# Cannabis and Nicotine Before Spine Fusion: Insights from a Large Cohort Study

> **Author:** Benjamin Caplan, MD (ABFM Board Certified, MA Lic. #240562, NPI: 1962722637)
> **Publisher:** CED Clinic (https://cedclinic.com)
> **Canonical URL:** https://cedclinic.com/cannabis-use-before-spine-surgery-risks-outcomes/
> **Published:** 2026-07-18T17:24:54-04:00 | **Last Modified / Clinically Audited:** 2026-09-28T10:48:48-04:00
> **Clinical Summary:** Explore cannabis use before spine surgery and its impact on postoperative outcomes, highlighting risks and the need for preoperative screening.

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CED Clinical Relevance #82 High Clinical Interest A June 2026 cohort of more than 144,000 spine fusion patients directly challenges the common assumption that cannabis eases perioperative pain, showing higher complication and opioid-related risk instead, with clear implications for preoperative screening.

Clinical Insight | CED Clinic
A June 2026 retrospective cohort study in the North American Spine Society Journal examined how documented cannabis and nicotine use relate to outcomes after cervical and lumbar interbody fusion. Using deidentified records from more than 144,000 adults across a national research network, the authors compared patients with no substance-use diagnosis, nicotine-only use, cannabis-only use, and concurrent use. Cannabis-only use, defined through cannabis-related disorder or poisoning codes rather than casual recreational use, tracked with higher odds of several adverse outcomes, including radiculopathy, [chronic pain](https://cedclinic.com/cannabinoids-pain-management-opioid-alternative/), psychiatric complications, opioid use disorder, and increased hospital utilization. Concurrent cannabis and nicotine use carried the broadest risk elevation across nearly every domain measured.

Spine SurgeryPerioperative Risk[Cannabis Use Disorder](https://cedclinic.com/sex-differences-cannabis-stress-reactivity-oxytocin/)NicotineCohort Study

Audience
Spine surgeons, anesthesiologists, primary care and pain physicians counseling patients before elective fusion, and patients with documented cannabis or nicotine use considering cervical or lumbar spine surgery

Primary Topic
A retrospective cohort study of cannabis and nicotine use and postoperative outcomes after cervical and lumbar interbody fusion

Source
[Read the full study in N Am Spine Soc J](https://pubmed.ncbi.nlm.nih.gov/42434720/)

## Cannabis and Nicotine Before Spine Fusion: What a 144,000-Patient Cohort Study Found

A June 2026 cohort study of more than 144,000 spine fusion patients found that documented cannabis-related diagnoses, not casual [cannabis use](https://cedclinic.com/cannabis-cardiovascular-health-insights-2024/), tracked with higher odds of pain, psychiatric, and opioid-related complications after surgery. Patients with both cannabis and nicotine diagnoses showed the broadest risk elevation, and the findings support preoperative screening rather than any assumption that cannabis reduces opioid needs after fusion.

What This Study Teaches Us
The study teaches that documented [cannabis use](https://cedclinic.com/cannabis-cardiovascular-health-insights-2024/) before spine fusion is not the opioid-sparing advantage some patients expect. Patients with cannabis-related diagnoses showed higher rates of pain, psychiatric, and opioid-related complications, and those who also had documented nicotine use showed the broadest risk elevation across neurologic, surgical, medical, and utilization outcomes.

Why This Matters
Many patients believe cannabis will ease their postoperative pain and reduce opioid needs after major spine surgery. This study challenges that assumption directly: rather than showing a protective, opioid-sparing signal, documented cannabis use identified a subgroup of patients with more complications and greater healthcare utilization after fusion, particularly when nicotine use was also present.

Study Snapshot

Study Type
Retrospective cohort study using a federated national EHR database

Data Source
TriNetX Research Network (over 200 US healthcare organizations)

Population
144,488 adults undergoing primary cervical or lumbar interbody fusion, 2015 to 2022

Groups Compared
Nonusers (75.4%), nicotine-only (23.1%), cannabis-only (0.4%), concurrent cannabis and nicotine (1.2%)

Cannabis Definition
ICD-10 cannabis-related disorder or cannabis poisoning codes, reflecting documented problematic use, not general recreational use

Key Finding, Cannabis-Only
Higher odds of radiculopathy, cauda equina syndrome, [chronic pain](https://cedclinic.com/cannabinoids-pain-management-opioid-alternative/), myocardial infarction, acute respiratory failure, acute kidney injury, depression, opioid use disorder, rehospitalization, and ED use

