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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Ann Surg. 2023 Aug 28;279(3):437–442. doi: 10.1097/SLA.0000000000006085

The Association of Cannabis Use After Discharge from Surgery with Opioid Consumption and Patient-Reported Outcomes

Mark C Bicket 1,2, Karim S Ladha 3, Kevin F Boehnke 1, Yenling Lai 2,4, Vidhya Gunaseelan 1,2, Jennifer F Waljee 2,4, Michael Englesbe 2,4, Chad M Brummett 1,2
PMCID: PMC10840622  NIHMSID: NIHMS1923800  PMID: 37638417

Abstract

Objective:

Compare outcomes of patients using vs. not using cannabis as a treatment for pain after discharge from surgery.

Summary Background Data:

Cannabis is increasingly available and is often taken by patients to relieve pain. However, it is unclear whether cannabis use for pain after surgery impacts opioid consumption and postoperative outcomes.

Methods:

Using Michigan Surgical Quality Collaborative registry data at 69 hospitals, we analyzed a cohort of patients undergoing sixteen procedure types between January 1, 2021, and October 31, 2021. The key exposure was cannabis use for pain after surgery. Outcomes included post-discharge opioid consumption (primary) and patient-reported outcomes of pain, satisfaction, quality of life and regret to undergo surgery (secondary).

Results:

Of 11,314 included patients (58% female, mean age 55.1 years), 581 (5.1%) reported using cannabis to treat pain after surgery. In adjusted models, patients who used cannabis consumed an additional 1.0 (95% CI 0.4 to 1.5) opioid pills after surgery. Patients who used cannabis were more likely to report moderate-to-severe surgical site pain at 1 week (aOR 1.7, 95% CI 1.4 to 2.1) and 1 month (aOR 2.1, 95% CI 1.7 to 2.7) after surgery. Patients who used cannabis were less likely to endorse high satisfaction (72.1% vs. 82.6%), best quality of life (46.7% vs. 63.0%), and no regret (87.6% vs. 92.7%) (all P<0.001).

Conclusions:

Patient-reported cannabis use to treat postoperative pain was associated with increased opioid consumption after discharge from surgery that was of clinically insignificant amounts, but worse pain and other postoperative patient-reported outcomes.

INTRODUCTION

Cannabis is one of the most commonly used substances, with monthly use reported by 13% of the US population in 2021.1 Medical use of cannabis has increased from 680,000 patients in 2016 to 2.9 million patients in 2020, and most patients now live in a US region that permits the use of medical cannabis for pain.2,3 Also, the prevalence of recreational use continues to rise as it becomes legal in nearly half of states.4 The analgesic potential of cannabis, which stems from active compounds such as delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) has raised questions about whether it may offset reliance of opioid prescriptions as a treatment for pain management, including acute pain after surgery.

Despite substantial policy changes, cannabis use in the postoperative setting remains controversial as evidence supporting cannabis use for acute pain is lacking.5 Some have proposed that cannabis may complement or help reduce reliance on existing analgesic medications after surgery.6 This aligns with patient reports that cannabis may be used as a substitute for prescription opioids or other analgesics for pain.7–9 However, others have expressed concerns about risks from cannabis such as cannabis use disorder and other harms such as surgical revision, nausea and vomiting, dizziness, and cognitive impairment.10,11 Therefore, the ability of cannabis to lower reliance on opioids or to improve outcomes for surgical patients recovering at home remains uncertain.12,13 Although a previous study evaluated cannabis use on opioids at two trauma centers, the analysis examined recreational use and included many patients who did not undergo surgery, and it is unclear if these findings would apply on a broader scale to the surgical community.14

Despite increasing use of cannabis over the past two decades, there remains a paucity of evidence on whether cannabis can reduce opioid use after surgery or improve post-surgical recovery.15 To address these gaps, we compared opioid consumption and patient outcomes in a longitudinal cohort of patients who reported using cannabis for pain after surgery with patients who did not report using cannabis using statewide risk-adjusted patient-reported outcomes data from 69 hospitals. Given reports that some patients perceive cannabis as a substitute for opioid use in the treatment of pain, we hypothesized that patients who reported using cannabis for pain after surgery would have lower opioid consumption in the 30 days after surgery (primary outcome) and similar rates of pain control, satisfaction, and quality of life when compared to patients who did not use cannabis for pain after surgery. A better understanding of opioid consumption, pain, and other patient outcomes when patients use cannabis after surgery has the potential to shape conversations between surgeons and patients about the proper role of cannabis in the context of multimodal pain management and optimizing post-discharge recovery.

