cbd for knee replacement painDecember 15, 2021
NORML, a national organization committed to revamping the U.S.’ marijuana believes in the power of cannabis in relieving pain and other organizations are starting to post their own guides for patients. The Arthritis Foundation , The Rheumatoid Arthritis Support Network , and many more organizations are starting to give their members new information on CBD and THC for pain. Even more, other studies are popping up from around the world, hoping to recruit individuals who are recovering from knee surgery to identify the benefits of THC and CBD in after-care.
“Medicinal cannabis has begun to emerge as a potential therapy for pain reduction and produces effects largely due to 2 active components: (1) cannabidiol (CBD), and (2) tetrahydrocannabinol (THC). Studies of CBD have shown analgesic, anti-inflammatory, and anti-anxiety properties, but without the psychoactive effects (feeling ‘high’) that THC produces. This study will assess the feasibility of a definitive trial to explore whether adding CBD vs. placebo to usual care before and after surgery can reduce the rate of persistent post-surgical pain after total knee replacement. This study will randomize 40 patients to receive either CBD or placebo and follow them for six months to confirm our ability to recruit patients, adhere to protocol, and capture full outcome data for at least 90% of patients.”
Additionally, the Foundation shared a study by the Agency for Healthcare Research and Quality, showcasing the fact that demand for the total knee replacement procedure has been steadily rising since 2011, as has patient questions about avoiding opioid addiction and additional therapies available in after care.
Dr. Michael Suk, chair of Geisinger’s Musculoskeletal Institute, shared recently with Modern Healthcare that while after-surgery care is set individually with each patient, certain best practices are a guideline. These include timeframes for check-ins with the health care team and offering specific resources for education. Noticing a need to offer home-bound patients a way to connect to resources throughout their recovery, Dr. Suk and his team partnered with Force Therapeutics to offer an app that allows patients to not only have touchpoints with nurses and gives access to detailed care plans. Geisinger’s strategic partnership has helped create big cost savings, and helped patients feel empowered.
“ Survey data indicates that the use of cannabis is common among patients with chronic pain  and patients who use it for this indication typically report it to be an effective treatment.  Majorities further report that cannabis possesses fewer side effects than conventional pain medications and that it provides greater symptom management than opioids.  ” ( NORML.org )
Multiple studies have shown that THC and CBD offer an alternative to opioids and other pain medicines but often patients don’t know where to look for proven studies on the effects of cannabis on pain within the body. As Brandon May from Clinical Pain Advisor shares, “Research examining the therapeutic effects of CBD remains limited, as the majority of clinical studies focus on THC, which binds CB1 receptors rather than on CBD itself.”
With opioid addiction facing unprecedented scrutiny, doctors and rehabilitation specialists are not only looking to new technologies to combat a dependence on painkillers, but also demonstrating a want to understand new ways of treating ancient issues of pain.
With knee pain, everything seems to be a chore. From climbing stairs, to getting in-and-out of the car, individuals that suffer from prolonged knee soreness and discomfort often benefit from surgery, with many stating that after-care can be almost as difficult as the pain itself. In fact, Googling “knee surgery aftercare” often brings up results in how to avoid surgery altogether.
With America being slow to warm to understanding cannabis’s role in medicine, a clinical trial sponsored by McMaster University in Canada is looking into the role of cannabis in post-surgical pain. In their trial brief, they explain :
With America being slow to warm to understanding cannabis’s role in medicine, a clinical trial sponsored by McMaster University in Canada is looking into the role of cannabis in post-surgical pain. Photo by iStock / Getty Images Plus.
TheFreshToast.com, a U.S. lifestyle site, that contributes lifestyle content and, with their partnership with 600,000 physicians via Skipta, medical marijuana information to The GrowthOp.
Other technologists and entrepreneurs have taken notice of recent trends in helping patients stay connected after surgery. The MyMobility app has been rolled out at Hoag Orthopedic Institute to allow patients to showcase their rehabilitation statistics (steps taken, amount of time spent in activity) so the care team can make further recommendations for follow-up care.
As the U.S. continues to struggle in hosting trials and studies due to the classification of cannabis, pressure continues to mount on all involved in healthcare to explore additional therapies.
If you’re readying for surgery, consider discussing CBD and THC with your medical practitioner and care team. Not only might the compounds play a role in decreasing a long-term dependence on opioids, but they may also provide other benefits as well.
Technology is helping care teams to better align best practices with patients who may need extra support or experience hesitation at completing physical therapy at home with the added bonus that more frequent communication may help identity an opioid addiction, with more eyes and ears on care. However, patients must feel empowered to share that they are dependent on opioids, which often is kept silent due to a myriad of reasons.
