Orthopedics

Feature Article Supplemental Data

Characteristics of Marijuana Use Among Orthopedic Patients

John J. Carney, BS; Alan Hwang, MD; Nathanael Heckmann, MD; Mitchell Bernstein, MD; Geoffrey S. Marecek, MD

Abstract

Marijuana use among orthopedic patients has not been extensively studied. The purpose of this study was to investigate the prevalence of marijuana use among orthopedic surgery patients. Additionally, the authors sought to better characterize how and why their patients use marijuana. Patients presenting at 3 institutions in 2 states for orthopedic surgery were asked to complete a voluntary survey. In addition to basic demographic information, the survey contained questions regarding the frequency of, methods of, and reasons for marijuana use. Patients who had used marijuana in the past year were categorized as marijuana users. A total of 275 patients completed surveys, of whom 94 (34%) endorsed marijuana use in the past year. A majority of marijuana users (55%) endorsed using marijuana either daily or weekly. Smoking was the most common means of marijuana use (90%), followed by edible products (35%) and vaporizing (24%). Pain management (54%) and recreation (52%) were the most commonly cited reasons for using marijuana. Eighty-six percent of marijuana users indicated that they would stop using marijuana if told by their physician that marijuana use would adversely affect their surgery. Marijuana use is common among orthopedic patients. Many patients believe marijuana is beneficial for managing pain and other medical conditions, although most would be willing to stop using marijuana if told it would negatively impact their surgery. Further study into the effects of marijuana use on musculoskeletal health is warranted because marijuana use may be a risk factor easily modified to improve surgical outcomes. [Orthopedics. 2020; 43(2): 108–112.]

Abstract

Marijuana use among orthopedic patients has not been extensively studied. The purpose of this study was to investigate the prevalence of marijuana use among orthopedic surgery patients. Additionally, the authors sought to better characterize how and why their patients use marijuana. Patients presenting at 3 institutions in 2 states for orthopedic surgery were asked to complete a voluntary survey. In addition to basic demographic information, the survey contained questions regarding the frequency of, methods of, and reasons for marijuana use. Patients who had used marijuana in the past year were categorized as marijuana users. A total of 275 patients completed surveys, of whom 94 (34%) endorsed marijuana use in the past year. A majority of marijuana users (55%) endorsed using marijuana either daily or weekly. Smoking was the most common means of marijuana use (90%), followed by edible products (35%) and vaporizing (24%). Pain management (54%) and recreation (52%) were the most commonly cited reasons for using marijuana. Eighty-six percent of marijuana users indicated that they would stop using marijuana if told by their physician that marijuana use would adversely affect their surgery. Marijuana use is common among orthopedic patients. Many patients believe marijuana is beneficial for managing pain and other medical conditions, although most would be willing to stop using marijuana if told it would negatively impact their surgery. Further study into the effects of marijuana use on musculoskeletal health is warranted because marijuana use may be a risk factor easily modified to improve surgical outcomes. [Orthopedics. 2020; 43(2): 108–112.]

For the past several decades, public attention regarding marijuana use has increased. As states begin to legalize its recreational use in conjunction with emerging scientific and anecdotal evidence about its potential health benefits, the medical community must improve its understanding of the prevalence of marijuana use and its effects on patient health.1

In the orthopedic literature, studies have indicated that marijuana may have a positive effect on bone health at the cellular level through stimulation of what is referred to as the “cannabinoid skeletal system,” in which osteoclastic activity is inhibited while osteoblastic activity is promoted.2,3 Furthermore, studies have reported that marijuana may prove to be a useful tool for managing pain and reducing opioid use, although there are mixed findings in the literature regarding this.4,5 Thus, from the perspective of an orthopedic surgeon, the potential benefits of marijuana for bone health may be outweighed by the possible negative systemic effects.

Emerging literature has indicated that orthopedic patients are increasingly comfortable discussing marijuana use with their surgeons.6 Despite this, to the authors' knowledge, no studies have attempted to elaborate on the details of marijuana use among orthopedic patients regarding frequency of use, means of use, and reason for use. Moreover, designing and conducting research on the effects of marijuana on orthopedic patients is not possible without an understanding of current use. The purpose of this study was to investigate the prevalence of marijuana use at the authors' institution and to better characterize the reasons why patients use marijuana.