METHODS

The University of Michigan Institutional Review Board deemed this study exempt from regulation given secondary analysis of de-identified data. Reporting followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Data Source and Study Cohort

The Michigan Surgical Quality Collaborative (MSQC) clinical registry served as the data source for this analysis. Sixty nine hospitals serving diverse communities across the state collaborate through this patient safety organization and robust quality improvement program.16,17 As previously described, data in the MSQC registry originates from the medical record of the charts, which is abstracted by trained nurses following a standard process, and from patient surveys on 30-day outcomes after surgery.18–20 Representation of the patient sample and minimization of selection bias result from a sampling algorithm that identifies cases for review.21 The sampling strategy captures cases performed at all hospitals where the included major surgical procedures in the state occur. A stratified sampling method ensures the number of cases selected from each procedure group is proportional to both the size and the previously calculated variance of morbidity for that procedure group. All hospitals contribute to data extracted from the electronic health record as well as patient-reported outcomes.

The analytic cohort included adult patients 18 years and older who underwent surgery at an MSQC-affiliated hospital during a 10-month period between January 1, 2021, and October 31, 2021. The State of Michigan legalized adult-use cannabis in November 2018, and medical cannabis was legalized in November 2008. Surgical procedures included common general and other procedures (Supplemental Digital Content 1 eTable 1). Patients were excluded if they had reoperation within 30 days after surgery, were not discharged home, or had length of stay >30 days. Patients with readmissions, complications, emergency room visits, who died within 30 days of surgery, and with missing covariate (with the exception of “Unknown” race and missing preoperative opioid use) or consumption data were also excluded (Supplemental Digital Content 1 eFigure 1).

Explanatory Variables

The key explanatory variable was use of cannabis to treat pain after surgery (yes/no), which was ascertained from the MSQC 30-day postoperative survey. The question asked “What things have you done to control your pain after surgery?” Patients could select any number of nine response options, with “CBD / marijuana” representing cannabis use. The full set of responses is presented in Supplemental Digital Content 1 eMethods.

Other covariates included demographics, patient comorbidities, and procedural characteristics. Demographic information included age in years, sex, race/ethnicity, and insurance type. Patient comorbidities included American Society of Anesthesiologists physical status classification (1, 2, 3, or 4/5), body mass index categories (underweight, normal, overweight, obese), and indicator variables (yes/no) for diagnoses of cancer, tobacco use, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and sleep apnea, given their prior association with opioid consumption and patient-reported outcomes.22–24 Preoperative opioid use in the year prior to surgery as reported by the patient and opioids prescribed on discharge as abstracted from the medical record were also included, given their association with opioid consumption and patient-reported outcomes.23,24 Prescription fills in the medical record appear to correlate well with prescription drug monitor program (Simha S, Waljee JF, Lai YL, et al. How Well Do Patients Report Opioid Use After Surgery? A Study of the Accuracy of Patient Reported Opioid Use to Verified Prescription Fills After Surgery. 2023 American Academy of Pain Medicine meeting abstract). Procedural characteristics included surgical priority (elective vs. urgent/emergent), length of hospital stay (0, 1, 2, or 3+ days), and procedure type.

