and propofol, in the performance of
&
endoscopic procedures [24 ].
A recent, retrospective review study assessing
preoperative cannabis impact on intraoperative
inhaled anesthetic delivery, in isolated tibia fracture
open reduction and internal fixation, demonstrated
increased delivery of inhaled anesthetic among pre-
operative cannabis users. The average total volume
of sevoflurane administered was significantly higher
among the cannabis user (37.4 versus 25 ml) [25].
It is important to note that as patients assessed
in these studies are mostly recreational users, con-
suming high THC cannabis, the increased require-
ment for anesthetic dose may not apply to low THC
products, as observed in some medical cannabis
users.
Cardiovascular
Cannabis has multiple effects on the cardiovascular
system. THC stimulates the sympathetic nervous
system while inhibiting the parasympathetic ner-
vous system; increases heart rate, myocardial oxy-
gen demand, supine blood pressure, and platelet
activation; and is associated with endothelial dys-
function and oxidative stress. In contrast, CBD may
reduce heart rate and blood pressure and improves
&&
vasodilation [26 ]. At low-to-moderate doses, can-
nabis leads to an increase in sympathetic and a
reduction in parasympathetic nervous system activ-
ity. This can present as tachycardia tachydysrhyth-
mia and hypertension, which could be diminished
with beta-blockers [28]. Chronic cannabis use, espe-
cially high-dose use, may lead to modulation of the
autonomic nervous system, with diminished sym-
pathetic activation and increased parasympathetic
response, leading to bradycardia and hypotension
[27]. The final endpoint cardiovascular effect
depends on THC/CBD ratio, chronic versus acute
consumption, dose, route of administration, and
elapsed time since last consumption.
Multiple case reports over the past years have
linked cannabis to acute myocardial infarction (MI)
&&
[26 ,28,30]. In many instances, the patient is a
young, healthy cannabis user who presents with
chest pain and is found to have MI. A study evalu-
ating adults who had had a myocardial infarction
www.co-anesthesiology.com 835
Pain medicine
Table 1. Practical recommendations in medical cannabis users admitted for elective surgery
Operative phase Concern
Preoperative Medical history of
cannabis use
Composition
Adverse effects
Dose
Duration consumption
What happens if skipped a
dose
Time since last exposure
What should we instruct
cannabis users before
elective surgery?
Cardiovascular effects
Withdrawal
Delayed gastric emptying
Intraoperative Airway
Hyperactive
Emphysema,
bronchospasm
Uvular edema
Induction dose
Drug interaction
Maintenance of anesthesia
Increased risk of MI
Increased risk of stroke
Postoperative Anxiety – stormy arousal
Difficulty in postoperative
pain management
Withdrawal
MI, Myocardial infarction.
836 www.co-anesthesiology.com
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Action
Routinely question all patients
about use of cannabis
Ask to see license/product label
Do they occur, patterns of adverse
effects
High dose/frequent users
How frequently administered
chronic use versus occasional
Delay surgery if recent cannabis
consumption?
Consider, recommend to continue
cannabis consumption till 2–6 h
before surgery
Routine ECG electrocardiography,
consider ECHO
bring your cannabis for postop
use
Preoperative aspiration
prophylaxis
In patients smoking or inhaling
Prepare managing situation
Consider preop steroids
Be prepared to increase dose of
induction agents
Careful titration of warfarin,
sympathomimetic meds, b-
blockers, anesthetic agents
May affect anesthetic dose
Patients should be monitored more
rigorously
Monitor patients more rigorously
consider: ECG ST analysis,
ECHO
EEG monitor
Be aware – possible need
pharmacologic or other
intervention
May need an increased opioid
dose
Consider early return to cannabis
maintenance
Volume 33  Number 6  December 2020
Remarks
10–20% of adult population consume
medical or recreational cannabis
Expect different effects depending on
THC/CBD ratio
May help preparing for, e.g.,
tachycardia
Increased cardiovascular and withdrawal
risk
Occasional versus daily user – will
patients develop withdrawal
symptoms?
Do withdrawal symptoms occur?
If intoxication, avoid elective surgery.
