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.
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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?