Key Finding, Concurrent Use
Broadly elevated risk across neurologic, surgical, medical, psychiatric, and utilization outcomes, generally the highest adjusted odds of any group

Notable Null Finding
Venous thromboembolism was not significantly associated with any exposure group

Journal
North American Spine Society Journal

Published
June 10, 2026

PMID
42434720

DOI
10.1016/j.xnsj.2026.100915

Clinical Bottom Line
Documented cannabis use before spine fusion, and especially combined cannabis and nicotine use, identified a higher-risk surgical population rather than an opioid-sparing one, supporting routine preoperative screening and counseling rather than any assumption of protective benefit.

What the Cohort Actually Found

Among 144,488 adults who underwent cervical or lumbar interbody fusion, the 540 patients with a documented cannabis-only diagnosis had higher adjusted odds of radiculopathy, cauda equina syndrome, chronic pain, myocardial infarction, acute respiratory failure, acute kidney injury, depression, and opioid use disorder, along with more rehospitalizations and emergency department visits.

The 1,677 patients with both cannabis and nicotine diagnoses fared the worst overall, with broadly elevated risk spanning neurologic, surgical, medical, psychiatric, and healthcare-utilization outcomes, including higher rates of infection and pseudarthrosis.

Cannabis Did Not Look Opioid-Sparing Here

Cannabis is often used because patients and some clinicians expect it to ease pain and reduce opioid requirements after surgery. This cohort found the opposite pattern: rather than demonstrating a protective, opioid-sparing effect, documented cannabis-related diagnoses identified patients with more opioid-related complications, not fewer.

The authors frame this as a marker of perioperative vulnerability rather than evidence that cannabis itself directly worsens fusion outcomes.

Why This Is a Risk Marker, Not Proof of Cause

This is a retrospective, registry-based study, not a randomized trial, and it cannot establish that cannabis use directly causes worse surgical outcomes. Patients with a documented cannabis-related disorder or poisoning code likely differ from average cannabis users in ways the database cannot fully capture, including heavier use patterns, other substance use, mental health comorbidity, and socioeconomic factors that independently affect surgical recovery.

Because cannabis exposure was defined by clinically coded diagnoses rather than a validated use questionnaire, the findings describe a subgroup of patients with a documented problematic-use history, not cannabis users in general, including many [medical cannabis](https://cedclinic.com/therapeutic-benefits-of-thc/) patients who would never receive such a diagnosis code.

What Preoperative Counseling Should Sound Like

For patients using cannabis before elective spine fusion, the responsible counseling message is not that cannabis use guarantees a bad outcome. It is that a documented cannabis-related diagnosis, especially alongside nicotine use, identifies a group whose perioperative risk profile deserves specific attention, transparent disclosure, and coordinated planning before surgery.

Surgeons and primary care clinicians should ask directly about cannabis and nicotine use before elective fusion, document it accurately, and use that information to inform realistic expectations about pain control, complication risk, and recovery, rather than assuming cannabis will reduce postoperative opioid needs.

How Strong Is This Evidence?
This analysis is stronger than a single-center case series because it draws on a federated national database of more than 144,000 surgical patients with multivariable adjustment for demographics, comorbidities, spine region, and surgical approach. It remains an observational, registry-based study, so it can identify associations and risk-stratify patients but cannot prove that cannabis or nicotine use directly causes the complications observed.

Where This Paper Deserves Skepticism
Readers should be cautious about two things: the cannabis-exposed group was small relative to the full cohort, 540 cannabis-only and 1,677 concurrent users out of 144,488, so estimates for cannabis-only outcomes rest on comparatively few patients, and the exposure definition itself, ICD-10 cannabis-related disorder or poisoning codes, selects for patients with clinically documented problematic use rather than the broader population of people who use cannabis, including many therapeutic or infrequent users who would not receive such a code.

What This Paper Does Not Show
This study does not show that cannabis use in general worsens spine fusion outcomes, since the cannabis-exposed group reflects clinically diagnosed cannabis-related disorder or poisoning, not typical medical or recreational cannabis use. It also does not identify a specific dose, product, route, or frequency threshold associated with risk, and it does not prove a causal mechanism linking cannabis to the complications observed.

