Guideline sources The following summarized guidelines for the evaluation and management of cannabis use disorder (CUD) are prepared by our editorial team based on guidelines from the American Society of Regional Anesthesia and Pain Medicine (ASRA 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022), the United States Department of Defense (DoD/VA 2021), the Canadian Coalition for Seniors' Mental Health (CCSMH 2020), and the American College of Obstetricians and Gynecologists (ACOG 2017). 1 2 3 4 5 6 Guidelines 1. Screening and diagnosis Indications for screening: insufficient evidence to recommend for or against screening for drug use disorders in primary care to facilitate enrollment in treatment. 2. Medical management https://web.pathway.md/diseases/recbXRbKkvoEaNDHg 1/6 6/29/23, 4:03 AM Cannabis use disorder Pathway Pharmacotherapy: insufficient evidence to recommend for or against the use of pharmacotherapy in the treatment of CUD. 3. Nonpharmacologic interventions Mutual help programs: consider promoting active involvement in group mutual help programs (using peer linkage or 12-step facilitation), taking into account patient preference and availability, in patients with drug use disorder in early recovery or following relapse. C Psychosocial therapy: Consider offering any of the following interventions as initial treatment in patients with CUD, taking patient preference and availability into account: CBT motivational enhancement therapy combined CBT/motivational enhancement therapy. C Avoid offering a brief intervention ( 60 minutes) for the treatment of CUD. D Mindfulness-based therapies: insufficient evidence to recommend for or against mindfulness- based therapies for the treatment of substance use disorders. Technology-based interventions: Consider implementing structured telephone-based care as an adjunct to usual care in patients with substance use disorder. C Insufficient evidence to recommend for or against the use of telemedicine-delivered treatment, computer-delivered behavioral treatments (either alone or in combination with usual care), and technology-based interventions (such as automated text/voice messaging, smartphone applications) in addition to usual care in patients with substance use disorder. 4. Perioperative care Perioperative considerations (screening for cannabis use): Obtain universal screening for cannabinoids (including the type of cannabis or cannabinoid product, time of last consumption, route of administration, and amount and frequency of use) before surgery. A Do not obtain universal toxicology screening for cannabinoids preoperatively. D Perioperative considerations (counseling): counsel patients on the potential risks of continued perioperative cannabinoids use. B Show 2 more Perioperative considerations (timing of surgery): postpone elective surgery in patients having altered mental status or impairment of decision-making capacity due to acute cannabis intoxication. A Show 2 more https://web.pathway.md/diseases/recbXRbKkvoEaNDHg 2/6 6/29/23, 4:03 AM Cannabis use disorder Pathway Perioperative considerations (cannabis dose tapering): insufficient evidence to recommend for or against routine tapering of cannabis and cannabinoids in the perioperative period. Perioperative considerations (anesthesia and analgesia): consider adjusting induction and maintenance doses of anesthetic agents based on clinical presentation and timing of the last consumption of cannabis in surgical and procedural patients. C Show 3 more Perioperative considerations (ventilation): do not make any adjustments in ventilatory settings in patients taking only oral cannabis. D Show 2 more Perioperative considerations (monitoring): insufficient evidence to recommend for or against obtaining intraoperative EEG monitoring in patients who have taken cannabinoids. Show 2 more Perioperative considerations (management of cannabis withdrawal): administer cannabinoid agonists (such as dronabinol) at a low dose for the management of severe postoperative cannabis withdrawal symptoms. B 5. Specific circumstances Female patients (screening for cannabis use): Screen females for cannabis use B using appropriate screening tools B as for other substance use and obtain further exploration of its impact. B Use a trauma-informed care approach and harm reduction when inquiring about cannabis use. B Female patients (counseling in cannabis users): advise females that cannabis use does not influence the choice of contraceptive method. B Show 3 more Elderly patients (screening for cannabis use): obtain screening for the use of non-medical and medically authorized cannabis and cannabinoids, and illicit synthetic cannabinoids as well as tobacco, alcohol, and other drugs in all patients regardless of age. Ask about the amount, type, and frequency of cannabis or cannabinoid used. B Show 2 more Elderly patients (education and counseling): provide education and