Materials and Methods

Following institutional review board approval, orthopedic surgical patients presenting at 3 institutions in 2 states on the day of their surgery between March 2015 and December 2015 were given a voluntary questionnaire to complete in the preoperative waiting area (Figure A, available in the online version of the article). The institutions included a county-operated urban level 1 trauma center, a university-affiliated tertiary care hospital, and a university-affiliated suburban level 1 trauma center. In addition to providing basic demographic information (age, sex, subspecialty of orthopedic surgeon providing care), patients were asked if they had ever used marijuana or if they had used marijuana within the past year. Patients were also asked about the frequency of marijuana use, reason for marijuana use, means of acquiring marijuana, and method by which they use marijuana. Finally, patients were asked if they would stop using marijuana if their physician told them that marijuana use would have a negative effect on their surgery.

Copy of Survey Given to PatientsResearch Study: Incidence of Marijuana Use in Orthopaedic SurgeryWe are conducting a survey to better understand the incidence of marijuana use in patients with orthopaedic injuries and conditions. Please answer honestly and remember that all responses are confidential. Do not fill out this form if you have done so already.Copy of Survey Given to PatientsResearch Study: Incidence of Marijuana Use in Orthopaedic SurgeryWe are conducting a survey to better understand the incidence of marijuana use in patients with orthopaedic injuries and conditions. Please answer honestly and remember that all responses are confidential. Do not fill out this form if you have done so already.

Figure A:

Copy of Survey Given to Patients

Research Study: Incidence of Marijuana Use in Orthopaedic Surgery

We are conducting a survey to better understand the incidence of marijuana use in patients with orthopaedic injuries and conditions. Please answer honestly and remember that all responses are confidential. Do not fill out this form if you have done so already.

Survey results were recorded with patient identifiers removed. Patients endorsing marijuana use in the past year were classified as marijuana users.7–9 Significant differences in demographic variables were calculated using the chi-square test. Significance was established as alpha=0.05.

Results

A total of 275 patients completed the survey. One hundred forty-nine (54%) endorsed marijuana use at some point in their lives, whereas 94 (34.2%) endorsed marijuana use within the past year. Marijuana users were more likely to be between the ages of 18 and 25 years than patients who had not used marijuana in the past year (28 [29.8%] vs 13 [8.1%], P<.001). Marijuana users were less likely to be between the ages of 46 and 65 years than patients who had not used marijuana in the past year (18 [19.2%] vs 61 [38.1%], P=.002). Marijuana users were less likely to be between the ages of 66 and 85 years than patients who had not used marijuana in the past year (7 [7.4%] vs 32 [20.0%], P=.007). Marijuana users were more likely to be male than patients who had not used marijuana in the past year (63 [73.3%] vs 90 [60.8%], P=.05). There were no significant differences in the rates of use according to the type of orthopedic subspecialist managing a patient's care (P>.05). Patient demographics are summarized in Table 1.

Patient Characteristicsa

Table 1:

Patient Characteristics

Among marijuana users, the most commonly reported frequency of marijuana use was daily (27 [30.7%]), followed by weekly (21 [23.9%]), less than 1 time per month (16 [18.1%]), 1 to 3 times per month (15 [17.0%]), and multiple times daily (9 [10.2%]). Smoking was by far the most common method by which marijuana was used (80 [89.9%]), followed by edible products (31 [34.8%]) and vaporizing (21 [23.6%]). Regarding the reason for smoking marijuana, pain relief and recreation were nearly equal (49 [54.4%] and 47 [52.2%], respectively), followed by other reason (24 [26.7%]) and medical condition (17 [18.9%]) (Table 2). Only 30 (32.6%) of the marijuana users obtained marijuana with a medical marijuana card. (At the time of this study, recreational marijuana use was not legal in either state.) Finally, 77 (86.5%) of the patients stated that they would stop using marijuana if they were told by their physician that marijuana use would negatively impact their surgery. The medical conditions cited for marijuana use are summarized in Table 3.

Characteristics of Marijuana Usersa

Table 2:

Characteristics of Marijuana Users

Medical Conditions Cited for Marijuana Use

Table 3:

Medical Conditions Cited for Marijuana Use

Discussion

As public interest in the medical benefits of marijuana use grows, it is becoming increasingly important for physicians to better understand the risks and benefits of marijuana use and the patterns of marijuana use among the patients for whom they provide care. At the time of this study, recreational marijuana use had not been legalized in either state; however, one-third of the patients endorsed using marijuana within the past year. This prevalence is higher than the rate of 21% reported in a 2018 study involving a group of orthopedic trauma patients in Massachusetts.10 A 1996 study from New Orleans also reported a prevalence rate of 21%.11 There are many possible geographic, cultural, and sociological explanations for the higher prevalence found in the current study. However, as the trend of legalization of marijuana for recreational and medicinal purposes spreads, it is likely that the prevalence will continue to rise across the country.6

Marijuana use was prevalent among patients being managed by surgeons of every orthopedic subspecialty. There is ample literature regarding the impact of marijuana use on the risk of sustaining traumatic injury, which may lead some to believe that marijuana use would only be of concern to the orthopedic traumatologist.7,12–14 However, the current study indicates that marijuana use is a factor that may be relevant to all orthopedic subspecialists.

