Bill Klaproth (Host): This is an AAOMS On the Go Podcast. I'm Bill Klaproth. And with me is Dr. Pooja Gangwani and Dr. Antonia Kolokythas. They are two of the recipients of the 2024 OMS Foundation Daniel M. Laskin Award. Dr. Gangwani and Dr. Kolokythas, welcome.

Dr. Antonia Kolokythas: Hi, Bill. Good to be here.

Dr. Pooja Gangwani: Hey, Bill. It's a pleasure. Thanks for having us.

Host: Absolutely. Great to talk with both of you. So, congrats are in order. The JOMS Editorial Board selected your research, “Is Recreational Marijuana Use Associated With Changes In The Vital Signs or Anesthetic Requirements During Intravenous Sedation?”, for the Foundation's Laskin Award. So, congratulations to you again and your co-authors. This is really cool. Looking forward to talking to you both about this. So, Dr. Kolokythas, let me start with you. So, what was your reaction to receiving this recognition?

Dr. Antonia Kolokythas: Bill, as you stated, this is the most prestigious award we can receive in our specialty from the OMFS Foundation. So, having this recognition is absolutely a spectacular accomplishment for all the authors of this group, and we're very grateful to be the recipient of the Daniel M. Laskin Award.

Host: Yeah, you've got to be very proud. Like you said, this is a big award. And Dr. Gangwani, I'm sure you felt the same way.

Dr. Pooja Gangwani: I did, Bill. I felt deeply honored and incredibly grateful, like Dr. Kolokythas mentioned. And it was a great, pleasant surprise. This award and recognition represents countless hours of teamwork, and I feel so proud and satisfied of what our team has accomplished together. And receiving such a prestigious award also reinforces that we're on the right track, you know.

Host: Absolutely. Great thoughts, Dr. Gangwani. Dr. Gangwani, let me stay with you for a minute. So, you talked about the countless hours that you and your team put into this. What led you and your team to pursue this research topic? And what was the development process?

Dr. Pooja Gangwani: Sure. You know, the idea of this research question was conceived in 2021. I was at University of Rochester with Dr. Kolokythas. And as we all know, recreational marijuana use in the United States has continued to increase since its legalization by many states. And what we were seeing that most of our patients were using recreational marijuana. And what we were noticing is difficulty with patients who were marijuana users during their office-based ambulatory anesthesia. And by that, I mean patients would require more anesthetic medications and sedating them would be challenging. And I guess what we were experiencing at our institution was pretty similar to what our colleagues were seeing at their respective practices as well. And at that time in 2021, there were no studies in the OMS literature on this topic. And you know, we decided to study it.

Host: Well, it really makes sense with the advent of the legalization of marijuana in some states. It really makes a lot of sense to try to put this research together and try to learn more about this. Is that right, Dr. Kolokythas?

Dr. Antonia Kolokythas: Absolutely. And Bill, when we presented our initial findings, our abstract at the AAOMS meeting – you know, I forget where was the meeting that we presented this, Pooja. But at that time, it was an abstract and Dr. Hupp, at that time Editor-In-Chief for the JOMS, listened to our presentation. And he said, "I really want to see this paper submitted in completion at the JOMS."

You know, you only present initial findings, you're not sure about how things are going to be perceived. And we know we had good data, but having that extra kind of like push – I want to see this as a submission in the JOMS – was another impetus to really make it happen.

Host: Well, that had to help when you have somebody like that saying, "Hey, I want to learn more about this," which kind of gives you the green light, "Okay, we need to keep going on this. We're on to something."

Dr. Antonia Kolokythas: And it seemed that it would have been certainly of interest to our readership, right?

Host: Absolutely, for sure. So, this is really an important research study. And Dr. Gangwani, did the results align with your original hypothesis, what you thought, or were there surprises, things that you learned along the way?

Dr. Pooja Gangwani: There were surprises, Bill. So we had hypothesized that patients who smoke marijuana will have increased mean arterial pressure, heart rate, respiratory rate, and medication requirements during the IV sedation. And our study did not affirm this hypothesis. In other words, when we compared the two groups, the THC-positive group to THC-negative group, which is marijuana smokers versus non-marijuana smokers.

In bivariate analysis, the marijuana smokers did require higher doses of fentanyl and propofol. But after adjusting the effect of age, gender, and weight, THC had no significant effect on these medications. So in summary, we found no differences in vital signs or anesthetic requirements between two groups, the marijuana smokers and non-smokers.