counseling about cannabis and cannabinoids in older patients and their family members/caregivers, both verbally and in writing. Show 8 more Elderly patients (advice for avoidance): Advise avoiding cannabis use by older adults with any of the following: history of, or currently experiencing, mental health disorders, problematic substance use, or substance use disorder https://web.pathway.md/diseases/recbXRbKkvoEaNDHg 3/6 6/29/23, 4:03 AM Cannabis use disorder Pathway cognitive impairment CVD, cardiac arrhythmias, coronary artery disease, unstable BP impaired balance. B Elderly patients (clinical assessment): conduct non-judgmental discussions related to cannabis and cannabinoid use. Elicit careful histories obtained from patients, caregivers, and families about signs and symptoms of CUD that may be similar to those of age-related nervous system changes, such as drowsiness, dizziness, memory impairment, and falls. A Show 5 more Elderly patients (management): consider using the Screening, Brief Intervention, and Referral to Treatment approach for assessing and managing CUD similar to other substance use disorders. B Show 4 more Pregnant patients, screening: As per SOGC 2022 guidelines: Screen all females, including during pregnancy, for cannabis use using a validated screening tool. B Document cannabis use in pregnancy both in the prenatal record and in the infant's medical record. B As per ACOG 2017 guidelines, ask all females before and in early pregnancy about their use of tobacco, alcohol, cannabis, and other medications used for non-medical reasons. Pregnant patients, counseling: As per ASRA 2023 guidelines, educate and counsel pregnant individuals about the risks of maternal cannabis use on the fetus/neonate. A As per ACOG 2017 guidelines, counsel females reporting cannabis use about concerns regarding potential adverse health consequences of continued use during pregnancy. Pregnant patients, advice for avoidance: As per ASRA 2023 guidelines, discourage cannabis use during pregnancy and the immediate postpartum period. B As per SOGC 2022 guidelines: Discourage cannabis use during pregnancy because prenatal exposure can increase the risk of neurobehavioural abnormalities in the child. B Offer a brief intervention and referral for treatment if appropriate in patients with at-risk cannabis use or CUD. B As per ACOG 2017 guidelines, encourage discontinuation of cannabis use both before and during pregnancy. Encourage discontinuation of cannabis use for medical purposes in favor of an alternative therapy having better pregnancy-specific safety data. Pregnant patients (monitoring): monitor patients regularly (near daily or more than twice weekly) using cannabis during pregnancy for potential intrapartum and/or postpartum withdrawal (or cannabis withdrawal syndrome). B https://web.pathway.md/diseases/recbXRbKkvoEaNDHg 4/6 6/29/23, 4:03 AM Cannabis use disorder Pathway Breastfeeding patients: As per SOGC 2022 guidelines, advise abstaining from cannabis use during breastfeeding. B As per ACOG 2017 guidelines, discourage cannabis use during lactation and breastfeeding because of the lack of evidence to evaluate the effects of cannabis use on infants. Clinical findings Symptoms Past medical history Abdominal pain AUD Anxiety Depression Clumsiness Neuropsychiatric disorder Confusion Substance use disorder Cough Medication history Dizziness Euphoria Cannabinoids Headache Vital signs Irritability Lightheadedness Bradycardia Memory impairment Hypotension Mood changes Nausea Nightmares Restlessness Sleeping disorder Suicidal ideation Trouble concentrating Vomiting Past events Suicide attempt Social history Cannabis use Respiratory exam Wheezing References 1. Shalini Shah, Eric S Schwenk, Samer Narouze. ASRA pain medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids: an infographic. Reg Anesth Pain https://web.pathway.md/diseases/recbXRbKkvoEaNDHg 5/6 6/29/23, 4:03 AM Cannabis use disorder Pathway Med. 2023 Jan 3;rapm-2022 104193. Open 2. No authors listed. Committee Opinion No. 722 Marijuana Use During Pregnancy and Lactation. Obstet Gynecol. 2017 Oct;130 4):e205-e209. Open 3. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF SUBSTANCE USE DISORDERS. VA/DoD. 2021 Aug. Open 4. Lisa E Graves, Magali Robert, Victoria M Allen et al. Guideline No. 425b: Cannabis Use Throughout Women's Lifespans Part 2 Pregnancy, the Postnatal Period, and Breastfeeding. J Obstet Gynaecol Can. 2022 Apr;44 4 436 444.e1. Open 5. Jonathan R Bertram, Amy Porath, Dallas Seitz et al. Canadian Guidelines on Cannabis Use Disorder Among Older Adults. Can Geriatr J. 2020 Mar 30;23 1 135 142. Open 6. Magali Robert, Lisa E Graves, Victoria M Allen et al. Guideline No. 425a: Cannabis Use Throughout Women's Lifespans Part 1 Fertility, Contraception, Menopause, and Pelvic Pain. J Obstet Gynaecol Can. 2022 Apr;44 4 407 419.e4. Open https://web.pathway.md/diseases/recbXRbKkvoEaNDHg 6/6