Reasons for marijuana use appear to be mixed, although recreation and pain management were by far the most common in the current study. Individuals often do not have just one reason for using marijuana. It has been reported that 80% of medical marijuana users also use marijuana for recreational purposes.15 The current authors' finding that pain management was a commonly cited reason for marijuana use is consistent with a previous study reporting that 79% of patients with musculoskeletal trauma believed that marijuana could be used to treat pain.10 Furthermore, 90% of marijuana users in that study believed that their marijuana use was helpful in reducing their pain, with 81% stating that it was related to a reduced need for opioids. Other studies have noted the potential of marijuana as a tool in fighting the nation's ongoing opioid epidemic.4,16 Many would argue that the side effects of opiate overuse are far worse than those of marijuana. However, recently published data indicate that marijuana users consume more opioids than non-marijuana users, so physicians should approach the use of marijuana for pain management with caution until there is further evidence better indicating its ability to reduce pain without harmful consequences.5

In this study, patients used marijuana predominately through smoking (89.9%), followed by edible products (34.8%) and vaporizing (23.6%). This is somewhat consistent with another study conducted in the same geographic area as 2 of the institutions that reported 47% of marijuana users smoked marijuana, 23% used vaporizers, and 17% used edible products.17 A key difference between that study and the current study that may account for the current study's higher reported smoking rate is that the former study distinguished smoking marijuana via cigarettes vs water pipes (each method used by approximately 50% of the study population), whereas the current study did not. Although the current study and the former study indicated that vaporizing and edible products were less frequently used, it is likely that the nationwide trend of legalization of recreational marijuana use will provide a growing market for these alternative methods. The potential consequences of increased marijuana use via vaporizing and edible products are unclear, but there is a concern that as marijuana use becomes more “normalized,” individuals may use marijuana more frequently and in higher quantities.18,19 Until the effects of marijuana on both musculoskeletal and non-musculoskeletal health are better understood, physicians should carefully monitor how often and in what quantity their patients use marijuana.

Most of the patients in this study stated that they would be willing to stop using marijuana if they were told by their surgeon that marijuana would negatively impact their surgery. It has also been reported that patients who used marijuana postoperatively were more likely to have signs and symptoms consistent with anxiety and post-traumatic stress disorder.10 Furthermore, one study reported an association between marijuana use and cardiovascular problems such as heart failure and stroke among patients who had undergone certain orthopedic procedures (spinal fusion, knee and hip arthroplasty), but also reduced odds of cardiovascular problems and decreased mortality for other procedures (femur fracture fixation, reverse total shoulder arthroplasty, knee and hip arthroplasty).20 That study identified marijuana users based on International Classification of Diseases, 9th Revision, codes for cannabis nondependence abuse and cannabis dependent use, whereas the current study defined marijuana users as survey responders who reported using marijuana within the past year. Until the benefits of marijuana use for pain management and other musculoskeletal factors are better understood, it would not be unreasonable for a physician to recommend avoidance of marijuana in the perioperative period given these findings. Should data become available demonstrating further negative consequences of marijuana use, the current finding that 86% of the patients using marijuana would be willing to make such a lifestyle modification is encouraging, in that marijuana use could be a risk factor easily modified to improve patient outcomes.

The main weakness of this study was that the data were acquired via a survey, which carries an associated selection bias regarding the individuals who choose to participate. Furthermore, the authors have no means by which to confirm the validity of the answers that the patients provided. Finally, not all patients fully completed the survey. This may have skewed the authors' results for select questions with lower response rates. Further studies are warranted to better characterize marijuana use among orthopedic patients and how it impacts surgical outcomes, pain tolerance, and patient satisfaction with orthopedic care.

Conclusion

Marijuana use is prevalent among orthopedic patients at the authors' institution. Recreation and pain management are the most common reasons for using marijuana, although most patients state they would stop using marijuana if they were told by a physician that marijuana use would have a negative impact on their surgery. However, sufficient evidence does not exist to determine whether marijuana should be avoided in the perioperative period. Further study is warranted to better understand the effect of marijuana use on surgical outcomes.