With many patients choosing to move forward with surgery, there seems to be a feeling of apprehension of what to expect after, as each individual’s recovery plan is usually customized. Medicare’s Comprehensive Care for Joint Replacement Model started recommending immediate discharge after surgery instead of placing patients in after-care facilities, which some say has added depth to the opioid-epidemic for those unable to discontinue pain medicine at proper times.
A 2018 report looked at opioid use after knee replacement surgery and found:
However, delaying surgery can have subtle effects that patients often don’t realize. BoneSmart , a website by AESCULAP Implant Systems, found research on why delaying surgery could bring additional complications. From a risk of deformities to the increased inability to manage pain, BoneSmart also found that delaying the procedure could prolong time under anesthesia.
The Arthritis Foundation also echoed the research of others like BoneSmart on the internet but added the caveat that most patients could make an informed decision with knowledge of weighing the pros and cons of having immediate surgery or choosing to delay the procedure.
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Why These 4 Professional Athletes Use CBD To Manage Pain.
A retrospective review of the Medicare database within the PearlDiver Supercomputer (Warsaw, IN) for TKA, cannabis use, revisions, and causes was performed. The PearlDiver database is a publicly available Health Insurance Portability and Accountability Act (HIPAA)-compliant national database compiled from a collection of Medicare records from 2005 to 2014. The database contains Current Procedural Terminology (CPT) and International Classification of Disease ninth revision codes (ICD-9).
People utilize cannabis for the perception of euphoria, alterations in mood, and changes in the per ception of time and place. 8 Alternatively, negative side effects can also occur, such as dysphoria, anxiety, sedation, dizziness, and cross tolerance to other substances. 9,10 Therefore, in the perioperative setting, all aspects of cannabis use must be taken into account. Anecdotal reports detail high anesthetic requirements, and a recent study demonstrated an increase in Propofol doses required to achieve successful laryngeal mask insertion and intubation in cannabis users. 11 Although rare, case reports have described reports of coronary ischemia, myocardial infarction, pulmonary edema, and cerebral ischemia even in young adult cannabis users. 7,12.
TKA and TKAR by Gender.
One of the strengths of this study is the large patient population that was analyzed. In addition, our study adds significant value to the body ofknowledge because it describes the effects of cannabis use on total joint arthroplasty patients, which has yet to be adequately in-vestigated in the orthopaedic surgery literature.
Substance misuse and dependence are a growing problem in the United States with approximately 8.1% of the population over the age of 12 being classified with substance use disorder in the past year. 1 Cannabis dependence has increased over time, reflected by a 22% increase in global burden since 1990, making it one of the most commonly used substances. 2 Smoking cannabis produces a wide array of psychotropic effects, as the plant contains multiple cannabinoids, of which delta-9-tetra hydrocannabinol (THC) is the most recognized, in addition to an estimated 340 additional chemical compounds. 3 Regular use has been associated with decreased pulmonary function and increased risk of anxiety, depression, and psychotic illness. 4–7.
Our analysis returned 2,718,023 nonuser TKAs and 247,112 (9.1 %) revisions between 2005 and 2014. Cannabis use was prevalent in 18,875 TKA patients with 2,419 (12.8%) revisions within the cannabis cohort. A description of annual trends in the TKA revision rate between cannabis users compared to nonusers is found in Table 1 , which demonstrates a significantly higher revision incidence ratio in cannabis users (p < 0.001).
This study is not without limitations. The PearlDiver database is reliant upon accurate CPT or ICD coding, which creates the potential for a reporting bias. In addition. cannabis codes were derived from ICD9 codes that code for dependence or abuse. Finally, patient comorbidities were not stratified within the scope of this study.
Patients who underwent TKA were identified with CPT-27447 and ICD-9 81.54. These patients were then cross-referenced for a history of cannabis use by querying ICD-9 codes 304.30–32, and 305.20 – 22. The resulting patients were then longitudinally tracked postoperatively for TKA revision (TKAR) by CPT codes 27486 and 27487, and ICD-9 codes 00.80–00.84 and 81.55. Causes for revision were identified with ICD-9 codes 996.40 – 47, 996.49, 996.66–67, 996.77–78, 718.46, 718.56, and 718.86. These codes correspond with mechanical loosening, failure/break, periprosthetic fracture, osteolysis, infection, pain, arthrofibrosis, instability, and trauma, respectively. Time to revision and gender were also investigated.
TKA and TKAR Annual Trend.
