Regardless of your personal bent on the topic, marijuana use for
medicinal purposes is now legal in 29 states plus the District of
Columbia. That's a lot of places where patients can legally be
prescribed and purchase medical marijuana for an assortment of ailments,
including recovery after surgery.
Before dismissing the idea because of
the perceived stigma, warranted or not, with marijuana use, consider
these 5 reasons why your postop patient should consider rolling a joint
after surgery:
1. Avoid opioid overdose and addiction
The current opioid crisis has contributed to over $55 billion in health and social costs. Could marijuana use after surgery ironically be the answer to the opioid crisis in America?
When you consider the following facts, it's not such an unreasonable conclusion. In this recent study,
most consumers try opioids (Percocet, Vicodin, etc.) for the first time
after undergoing surgery.
Of those, 6% continue using opioids for at
least three months after surgery. So, what if those patients were never
offered opioids in the first place? What if their doctors gave them a
prescription for marijuana instead?
There's reason to believe the replacement of opioids with marijuana can reduce dependency on opioids. According to this study in JAMA Internal Medicine,
"Medical cannabis laws are associated with significantly lower
state-level opioid overdose mortality rates." The article goes on to
say, "In states with a medical marijuana law, overdose deaths from
opioids like morphine, oxycodone and heroin decreased by an average of
20% after one year, 25% by two years and up to 33% by years five and six
compared to what would have been expected..."
And it's not just the risk of dependency that's concerning. There's
also the risk of an accidental overdose. I prescribe Percocet for all of
my postop patients. Usually there's not a problem with dependency or
overdose but an overdose occurred once, and once is enough. Instead of
taking their Percocet "prn pain,"
the patient took their pain medication around the clock. When combined
with the fact that the patient was opioid naive, their respiratory rate
dropped and the patient had to go to the hospital. The patient recovered
without any need for reversal medications like Narcan but obviously it
was a scary, avoidable situation for the patient and family (and me).
In contrast to opioids, the risk of overdose with marijuana is impossible because according to the National Cancer Institute,
“cannabinoid receptors, unlike opioid receptors, are not located in the
brainstem areas controlling respiration.” In other words, my patient
whose respirations slowed from Percocet would not have had the same
experience with marijuana.
Additionally, opioid addiction can be evident in other ways. As I wrote in this post,
opioid addicted patients can skewer their doctor with a negative Yelp
review if they don't receive the meds they demand. While this could also
occur if a doctor doesn't refill a patient's marijuana prescription,
that is less of a problem since recreational marijuana use is becoming
more prevalent in several states (Oregon, Washington, California and
Colorado to name a few).
2. Decrease pain and increase appetite
In addition to the benefit of avoiding an overdose, marijuana decreases
pain and increases the appetite. Increasing appetite for chemotherapy
patients is well documented but the importance of eating after any major
operation can't be overstated. Consuming foods high in protein
contributes to wound healing. Marijuana clearly reduces pain, nausea and vomiting whereas opioids can actually increase nausea and vomiting.
For those of you worried about prescribing a medication that will make
patients "high," there's an alternative that can avoid that stigma.
3. CBD versus THC
Cannabidiol, also known as CBD, is one of many active ingredients in
marijuana. The more commonly known chemical compound is
THC—tetrahydrocannabinol—the psychoactive ingredient in marijuana. As
explained in this article here,
CBD, in appropriate ratios can actually counteract the negative effects
of THC. So, by using a marijuana strain that is relatively higher in
CBD than THC, the typical paranoia and euphoric effects of the marijuana
high are less. At the same time, the beneficial effects of less pain,
nausea and vomiting are still present.
4. Lack of nicotine avoids issues of wound healing associated with cigarettes and other tobacco products
As noted here,
nicotine before or after surgery can constrict blood vessels and
adversely affect wound healing. Marijuana on the other hand does not
contain nicotine. Additionally, the risk of lung cancer seen with
tobacco products doesn't translate to marijuana either. According to
this article,
"Marijuana use also was not associated with tobacco-related cancers or
with cancer of the following sites: colorectal, lung, melanoma,
prostate, breast, cervix. Among nonsmokers of tobacco cigarettes, ever
having used marijuana was associated with increased risk of prostate
cancer (RR = 3.1, CI = 1.0-9.5) and nearly significantly increased risk
of cervical cancer (RR = 1.4, CI = 1.0-2.1)."
5. No constipation
With either short or prolonged use of opioids, patients complain of
constipation. This is a vicious cycle. As patients take more opioids for
pain, the resulting constipation can cause more pain and the cycle
begins anew. That is not an issue with marijuana.
Conclusion
Granted, the use of marijuana to control pain postoperatively only
pertains to the states where it is legal. In a situation where there is a
process for obtaining marijuana, the stigma is less. Whereas, in states
where medical marijuana is not approved, going to a drug dealer to fill
your prescription is obviously a non-starter for most consumers. And it
is exceedingly awkward for law-abiding citizens.
So, should you recommend medical marijuana postop instead of opioids?
That's a decision for you and your patient. However, the point is that
this is a legally viable option in many states and no longer on the
fringes of society.
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