Outcomes

The primary outcome was consumption of opioid pills in the 30 days after discharge from surgery. Consumption was evaluated only in patients with an opioid prescription at discharge (Supplemental Digital Content 1 eTable 2). Pills were measured in oxycodone 5 mg equivalents after converting all opioid types using standard equivalence conversions from the Centers for Disease Control opioid data file.22 Secondary outcomes were patient-reported outcomes of postoperative surgical site pain during the first week of surgery, postoperative surgical site pain at one month after surgery, satisfaction with care, quality of life, and regret of the decision to undergo surgery. Given skew of responses, scores for secondary outcomes were dichotomized using methods described previously and in line with national patient surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).23,24 Pain at 1 week and 1 month after surgery were both measured on a 0 (no pain) to 10 (worst imaginable) scale and dichotomized into “moderate-to-severe pain” for scores of 4 to 10. Satisfaction was measured on a 0 (extremely dissatisfied) to 10 (extremely satisfied) scale and dichotomized into “high satisfaction” for scores of 9 or 10. Quality of life was measured on a 1 (worst possible) to 5 (best possible) scale and dichotomized into “high quality of life” for a score of 5. Regret of the decision to undergo surgery was measured on a 1 (strongly regret) to 5 (absolutely no regret) scale and dichotomized into “no regret” for a score of 5. The secondary outcomes were assessed only in patients who had valid data for the specific outcome.

Statistical analysis

A data analysis and statistical plan was written, date-stamped, and recorded in the investigators’ files before data were accessed. We calculated descriptive statistics for the analytic sample based on use of cannabis to treat pain after surgery, with chi-squared tests or t-tests for univariate differences. To address clustering within hospitals, multilevel logistic regression models with hospital as a random intercept were used to examine differences in patient-reported outcomes. For opioid consumption, a two-part model was used with a binary choice model for probability of any consumption versus no consumption and then, conditional on any consumption, a linear regression model was used for consumption size. Predicted probabilities were calculated using post-estimation commands. We also calculated the proportion of cannabis use by type of procedure. Analyses were performed using Stata version 15. The twopm package was used for the two-part model. Two-tailed P values with significance set at 0.05 were used.

RESULTS

A total of 11,314 patients met inclusion criteria, of whom 581 (5.1%) reported cannabis use as a treatment for postoperative pain. Compared to those without use, patients using cannabis for pain after surgery were more likely to be younger, white, and insured by Medicaid (Supplemental Digital Content 1 eTable 3). Patients with cannabis use also were more likely to smoke tobacco (31.3% vs. 14.1%). Prescription opioid use in the year before surgery was more common among patients using cannabis (21.9%) compared to those with no use (16.9%).

Regarding procedural characteristics, most operations were conducted on an elective basis and with a hospital length of stay of 0 days whether or not patients reported using cannabis. The distribution of the types of surgical procedures between the two groups did not differ, with approximately half of patients in both groups undergoing either minor hernia repair or laparoscopic cholecystectomy.

Primary Outcome of Opioid Consumption after Surgery

Overall, 6,392 (68.2%) patients consumed at least one opioid pill after discharge from surgery, with consumption reported by 401 (79.7%) of patients using cannabis and 5,991 (67.5%) of patients not using cannabis. After adjusting for patient, procedural, and clinical characteristics, the predicted mean number of opioid pills consumed by patients with cannabis use was 5.0 (95% CI 4.4 to 5.5) versus 4.0 (95% CI 3.8 to 4.1) pills consumed by patients without cannabis use. The overall difference in pills consumed was statistically significant and small, with cannabis use associated with an increase of 1.0 pills (95% CI, 0.4 to 1.5 pills) consumed (Figure 1, Supplemental Digital Content 1 eTable 4).

Figure 1.

Figure 1.

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Opioid consumption after discharge from surgery based on postoperative cannabis use for pain among adult surgical patients in the Michigan Surgical Quality Collaborative in January-October 2022

Measures were from 30-day surveys administered after discharge from surgery through the Michigan Surgical Quality Collaborative from January 1, 2021, to October 31, 2021 among those responding to the question “What things have you done to control your pain after surgery?” Postoperative cannabis use was determined based on the response of “CBD / marijuana”. Opioid consumption was measured in oxycodone 5 mg equivalents, which is the same as oral morphine 7.5 mg. Bars signify the opioid consumption in pills based on cannabis use for pain after surgery in unadjusted (gray) and adjusted (black) models. Adjusted models incorporated age, gender, race/ethnicity, insurance, American Society of Anesthesiologists classification, body mass index, six comorbidities, surgical priority, length of stay, procedure type, prescription opioid use in the year before surgery, amount of prescription of opioids at discharge, and hospital correlation.