Chronic users delay 2–6 h
Concern: avoid acute effects of cannabis
versus potential of developing
withdrawal syndrome
Depending on: cardiovascular med
history, cannabis dose
cannabis oil can exchange smoke/vapor
THC administration slows gastric
emptying
Some authors have expressed concern
that cannabis may be more irritating to
airways than tobacco
Chronic cannabis use: increased
propofol dose required for induction,
increased need of inhaled anesthetic,
increased need of sedation dose
fentanyl/midazolam
Delayed metabolism – cannabis
competitor Cp450
Ketamine ephedrine atropine may cause
extreme additive effects
Possible increased dose anesthesia
Possible hemodynamic instability
BIS monitor may be misleading
Cannabis toxicity or cannabis
withdrawal may present similarly
Multimodal analgesia þ consider early
return to cannabis maintenance
Withdrawal onset within hours to 1–2
days may last for 1–2 weeks
If unable to smoke/vapor consider
convert to oral/sub lingual
formulations
 Anesthetic considerations in medical cannabis patients Davidson et al.
demonstrated that the risk of MI increased almost
five-fold after smoking. This heightened risk was
limited to the first-hour postsmoking [30].
A recent publication in anesthesiology exam-
ined, in a retrospective population-based cohort
study using a large nationwide inpatient sample,
whether patients on chronic cannabis use have an
elevated risk of postoperative complications. This
study demonstrated that chronic cannabis con-
sumption is associated with a meaningful (adjusted
odds were 1.88 times higher) increase in the risk of
&&
postoperative myocardial infarction [31 ].
Cerebrovascular – coagulation
Recent studies have reported a 2.3–2.9-fold inci-
dence of cerebrovascular ischemia in young canna-
bis users when compared with tobacco smokers [32].
Cerebral vasospasm and atherosclerosis have been
also identified as the main etiologic factors for can-
nabinoid-related cerebrovascular disease.
PERIOPERATIVE PAIN
Does medical cannabis use affect
postoperative pain management?
A recent retrospective cohort study examined the
impact of preoperative cannabinoid use on postop-
erative pain scores, in patients who had undergone
major orthopedic surgery. One hundred and fifty
cannabis users and 155 nonusers were compared
[33]. Among the cannabinoid users, (21.9%) were
on nabilone (a synthetic THC analog agonist) pre-
scription and the rest were on other cannabinoid
preparations (inhaled cannabis and cannabis oils)
for medical or recreational purposes. In the postop-
erative period, patients on preoperative cannabi-
noids had higher pain scores at rest and at
movement. This study also noted a higher incidence
of sleep impairment in cannabis-using patients. The
authors proposed that sleep impairment may be a
reflection of increased pain or as result of acute
withdrawal from cannabinoids and suggested con-
sidering administration of synthetic cannabinoids
in those patients. They conclude that patients who
are on preoperative cannabinoids should be
regarded as being at higher risk for poorly controlled
postoperative pain, and more aggressive analgesic
&
strategies may be indicated [34 ].
Jamal et al. [35], in a similar retrospective cohort
of recreational cannabis users admitted for abdomi-
nal surgery, report that Cannabis users required 23%
more opioids and therefore conclude that perioper-
ative cannabis use may complicate postoperative
pain management.
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DOES CANNABIS HAVE ANALGESIC AND
OPIOID-SPARING EFFECTS IN ACUTE
PAIN?
A most recent systematic review and meta-analysis
was set to determine the analgesic efficacy of peri-
operative cannabinoid compounds for acute pain
&&
management after surgery [36 ]. Eight randomized
controlled trials (924 patients) and four observa-
tional studies (4259 patients) were evaluated. There
were no differences in cumulative oral opioid con-
sumption or pain at rest 24 h postoperatively with
the addition of cannabinoids in comparison to con-
trol. Patients receiving cannabinoids appeared to
have increased pain at 12 h postoperatively and
3.24 times increased odds of developing hypoten-
sion postoperatively. This updated and extended
literature review suggests that the analgesic role of
perioperative cannabinoid analgesic compounds is
limited, with no clinically important benefits
detected when cannabinoids are added to tradi-
&&
tional systemic analgesics. The authors [36 ] dis-
cussed the plausible discrepancy between the
recognized analgesic role of cannabis in chronic
pain and the lack of analgesia in acute pain. They
propose that in chronic pain, analgesia from canna-
bis may be because of neuroplastic changes that
occur over time, such as an upregulation of the
cannabinoid receptor CB1 and CB2 or alteration
of cannabinoid receptor function.
