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| Title |
Chronic Use of Tetrahydrocannabinol (THC) May Require Increased Doses of Benzodiazepines and Opioids to Achieve Moderate Sedation Levels |
| Clinical Question |
In human patients receiving surgical procedures with sedation (P), do people who use cannabis [THC+] (I) require more opioid and benzodiazepine to achieve moderate sedation level (O) than patients who do not use THC [THC-] (C)? |
| Clinical Bottom Line |
Patients who chronically use THC may require more opioid and benzodiazepine medication to achieve moderate sedation levels compared to those who do not use THC. This is supported by several retrospective cohort studies in which patients that used THC required significantly more benzodiazepine and opioids to reach a moderate sedation. However, some studies showed there to be no significant difference and a conclusion could not be reached. The difference appears dependent on the specific type of benzodiazepine/ opioid being used. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 36746375 | Gangwani/2023 | OMS patients at Temple School of Dentistry (n=53) | Retrospective Cohort Study | | Key results | The THC + group had a significant dose increase of fentanyl and propofol (p=0.02 and p=0.03 respectively) but not ketamine or midazolam. Interestingly, when the study was adjusted for age, gender, and weight, there was no significant difference in dosage between groups when using fentanyl, propofol, ketamine, or midazolam. | | #2) 30985870 | Twardowski/ 2019 | Patients having endoscopic procedures (n=250) | Retrospective Cohort Study | | Key results | Compared with people who did not regularly use cannabis, people who regularly used cannabis required an amount of sedation for endoscopic procedures that was significantly higher (P=.05). The statistical significance persisted when adjusted for age, sex, and use of alcohol, benzodiazepines, and opiates. | | #3) 39087994 | Smith/2024 | Patients having endoscopic procedures (n=1,018) | Retrospective Cohort Study | | Key results | In this study, Smith found that patients who were THC+ used significantly higher doses of propofol (p <0.01) but no significant difference in fentanyl or midazolam doses. This article is important because they quantified sedation levels by use of the Aldrete scoring system. | | #4) 36746375 | Ripperger/2023 | OMFS patients (n=189) | Retrospective Cohort Study | | Key results | THC+ patients received significantly more propofol (p=0.004), midazolam (p=0.01), ketamine (p=0.01), and fentanyl (p=0.002). | |
| Evidence Search |
(THC) AND (IV sedation) Filters: Full text
(Cannabis) AND (sedation procedure)
|
Comments on
The Evidence |
Gangwani did a retrospective cohort study with the exposure to THC measured in a valid and reliable way. Recent history of THC use was evaluated with a urine toxicology report. Patients were also excluded if they tested positive for any other substance. The results were further analyzed by adjusting for covariates such as age, gender and weight. The study, however, did have limitations. The sample size was only 53 patients due to the stringent inclusion criteria for a retrospective study. As such, the power may be inadequate to completely reveal statistical significance. The study was done on a younger population, and results may not be applicable to the entire population at large.
Twardowski did a retrospective cohort study where the patient's medical record was reviewed by a single provider. The data about cannabis use was collected by registered nurses during the admission assessment under the query of illicit drug use. Patients who had sporadic or topical cannabis use were included in the non-user group. This may influence the result and skew the data. Statistical analysis was performed by using the t-test and Mann- Whitney U test.
Smith completed a retrospective cohort study that seems to be searching for statistical significance, as they briefly state in their data analysis that they used Mann-Whitney U tests to explore differences in outcome variables. There was no randomization in this study design because the exposure was THC+ patients. This evidence, however, may be strengthened by their study size of 1,018 participants.
Ripperger noted that THC+ and THC- users age was not significantly different. There was no randomization in this study design because they studied the exposure of THC+ patients. Age is a large factor in moderate sedation where older pts. usually require less sedation. We think it is important that this was analyzed as well.
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| Applicability |
There is no research in any periodontics literature suggesting that THC users require increased doses of opioids or benzodiazepines. The Gangwani study is important because oral surgery clinics perform dental procedures of similar length. However, oral surgery clinics typically use drugs like propofol that are also used in general anesthesia. Twardowski disagrees with Gangwani and Smith with contradicting results on increasing doses for moderate sedation medications. Performing moderate sedation is often considered a standard of care in periodontal procedures for patient comfort and anxiety due to the invasiveness and length of dental procedures. With the evidence provided, readers should understand that some studies included general anesthesia, deep sedation, and endoscopic procedures. These variables likely have an effect on the outcome that is unmeasurable. Because there is no consensus on the findings, more research should be completed to help aid clinicians on maintaining the safe boundaries of moderate sedation levels, especially when considering THC users. |
| Specialty/Discipline |
(Periodontics) |
| Keywords |
periodontal surgery, THC, moderate sedation
|
| ID# |
3571 |
| Date of submission: |
10/22/2024 |
| E-mail |
mcquillan@uthscsa.edu |
| Author |
Dan McQuillan |
| Co-author(s) |
John Corbett |
| Co-author(s) e-mail |
corbettj@uthscsa.edu |
| Faculty mentor/Co-author |
Charles Anthony Powell |
| Faculty mentor/Co-author e-mail |
powellc2@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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