A propensity-matched study of over 500 older surgical patients found that those who used cannabis before surgery reported modestly higher pain scores and received slightly more opioids in the first 24 hours after surgery. While statistically significant, the differences were small and the observational design cannot prove cannabis caused the worse outcomes, making these findings a starting point for further research rather than a basis for changing perioperative care.

Cannabis use among older adults has risen sharply over the past decade, yet perioperative guidelines have almost no evidence base specific to this age group. Older surgical patients already face elevated risks from opioid-related respiratory depression, delirium, and falls, making any factor that increases postoperative opioid requirements clinically consequential. Understanding how preoperative cannabis use intersects with acute surgical pain management in geriatric patients is increasingly urgent as surgical volumes and cannabis accessibility both grow in this demographic.

As cannabis legalization expands, an increasing number of older adults present for surgery with some history of cannabis use, raising questions about how this exposure interacts with anesthesia, acute pain, and opioid requirements. Prior studies in younger and mixed-age populations have suggested that cannabis users may experience greater postoperative pain and consume more opioids, but data specific to older adults have been notably absent. This study, drawn from the PRECEDE Bank electronic health record repository at the University of Florida, used a validated natural language processing algorithm with 93% precision and 95% recall to identify cannabis use from unstructured clinical notes, a meaningful methodological advance over ICD-code-only approaches that systematically undercount non-disordered cannabis use.

Among 22,476 patients aged 65 and older undergoing surgery between 2018 and 2020, 126 cannabis users were identified and matched 1:3 to non-users on demographic and clinical covariates. Cannabis users had a median postoperative pain score 0.80 points higher on the 0 to 10 Defense and Veterans Pain Rating Scale (median 4.68 versus 3.88; 95% confidence limits 0.19 to 1.36; p=0.01) and received 12.5 mg more total oral morphine equivalents (42.50 versus 30.00 mg; 95% confidence limits 3.80 to 21.20 mg; p=0.02) in the first 24 hours. These differences were statistically significant but numerically modest. No data on cannabis dose, frequency, route, or THC/CBD composition were available, and the single-center retrospective design with a small exposed group means these findings should be considered hypothesis-generating rather than definitive. The authors appropriately call for prospective, multi-center studies with more granular exposure characterization.

This study does something genuinely useful by deploying NLP to catch cannabis use that would otherwise slip through the cracks of standard coding. That methodological step alone makes it worth paying attention to. What the study gets right is asking the right question of the right population. What it cannot do, and the authors are appropriately transparent about this, is tell us why cannabis users had modestly higher pain and opioid use. The differences, while statistically significant, are on the order of less than one point on a ten-point pain scale and about one additional dose of a mild opioid. We do not know whether these patients had higher baseline pain burdens, greater anxiety, or underlying conditions that led to both cannabis use and more postoperative discomfort.

In my practice, I routinely ask older surgical candidates about cannabis use, not to withhold it but to plan more thoughtfully around perioperative pain management. If a patient has been using cannabis regularly, I coordinate with anesthesia colleagues to ensure multimodal analgesia strategies are in place and expectations are set for both the patient and the care team. This study reinforces the importance of that conversation without justifying any reflexive decision to alter cannabis recommendations preoperatively.

This study sits at an early but important position in the research arc concerning cannabis and perioperative care in geriatric patients. It builds on a handful of studies in younger or mixed-age populations that have found similar associations, most notably work by Liu and colleagues and by Hah and colleagues in general surgical cohorts. What it adds is age-specific data and a more sensitive exposure detection method. However, the absence of dose-response data, the inability to distinguish daily heavy users from occasional users, and the lack of information about whether patients used cannabis for chronic pain (which itself predicts higher postoperative opioid requirements) are significant gaps that prevent translation into specific perioperative protocols.

From a pharmacological standpoint, the theoretical concern is that chronic cannabinoid receptor activation may lead to cross-tolerance with opioid pathways, though evidence for this in humans remains limited and inconsistent. Clinicians should also consider that older adults metabolize both cannabinoids and opioids differently, and polypharmacy in this population raises drug-interaction concerns that this study was not designed to address. The most actionable recommendation from this evidence is straightforward: routinely screen older preoperative patients for cannabis use through direct questioning, document it clearly, and incorporate this information into multimodal pain management planning rather

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