How This Fits With the Broader Clinical Conversation

Perioperative cannabis counseling has often been shaped by anecdotal reports of pain relief and opioid-sparing potential, with comparatively few large studies looking directly at surgical complication data.

This cohort adds to a growing body of orthopedic and spine literature, including prior work on cannabis and revision risk after lumbar fusion, suggesting that documented cannabis use, particularly when combined with nicotine, is more often a marker of perioperative vulnerability than a therapeutic advantage in the surgical setting.

Dr. Caplan’s Take

*Patients frequently tell me they expect cannabis to help them get through surgery with less pain and fewer opioids. This study is a useful reality check: a documented cannabis-related diagnosis in this cohort tracked with more complications, not fewer, and combined cannabis and nicotine use tracked with the broadest risk of all.*

*My takeaway for my own patients considering spine surgery is not to abandon cannabis use as a talking point, but to bring it into the open. I would rather know about a patient’s cannabis and nicotine use well before surgery, discuss realistic expectations for pain control, and coordinate perioperative planning than have that information surface only after a complication.*

What a Careful Reader Should Take Away
A careful reader should conclude that documented cannabis use before spine fusion, especially combined with nicotine use, flags a higher-risk surgical population that benefits from proactive screening and counseling, not that cannabis use itself has been proven to cause worse fusion outcomes.

Evidence Interpretation Guide

## How to Read a Large Registry Study Without Overclaiming Causation

Large database studies like this one are powerful for spotting patterns across huge populations, but they are easy to overread if a reader treats an association as proof of a direct cause.

The most useful approach is to separate what the numbers show from what they can plausibly explain.

### A Four-Step Reading Frame

**Start With the Data Source**This is a retrospective analysis of deidentified electronic health records from a federated research network, not a randomized trial, so it excels at detecting associations across a large population but cannot isolate cause and effect.

**Look Closely at How Exposure Was Defined**Cannabis use here means a clinically coded cannabis-related disorder or poisoning diagnosis, a narrower and more severe definition than cannabis use in general, which shapes how far the findings can be generalized.

**Separate Cannabis-Only From Concurrent Use**Cannabis-only use and combined cannabis-and-nicotine use showed different risk patterns, with concurrent use carrying the broadest elevation, so lumping every substance-use group together would blur an important distinction.

**Translate the Result Into Screening, Not Prohibition**The most defensible clinical use of this study is to support routine preoperative screening and counseling, not to withhold surgery from patients who use cannabis or to assume every cannabis user faces the same risk.

The Research Question
Do documented cannabis and nicotine use, independently and combined, track with worse outcomes after cervical or lumbar interbody fusion in a large national patient sample?

The Patient Question
If I use cannabis and I’m considering spine fusion, does this study mean my surgery will go badly, or does it mean my care team should know about my cannabis and nicotine use so they can plan around it?

The Bottom Line
The study supports proactive screening and honest disclosure rather than either reassurance or alarm about a single patient’s outcome.

CED Perspective Lens

## The Same Study Can Mean Different Things Depending on the Question Being Asked

Scientific papers rarely answer a single question. Patients, clinicians, researchers, policymakers, and critics often read the same data differently. The perspectives below explore how this study looks through several evidence-based lenses.

Lens Overview
This cohort study reads differently depending on whether you are a patient, spine surgeon, anesthesiologist, addiction-medicine clinician, or research methodologist. These lenses keep the takeaways precise rather than overstated.

#### Disclosure Matters More Than Guilt

If you use cannabis and are considering spine fusion, this study is not a reason to panic or to hide your use from your surgical team. The point is that documented cannabis use, especially alongside nicotine, was linked to more complications, so your care team needs accurate information to plan your surgery and recovery well.

Being honest about cannabis and nicotine use before surgery gives your surgeon and anesthesiologist the chance to adjust expectations, monitoring, and pain-control planning around your specific risk profile.

Lens takeaway
Disclosing cannabis and nicotine use before spine surgery is more protective than concealing it.

#### A Case for Routine Preoperative Screening

For spine surgeons, this cohort reinforces that cannabis-related diagnoses deserve the same systematic preoperative attention already given to nicotine use, since both independently and jointly tracked with worse outcomes across neurologic, surgical, medical, and utilization measures.

The authors explicitly recommend routine preoperative screening and targeted counseling, which this data set supports given the scale of the sample and the consistency of findings across cervical and lumbar procedures.

