The Association Between Preoperative Cannabis Use and Anxiety,Pain Scores and Opioid Consumption in Patients Undergoing Spinal Fusion: A Retrospective Cohort Study

Abstract

Study Design

Retrospective cohort study.

Objective

Despite increasing cannabis use, its prevalence in specific surgical groups is unclear, and its impact on perioperative care and outcomes is understudied. This study estimates cannabis use incidence in patients undergoing lumbar spine surgery and explores associations between preoperative use and anxiety, pain scores, and postoperative opioid consumption. We hypothesized a correlation between cannabis use and decreased reliance on opioids for postoperative pain relief.

Methods

This single-center retrospective cohort study included 204 patients undergoing single or multilevel spinal fusion surgery between July 2022 and August 2023. Self-reported cannabis use, demographics, surgical characteristics, numeric rating scale (NRS) pain scores, anxiety, inpatient opioid consumption, and discharge prescribing (total morphine equivalent dose) were extracted from electronic medical records (EMR). Patients were categorized into cannabis users or non-cannabis users, and group differences were analyzed using bivariable and multivariable regression.

Results

Of 204 patients, 27 (13.2%) were cannabis users and 177 (86.8%) were non-users. Cannabis users were younger (P = 0.007), more likely male (P = 0.028), and Caucasian (P = 0.032) than non-users. Preoperative cannabis use correlated significantly with anxiety disorder (P = 0.023) and higher preoperative (P = 0.016) and postoperative (P = 0.002) NRS pain scores. Multivariable analysis showed cannabis use associated with higher preoperative (P = 0.015) but not postoperative (P = 0.073) pain scores. No significant differences were found in preoperative, discharge opioid prescribing or postoperative opioid consumption.

Conclusion

The incidence of cannabis use was low, but positively associated with anxiety and higher preoperative NRS pain scores. Large, well-powered trials are needed to understand cannabis’s impact on spine surgery outcomes.

Keywords

cannabis pain anxiety spine surgery outcomes

Introduction

The widespread use of cannabis is evident on a global scale: The 2021 United Nations World Drug Report estimates approximately 219 million users, constituting 4.3% of the global adult population.¹ In the United States, cannabis ranks as the third most used recreational substance, with 15% of the population overall and 22% of individuals aged 12 or older reporting cannabis use in the past year.² In parallel, as of April 2023, medical cannabis programs operate in 38 states and 4 territories, with 24 states allowing non-medical use.³ These trends suggest the need to explore the incidence of cannabis use among select surgical populations, to evaluate the impact of use on outcomes after surgery, and to consider whether there are differential effects of cannabis on outcomes after painful procedures, including spine surgery. Each of these topics are currently undefined and understudied.

Despite advances in multimodal analgesic strategies for spine surgery, opioids remain the cornerstone of pain management regimens.^4,5 The ongoing opioid epidemic has prompted a search for alternative pain management strategies, and recent studies suggest a potential synergistic effect between cannabis and reduced opioid use, with preclinical data demonstrating opioid-sparing effects of cannabis.⁶ These forces, combined with trends in population use highlight the need to understand how baseline cannabis use influences postoperative outcomes after spine surgery.

The primary objective of this study is to estimate the incidence of cannabis use among patients presenting for lumbar spine surgery. We additionally aimed to assess the impact of patient-reported preoperative cannabis use on pain scores and opioid consumption for postoperative analgesia. We hypothesized the incidence of cannabis use would mirror population use, and that cannabis use would correlate with lower pain scores and decreased opioid prescribing after lumbar spinal fusion.

Methods

Study Design and Patients

This is a single-center observational, retrospective cohort study. The study was performed after approval from the Institutional Review Board at Hospital for Special Surgery (HSS-IRB #2021-2137). Written patient consent was waived by the IRB due to the anonymous, retrospective nature of the data collection.

The study population comprised consecutive patients undergoing single or multilevel spinal fusion surgery at our institution between July 2022 and August 2023. All patients with documented cannabis use or non- use in the electronic medical record (EMR) were eligible for inclusion in the analysis. Surgical procedures included posterior lumbar interbody fusion (PLIF), extreme lateral interbody fusion (XLIF), anterior lumbar interbody fusion (ALIF), and circumferential fusion (A/PLIF). Exclusion criteria included emergency surgery and surgery for trauma, infection, or neoplasm.