Secondary Outcomes

In adjusted models, cannabis use for pain after surgery was associated with a greater predicted probability of reporting moderate-to-severe pain at both 1 week after surgical discharge (68.2%, 95% CI 64.0% to 72.5% vs. 57.3%, 95% CI 55.1% to 59.5%) and at 1 month after surgical discharge (16.5%, 95% CI 13.1% to 19.9% vs. 9.0%, 95% CI 7.7% to 10.3%) (Figure 2). Compared to those not using cannabis, a lower proportion of patients who used cannabis for pain after surgery reported high satisfaction (72.1%, 95% CI 67.8% to 76.3% vs. 82.6%, 80.8% to 84.4%), best quality of life (46.7%, 95% CI 41.9% to 51.5% vs. 63.0%, 95% CI 60.3% to 65.7%), and no regret of undergoing surgery (87.6%, 95% CI 84.6% to 90.6% vs. 92.7%, 95% CI 91.7% to 93.8%) (Figure 3). Multivariable models for secondary outcomes are presented in supplemental Supplemental Digital Content 1 eTables 5–9. Cannabis use for pain after surgery ranged from 1.7% for patients undergoing open appendectomy to 7.2% for open colectomy (Figure 4).

Figure 2.

Figure 2.

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Patient-reported pain outcomes after discharge from surgery based on postoperative cannabis use for pain among adult surgical patients in the Michigan Surgical Quality Collaborative in January-October 2022

Measures were from 30-day surveys administered after discharge from surgery through the Michigan Surgical Quality Collaborative from January 1, 2021, to October 31, 2021 among those responding to the question “What things have you done to control your pain after surgery?” Postoperative cannabis use was determined based on the response of “CBD / marijuana” Outcomes reported by patients included high pain (rating 4 to 10 on a 0 to 10 point numeric rating scale) at the site of surgery in the first week and in the first month after discharge from surgery; high satisfaction at 30 days; best quality of life at 30 days; and no regret for undergoing surgery at 30 days. Bars signify the adjusted proportion reporting an outcome based on cannabis use for pain after surgery (black) or no cannabis use (gray). Adjusted models for outcomes incorporated age, gender, race/ethnicity, insurance, American Society of Anesthesiologists classification, body mass index, six comorbidities, surgical priority, length of stay, procedure type, prescription opioid use in the year before surgery, amount of prescription of opioids at discharge, and hospital correlation.

Figure 3.

Figure 3.

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Satisfaction, quality of life, and regret after discharge from surgery based on postoperative cannabis use for pain among adult surgical patients in the Michigan Surgical Quality Collaborative in January-October 2022

Measures were from 30-day surveys administered after discharge from surgery through the Michigan Surgical Quality Collaborative from January 1, 2021, to October 31, 2021 among those responding to the question “What things have you done to control your pain after surgery?” Postoperative cannabis use was determined based on the response of “CBD / marijuana” Outcomes reported by patients included high satisfaction at 30 days; best quality of life at 30 days; and no regret for undergoing surgery at 30 days. Bars signify the adjusted proportion reporting an outcome based on cannabis use for pain after surgery (black) or no cannabis use (gray). Adjusted models for outcomes incorporated age, gender, race/ethnicity, insurance, American Society of Anesthesiologists classification, body mass index, six comorbidities, surgical priority, length of stay, procedure type, prescription opioid use in the year before surgery, amount of prescription of opioids at discharge, and hospital correlation.

Figure 4.

Figure 4.