References

  1. Weaver MJ. CORR Insights®. Has self-reported marijuana use changed in patients undergoing total joint arthroplasty after the legalization of marijuana?Clin Orthop Relat Res. 2019;477(1):101–103. doi:10.1097/CORR.0000000000000386 [CrossRef]
  2. Kogan NM, Melamed E, Wasserman E, et al. Cannabidiol: a major non-psychotropic cannabis constituent enhances fracture healing and stimulates lysyl hydroxylase activity in osteoblasts. J Bone Miner Res. 2015;30(10):1905–1913. https://doi.org/10.1002/jbmr.2513 PMID: doi:10.1002/jbmr.2513 [CrossRef]25801536
  3. Bab I, Zimmer A, Melamed E. Cannabinoids and the skeleton: from marijuana to reversal of bone loss. Ann Med. 2009;41(8):560–567. https://doi.org/10.1080/07853890903121025 PMID: doi:10.1080/07853890903121025 [CrossRef]19634029
  4. Wen H, Hockenberry JM. Association of medical and adult-use marijuana laws with opioid prescribing for Medicaid enrollees. JAMA Intern Med. 2018;178(5):673–679. https://doi.org/10.1001/jamainternmed.2018.1007 PMID: doi:10.1001/jamainternmed.2018.1007 [CrossRef]29610827
  5. Salottolo K, Peck L, Tanner A Ii, et al. The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury. Patient Saf Surg. 2018;12(1):16. https://doi.org/10.1186/s13037-018-0163-3 PMID: doi:10.1186/s13037-018-0163-3 [CrossRef]29946360
  6. Jennings JM, Williams MA, Levy DL, Johnson RM, Eschen CL, Dennis DA. Has self-reported marijuana use changed in patients undergoing total joint arthroplasty after the legalization of marijuana?Clin Orthop Relat Res. 2018; published ahead of print. doi:10.1097/CORR.0000000000000339 [CrossRef]
  7. Blows S, Ivers RQ, Connor J, Ameratunga S, Woodward M, Norton R. Marijuana use and car crash injury. Addiction. 2005;100(5):605–611. https://doi.org/10.1111/j.1360-0443.2005.01100.x PMID: doi:10.1111/j.1360-0443.2005.01100.x [CrossRef]15847617
  8. Choi NG, Marti CN, DiNitto DM, Choi BY. Older adults' marijuana use, injuries, and emergency department visits. Am J Drug Alcohol Abuse. 2018;44(2):215–223. https://doi.org/10.1080/00952990.2017.1318891 PMID: doi:10.1080/00952990.2017.1318891 [CrossRef]
  9. Phillips KT, Lalonde TL, Phillips MM, Schneider MM. Marijuana use and associated motives in Colorado university students. Am J Addict. 2017;26(8):830–837. https://doi.org/10.1111/ajad.12640 PMID: doi:10.1111/ajad.12640 [CrossRef]29125218
  10. Heng M, McTague MF, Lucas RC, Harris MB, Vrahas MS, Weaver MJ. Patient perceptions of the use of medical marijuana in the treatment of pain after musculoskeletal trauma: a survey of patients at 2 trauma centers in Massachusetts. J Orthop Trauma. 2018;32(1):e25–e30. https://doi.org/10.1097/BOT.0000000000001002 PMID: doi:10.1097/BOT.0000000000001002 [CrossRef]
  11. Levy RS, Hebert CK, Munn BG, Barrack RL. Drug and alcohol use in orthopedic trauma patients: a prospective study. J Orthop Trauma. 1996;10(1):21–27. https://doi.org/10.1097/00005131-199601000-00004 PMID: doi:10.1097/00005131-199601000-00004 [CrossRef]8926551
  12. Braun BL, Tekawa IS, Gerberich SG, Sidney S. Marijuana use and medically attended injury events. Ann Emerg Med. 1998;32(3 pt 1):353–360. https://doi.org/10.1016/S0196-0644(98)70013-7 PMID: doi:10.1016/S0196-0644(98)70013-7 [CrossRef]9737499
  13. Gerberich SG, Sidney S, Braun BL, Tekawa IS, Tolan KK, Quesenberry CP. Marijuana use and injury events resulting in hospitalization. Ann Epidemiol. 2003;13(4):230–237. https://doi.org/10.1016/S1047-2797(02)00411-8 PMID: doi:10.1016/S1047-2797(02)00411-8 [CrossRef]12684188
  14. Steinemann S, Galanis D, Nguyen T, Biffl W. Motor vehicle crash fatalities and undercompensated care associated with legalization of marijuana. J Trauma Acute Care Surg. 2018;85(3):566–571. https://doi.org/10.1097/TA.0000000000001983 PMID: doi:10.1097/TA.0000000000001983 [CrossRef]29787529
  15. Furler MD, Einarson TR, Millson M, Walmsley S, Bendayan R. Medicinal and recreational marijuana use by patients infected with HIV. AIDS Patient Care STDS. 2004;18(4):215–228. https://doi.org/10.1089/108729104323038892 PMID: doi:10.1089/108729104323038892 [CrossRef]15142352
  16. Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999–2010. JAMA Intern Med. 2014;174(10):1668–1673. https://doi.org/10.1001/jamainternmed.2014.4005 PMID: doi:10.1001/jamainternmed.2014.4005 [CrossRef]25154332
  17. Grella CE, Rodriguez L, Kim T. Patterns of medical marijuana use among individuals sampled from medical marijuana dispensaries in Los Angeles. J Psychoactive Drugs. 2014;46(4):267–275. https://doi.org/10.1080/02791072.2014.944960 PMID: doi:10.1080/02791072.2014.944960 [CrossRef]25188696
  18. Duff C, Asbridge M, Brochu S, et al. A Canadian perspective on cannabis normalization among adults. Addict Res Theory. 2012;20(4):271–283. https://doi.org/10.3109/16066359.2011.618957 doi:10.3109/16066359.2011.618957 [CrossRef]
  19. O'Callaghan FV, Hannon T. Normalization of marijuana use: its effects on adolescents' intentions to use marijuana. Subst Use Misuse. 2003;38(2):185–199. https://doi.org/10.1081/JA-120017244 PMID: doi:10.1081/JA-120017244 [CrossRef]12625427
  20. Moon AS, Smith W, Mullen S, et al. Marijuana use and mortality following orthopedic surgical procedures. Subst Abus. 2018;0(0):1–5. https://doi.org/10.1080/08897077.2018.1449054 PMID:29558287