Demographic information, surgical characteristics, and outcomes were extracted through manual EMR chart review. Data extracted included: patient age, gender, race, American Society of Anesthesiologists classification (ASA), body mass index (BMI), history of depression, history of anxiety, chronic pain (diagnosis and/or opioid prescriptions for >3 months before the date of surgery), systemic respiratory or cardiac comorbidity, preoperative numeric rating scale (NRS) pain scores (0-10 where 0 = no pain and 10 = worst imaginable pain), preoperative opioid prescribing (yes/no), antidepressant, benzodiazepine, NSAIDs, and pregabalin/gabapentin use, smoking status, alcohol consumption, and cannabis use.

Hospitalization data included inpatient benzodiazepine administration, opioid consumption during the admission, postoperative NRS pain scores, postoperative nausea and vomiting (PONV), length of stay (LOS) and discharge opioid prescribing. Operative and anesthetic variables included number of operative levels, operative time (from incision to closure), duration of anesthesia (from induction to emergence), and time to emergence from anesthesia (defined as the time between closure of the surgical incision to extubation).

Patients were categorized into cannabis users and non-cannabis users based on self-reported preoperative use. All patients are asked about cannabis use as part of the social history at the pre-surgical screening appointment, by the hospitalist and/or by the surgeon’s office and/or as part of the anesthetic pre-evaluation. Manual review of the EMR was conducted to assess recreational and/or medical cannabis use up to and including the latest preoperative appointment(s) or at the anesthetic evaluation on the day of surgery. Details such as strain, potency, method of intake, or duration of use are not reliably available in the EMR; hence, only “yes/no” documented cannabis use was recorded. Opioid consumption was calculated as the total morphine equivalent dose (MED) of all opioid medications administered during inpatient hospitalization (including oral and intravenous (IV) patient-controlled analgesia (PCA) use). Post-discharge opioid prescribing was calculated as the total MED of opioids prescribed at discharge.

All patients received perioperative comprehensive multimodal analgesia (MMA), including a regional anesthetic technique, according to surgical approach (transversus abdominis plane block for anterior or lateral approach; erector spinae plane blocks for posterior),^7,8 ketorolac (15 mg every 8 h up to 3 doses), acetaminophen (1000 mg every 8 h) and opioids on an as-needed basis (tramadol 50 mg every 4 h, or oxycodone, 5-10 mg every 4 h, according to pain scores) and PONV prophylaxis (intraoperative dexamethasone, 4-8 mg and ondansetron 4 mg).⁴

Statistical Analysis

The normality of continuous variables was assessed using the Shapiro-Wilk test. Median and Interquartile range (IQR) were utilized to summarize non-normally distributed continuous variables, while count and percentage were calculated for discrete variables. The Kruskal-Wallis test examined differences in continuous variables between 2 groups, and Fisher’s exact test or Chi-square test was applied for categorical variables based on cell sizes. Multivariable linear regression, adjusting for age, sex, BMI, anxiety, levels fused, and procedure, was employed to evaluate the association between cannabis use and preoperative pain score. Similarly, multivariable linear regression adjusting for preoperative pain score, age, sex, BMI, anxiety, levels fused, and procedure, was used to assess the relationship between cannabis use and postoperative pain score. Statistical significance was defined as P < 0.05, and R-Studio version 2023.06.0 was used for statistical analysis.⁹

Results

Incidence of Cannabis Use

A total of 204 patients undergoing single or multilevel spinal fusion surgery met criteria for inclusion in the analysis. Of these, 27 (13.2%) were cannabis users, and 177 (86.8%) were non-cannabis users (Table 1).

Table 1.

Patient Demographics.

