In Reply We thank Ladha et al and Davidson et al for their Letters to the Editor regarding our Review article on perioperative cannabis¹ and for bringing some additional published research to the forefront. This includes a recent retrospective study demonstrating the association of cannabis use disorder with perioperative myocardial infarction.² It should be noted that regular cannabis use is not synonymous with cannabis use disorder and that 42% of these patients were also tobacco smokers,² potentially confounding examination of perioperative cardiac events. However, we agree that given the known association of cannabis use with tachycardia, caution should be used in patients with a predisposition to cardiac disorders. Such warnings exist in the package inserts for dronabinol and nabilone. Ladha et al and Davidson et al also cite a retrospective study from a center that used dronabinol off label for pain control primarily in patients with prehospitalization cannabis use.³ The authors of this study found a decrease in opioid use in the first 48 hours after initiation of treatment, which is encouraging, but did not find a difference in overall opioid use or pain scores. In our Review article, we attempted to focus on level 1 data when available and agree that more data are needed to render final conclusions regarding efficacy of cannabis as an analgesic. Ladha et al and Davidson et al also raised concerns regarding our recommendation to hold cannabis use 10 days prior to surgery. This recommendation was made based on our current poor understanding of its perioperative effects and the known half-lives of cannabidiol and delta-9-tetrahydrocannabinol (THC) analogues to enable significant clearance from the patient. We recognize that cannabis withdrawal syndrome is a described entity characterizing the psychiatric adverse events experienced by approximately 12% of long-term frequent cannabis users after abrupt reduction or cessation of use.⁴ These effects primarily consist of nervousness/anxiety, sleep difficulty, and depressed mood.⁴ We were unable to find data regarding how withdrawal from cannabis might affect perioperative outcomes, but we agree that support should be offered if cannabis withdrawal syndrome is a clinical concern. We acknowledge that others may have different practice patterns but noted that in the panel of experts assembled for the referenced consensus,⁵ only 1 author was a surgeon. We would be happy to participate in future consensus panels to increase surgeon participation.

作为回复，我们感谢 Ladha 等人和 Davidson 等人就我们关于围手术期大麻^{1 的}评论文章致编辑的信，并将一些额外的已发表研究带到了最前沿。这包括最近的一项回顾性研究，证明大麻使用障碍与围手术期心肌梗死之间存在关联。²应该指出的是，经常使用大麻并不是大麻使用障碍的同义词，这些患者中有 42% 也是吸烟者，²围手术期心脏事件的潜在混淆检查。然而，我们同意，鉴于大麻使用与心动过速的已知关联，应谨慎对待有心脏病倾向的患者。屈大麻酚和萘比隆的包装说明书中存在此类警告。Ladha 等人和 Davidson 等人还引用了一个中心的回顾性研究，该研究主要在住院前使用大麻的患者中使用非标签屈大麻酚来控制疼痛。³这项研究的作者发现，在开始治疗后的前 48 小时内，阿片类药物的使用有所减少，这是令人鼓舞的，但并未发现总体阿片类药物的使用或疼痛评分存在差异。在我们的评论文章中，我们试图在可用的情况下关注 1 级数据，并同意需要更多数据来得出关于大麻作为镇痛剂功效的最终结论。Ladha 等人和 Davidson 等人也对我们建议在手术前 10 天停止使用大麻提出了担忧。该建议是基于我们目前对其围手术期影响以及大麻二酚和 delta-9-四氢大麻酚 (THC) 类似物的已知半衰期缺乏了解，以使患者能够显着清除。⁴这些影响主要包括紧张/焦虑、睡眠困难和情绪低落。⁴我们无法找到有关大麻戒断如何影响围手术期结果的数据，但我们同意，如果大麻戒断综合征是一个临床问题，应提供支持。我们承认其他人可能有不同的实践模式，但注意到在为参考共识而聚集的专家小组中，⁵只有 1 位作者是外科医生。我们很乐意参与未来的共识小组，以增加外科医生的参与。