Patient Characteristicsa

CharacteristicMarijuana Use in the Past Year, No.P

YesNo
Age
  18–25 y28 (29.8%)13 (8.1%)<.001
  26–45 y41 (43.6%)52 (32.5%).08
  46–65 y18 (19.2%)61 (38.1%).002
  66–85 y7 (7.4%)32 (20.0%).007
  >85 y0 (0%)2 (1.3%).28
  Total94160
Sex
  Female23 (26.7%)58 (39.2%).05
  Male63 (73.3%)90 (60.8%).05
  Total86148
Orthopedic subspecialty
  Trauma50 (58.8%)51 (39.5%).006
  Foot and ankle20 (23.5%)26 (20.2%).56
  Hand16 (18.8%)31 (24.0%).37
  Sports11 (12.9%)16 (12.4%).91
  Spine3 (3.5%)4 (3.1%).86
  Joints2 (2.4%)7 (5.4%).27
  Tumor1 (1.2%)4 (3.1%).36
  Total85129

Characteristics of Marijuana Usersa

CharacteristicNo.
Frequency of marijuana use
  <1 time/month16 (18.2%)
  1–3 times/month15 (17.0%)
  Weekly21 (23.9%)
  Daily27 (30.7%)
  Multiple times daily9 (10.2%)
  Total88
Form of marijuana use
  Smoking80 (89.9%)
  Edible products31 (34.8%)
  Vaporizing21 (23.6%)
  Total89
Reason for use
  Pain relief49 (54.4%)
  Recreational use47 (52.2%)
  Other24 (26.7%)
  Medical condition17 (18.9%)
  Total90
Use of medical card to purchase marijuana
  Yes30 (32.6%)
  No62 (67.4%)
  Total92
Would stop using marijuana if told by physician that marijuana use would negatively impact surgery
  Yes77 (86.5%)
  No12 (13.5%)
  Total89

Medical Conditions Cited for Marijuana Use

ConditionNo.
Insomnia3
Depression2
Anxiety2
Osteoarthritis2
HIV2
Carpal tunnel syndrome1
Systemic juvenile rheumatoid arthritis1
Obstructive sleep apnea1
Did not specify6
Authors

The authors are from Keck School of Medicine (JJC, NH, GSM), University of Southern California, Los Angeles, California; the University of Rochester Medical Center (AH), Rochester, New York; and McGill University Health Center (MB), Montreal, Quebec, Canada.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Geoffrey S. Marecek, MD, Keck School of Medicine, University of Southern California, 1520 San Pablo St, Ste 2000, Los Angeles, CA 90033 ( marecek@usc.edu).

Received: August 16, 2018
Accepted: January 14, 2019
Posted Online: December 16, 2019

10.3928/01477447-20191212-07

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