Our analysis additionally demonstrates a lower rate of periprosthetic fracture, mechanical loosening, implant failure, and osteolysis as a cause ofTKAR in the cannabis-user group. Although these findings did not reach statistical significance, they may in part be explained by studies that investigated the effect of up-regulating cannabinoid receptors (CB) of the skeleton in mice. Bab et al. 19 illustrated that THC activates CB-2, a cannabinoid receptor expressed on osteo-blasts and osteoclasts. Activating the CB-2 receptor was found to stimulate bone formation, balance bone remodeling, and perhaps play a protective role against age-related bone loss. 19,20 However, a clinical cross-sectional study of a group of 109 heavy cannabis users (comprised of mostly young men) showed that the heavy cannabis user group had substantially lower bone mineral density (BMD) Z-score values at the lumbar spine and hip evident on DEXA scans, and therefore concluded that heavy cannabis use may lead to an increased risk of fracture compared to non-heavy cannabis users. 21 Furthermore, a retrospective study that utilized the National Health and Nutrition Examination Survey from 2007 to 2010 investigated 4,743 participants between the age of 20 and 59 with self-reported history of cannabis use. This study, on the contrary, did not find a correlation between cannabis use and low BMD through DEXA scans of the proximal femur and lwnbar spine. 22 In general, there is a considerable lack of evidence-based research discussing the effect of cannabis on musculoskeletal and bone health. This study aims to emphasize on the need for future research on this topic and highlights findings related to cannabis use and primary TKA.
Cause for Revision.
As an increasing number of states begin to legalize marijuana for either medical or recreational use, it is important to determine its effects on joint arthroplasty. The purpose of this study is to determine the impact of cannabis use on total knee arthroplasty (TKA) revision incidence, revision causes, and time to revision by analyzing the Medicare database between 2005 and 2014. A retrospective review of the Medicare database for TKA, revision TKA, and causes was performed utilizing Current Procedural Terminology (CPT) and International Classification of Disease ninth revision codes (ICD-9). Patients who underwent TKA were cross-referenced for a history of cannabis use by querying ICD-9 codes 304.30–32 and 305.20–22. The resulting group was then longitudinally tracked postoperatively for revision TKA. Cause for revision, time to revision, and gender were also investigated. Our analysis returned 2, 718,023 TKAs and 247,112 (9.1%) revisions between 2005 and 2014. Cannabis use was prevalent in 18,875 (0.7%) of TKApatients with 2,419 (12.8%) revisions within the cannabis cohort. Revision incidence was significantly greater in patients who use cannabis (p < 0.001). Time to revision was also significantly decreased in patients who used cannabis, with increased 30- and 90-day revision incidence compared to the noncannabis group (P < 0.001). Infection was the most common cause of revision in both groups (33.5% nonusers versus 36.6% cannabis users). Cannabis use may result in decreasing implant survivorship and increasing the risk for revision within the 90-day global period compared to noncannabis users following primary TKA.
Time to revision was found to be significantly decreased in patients who used cannabis, with mean time to revision in the cannabis group being 739.2 days compared to 828.2 days in nonusers (89 days sooner in cannabis users) (P < 0.001). Notably, mean time to revision was significantly increased in the cannabis group for both 30-day (3. 7% nonusers versus 5.8% in cannabis users) and 90-day (8.5% nonusers versus 11.5% in cannabis users) postoperatively ( Table 3 ). Survivorship was measured utilizing the Kaplan-Meier survival curves as depicted in Fig. 1 .
Statistical analysis of this study was primarily descriptive. A Kaplan Meier Survival analysis was performed to determine significance of survival and time to revision. Statistical analysis was performed with SPSS Version 21 (IBM, Armonk, NY).
Few studies have examined the influence of cannabis use on total joint replacement to date. This study is the first to evaluate the influence of cannabis use in the setting of TKA. The primary results of this study suggest that cannabis use may be a risk factor for postoperative infection, requiring revision surgery following primary TKA. Our study also shows that the TKAR incidence increased mostly during the 30- and 90-day postoperative period, which, especially in the era of the comprehensive care for joint replacement model and bundled-payment initiatives, could have a substantial effect on the overall cost of the index procedure considering that the increased revision rate lies within the 90-day global postoperative period.
Infection was found to be the most common cause of revision in both groups, with the overall infection incidence being higher in the cannabis group (33.5% nonusers versus 36.6% in cannabis users). Mechanical loosening, implant failure, peri-prosthetic fracture, and osteolysis were found to be somewhat lower in the cannabis group (17.4, 4.6, 2.2, and 1.1%) versus nonusers (20, 6.1, 2.9, and 1.6%), respectively ( Table 4 ).
Kaplan-Meier Survival Analysis curve comparing implant survival until revision between cannabis users and nonusers. Survival rates are shown at 30 and 90 days postoperatively.
TKA utilization was greatest in patients aged 65–69 in nonusers (688,579; 27.4%) and < 65 in cannabis users (6,924; 73.5%) ( Table 2 ). Chi square analysis demonstrated significantly higher revision rates in both cohorts in patients < 65 (p < 0.001) (Odds Ratio 0.72, 95% CI 0.67–0.77). Female patients were also more likely to receive TKA in both study groups compared to their male counterparts.