What’s the pathway to recovery for medical patients?

A friend recently shared a research summary reporting that cannabis users are at higher risk of clots and limb amputation following a common surgery.

Researchers at Michigan Medicine analyzed more than 11,000 cases from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium, known as BMC2, to review patient cannabis use and postoperative outcomes for lower extremity bypass after 30 days and one year. The minimally invasive procedure, also called a peripheral artery bypass, involves detouring blood around a narrowed or blocked artery in one of the legs with a vein or synthetic tube.

Results published in Annals of Vascular Surgery reveal that patients who used cannabis prior to lower extremity bypass had decreased patency, meaning the graft had a higher chance of becoming blocked or occluded, and were 1.25 times more likely to require amputation one year after surgery. Cannabis users were also 1.56 times more likely to use opioids after discharge.

Cannabis users had worse bypass outcomes, increased amputation and opioid use. (2022). University of Michigan.

Over the years, I’ve been involved in caring for many patients who received or needed a heart valve replacement due to endocarditis. Denial of life-saving surgery was shockingly common on the basis of the patient’s addiction. (It’s worth noting that these surgeries are done with pig valves, so scarcity is not a concern.) More recently, I’ve been peripherally involved in some cases where a patient required a transplant and substance use was an exclusionary criteria.

These are often terrible situations for everyone involved–the patient in need of multiple kinds of care (often urgently), the medical team faced with a decision to deny life-saving care, and families feeling powerless on multiple levels.

I assumed stigma was a driver of these barriers to life-saving care, but this suggests there may be legitimate reasons to be concerned about the impact of cannabis use on surgical outcomes.

If that’s true, two important questions come to mind:

  • First, I’m sure there are other conditions and behaviors that are associated with bad outcomes. Is there parity between the response to this risk factor and other risk factors?
  • Second, how do we put these patients on a pathway to becoming a good candidate for surgery with a good long-term prognosis?

The good news is that most people who use cannabis (and other substances) have mild to moderate use disorders, if they have a disorder at all. For those with severe and chronic problems, we have a great model that could be adapted to the needs of these patients. Unfortunately, this model is only used for health professionals, pilots, and sometimes lawyers. These models deliver outstanding substance use outcomes and are associated with improvements in quality of life.

Those models are built around occupational licenses and maintaining public safety and are intrusive, but can provide a framework for stabilizing patients, recovery management, and monitoring. It’s easy to imagine using higher intensity specialty care up front, ongoing recovery support services (peers and/or mutual aid, for example), and integrating recovery check-ups into the rest of their primary and specialty care.

We have models, and we know people recover every day to become “better than well.” Do we have the will?

One thought on “What’s the pathway to recovery for medical patients?

  1. For me, the topic you raise is a whole category under the broader concern I call “Harms of Use”. https://recoveryreview.blog/2019/10/24/harms-of-use-a-list-of-references/

    Your writing raises awareness of natural consequences (harms) of use that are later factored into medical care. In my experience, these factors and the way they are factored into medical care are often not interesting enough to get wide attention. But when the presence of these kinds of factors end up precluding access to life-saving care, or greatly diminish the odds that an otherwise routinely life-saving medical intervention will work, attention to these factors rises.

    But your writing raises another interesting component: deaths that are greatly delayed and seemed removed from the use itself.

    We all know about fentanyl overdose deaths that arise immediately from simple experimental use of marijuana that has been laced with fentanyl, in someone with no substance use disorder. In that scenario, a young person passes away from overdose and never had a substance use disorder (or any disorder). That is an early death not caused by a disease. But is caused by use.

    By contrast, in the scenario you wrote about, we are forced to consider someone dying years after using due to a disease that might have been treatable – but was less treatable, or not treatable, due to the direct impacts of their substance use. In that scenario, their use occurred in the context of a substance use disorder.

    It is illuminating to consider deaths caused by use in the absence of a use disorder. And it is illuminating to consider deaths caused by an illness where the driver of the death is found in linkages starting with their substance use, rather than the illness alone that they died from.

    Your writing brings the clinical relevance of criteria #9 for SUDs from the DSM-5-TR to the forefront: use in spite of medical or psychological conditions caused or exacerbated by use.


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