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Regular Cannabis Users Need More Sedation During Endoscopic Procedures

Grand Junction, CO—Hospitals pharmacists might want to take note: Patients who regularly use cannabis might require much more sedation when undergoing medical procedures.

A recent report in the Journal of the American Osteopathic Association suggests that could be as much as double the dosage.

To reach that conclusion, researchers in Colorado—where adults can legally possess an ounce of marijuana—examined medical records of 250 patients who received endoscopic procedures after 2012, when the state legalized recreational cannabis.

Results indicate that patients who smoked or ingested cannabis on a daily or weekly basis required 14% more fentanyl, 20% more midazolam, and 220% more propofol to achieve optimum sedation for routine procedures. That included common screening procedures, such as colonoscopy.

“Some of the sedative medications have dose-dependent side effects, meaning the higher the dose, the greater likelihood for problems,” explained lead researcher Mark Twardowski, DO, of Western Medical Associates in Grand Junction. “That becomes particularly dangerous when suppressed respiratory function is a known side effect.”

Twardowski raised concerns about lack of research on adverse effects of cannabis, pointing out, “Cannabis has some metabolic effects we don’t understand and patients need to know that their cannabis use might make other medications less effective. We’re seeing some problematic trends anecdotally, and there is virtually no formal data to provide a sense of scale or suggest any evidence-based protocols.”

He notes that anecdotal information from anesthesiology colleagues suggests that regular cannabis users not only need higher dosages for general anesthesia but also appear to have higher rates of postoperative seizures. Emergency-medicine clinicians, meanwhile, have reported many patients complaining of chronic nausea after regular use of the drug, he adds.

Based on those reports, Twardowski and his colleagues embarked on their study.

Adding specific questions regarding cannabis use to patient-intake forms is the first step to acquiring useful information that influences patient care, according to researchers, who added, “Determining cannabis use before procedural sedation can be an important tool for planning patient care and assessing both medication needs and possible risks related to increased dosage requirements during endoscopic procedures.”

“This study really marks a small first step,” says Dr. Twardowski. “We still don’t understand the mechanism behind the need for higher dosages, which is important to finding better care management solutions.”

Regular Cannabis Users Need More Sedation During Endoscopic Procedures Grand Junction, CO— Hospitals pharmacists might want to take note: Patients who regularly use cannabis might require much

Why Daily Cannabis Users May Need More Than Double The Dosage for Sedation

People who use cannabis regularly may need up to two times more sedation if they undergo a medical procedure, a new study claims. Users were defined as those who self-reported using cannabis — by smoking or ingesting edibles — on a daily or weekly basis.

Share on Pinterest Experts say more research is needed on the topic. Getty Images

People who use cannabis regularly may need up to two times more sedation if they undergo a medical procedure compared to those who don’t use the drug regularly, a new study claims.

But the study’s research methods are under scrutiny, as other experts say there’s not enough credible evidence to make a correlation between cannabis use and more sedation.

A report in The Journal of the American Osteopathic Association looked at records from 250 people from Colorado undergoing an endoscopic procedure between 2015 and 2017. They were randomly chosen from a pool of 1,158 cases. In 2012, the state legalized recreational cannabis.

In the study, patients who reported sporadic use or topical use — usually consisting of cannabidiol (CBD) oils or ointments — were considered non-users. Those who reported not using at all were also non-users. Users were defined as those who self-reported using cannabis — by smoking or ingesting edibles — on a daily or weekly basis.

Out of 250 people, 25 were regular cannabis users. They received 19 colonoscopies, two esophagogastroduodenoscopies (EGDs), and four colonoscopy/EGDs. Of 225 non-users, 180 had colonoscopies, 27 EGDs, and 18 had colonoscopies/EGDs.

Those who smoked or ingested cannabis on a daily or weekly basis required 14 percent more fentanyl, 20 percent more midazolam, and 220 percent more propofol to achieve optimum sedation for the aforementioned routine procedures.

The concern about giving patients more sedation is that some of the medications pose a greater likelihood for problems the higher the dose gets.

“The dangers of progressively higher doses of sedatives and opiates is that of respiratory suppression. The other potential risk of some of the medications is low blood pressure,” Dr. Mark Twardowski, an osteopathic internal medicine physician and lead author of the study, told Healthline.

Twardowski said it’s unclear what the mechanism is that seems to make cannabis users require more sedation.

“We and others suspect that the effect lies at the receptor level — possibly through some sort of down regulation, but the specifics are not known,” Twardowski said.

Physicians who regularly work with sedation have a rough idea how much is used for the average person dependent on different procedures. They recognize when a patient is responding more slowly and less vigorously to usual sedation doses, he said.

Using more sedation poses health risks to the patient, and can create an increased cost burden when more medication must be used.

Dr. Yury Khelemsky, an associate professor of anesthesiology, perioperative and pain medicine, and neurology at the Icahn School of Medicine at Mount Sinai, questioned several aspects of the study. He noted that Twardowski lacks specific expertise in the anesthesiology field, as he is a primary doctor.

“The study had many critical flaws, which render it useless,” Khelemsky told Healthline. “Overall, the conclusion that cannabis use has anything to do with increased doses of sedation cannot be supported or disputed by looking at this data.”

He noted that 16 percent of cannabis users underwent longer procedures compared to 8 percent of non-users, which could be a reason why cannabis users needed more medication.

While it may be true that some cannabis users underwent longer procedures, that’s largely attributed to the fact that accomplishing sedation took more time. The procedure is begun once the patient is adequately sedated, and if they become uncomfortable during the procedure, it’s paused until comfort is reestablished, which would lengthen the procedure.

If patients were using other drugs such as methamphetamines, that could alter the dose of medication required to sedate the patient, Khelemsky said. “This was not accounted for in the study design or analysis. Cannabis users are also more likely to use other illicit drugs, this was also not accounted for,” Khelemsky explained.

He also questioned if the nurses or doctors knew ahead of time which patients used cannabis. According to the report, information on drug use was collected, but the endoscopist wasn’t aware of a patient’s cannabis use when performing procedures, Twardowski said.

Khelemsky also contends that self-reporting drug use, especially when it’s not done anonymously, produced unreliable data.

“As of now, there is no good evidence that cannabis use alters anesthetic dosing,” Khelemsky said.

Twardowski said self-reporting is never 100 percent accurate, but his team felt that people would be more likely to report accurately due to legalization in the state.

Dr. James Lozada, an anesthesiologist at Vanderbilt University Medical Center, said weight can play a role in whether or not a patient requires more of a sedative, especially propofol. Anxiety is another factor that can affect the levels of medication needed, and many people take cannabis for anxiety. Those factors aren’t reflected in the research.

“We don’t yet have good research that says regular cannabis users require more medicine for anesthesia,” Lozada said. “To truly assess something like this, blood levels need to be drawn to compare groups… because it’s not just that cannabis is there, it’s also in what level.”

“While this study is interesting, important details are missing which prevent us from drawing meaningful conclusions,” Lozada added.

He noted research released this month about anesthesia and children who take medicinal marijuana for seizures. The authors recommend using caution when administering sedatives and opioids, as the effect may be additive and lead to excess sedation.

People who use cannabis regularly may need up to two times more sedation if they undergo a medical procedure, a new study claims. Users were defined as those who self-reported using cannabis — by smoking or ingesting edibles — on a daily or weekly basis. ]]>