Another retrospective cohort study examined
the association between cannabis use and opioid
consumption and pain scores in acute pain setting
of patients admitted with traumatic injuries. These
patients were followed up during 14 days. Cannabis
use was reported in 21% of all patients of which 30%
reported chronic use and the rest were occasional
cannabis users that reported using cannabis follow-
ing traumatic injury. Cannabis users received signif-
icantly more opioids than nonusers. Pain scores
were significantly greater for the cannabis users.
These findings suggest that cannabis use, particu-
larly in chronic users, may affect pain response to
injury by requiring greater frequency and dosing of
opioid analgesia [37]. Another recent prospective
cohort study reported that patients admitted for
total hip or knee replacement and consumed can-
nabis in perioperative period had similar opioid
requirements [29].
On the other hand, there are recent studies that
have reported analgesic and opioid-sparing effects of
cannabis in acute pain setting.
Gazendam et al. [38] recently published a sys-
tematic review and meta-analysis, on cannabinoids
in the management of acute pain. Overall, there was
a small but statistically significant treatment effect
favoring the use of cannabinoids over placebo.
www.co-anesthesiology.com 837
Pain medicine
Schneider et al. in a recent matched cohort
study, included patients who were admitted with
a traumatic injury. This study was designed to deter-
mine whether adjunctive dronabinol reduces opioid
consumption following acute pain from traumatic
injury. Thirty-three patients receiving cannabis 55
(28–107) h from admission were matched to 33
patients who did not receive dronabinol (controls).
Dronabinol was administered twice daily at doses of
5–16 mg/day. The median number of days receiving
dronabinol was three days. Dronabinol cases had a
significant reduction in opioid consumption [39].
Owing to the promising results from this retro-
spective cohort this group is currently conducting a
prospective randomized controlled trial to evaluate
the efficacy of adjunctive dronabinol versus control
for reducing opioid consumption in adults with
traumatic injury [40].
POSTOPERATIVE NAUSEA AND VOMITING
The literature supports the use of cannabinoids in
the treatment of chemotherapy-induced nausea and
vomiting, but data supporting its application for
treating nausea and vomiting associated with sur-
gery are lacking. Paradoxically, cannabinoids can
also elicit nausea, as seen in cannabinoid hyper-
emesis syndrome, a condition associated with heavy
daily use of cannabis. In addition, withdrawal symp-
toms after cessation of chronic cannabis use may
cause nausea. In a trial by Levine et al. [41] compar-
ing nabilone to placebo in patients at high risk of
postoperative nausea and vomiting (PONV) follow-
ing surgery, the authors concluded that nabilone
did not decrease the incidence of PONV.
A recent study examined impact of chronic use
of cannabis on the risk for developing PONV. Can-
nabis use was classified as ‘daily’ (used on a daily
basis), ‘current’ (used at present, but less often than
daily), or ‘none.’ Daily cannabis users’ were found to
be at increased risk of PONV [42].
No difference in rate of PONV among chronic
cannabis users and cannabis naı̈ve patients was
&
found in another study [34 ].
WITHDRAWAL
Long-term cannabis users may experience a with-
drawal syndrome when cannabis is suddenly
stopped. Patients report feelings of fatigue,
depressed mood, irritability, agitation, insomnia,
‘hot flashes,’ sweating, rhinorrhea, loose stools, hic-
cups, nausea, and anorexia. Withdrawal symptoms
in humans are usually mild. The onset of withdrawal
symptoms generally occurs within 1–2 days, and the
symptoms typically peak within one week and
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dissipate within about 2–4 weeks. On the one hand,
there is an argument to instruct chronic cannabis
users to continue cannabis till surgery and supply a
similar cannabis dose in an oil form as replacement
for smoked/vaporized cannabis in the postoperative
period. This might, however, conflict with adverse
effects of cannabis on anesthesia and is not the
currently accepted recommendation. The ASA
(American Society of Anesthesiology) urges patients
to be forthcoming about preoperative cannabis use.