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Postoperative cannabis use for pain by type of procedure in the Michigan Surgical Quality Collaborative

Measures were from 30-day surveys administered after discharge from surgery through the Michigan Surgical Quality Collaborative from January 1, 2021, to October 31, 2021 among those responding to the question “What things have you done to control your pain after surgery?” (N=11,314) who indicated use of cannabis for pain after discharge as determined by selection of the response of “CBD / marijuana” (N=581). Bars signify the proportion of all patients reporting cannabis use for pain after surgery stratified by type of procedure.

DISCUSSION

In this large observational study of postoperative outcomes, 5.1% of patients undergoing common surgical procedures reported using cannabis as a treatment for acute pain after surgery. After adjusting for demographic, patient, and procedural characteristics, cannabis use was associated with a slightly higher amount of opioid following surgery (1 additional pill), but unlikely to represent a clinically meaningful difference. However, patients who reported using cannabis for pain after surgery were more likely to report moderate-to-severe pain at both 1 week and 1 month after discharge from surgery after adjusting for other patient- and clinical covariates. Further, patients using cannabis reported lower satisfaction and quality of life, as well as higher regret of undergoing surgery. This suggests that patients using cannabis for pain after surgery do not consume fewer prescription opioids, but do experience worse short-term outcomes, when compared to patients who do not use cannabis for pain after surgery. Based on these findings, the use of cannabis as a treatment for pain after surgical discharge remains of concern and may be correlated with poorer patient-reported outcomes alongside other cannabis-related risks (e.g., use disorder, side effects).

This analysis directly informs recent guidelines on the perioperative use of cannabis, which have reported limited evidence on the relationship between cannabis, opioids, and pain in the postoperative period.5,15 The finding of increased post-discharge pain and clinically insignificant differences in the number of opioid pills consumed among surgical patients using cannabis as a treatment for pain aligns with studies of smaller cohorts examining postoperative outcomes in the hospital. For example, Liu et al. retrospectively compared 155 patients with preoperative cannabis use to similar non-users matched by propensity scores, noting no difference in opioid use but increased pain scores within the first 36 hours after joint or spine surgery.25 Other studies indicate similar results for surgical patients in the hospital after surgery before discharge, with higher pain scores and similar opioid use based on whether or not patients had preoperative cannabis use.26,27 Also, clinical trials on cannabinoids for acute pain management using THC or THC-analogs for short time windows have not shown promising effects.28 Patients may turn to cannabis because other treatments are not working and after exhausting other conventional medical therapies, so in some patients cannabis may be a signifier of a more intractable pain phenotype. While a subset of patients may avoid prescription medications and try cannabis first, many people likely turn to cannabis as an act of last resort, which is an area that calls for more detailed investigations to understand when how, if at all, it may be used appropriately. Taken together, these investigations suggest that cannabis should not be routinely added as an adjunct to the post-discharge pain management plan. Further, surgeons should counsel patients planning to use cannabis for the treatment of acute pain about a possible link between its use and worse outcomes for pain and other measures after surgery.

The dynamic changes in the availability of cannabis in the United States highlight the importance of characterizing the products available and used by patients, especially those in the perioperative setting. While not directly ascertained in this study, cannabis use among included patients most likely represented recreational, medical, or combined recreational and medical use, given their approval in 23 and 38 states, respectively.3,4 Such use of cannabis has the potential for heterogeneity in several important aspects, which range from product source and formulation to route of application, mixture of THC and/or CBD, and dose consumed, among others.29,30 In contrast to the cannabis supply permitted by states, the Food and Drug Administration has approved three cannabis-related drug products, which include CBD and the synthetic products dronabinol (synthetic THC) and nabilone. Unlike the variation among medical or recreational cannabis, FDA-regulated cannabis products have product labeling with known formulations, consistent sourcing, and verifiable composition of cannabinoids. It is worth noting that none of the FDA-regulated products currently have indications for treating acute or chronic pain, so their use for pain is unlikely to be common among patients receiving surgical care.