Variables	Cannabis Non-Users	Cannabis Users	Total	P Value
Patients (%)	177 (86.8%)	27 (13.2%)	204
Age, median (IQR)	65 (58-73)	58 (51-67)	64 (57-72)	0.007
Sex, male (%)	91 (51.4%)	20 (74.1%)	111 (54.4%)	0.028
Race, white (%)	159 (89.8%)	22 (81.5%)	181 (88.7%)	0.032
BMI, median (IQR)	28 (25-31.9)	29.8 (26.7-34.4)	28.45 (25.17-32)	0.074
ASA				0.304
1	8 (4.5%)	0 (0.0%)	8 (3.9%)
2	152 (85.9%)	22 (81.5%)	174 (85.3%)
3	16 (9.0%)	5 (18.5%)	21 (10.3%)
4	1 (0.6%)	0 (0.0%)	1 (0.5%)
Smoking status (%)	12 (6.8%)	2 (7.4%)	14 (6.9%)	0.747
Alcohol use (%)	41 (23.2%)	6 (22.2%)	47 (23.0%)	0.57
History of chronic pain (%)	7 (4.0%)	1 (3.7%)	8 (3.9%)	0.999
DM (%)	27 (15.3%)	4 (14.8%)	31 (15.2%)	0.999
HTN (%)	91 (51.4%)	11 (40.7%)	102 (50.0%)	0.302
CHF (%)	15 (8.5%)	1 (3.7%)	16 (7.8%)	0.701
COPD (%)	1 (0.6%)	0 (0.0%)	1 (0.5%)	0.999
Depression (%)	28 (15.8%)	8 (29.6%)	36 (17.6%)	0.08
Anxiety (%)	42 (23.7%)	12 (44.4%)	54 (26.5%)	0.023
Preop BZD use (%)	33 (18.6%)	5 (18.5%)	38 (18.6%)	0.988
Preop antidepressant use (%)	38 (21.5%)	10 (37.0%)	48 (23.5%)	0.076
Preop pregabaline/Gabapentine use (%)	53 (29.9%)	11 (40.7%)	64 (31.4%)	0.26
Preop NSAIDs use (%)	49 (27.7%)	12 (44.4%)	61 (29.9%)	0.076
Inpatient BZD use (%)	33 (18.6%)	2 (7.4%)	35 (17.2%)	0.18

Abbreviations: IQR, Interquartile Range; BMI, Body Mass Index; ASA, American Society of Anesthesiologists; DM, Diabetes Mellitus; HTN, Hypertension; CHF, Congestive Heart Failure; COPD, Chronic Obstructive Pulmonary Disease; BZD, Benzodiazepine.

Patient Demographics

Significant associations were found in baseline demographics, with cannabis users being younger (median 58, IQR 51-67 vs median 65, IQR 58-73 years, P = .007), predominantly male (74.1% vs 51.4%, P = .028), and of Caucasian race (81.5% vs 89.8%, P = .032). On bivariable comparisons, there was a significant association between cannabis use and the prevalence of anxiety (44.4% vs 23.7%, P = .023), but not between cannabis use and anxiolytic medication use (18.6% of non-users vs 18.5% of users, P = 0.988). There were no significant associations between cannabis use and the prevalence of depression (29.6% of cannabis users vs 15.8% of non-cannabis users, P = .08), or antidepressant and cannabis use (37% of cannabis users vs 21.5% of non-users, P = .076). No statistically significant differences were found in BMI (29.8, 26.7-34.4 vs 28, 25-31.9, P = .074), ASA class (P = .304), smoking status (current smokers: 7.4% vs 6.8%, P = .747), alcohol consumption (22.2% vs 23.2%, P = .57), history of chronic pain (3.7% vs 4%, P = .999), diabetes mellitus (14.8% vs 15.3%, P = .999), hypertension (40.7% vs 51.4%, P = .302), congestive heart failure (CHF) (3.7% vs 8.5%, P = .701), and chronic obstructive pulmonary disease (COPD) (0% vs 0.6%, P = .999). Also, while not reaching statistical significance, a greater number of cannabis users took NSAIDs (44.4% vs 27.7%, P = .076) and pregabalin/gabapentin (40.7% vs 29.9%, P = .26) (Table 1).

Surgical Characteristics

There were no statistically significant differences in type of procedure (ALIF, XLIF, PLIF, A/PLIF) (P = 0.533), number of levels fused (2, 1-2 vs 2, 1-3, P = 0.307), duration of surgery (144, 102-220 vs 174, 120-246 minutes, P = 0.21), duration of anesthesia (212 170-306.5 vs 259, 204-334 minutes, P = 0.115), and/or time to emergence from anesthesia (8, 6.5-11 vs 9, 6-13 minutes, P = 0.313) between cannabis users and non-users (Table 2).

Table 2.

Surgical Characteristics.