Lens takeaway
Preoperative cannabis screening deserves the same routine attention as nicotine screening.

#### Planning Around Documented Use, Not Assumptions

Anesthesiologists and perioperative teams may be interested that concurrent cannabis and nicotine users showed the broadest risk elevation, which argues for coordinated planning across surgical and anesthesia teams rather than treating cannabis as a minor detail.

This study does not provide guidance on perioperative cannabis cessation timing or anesthetic dosing adjustments, so those decisions still rely on separate clinical protocols and judgment.

Lens takeaway
Coordinated perioperative planning should account for both cannabis and nicotine status, not just one or the other.

#### The Exposure Definition Is the Whole Story

From an addiction-medicine perspective, the most important detail in this study is that cannabis exposure was defined by a diagnosed cannabis-related disorder or poisoning code, not simple cannabis use. That means the cannabis-only group likely already carried more clinical severity, more comorbidity, and less social stability than a typical [medical cannabis](https://cedclinic.com/therapeutic-benefits-of-thc/) patient.

This distinction matters enormously for how the findings should be applied to the much larger population of people who use cannabis without ever receiving such a diagnosis.

Lens takeaway
The findings describe a clinically severe subgroup, not cannabis users broadly.

#### Utilization Signals Are as Important as Complication Rates

Beyond individual complications, the study found higher rehospitalization and emergency department use among cannabis-only patients, and broadly elevated utilization among concurrent users. From a patient-safety standpoint, that utilization signal is itself clinically meaningful, since it points to a group needing closer post-discharge follow-up.

Health systems planning post-fusion care pathways may want to flag documented cannabis and nicotine use as risk factors for early return visits, independent of any single complication type.

Lens takeaway
Elevated healthcare utilization after discharge is itself a safety signal worth planning around.

#### Small Exposed Groups, Big Claims Risk

A skeptical reader should note that the cannabis-only group included only 540 of 144,488 patients, a small fraction of the total cohort. Estimates built on a comparatively small, clinically severe subgroup can be sensitive to unmeasured confounding and coding inconsistencies across the many contributing health systems.

Skepticism here should sharpen the takeaway, not erase it: the direction and consistency of the associations across multiple outcome domains make the signal worth taking seriously, even while the precision of any single estimate should be interpreted cautiously.

Lens takeaway
Respect the consistent direction of the signal while staying cautious about precision in the smaller exposure groups.

#### Real Strength, Real Limits of Registry Data

Methodologically, this study benefits from a large, multi-institution federated database and multivariable adjustment for demographics, comorbidities, spine region, and surgical approach, which is a meaningful strength compared with single-center case series.

It remains limited by its reliance on ICD-10 coding to define exposure, its retrospective design, and its inability to capture cannabis product type, dose, frequency, or route, all of which limit causal interpretation and mechanistic understanding.

Lens takeaway
Large registry data can detect robust associations but cannot substitute for prospective, exposure-validated research.

#### What Better Perioperative Cannabis Evidence Would Need

Stronger future research would need validated, self-reported cannabis use data alongside clinical coding, information on product type, dose, frequency, and timing relative to surgery, and prospective designs that can better separate cannabis’s direct physiological effects from the comorbidities associated with a cannabis-related disorder diagnosis.

Until that research exists, this study is best used as a screening and counseling tool rather than a definitive statement about cannabis and surgical risk.

Lens takeaway
The next research step is validated exposure data, not just larger sample sizes.

Join the Conversation

Have a question about how this applies to your situation? [Ask Dr. Caplan](https://benjamincaplan.com/ask-dr-caplan)

Want to discuss this topic with other patients and caregivers? [Join the forum discussion](https://cedclinic.com/interact/discussion-forums/forum/cannabis-industry/)

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Source: [Independent and combined associations of cannabis and nicotine use with postoperative outcomes after cervical and lumbar interbody fusion: a retrospective cohort study.](https://pubmed.ncbi.nlm.nih.gov/42434720/)

Related Reading at CED Clinic
Continue exploring the evidence

[Cannabis Before Lumbar Fusion: What the Revision-Risk Meta-Analysis Actually Shows](https://cedclinic.com/lumbar-fusion-revision-risk-cannabis/)

An earlier CED evidence report on a meta-analysis linking cannabis use with higher odds of revision surgery after lumbar fusion, useful for comparing a pooled meta-analytic signal with this larger single-cohort study.

