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Unknown Effect of Cannabis Use on Procedural Sedation Requirements

  • Jonathan Schimmel and Kennon Heard
Published/Copyright: January 1, 2020
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Journal of Osteopathic Medicine
From the journal Journal of Osteopathic Medicine Volume 120 Issue 1

To the Editor:

We read with great interest the recent report by Twardowski et al1 regarding the impact of regular cannabis use on procedural sedation requirements. This area remains poorly studied, and we applaud the authors for investigating this timely and germane issue. However, owing to methodologic flaws, we believe that the interpretation and clinical utility of the study are extremely limited. The primary shortcomings relate to sedative administration and confounding variables. Furthermore, the abstraction process was not described with regard to a standardized abstraction tool, blinded trained abstractors, and interrater reliability. Unstructured data abstraction is more likely to identify outcome differences.

Data were included for 3 sedatives (fentanyl, midazolam, and propofol), but information is absent on additional drugs an endoscopist may use, such as lorazepam, diazepam, or diphenhydramine. Administration of nonabstracted sedatives would reduce the required doses of the 3 included sedatives. Additionally, it is unknown whether every patient (N=250) received all 3 sedatives. Data were described as nonnormal with absent measures of dispersion, and if select sedatives were received by only a portion of the cohort, this factor may have introduced error.

The study failed to account for at least 4 confounding variables. The first is regular recent alcohol, sedative, or opioid use (listed in data collection but not reported on). Alcohol use is more common among cannabis users, which may increase sedative requirements.2 The second is body weight, which is important because of volumes of distribution. Studies vary on optimal body weight indices, such as ideal body weight or lean body mass, but dose requirements would be affected if the 2 groups had differing body weights. Future studies should report dosing by a body mass index.3 The third is age, a variable that is related to cannabis use and sedation requirements, with younger patients more likely to be regular cannabis users and elderly patients likely to require less sedation.4 Age was not reported, and groups were not matched by age if applicable. Last, scant endoscopy details are provided. If a patient required polypectomies, this factor would increase procedure duration and likely sedative dosing. Similarly, combination esophagogastroduodenoscopy and colonoscopy increases procedure duration and likely sedative dosing. In fact, the combined procedure occurred in 4 of 25 regular cannabis users (16%) and 18 of 225 nonusers (8%). This significant difference alone may account for the increased sedative requirements in the regular cannabis user group.

Cannabis may affect pharmacokinetic or pharmacodynamic tolerance to procedural sedatives. The limitations in this study preclude additional insight into the study question.

Department of Emergency Medicine, Division of Medical Toxicology, Icahn School of Medicine at Mount Sinai, New York, New York
University of Colorado Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado
Rocky Mountain Poison and Drug Center, Denver, Colorado

References

1. TwardowskiMA, LinkMM, TwardowskiNM. Effects of cannabis use on sedation requirements for endoscopic procedures. J Am Osteopath Assoc. 2019;119(5):307. doi:10.7556/jaoa.2019.052.Search in Google Scholar PubMed

2. YurasekAM, AstonER, MetrikJ. Co-use of alcohol and cannabis: a review. Curr Addiction Rep. 2017;4(2):184-193. doi:10.1007/s40429-017-0149-8Search in Google Scholar PubMed PubMed Central

3. LangLH, ParekhK, TsuiBYK, MazeM. Perioperative management of the obese surgical patient. Br Med Bull. 2017;124(1):135-155. doi:10.1093/bmb/ldx041Search in Google Scholar PubMed PubMed Central

4. PatanwalaAE, ChristichAC, JasiakKD, et al.. Age-related differences in propofol dosing for procedural sedation in the emergency department. J Emerg Med. 2013;44(4):823-828. doi:10.1016/j.jemermed.2012.07.090Search in Google Scholar PubMed

Published Online: 2020-01-01
Published in Print: 2020-01-01

© 2020 American Osteopathic Association

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  5. LETTERS TO THE EDITOR
  6. Unknown Effect of Cannabis Use on Procedural Sedation Requirements
  7. CORRECTION
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  9. ORIGINAL CONTRIBUTION
  10. Burnout, Perceived Stress, Sleep Quality, and Smartphone Use: A Survey of Osteopathic Medical Students
  11. CLINICAL REVIEW
  12. Food Sensitivity Testing and Elimination Diets in the Management of Irritable Bowel Syndrome
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  15. REVIEWS IN MUSCULOSKELETAL MEDICINE
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https://doi.org/10.7556/jaoa.2020.002

Articles in the same Issue

  1. LETTERS TO THE EDITOR
  2. Lateral Strain Patterns at the Sphenobasilar Synchondrosis
  3. OMT MINUTE
  4. High-Velocity, Low-Amplitude Management of Posterior Rib Somatic Dysfunction
  5. LETTERS TO THE EDITOR
  6. Unknown Effect of Cannabis Use on Procedural Sedation Requirements
  7. CORRECTION
  8. Correction
  9. ORIGINAL CONTRIBUTION
  10. Burnout, Perceived Stress, Sleep Quality, and Smartphone Use: A Survey of Osteopathic Medical Students
  11. CLINICAL REVIEW
  12. Food Sensitivity Testing and Elimination Diets in the Management of Irritable Bowel Syndrome
  13. CLINICAL PRACTICE
  14. Taxonomy of the Lateral Strain Patterns at the Sphenobasilar Synchondrosis for Osteopathic Cranial Manipulative Medicine
  15. REVIEWS IN MUSCULOSKELETAL MEDICINE
  16. The Many Facets of Hypermobile Ehlers-Danlos Syndrome
  17. SPECIAL COMMUNICATION
  18. 2019 United States Osteopathic Medical Regulatory Summit: Consensus, Recommendations, and Next Steps in Defining Osteopathic Distinctiveness
  19. CASE REPORT
  20. Topical Imiquimod and Subsequent Erythema Multiforme
  21. CLINICAL IMAGES
  22. Reexpansion Pulmonary Edema
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