Variables	Cannabis Non-Users	Cannabis Users	Total	P Value
Procedure				0.533
ALIF	6 (3.4%)	2 (7.4%)	8 (3.9%)
PLIF	102 (57.6%)	16 (59.3%)	118 (57.8%)
XLIF	36 (20.3%)	6 (22.2%)	42 (20.6%)
A/PLIF	33 (18.6%)	3 (11.1%)	36 (17.6%)
Levels fused, median (IQR)	2 (1-3)	2 (1-2)	2 (1-2)	0.307
Duration of surgery (min), median (IQR)	174 (120-246)	144 (102-220)	174 (118.75-243)	0.21
Duration of anesthesia (min), median (IQR)	259 (204-334)	212 (170-306.5)	254 (197-331.75)	0.115
Time to emergence (min), median (IQR)	9 (6-13)	8 (6.5-11)	9 (6-13)	0.313

Abbreviations: ALIF, Anterior Lumbar interbody Fusion; PLIF, Posterior Lumbar Interbody Fusion; XLIF, Extreme Lateral Interbody Fusion; IQR, Interquartile Range.

Pain Scores, Opioid Consumption, and Postoperative Outcomes

Cannabis use was associated with higher preoperative (8, 7-8 vs 6, 4-8, P = 0.016) and postoperative (6, 5-6 vs 5, 3-5, P = 0.002) NRS pain scores. However, no significant associations were found between cannabis use and opioid prescribing in the preoperative period (MED/day 0, 0-0 vs 0, 0-5, P = 0.936) or at discharge (MED/day 67.5, 45-90 vs 60, 45-90, P = 0.441). Likewise, no significant associations were found between cannabis use and total postoperative opioid consumption (MED 176.5, 74.25-251.5 vs 120, 52.5-217.5, P = 0.247), IV PCA use (66.7% vs 66.1%, P = 0.954), PONV (7.4% vs 13%, P = 0.41), or LOS (57.9, 51.75-99.45 vs 75.4, 54.1-105.5 hours, P = 0.145) (Table 3).

Table 3.

Pain Scores, Opioid Consumption and Outcomes.

Variables	Cannabis Non-Users	Cannabis Users	Total	P Value
Preop NRS pain score, median (IQR)	6 (4-8)	8 (7-8)	7 (5-8)	0.016
Preop opioid use (%)	57 (32.2%)	7 (25.9%)	64 (31.4%)	0.513
Preop opioid amount (MED/Day), median (IQR)	0 (0-5)	0 (0-0)	0 (0-5)	0.936
Postop NRS pain score, median (IQR)	5 (3-5)	6 (5-6)	5 (4-6)	0.002
Postop opioid use (MED), median (IQR)	120 (52.5-217.5)	176.5 (74.25-251.5)	120.75 (56.12-218.5)	0.247
IV PCA use (%)	117 (66.1%)	18 (66.7%)	135 (66.2%)	0.954
Opioid prescribed at discharge (MED/Day), median (IQR)	60 (45-90)	67.5 (45-90)	60 (45-90)	0.441
PONV (%)	23 (13%)	2 (7.4%)	25 (12.3%)	0.41
LOS (hours), median (IQR)	75.4 (54.1-105.5)	57.9 (51.75-99.45)	75.15 (53.42-104.05)	0.145

Abbreviations: NRS, Numerical Rating Scale; IQR, Interquartile Range; IV PCA, Intravenous Patient-Controlled Analgesia; PONV, Postoperative Nausea and Vomiting; LOS, Length of Stay. Bold values indicate statistical significance (p<0.05).

Multivariable linear regression analysis demonstrated a significant association between cannabis use and higher preoperative NRS pain scores (CI: .27-2.46, P = .015). Male sex was significantly associated with lower preoperative NRS pain scores (CI: −2.39–-0.93, P < .001). No significant associations were observed for preoperative pain and the number of levels fused, procedure-type, age, BMI, and anxiety (Table 4).

Table 4.

Multivariable Linear Regression for Preoperative Pain Scores.