[Compare the revision-risk evidence](https://cedclinic.com/lumbar-fusion-revision-risk-cannabis/)

[Cannabis Use in Orthopaedic Surgery: Effects on Fracture Healing, Opioid Requirements, and Clinical Outcomes](https://cedclinic.com/cannabis-effects-bone-healing-orthopaedic-surgery-review/)

A broader CED review of cannabis and orthopedic surgical outcomes, including fracture healing and opioid requirements, for context beyond spine-specific procedures.

[Read the orthopedic surgery review](https://cedclinic.com/cannabis-effects-bone-healing-orthopaedic-surgery-review/)

[A Synthetic Cannabinoid Did NOT Reduce Opioid Use After Knee Replacement Surgery](https://cedclinic.com/cannabinoids-postoperative-opioid-use-knee-replacement/)

A randomized postoperative trial that also challenged the assumption that cannabinoids reliably reduce opioid use after major orthopedic surgery.

[Read the knee-replacement trial coverage](https://cedclinic.com/cannabinoids-postoperative-opioid-use-knee-replacement/)

## Frequently Asked Questions

Does this study prove cannabis use causes worse outcomes after spine fusion?

No. It is a retrospective cohort study that found associations between documented cannabis-related diagnoses and worse outcomes, but it cannot prove that cannabis use directly causes those complications.

How was cannabis use defined in this study?

Cannabis exposure was identified using ICD-10 codes for cannabis-related disorder or cannabis poisoning, meaning the cannabis-only group reflects clinically documented problematic use rather than general recreational or medical cannabis use.

What outcomes were worse in cannabis-only patients?

Cannabis-only patients had higher odds of radiculopathy, cauda equina syndrome, chronic pain, myocardial infarction, acute respiratory failure, acute kidney injury, depression, opioid use disorder, and increased rehospitalization and emergency department use.

Did cannabis reduce opioid use after spine fusion in this study?

No. Rather than showing an opioid-sparing effect, documented cannabis-related diagnoses were associated with more opioid-related complications, not fewer.

What happened in patients who used both cannabis and nicotine?

Concurrent cannabis and nicotine users showed the broadest risk elevation of any group, with higher rates across neurologic, surgical, medical, psychiatric, and healthcare-utilization outcomes, including infection and pseudarthrosis.

Was blood clot risk higher in cannabis or nicotine users?

No. Venous thromboembolism was not significantly associated with any exposure group in this study.

How many patients were in the cannabis-only group?

540 of the 144,488 patients in the cohort were classified as cannabis-only users, a small fraction of the total sample, which should temper confidence in the precision of that group’s estimates.

Does this study apply to all cannabis users considering spine surgery?

Not directly. Because cannabis exposure was defined by a diagnosed cannabis-related disorder or poisoning code, the findings describe a more clinically severe subgroup and may not generalize to typical medical or occasional cannabis users.

What should patients do with this information before spine surgery?

Patients should disclose cannabis and nicotine use to their surgical and anesthesia teams so that realistic expectations, monitoring, and perioperative planning can be built around their individual risk profile.

What is the most practical clinical takeaway from this study?

The most practical takeaway is that documented cannabis use, and especially combined cannabis and nicotine use, should prompt routine preoperative screening and counseling rather than an assumption that cannabis will ease recovery or reduce opioid needs.

 

 

 

### Related

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### Verification & Medical Governance

- **Lead Clinical Author:** Benjamin Caplan, MD
- **Credentials:** Board Certified in Family Medicine (ABFM), Former CMO Canna Care Docs (250,000+ patients supervised), Founder & CMO CED Clinic & CED Foundation, Author of *The Doctor-Approved Cannabis Handbook* (Penguin Random House).
- **Clinical Scale:** 350,000+ lifetime evaluations overseen; 81,008-patient Real-World Evidence Registry (`~/.ced_rwe_vault.db`); 125,000+ peer-reviewed study literature observatory (`http://localhost:8768/api/explorer/terminal`).
- **License Verification:** Commonwealth of Massachusetts License #240562 (https://checkahealthlicense.mass.gov/).
- **NPI Registry:** 1962722637 (https://npiregistry.cms.hhs.gov/provider-view/1962722637).
- **Ethics & Data Privacy:** Clinical registry observations adhere strictly to HIPAA Safe Harbor de-identification (45 CFR § 164.514(b)) and criteria for secondary research exemption under 45 CFR § 46.104(d)(4).