Activation of cannabinoid receptors has been shown to enhance dopamine,which may be another pathway by which marijuana affects sexual function. Cannabinoid receptors have also been localized to other areas of the brain that control sexual function, including the hypothalamus, prefrontal cortex, amygdala, and hippocampus.Serum levels of endocannabinoids have been correlated with both subjective and objective measures of arousal.6 The strength and weakness of this study is that it is a single center study, which allows consistency of patient recruitment but does not allow for assessment of generalizability. It relied on women’s memory and perceptions of the sexual experience; however, it is real life, and all questionnaires rely on recall. It did not address the context of the relationship, co-use with other drugs, or the timing and quantity of marijuana use before sex, all of which contribute to the memory of the sexual experience. It does not specifically ask whether the marijuana was taken because the patient had the perception that it would enhance performance, which would be an inherent bias. This may be less likely because women who were frequent users  had the same positive relationship with improvement in satisfying orgasm. A further study could address the specific timing of marijuana use on the sexual domains though this would be difficult unless patients were enrolled in a study that required certain timing .Marijuana use dates back to 2727 BC to Chinese Emperor Shen Nung. After spreading through the Greek and Roman empires and into the Islamic empire of North Africa and the Middle East, it was brought to the Western hemisphere by the Spanish.

Originally lauded for its utility as fiber, it was not until its migration into North America that it began to be used in a similar fashion as it is today. Used in the form of hemp, it was seen throughout society as rope, clothing and even paper. While marijuana has been used by Americans recreationally for years, it is a subject that is becoming more commonplace in our modern society. According to the National Institutes of Health, marijuana use in 2015e2016 rose from 4.1% to 9.5% of the U.S. adult population. With more states eliminating the legal ramifications of its use and a growing debate about its federal legality, this is a subject that routinely makes local and national headlines. With a diverse array of commercial products becoming available from chocolate squares to oral sprays, cannabis grow racks is also no longer restricted to a rolled cigarette. The medical community has also joined the debate. The most obvious correlation between medicine and marijuana is medicinal marijuana. Marijuana’s effects have been well documented, allowing the push for its use as medicine within multiple specialities. Proponents of its use point to its effects on the endocannabinoid system. Studies show that through its impact on different pathways it may be used as an analgesic, immunosuppressant, muscle relaxant, anti-inflammatory agent, appetite modulator, antidepressant, antiemetic, bronchodilator, neuroleptic, antineoplastic and antiallergen.Medical marijuana also differs in chemical composition, containing a higher tetrahydrocannabinol  concentration and less cannabinol than the recreational version. This is even before taking into consideration the various extraneous agents that may be found within the available recreational drug.There is however, very little, if any research evaluating marijuana’s use in surgery. This paucity of literature presents a problem. While many surgeons may ask about recreation drug use including marijuana, many other drugs have established evidence based outcomes that allow variation in surgical planning as needed.

However, when it comes to marijuana, surgeons are left to determine what to do with this information on their own.Despite the multiple studies on the physiologic effects of marijuana use, clinical studies, if any, are not cited in the medical literature. This study reviews the literature available on marijuana’s effects and discusses potential complications that may result within the surgical setting. With a reported estimation of 10%e20% of patients between the ages of 18 and 25 years regularly using marijuana, this review seeks to become an initial step for further exploration of the subject and to reveal why there is a need for more in-depth research.A search on the effects of marijuana, marijuana and elective surgery, and marijuana’s effects on surgery was undertaken in PubMed, Medline, EMBASE, Google.com and Scholar.google.com. Articles were reviewed using the keywords “marijuana,” “elective surgery,” “surgery,” “anesthesia,” “complication,” “THC,” “tobacco” and “cannabis.” After removing duplicates, 263 studies resulted. After articles were identified, attention was paid to study design, type, outcomes and publication. The authors independently reviewed titles and abstracts to ascertain relevance to the topic at hand. Authors also searched reference lists of included studies as well as other narrative reviews.Due to limited research and reviews on this subject, information was utilized from articles on surgery in various fields, such as orthopedic, dental and bariatric with anesthesia considerations and general topics related to marijuana also examined. The following information was gathered: marijuana’s prevalence in the United States, marijuana’s effects on the cardiovascular system and pulmonary system, potential coagulopathies, marijuana’s effects in relation to anesthesiology, evidence based screening methods for recreational drug use, potential surgical complications that may result from marijuana use, and recommendations on marijuana use and surgery.When marijuana is smoked, THC and other cannabinoids are absorbed rapidly through the lungs with effects peaking in 15 minutes.