	Preoperative NRS Pain Score
Predictors	Estimates	CI	P value
(Intercept)	5.98	3.00–8.96	<0.001
Cannabis use	1.37	0.27–2.46	0.015
Levels fused	−0.13	−0.36–0.10	0.272
Procedure (A/PLIF)	0.64	−1.35–2.64	0.526
Procedure (PLIF)	0.15	−1.71–2.00	0.877
Procedure (XLIF)	0.5	−1.46–2.45	0.616
Age	−0.01	−0.04–0.01	0.342
Sex (Male)	−1.66	−2.39– -0.93	<0.001
BMI	0.06	−0.01–0.12	0.093
Anxiety	0.33	−0.48–1.15	0.421

Bold values indicate statistical significance (p<0.05).

Conversely, there was no significant association between cannabis use and postoperative pain scores (CI: −0.06-1.32, P = 0.073), although significant and positive associations were found for both preoperative NRS pain scores (CI: 0.02-0.20, P = 0.014) and the number of levels fused (CI: 0.08-0.37, P = 0.002). Cannabis use, procedure variables, male sex and BMI were not significant predictors of postoperative NRS pain scores (Table 5).

Table 5.

Multivariable Linear Regression for Postoperative Pain Scores.

	Postoperative NRS Pain Score
Predictors	Estimates	CI	P Value
(Intercept)	3.85	1.94–5.77	<0.001
Cannabis use	0.63	−0.06–1.32	0.073
Preop NRS pain score	0.11	0.02–0.20	0.014
Levels fused	0.22	0.08–0.37	0.002
Procedure (A/PLIF)	0.15	−1.09–1.38	0.817
Procedure (PLIF)	−0.17	−1.32–0.97	0.764
Procedure (XLIF)	0.52	−0.69–1.73	0.395
Age	−0.02	−0.04–0.00	0.032
Sex (Male)	0.21	−0.27–0.69	0.385
BMI	0.01	−0.03–0.06	0.48
Anxiety	0.24	−0.26–0.75	0.344

Bold values indicate statistical significance (p<0.05).

Discussion

We estimated the incidence of cannabis use in a cohort presenting for lumbar spinal fusion at 13.2%. Although this represents a substantial number of spine surgery patients anticipated to use cannabis, the proportion of users found here is substantially lower than the population incidence (22%) that has been estimated in national surveys over the past year.² This could represent underreporting, since we used self-reporting as our means of estimating cannabis use in this population. However, as the perception of cannabis becomes increasingly favorable and more U.S. states implement decriminalizing legislation, the prevalence of cannabis use is expected to rise. Indeed, the percentage of the population using cannabis in 2018 exceeded the figures reported between 2002 and 2017, reflecting a 6.1% increase in cannabis use over a 5-year period.^2,10 These trends suggest prospective investigation of the incidence of cannabis use among spine surgery patients as well as effects on outcomes after surgery are warranted.

Effective pain management after spine surgery contributes to improved outcomes, fewer adverse events, and prompt discharge from hospital without increased readmission.⁴ Conversely, inadequate pain control correlates with less patient satisfaction and prolonged hospitalization. Amidst the ongoing opioid epidemic, there is a critical need for alternative pain management strategies to reduce postoperative opioid consumption. The rationale for considering cannabis as an adjunctive analgesic lies in its potential opioid-sparing effects through cannabinoid-receptor 1 (CB1) activation, inhibiting calcium release and reducing nociceptor signaling.^11,12 Cannabinoids can also activate cannabinoid-receptor 2 (CB2) on immune cells, releasing cytokines that indirectly stimulate various receptors, including μ-opioid receptors, transient receptor potential vanilloid 1 (TRPV1) located on sensory Aδ and C-fibers, N-methyl-D-aspartate (NMDA) and gamma-aminobutyric acid (GABA) receptors within the nervous system.^12-15 An additional factor supporting cannabis use as an analgesic adjunct is the potential to reduce postoperative opioid-induced respiratory depression: Cannabinoids lack CB1 receptors in the central nervous system respiratory center and could improve pain control while minimizing opioid-induced respiratory depression.¹⁴

Despite its theoretical benefits, clinical evidence on cannabis for perioperative pain management remains inconclusive. While cannabinoids have demonstrated efficacy in neuropathic and cancer-related pain,¹¹ their role in acute postoperative pain is less clear. Systematic reviews and randomized trials report mixed results, with most studies showing no significant benefit over placebo in acute pain management.^16-18