Several publications recommend stopping cannabis
&&
72 h before surgery [5,4 ]. Conversely, recent pub-
lications mention their practice of continuing can-
nabis till day of surgery and providing cannabis to
chronic cannabis consumers postoperatively
&&
[3 ,39,40]. Continuation of cannabis use postoper-
atively may be a safer recommendation in medical
cannabis patients.
DIFFICULTY MONITORING
Anesthetic depth
Anesthetic depths is measured frequently with a BIS
monitor (bispectral index). Ibera et al. [43] studied
the effects of nabiximols (Savitex) premedication on
intraoperative BIS values for patients undergoing
general anesthesia. High doses of nabiximols were
associated with significantly higher BIS values. The
authors considered these outcomes as a cannabis-
induced abnormal electroencephalogram (EEG)
activity rather than a light anesthetic state [43].
Therefore, these findings may render BIS an inap-
propriate marker of anesthetic depth in cannabis
users.
Heart rate and blood pressure
Heart rate and blood pressure are basics interpreters
of anesthetic depth. As mentioned above, cannabis
may affect both of these parameters and complicate
interpretation of these measures.
Drug–drug interaction
Drug interactions with cannabinoids can occur
through several mechanisms. Cannabinoids levels
can be increased by other drugs and cannabinoids
can affect levels of other drugs by competing against
drugs metabolized by cytochrome P450 [44]. Keto-
conazole, cotrimoxazole, fluoxetine, amiodarone,
and warfarin are some examples where this should
be expected to arise. Additive effects can occur with
other drugs when cannabis is combined with sym-
pathomimetics, anticholinergics, and CNS depres-
sants and others [45].
Volume 33  Number 6  December 2020
 Anesthetic considerations in medical cannabis patients Davidson et al.
RECOMMENDATIONS
As suggested above, it is problematic to simplify
anesthetic recommendations for the heteroge-
neous group of cannabis users. It is more practical
to make suggestions for the medical cannabis
patients, a relatively homogenous group for whom
much useful information is available. Based on the
knowledge summarized above and on our personal
experience, we feel that we are in a position to make
practical recommendations for anesthesia pro-
viders to medical cannabis patients in the following
table (Table 1).
CONCLUSION
Growing numbers of medical and recreational can-
nabis consumers have led to an increasing propor-
tion of the patients admitted for surgery that are
chronic cannabis users. Cannabis has multiple
effects on the anesthetic perioperative plan. Provid-
ing unequivocal recommendations for anesthetic
management of cannabis consumers is complicated
by the large diversity of parameters such as cannabis
use method, cannabis compositions consumed,
doses, experience and frequency of use, personal
parameters, and medical situation. In this review,
we provide recommendations to anesthetic man-
agement of medical cannabis consumers. Patients
from medical cannabis group can provide the medi-
cal team with much useful information, including
exact composition, the modes of use, adverse effects
and withdrawal effects. For this group, adjustments
can be suggested to the perioperative anesthetic
plan, including ones related to cardiovascular, gas-
tric emptying, airway protection, induction dose,
maintenance of anesthesia, risks of MI and stroke,
anxiety, and postoperative pain. We propose ques-
tioning every patient in the preoperative discussion
about cannabis consumption and getting detailed
information related to cannabis use. Anesthesia
providers have to relate these details and modify
anesthetic plan accordingly. We provide periopera-
tive anesthetic recommendations related to medical
cannabis consumers. In future, additional informa-
tion, from ongoing studies, may provide recommen-
dations that are more detailed for medical cannabis
patients under anesthesia.
Acknowledgements
None.
Financial support and sponsorship
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.
0952-7907 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Conflicts of interest
The authors declare that no grants/founding were
involved in supporting this manuscript.
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