A better understanding of the potential risks and benefits of cannabis is warranted, given one in 20 patients used cannabis as a treatment for post-discharge pain. However, several barriers exist to generating high-level evidence for the impact of cannabis on perioperative outcomes. First, federal law classifies cannabis as a Schedule I substance under the Controlled Substance Act, indicating a high addictive potential with “no accepted medical use.” This classification imposes substantial burden on researchers, including blocking them from conducting studies with cannabis that is otherwise available in the legal cannabis marketplace. Recent calls by The White House for the Department of Justice to examine rescheduling may serve as the initial steps to changing this classification, which may take years.31 Without a change in scheduling, the need exists for researchers to meet more stringent requirements on sourcing cannabis, special controlled substance licensing, and other approvals from the Drug Enforcement Agency. Second, a lack of standards and reliable product labeling creates impediments for both patients and providers to understand the potential benefits and risks of cannabis products. For example, the levels of cannabidiol reported on product labels varied widely compared to actual amounts present, and were inaccurately low in 26% of examined products.32 Third, the heterogeneity of non-FDA-regulated cannabis products used by patients including routes of administration, frequency of use, and dosing differences creates difficulties in properly measuring patient exposures. Surgeons, anesthesiologists, and other clinicians currently lack efficient and validated tools to ascertain the type, route, and composition of cannabis use when patients present for care.

Findings in this analysis should be considered in the context of additional limitations. Participant use of other prescriptions relevant to potential cannabis use, such as dronabinol, was not available for the cohort. Preoperative pain, mental health conditions, and risky use of substances before surgery, including cannabis, represent important drivers of opioid prescribing and contributors to pain and were not assessed in the current cohort. This analysis accounts for smoking and the amount of opioids prescribed at discharge, the latter of which would account for some of these factors and is known to impact opioid consumption.33 Unmeasured procedural characteristics such as the invasiveness of surgery, case complexity, and intraoperative challenges have the potential to relate to opioid prescribing and pain intensity after surgery. At the same time, including the type of surgical procedure, surgical priority, and length of stay permits addressing certain characteristics that differ when examining different operations. Because outcomes including cannabis use, pain, and secondary measures were self-reported, biases may be introduced by the timing of the survey and the choice of some patients to not respond. It remains relevant to examine how outcomes about cannabis use and pain may differ among non-respondents, given lack of response has previously correlated with higher substance use.34,35 The observational nature precludes establishing a causal relationship between cannabis use for pain and outcomes such as opioid consumption, pain, and other patient-reported outcomes. Finally, this study analyzes outcomes reported by patients up to 90 days after surgery, which represents a relevant time period for surgical recovery, though knowledge of how cannabis use may influence longer-term outcomes for surgical patients remains incomplete.

Conclusion

In this large observational study of patients, cannabis use for pain after discharge from surgery was associated with a statistically significant increase in opioid consumption that was small but clinically insignificant. Patients using cannabis for post-discharge pain also reported worse outcomes for pain, satisfaction, and quality of life. Given the lack of substitution observed of cannabis for prescription opioids, combined with inferior patient-reported outcomes, these findings indicate that cannabis should not be routinely recommended as an adjunct to multimodal pain regimens after surgery.

Supplementary Material

Supplementary Digital Content

Funding

This study is supported by the National Institute on Drug Abuse (NIDA) grant number R01DA042859.

Role of Funder/Sponsor Statement

The funder did not contribute to the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnotes

Access to Data and Data Analysis

Ms. Gunaseelan had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ms. Gunaseelan and Ms. Lai analyzed the data.

Competing interests

Dr. Brummett serves as a consultant for Heron Therapeutics, a biotech company that produces a non-opioid analgesic for acute pain, and he served as a consultant for Vertex Pharmaceuticals, Alosa Health, and the Benter Foundation. In addition, Dr. Brummett provides expert medicolegal testimony unrelated to this analysis. Dr. Boehnke has received protocol development funding from Tryp Therapeutics and currently sits on a Data Safety and Monitoring Committee for Vireo Health (unpaid). Dr. Ladha is a co-principal investigator on an observational study on medical cannabis funded by Shoppers Drug Mart. The other authors report no conflicts of interest.

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