Our findings align with Liu et al, who observed higher preoperative and postoperative pain scores in cannabis users undergoing orthopedic procedures.¹⁹ Although our study identified similar trends, the differences did not reach statistical significance after adjusting for multiple variables. Jennings et al also reported no differences in opioid consumption postoperatively but noted increased early postoperative pain scores in cannabis users.²⁰ While some studies report no significant differences in postoperative opioid consumption,^19-25 others suggest a potential opioid-sparing effect.²⁶'²⁷ One proposed mechanism is cannabinoid-opioid synergy, as both act on overlapping neural pathways. However, chronic CB1 receptor activation may lead to receptor downregulation, necessitating higher opioid doses for adequate pain control.¹¹'²⁸ This phenomenon is supported by studies identifying increased postoperative opioid requirements in cannabis users.^29,30

Expanding on the relationship between cannabis use and surgical outcomes, Van Halm-Lutterodt et al and Razzouk et al found that cannabis use disorder (CUD) was associated with higher hospital readmission rates, increased revision surgery risk, and greater postoperative opioid consumption after anterior cervical discectomy and fusion (ACDF).^31,32 Similarly, Dietz et al and Brenne et al identified increased complication rates, longer hospital stays, and higher opioid consumption among cannabis users undergoing cervical and lumbar spine fusions.^33,34 However, Dietz et al also noted a decrease in long-term opioid dependence, suggesting cannabis may aid in opioid tapering strategies. While our study did not demonstrate significant differences in postoperative opioid consumption, it aligns with prior literature indicating that cannabis use does not provide an opioid-sparing effect in the acute postoperative period. Taken together, these studies suggest that cannabis use may be linked to greater perioperative risks, yet its long-term impact on pain management remains uncertain, warranting further research.

Our study also found a positive association between cannabis use and baseline anxiety disorders. A prospective study by Blanco et al reported increased odds of developing anxiety disorders with cannabis use,³⁵ though adjusted models did not confirm this association.³⁶ Anxiety is a well-established predictor of heightened postoperative pain perception,^35-39 which may confound interpretations of cannabis’ effects on surgical pain. In our study, cannabis users demonstrated increased pain scores, but no significant association was observed between anxiety and postoperative pain after adjustment for confounders.

This study has several limitations. As a retrospective, single-center study at a specialty orthopedic hospital, generalizability is limited. While perioperative pain management regimens were standardized, variations in surgical technique across providers may have influenced pain and opioid consumption outcomes. Although the primary goal was to estimate the incidence of cannabis use in spinal fusion patients, the proportion of patients reporting use was low, which hampers attempts to draw strong conclusions regarding associations between other variables of interest. Additionally, the reliance on self-reported cannabis use likely led to underestimation, introducing potential bias. Details such as cannabis potency, strain, frequency, and method of consumption were inconsistently documented and thus could not be analyzed.

While our study assessed pain scores and opioid use, we did not evaluate functional outcomes, such as return to daily activities or work. These metrics would provide greater insight into cannabis’ clinical impact on postoperative recovery. However, due to the retrospective nature of our study, such data were not consistently recorded in medical records. Future prospective studies should incorporate standardized functional assessments to better characterize cannabis’ role in perioperative care. Finally, we were unable to determine whether cannabis use persisted postoperatively, limiting our ability to analyze its impact on longer-term recovery.

Conclusion

We estimated the incidence of cannabis use in a cohort undergoing lumbar spinal fusion to be low, and lower than population estimates of use. We found significant associations between cannabis use and anxiety disorder, and cannabis use and higher preoperative pain scores. It is unclear whether anxiety was risk factor for cannabis use, or if cannabis use led to a higher likelihood of anxiety in this cohort, but neither factor appeared to negatively affect the outcomes analyzed here. Likewise, postoperative pain scores, opioid consumption and discharge opioid prescribing were not different between cannabis users and non-users, suggesting pre-operative cannabis use did not negatively influence recovery after spine surgery. These results highlight the need for continued prospective research in this evolving landscape.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Krizia Amoroso

Ali E. Guven

Andrew A. Sama

Alexander P. Hughes

Ellen M. Soffin

References

UNODC . World Drug Report 2023 (United Nations Publication); 2023. https://www.unodc.org/unodc/en/data-and-analysis/world-drug-report-2023.html

