ACE 21A Sample Question

A patient with a long history of heavy cannabis use begins to show symptoms of cannabis withdrawal on postoperative day 1. Approximately how long are these symptoms MOST likely to continue?

A. 3 days X

B. 7 days X

C. 14 days ✔

Read the discussion below.

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Discussion

Cannabis is one of the most commonly used psychoactive agents. Its properties are primarily attributed to delta-9-tetrahydrocannabinol (THC). The concentration of THC is often correlated to the potency of the cannabis. While the legal status of cannabis remains complicated in the United States, legalization and decriminalization at the state level are leading to increased use. With chronic use, concerns regarding addiction, correlated psychiatric disorders, and cannabis hyperemesis syndrome are ever present. Perioperatively, cessation of cannabis—particularly in heavy, chronic users—poses a risk of cannabis withdrawal syndrome.

Data come primarily from observational studies. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) lists various signs and symptoms as part of the diagnostic criteria for cannabis withdrawal. These include irritability, anxiety, difficulty with sleep, reduced appetite, depressed mood, tremors, sweating, fever, chills, and headache. Many of these symptoms overlap with withdrawal symptoms from other drugs with sedative properties, including opioids and benzodiazepines. Prospective studies show that cannabis withdrawal can present within 1 day of cessation, peaks within the first week, and begins to subside by 2 weeks. Specific symptoms of withdrawal, particularly sleep disturbances, have been noted to last for weeks. Several tools are available to assess the severity of withdrawal, including the Marijuana Withdrawal Checklist.

No medications are specifically approved for the management of cannabis withdrawal. However, studies have demonstrated the utility of synthetic cannabinoids (eg, dronabinol, nabiximols) along with agents such as gabapentin. Individuals with a history of heavier and more prolonged cannabis use are at higher risk of withdrawal and should be monitored postoperatively.

REFERENCES

1. Gropper MA, Cohen NH, Eriksson LI, Fleisher LA, Leslie K, Wiener-Kronish JP, eds. Miller’s Anesthesia. 9th ed. Elsevier; 2020:982-983.
2. Connor JP, Stjepanović D, Budney AJ, Le Foll B, Hall WD. Clinical management of cannabis withdrawal. Addiction. 2022;117(7):2075-2095. doi:10.1111/add.15743
3. Budney AJ, Moore BA, Vandrey RG, Hughes JR. The time course and significance of cannabis withdrawal. J Abnorm Psychol. 2003;112(3):393-402. doi:10.1037/0021-843x.112.3.393
4. Shah S, Schwenk ES, Sondekoppam RV, et al. ASRA pain medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med. 2023;48(3):97-117. doi:10.1136/rapm-2022-104013
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association Publishing; 2013:517-519.

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