These effects can persist for up to a dose-dependent 4 hours in the acute setting. When ingested orally however, onset of effects is slower  but has a longer duration of action,due to continued absorption in the gut. This is despite a lower bioavailability due to first-pass metabolism by the liver which results in a blood concentration 25% of what is obtained if smoked. The cognitive/psychomotor effects can be present for up to 24 hours regardless of administration route. Cannabinoids are highly lipid soluble. This leads to a slow release into the bloodstream with a single dose not fully eliminated for up to 30 days. The cardiovascular effects of marijuana use range from benign to worrisome based on the timeline of use and dosage. In a series single blind study comparing the effects of high and low doses of THC in healthy young men, tachycardia was induced beginning within the time of inhalation, and persisting at least 90 minutes, with the maximum heart rate reached at an average of 30 minutes. The study also found a significant elevation in systolic and diastolic blood pressures as well as the presence of premature ventricular contractions in subjects who received the higher doses. These experiments showed a correlation between the dose and the tachycardic and cardiovascular changes. In addition, Malit et al.’s study on the effects of intravenous THC found the majority of patients to exceed the 100 beats per minute mark but also experience intermittent spikes in heart rate with a possible etiology of psychological distress. Beacons field et al. postulated a mechanism of beta adrenergic stimulation for the tachycardia as he was able to block the tachycardia with the use of propranolol.Pharmacology lays credence to this. At lower or moderate doses, marijuana increases sympathetic activity reducing parasympathetics and producing an elevation in heart rate, cardiac output and blood pressure. However, the opposite is true as the dosage increases.

At high doses, the parasympathetic system takes over, leading to bradycardia and hypotension with animal studies postulating that the sympathetic inhibition occurs due to the bio-active constituent of cannabis’s effects on the CB1 receptors. In addition to sinus tachycardia, marijuana use has been linked to multiple electrocardiogram  changes in various case reports. Daccarrett et al. found Brugadalike changes in a 19 year old male with a known history of cannabis use and no anatomical/functional abnormalities. A case was also reported in which cannabis use was linked to the development of atrial flutter and atrial fibrillation, while other studies have reported the presence of sinus bradycardia and AV block.Marijuana use also has a role as a risk factor for myocardial infarction. Aronow et al., found that while comparing marijuana to placebo, cannabis causes an increase in carboxyhemoglobin, a resultant increase in myocardial oxygen demand, decrease in oxygen supply as well as an induction of platelet aggregation. One case report showed a 21 year old male who presented with a ST elevation myocardial infarction due to plaque rupture as a complication of marijuana use. In Mittleman et al.’s analysis of over 3,800 cases of myocardial infarction, 124 patients reported use within the last year of which 37 reported use within 24 hours, with 9 reporting use within an hour of the event. The study found a statistically significant 4.8 fold increase in myocardial infarction within the first hour of marijuana use.In fact, as THC content of marijuana increases, there are a growing number of clinical studies demonstrating the association between cannabis use and adverse cardiovascular events. One such study followed 1913 adults prospectively and demonstrated that in patients with prior myocardial infarction, marijuana use up to once per week increased risk of death 2.5 fold while more frequent use yielded a fourfold risk of dying. Marijuana has also been reported as a risk factor for stroke. Over 80 cases have been reported in which patients had strokes, with a higher prevalence of ischemic strokes, that were associated with either a recent increase, in the days leading up to the event, or chronic history of heavy marijuana use.

They believed that the marked swings in blood pressure or the reversible cerebral vasoconstriction that resulted from cannabis grow system use were likely mechanisms of stroke but admitted that no firm conclusions could be drawn without further studies.In addition, Lawson reported a similar belief that drug induced vasospasm was a plausible explanation for TIAs, but also with the caveat that due to the confounding medications/illicit substances being used in his patient, no direct association could be determined. Also of interest is marijuana use’s effect on other cardiovascular vessels. When cohort studies were performed comparing marijuana users with resultant limb arteritis to patients suffering from thromboangiitis obliterans, marijuana associated arteritis occurred in younger, usually male patients with a unilateral, lower limb as the common presentation. The most common route of marijuana administration is inhalation via smoking. Due to the unfiltered nature of the marijuana cigarette compared to commercially available tobacco cigarettes, the amount of carcinogens and irritants, like tar, that enter the upper airway is increased with approximately a three-fold increase in tar inhalation and one third more tar deposition in the respiratory tract. More specifically, the tar produced from cannabis smoke contains greater concentration of benzanthracenes and benzopyrenes  than tobacco smoke. In addition, as compared to smoking tobacco, there is a two-thirds greater puff volume, one-third greater depth of inhalation and a four-fold longer breath-holding time, all of which are common practices to try to maximize THC absorption, which is around 50% of cigarette content. These practices result in five times the amount of carboxyhemoglobin levels as compared to the typical tobacco smoker despite the presence of similar quantities of carbon monoxide from the incomplete combustion of the organic compounds found within each product. In reporting his case, Schwartz theorized that high temperatures in which marijuana burns compared to tobacco may increase the irritancy of marijuana to the mucous membranes. While the higher temperature is a possibility, the evidence of marijuana’s irritancy is well documented. In a cohort study comprised of 40 healthy patients, Roth et al. showed that cannabis smokers had significantly increased visual bronchitis index scores resulting from large airway epithelial damage, edema, and erythema. On mucosal biopsy, goblet cell hyperplasia with subsequent increase in secretions, loss of ciliated epithelium and squamous metaplasia were also present in 97% of smokers. They concluded that marijuana use is associated with airway inflammation that is similar to that of a tobacco smoker. A cross-sectional study on over 6000 patients, from 1988 to 1994, found an increased incidence of chronic bronchitis symptoms such as wheezing and productive cough occurring in patients 10 years younger, on average, than tobacco smokers. Case-control trials performed found similar findings with regards to increases in wheezing, shortness of breath, cough and phlegm as well as the similarities with tobacco use.