Substance Abuse and Mental Health Services Administration . Key Substance Use and Mental Health Indicators in the United States: Results from the 2022 National Survey on Drug Use and Health (HHS Publication No. PEP23-07-01-006, NSDUH Series H-58). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2023. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report

National conference of state legislatures (NCSL). 2023. https://www.ncsl.org/health/state-medical-cannabis-laws

Soffin

Beckman

Tseng

, et al. Enhanced recovery after lumbar spine fusion: a randomized controlled trial to assess the quality of patient recovery. Anesthesiology. 2020;133(2):350-363. doi:10.1097/ALN.0000000000003346

Reisener

Hughes

Okano

, et al. Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients. J Neurosurg Spine. 2021;36(5):713-721. doi:10.3171/2021.8.SPINE21599

Nielsen

Picco

Murnion

, et al. Opioid-sparing effect of cannabinoids for analgesia: an updated systematic review and meta-analysis of preclinical and clinical studies. Neuropsychopharmacology. 2022;47(7):1315-1330. doi:10.1038/s41386-022-01322-4

Reisener

Hughes

Okano

, et al. The association of transversus abdominis plane block with length of stay, pain and opioid consumption after anterior or lateral lumbar fusion: a retrospective study. Eur Spine J. 2021;30(12):3738-3745. doi:10.1007/s00586-021-06855-8

Soffin

Okano

Oezel

, et al. Impact of ultrasound-guided erector spinae plane block on outcomes after lumbar spinal fusion: a retrospective propensity score matched study of 242 patients. Reg Anesth Pain Med. 2022;47(2):79-86. doi:10.1136/rapm-2021-103199

Chambers

. Software for Data Analysis: Programming with R (Vol. 2, No. 1). New York: Springer; 2008.

10.

Substance Abuse and Mental Health Services Administration . Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2019. https://www.samhsa.gov/data

11.

Jensen

Chen

Furnish

Wallace

. Medical marijuana and chronic pain: a review of basic science and clinical evidence. Curr Pain Headache Rep. 2015;19(10):50. doi:10.1007/s11916-015-0524-x

12.

Pacher

Batkai

Kunos

. The endocannabinoid system as an emerging target of pharmacotherapy. Pharmacol Rev. 2006;58(3):389-462.

13.

Yuill

Hale

Guindon

Morgan

. Anti-nociceptive interactions between opioids and a cannabinoid receptor 2 agonist in inflammatory pain. Mol Pain. 2017;13:1744806917728227. doi:10.1177/1744806917728227

14.

Kim

Townsend

Branch

Romero-Sandoval

Hsu

. Cannabinoids in the treatment of back pain. Neurosurgery. 2020;87(2):166-175. doi:10.1093/neuros/nyz573

15.

Narouze

. Antinociception mechanisms of action of cannabinoid-based medicine: an overview for anesthesiologists and pain physicians. Reg Anesth Pain Med. 2021;46:240-250.

16.

Stevens

Higgins

. A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain. Acta Anaesthesiol Scand. 2017;61:268-280.

17.

Ladha

Manoo

Virji

A-F

, et al. The impact of perioperative cannabis use: a narrative scoping review. Cannabis Cannabinoid Res. 2019;4(4):219-230.

18.

Abdallah

Hussain

Weaver

Brull

. Analgesic efficacy of cannabinoids for acute pain management after surgery: a systematic review and meta-analysis. Reg Anesth Pain Med. 2020;45:509-519.

19.

Liu

Bhatia

Buzon-Tan

, et al. Weeding out the problem: the impact of preoperative cannabinoid use on pain in the perioperative period. Anesth Analg. 2019;129(3):874-881.

20.

Jennings

McNabb

Johnson

Brady

Kim

Dennis

. Use of cannabis does not decrease opioid consumption in patients who underwent total joint arthroplasty. Arthroplast Today. 2022;15:141-146. doi:10.1016/j.artd.2022.03.018

21.

D’Antonio

Lambrechts

Heard

, et al. The effect of preoperative marijuana use on surgical outcomes, patient-reported outcomes, and opioid consumption following lumbar fusion. Glob Spine J. 2022;14:568-576.

22.

Trenchfield

Lee

Brush

, et al. Effect of preoperative marijuana on patient outcomes and opioid use after lumbar decompression. Glob Spine J. 2023;15:633-638. doi:10.1177/21925682231203650

23.

