Considerations for the practicing surgeon: Substance use and abuse in the elective surgery patient

The Patient Education Program, Division of Education is sponsoring two panel sessions at the virtual Clinical Congress 2020 that will inform and update surgeons on the current issues, guidelines, and legislation surrounding the use and abuse of smoking and vaping tobacco and marijuana in elective surgery patients.

These sessions will support the College’s long-standing position on smoking cessation initiated by the Surgeon General in 1964 and reinforced with the ACS Position Statement, “Statement on the Effects of Tobacco Use on Surgical Complications and the Utility of Smoking Cessation Counseling” (2014) and the introduction of smoking cessation tools and resources for patients and professionals.

  • CC2020-390: The Impact of Marijuana Use in the Surgical Patient: Monday, October 5, 4:00 pm–4:55pm CDT—Knowledge on the medicinal and recreational use of marijuana has become increasingly important to all health care providers, as its use increases across the United States. This is especially true for surgeons with patients who admit to frequent use before surgery or whose patients request marijuana for pain control. This session will review the evidence and provide scientific guidance and precautions for surgery on the current, regular marijuana user, discuss marijuana’s interactions with other medications, and review the benefits and evidence for its use with surgical cancer patients.
  • CC2020-395: When and How to Quit Cigarettes, Vaping and Marijuana Use Prior to Surgery: Tuesday, October 6, 12:00 noon–12:55pm CDT—This panel session will review the importance of smoking cessation counseling during all non-emergent patient consults, and highlights the evidence-based education programs and resources the College has in place to reduce smoking-related surgical complications and smoking prevalence in general including Strong for Surgery and the Patient Education “Quit Smoking” resources. Controversy exists as to when and how perioperative smoking cessation should be instituted. New findings on the negative impact on surgical outcomes with tobacco use, vaping, and marijuana use as well as the need for increased use of anesthesia and post-operative pain medication in these patients will be discussed.

Smoking tobacco remains a deadly and prevalent addiction among adults, and the impact of smoking on surgical patients can be considerable. Approximately 30 percent of all patients undergoing elective general surgery procedures smoke, meaning an estimated 10 million operations are performed on smokers annually, according to “Operating on Patients who Smoke: A Survey of Thoracic Surgeons in the United States,” published in The Annals of Thoracic Surgery (2016). Smoking correlates with a 40 percent higher prevalence of postoperative complications and is an independent risk factor for infections and cardiovascular events after an operation. These complications are seen throughout the surgical specialties as well as deleterious effects on wound healing thought to be related to the nicotine content of conventional tobacco products and tobacco substitutes containing nicotine.

At least 33 U.S. states have legalized medical marijuana and 11 have also legalized it for recreational use. Thus, patients are potentially exposed to and/or using this drug more. Patients should acknowledge its use during the medication review when asked about alcohol and tobacco use.

Research on the impact of marijuana on patient health is just beginning to be rigorously studied and reviewed. Smoking marijuana is similar to smoking cigarettes and damages the lungs, as smoking marijuana releases some of the same harmful chemicals as tobacco smoke. Furthermore, because marijuana cigarettes are unfiltered, patients can be exposed to more tar than in a traditional tobacco cigarette. Additionally, when smoking marijuana, users tend to take deeper breaths and hold their breath for longer times, thus increasing the amount of tar and other chemicals deposited in the airway. Smoking marijuana can also result in wheezing, chronic bronchitis, and coughs.

Research has shown that patients who self-report regular marijuana use need higher doses of fentanyl, midazolam, and propofol for endoscopic procedures, as published in “Effects of cannabis use on sedation requirements for endoscopic procedures” in The Journal of the American Osteopathic Association (2019). Patients who reported chronic  marijuana use  demonstrated a need for more opioid analgesia as inpatients while recovering from the trauma associated with motor vehicle accidents, according to “The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury,” published in Patient Safety in Surgery (2018). Many patients with chronic pain have also turned to marijuana and its components (THC and CBD) for pain relief. Evidence-based data for marijuana’s effects on acute pain, specifically postoperative pain, are sparse.

Resources for Patients and Medical Professionals related to smoking and cessation

ACS Patient Education

ACS Patient Education for Medical Professionals

Strong for Surgery