Cannabis smokers may need more anesthesia during upper endoscopy

Patients who smoke or vape cannabis may need more anesthesia during an upper endoscopy than those who use edibles or do not use cannabis, according to a new study presented at the ANESTHESIOLOGY^® 2026 annual meeting.

The study suggests "not all cannabis is equal" when it comes to sedation during procedures, and that the route of cannabis use may matter for anesthetic planning.

The most important message for patients is to be honest with their anesthesiologist about cannabis, including how they use it - smoking, vaping or edible products - how often they use it and when they last used it. For physicians, simply asking, 'Do you use cannabis?' may no longer be sufficient."

Basavana Goudra, M.D., FCARCSI, FRCA, FASA, lead author of the study and anesthesiologist, Sidney Kimmel Medical College, Philadelphia

The study authors, who included Katherine Green from Johns Hopkins University in Baltimore and Ankitha Jagadeesh from Rutgers University in New Brunswick, New Jersey, reviewed 280 gastrointestinal endoscopic procedures (i.e., colonoscopies and upper endoscopies) at a single center. The analysis included 264 patients with complete information about their cannabis use: 217 non-users, 38 who reported inhaled use and nine who reported oral use, such as gummies or other edibles.

When the researchers looked at all cannabis users together, they found no significant difference in the initial propofol dose compared to non-users. But when they separated patients by how they used cannabis, a sharper pattern emerged.

Overall, the average initial propofol dose was 138.7 mg among non-users, 168.5 mg among those who inhaled cannabis and 114.2 mg among those who consumed it orally. This suggests that, unlike those who smoked or vaped cannabis, those who used edibles did not appear to have the same increased need for propofol, although the edible group was small.

The difference was most substantial among patients undergoing upper endoscopy (EGD). Patients who inhaled cannabis required substantially higher doses during EGD, a procedure where an endoscope, a thin tube with a camera used to look inside the body, passes through the patient's mouth, throat and upper airway. In EGD patients, inhaled cannabis users required 192.8 mg of propofol, compared to 151.4 mg among non-users and 145.0 mg among oral cannabis users. No meaningful differences were observed among patients undergoing colonoscopy.

The findings may help explain conflicting results in earlier research on cannabis and anesthesia, which often grouped cannabis users together without distinguishing how they consumed it. Inhaled and edible cannabis products are processed differently by the body. Smoking or vaping delivers tetrahydrocannabinol (THC), the main psychoactive component in cannabis, rapidly through the lungs, while edible THC is processed through the liver, producing different metabolites and changing how quickly the effects begin and how long they last. The researchers also noted that regular inhalation of cannabis may irritate the upper airway, potentially requiring deeper anesthesia to help patients tolerate the endoscope.

The authors said the results do not suggest patients who inhale cannabis should delay or avoid medically necessary endoscopy. Instead, the findings underscore the importance of sharing complete and accurate information before a procedure so anesthesiologists can anticipate sedation needs and tailor care to the patient.