McAfee

Boehnke

Moser

Brummett

Waljee

Bonar

. Perioperative cannabis use: a longitudinal study of associated clinical characteristics and surgical outcomes. Reg Anesth Pain Med. 2021;46(2):137-144. doi:10.1136/rapm-2020-101812

24.

Lambrechts

D'Antonio

Toci

, et al. Marijuana use and its effect on clinical outcomes and revision rates in patients undergoing anterior cervical discectomy and fusion. Spine. 2022;47(22):1558-1566. doi:10.1097/BRS.0000000000004431

25.

Bowers

Hao

Trivedi

, et al. Self-reported cannabis use is not associated with greater opioid use in elective hand surgery patients. Eur J Orthop Surg Traumatol. 2023;33(5):1857-1862. doi:10.1007/s00590-022-03321-z

26.

Khalid

Jiang

Khilwani

Thomson

Mirpuri

Mehta

. Postoperative opioid use among opioid-naive cannabis users following single-level lumbar fusions. World Neurosurg. 2023;175:e644-e652. doi:10.1016/j.wneu.2023.04.001

27.

Silver

Pavano

Bellas

, et al. Cannabis use is associated with decreased opioid prescription fulfillment following single level anterior cervical discectomy and fusion (ACDF). N Am Spine Soc J. 2023;14:100226. doi:10.1016/j.xnsj.2023.100226

28.

Echeverria-Villalobos

Todeschini

Stoicea

Fiorda-Diaz

Weaver

Bergese

. Perioperative care of cannabis users: a comprehensive review of pharmacological and anesthetic considerations. J Clin Anesth. 2019;57:41-49.

29.

Moon

LeRoy

Yacoubian

Gedman

Aidlen

Rogerson

. Cannabis use is associated with increased use of prescription opioids following posterior lumbar spinal fusion surgery. Glob Spine J. 2024;14(1):204-210. doi:10.1177/21925682221099857

30.

Salottolo

Peck

Tanner Ii

, et al. The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury. Patient Saf Surg. 2018;12:16. doi:10.1186/s13037-018-0163-3

31.

Van Halm-Lutterodt

Albright

Storlie

, et al. Cannabis use disorder and complications after anterior cervical diskectomy and fusion. World Neurosurg. 2024;181:e1001-e1011. doi:10.1016/j.wneu.2023.11.028

32.

Razzouk

Chung

Lindsey

Ramos

Cheng

Danisa

. Preoperative cannabis use associated with an increased rate of reoperation and postoperative opioid use following anterior cervical decompression and fusion. Cureus. 2022;14(11):e31285. doi:10.7759/cureus.31285

33.

Dietz

Alkin

Agarwal

, et al. Cannabis use disorder trends and health care utilization after cervical and lumbar spine fusions. Spine. 2024;49(4):E28-E45. doi:10.1097/BRS.0000000000004874

34.

Brenne

Burney

Mauer

Orina

Philipp

Yoo

. Risks associated with chronic cannabis use on opioid use, length of stay, and revision rate for patients undergoing posterior lumbar interbody fusion. Spine J. 2024;24:851-857. doi:10.1016/j.spinee.2024.01.011

35.

Blanco

Hasin

Wall

, et al. Cannabis use and risk of psychiatric disorders: prospective evidence from a US National Longitudinal Study. JAMA Psychiatry. 2016;73:388-395.

36.

Shalit

Lev-Ran

. Does cannabis use increase anxiety disorders? A literature review. Curr Opin Psychiatr. 2020;33(1):8-13. doi:10.1097/YCO.0000000000000560

37.

Robleda

Sillero-Sillero

Puig

Gich

Baños

. Influence of preoperative emotional state on postoperative pain following orthopedic and trauma surgery. Rev Lat Am Enfermagem. 2014;22:785-791.

38.

Tapar

Özsoy

Balta

Daşıran

Tapar

Karaman

. Associations between postoperative analgesic consumption and distress tolerance, anxiety, depression, and pain catastrophizing: a prospective observational study. Braz J Anesthesiol. 2022;72(5):567-573. doi:10.1016/j.bjane.2021.07.007

39.

Yang

MMH

Hartley

Leung

, et al. Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ Open. 2019;9(4):e025091. doi:10.1136/bmjopen-2018-025091