Host: Yeah, that's interesting. From what you explain in that, you would think that there would be, but you found that there's no difference.

Dr. Pooja Gangwani: That is correct, but I would say that this was a retrospective study. And so, there's always some limitations and more work is required on this topic.

Host: Absolutely.

Dr. Antonia Kolokythas: I would agree with Pooja on, yes, our initial hypothesis was not supported, but this article and this work was a springboard for others to follow. And working on retrospective data, we had to be very specific in selection and inclusion criteria. So, by being the first to publish on the association, if any, between marijuana smoking and perioperative sedation or analgesia means for our patients, it's definitely a work that's an impetus for others to follow and design different kinds of prospective studies.

Host: Absolutely. So, that makes sense, that usually how these things go, you will learn something along the way that might send you off in a different direction. Is that right, or a bit of a different direction?

Dr. Antonia Kolokythas: Absolutely.

Host: Yeah. Dr. Kolokythas, then, we talked about how important this is, but can you explain the relevancy then of this research to the OMS specialty?

Dr. Antonia Kolokythas: I think the more important thing that we learned is that, you know, obtaining a very detailed history on our patients remains the most critical part on how we plan our approach to their anesthesia and analgesia. And being good investigators and good detectives on our patients. As you mentioned, the legalization, decriminalization of marijuana use and the widespread, especially among the youth, which is the most common population in especially private practice offices. We need to increase our awareness about the usage of these medications and the potential impact on our regimen and how we approach these patients.

Host: And let me follow up on that. You said it's really a best practice to obtain a detailed history and do your homework. Are there people that don't want to share that they are marijuana users?

Dr. Antonia Kolokythas: Absolutely. Especially among the youth, right? Especially when you see these patients in a practice with their parents perhaps and there are certain things that they don't feel comfortable sharing. And some patients, they just don't think it's important or they don't think it's relevant and they don't share that or they don't openly admit. Even if they do admit, sometimes, they may not understand the importance of relating the frequency of the use, right? And those are the things that we have to probe further and deeper and get through the true story.

Host: Yeah, they might underestimate their usage.

Dr. Antonia Kolokythas: Absolutely. I mean, what everybody thinks is normal, right? It's their normal. And they don't have a baseline or a reference point.

Host: Yeah, really good point, Dr. Kolokythas. And Dr. Gangwani, then how can the average OMS apply these findings to their everyday practice, and knowing that some people might not reveal that they are marijuana users?

Dr. Pooja Gangwani: Yeah, Bill. So as OMS, we must deliver safe anesthesia and recognizing when patients are acutely intoxicated and canceling their procedures. And having protocols surrounding this would be extremely helpful. And I'm sure all our colleagues are mindful of this and are doing this anyway.

Host: So, Dr. Kolokythas, then what advice would you give to other researchers interested in exploring similar topics or conducting studies in this field?

Dr. Antonia Kolokythas: I always advise people around me who are interested in research, if you have a question, investigate it, go after it, see what's out there in the literature, see what's published, see what others are doing, and take it a step further if you can. And when articles are published, it's important, especially for young investigators, to read the methods, to read the results, to read the inclusion-exclusion criteria and see if there is anything that can be done differently or been approached in a different angle. So these topics are further investigated and in every possible angle. And never, ever, ever stop asking questions when it comes to research and getting answers.

Host: So when you say further investigated, I'm just wondering from everything that you've uncovered then, Dr. Gangwani, what implications do these findings have for future research in anesthesia management on patients with certain social habits as we've been talking about?

Dr. Pooja Gangwani: Yes, Bill, although our findings were not something that we had expected, remember that this was a retrospective study. And our study had some limitations like small sample size, variability of procedures that were included in the study that Dr. Kolokythas was talking about that we could not exclude, otherwise we would have even smaller sample size, you know. So, we had procedures that ranged from third molars to full mouth extractions to single tooth extractions to biopsies, and their expected times potentially created inconsistencies in the data. And an increased number of providers, meaning our patients were treated by residents at all levels. And there was variability in sedation administration and surgical experience that created variability in the data.

So I would say that the research gap still exists. No prospective studies have been performed and that has left a large void in the availability of quality data. And future studies could actually use prospective designs to eliminate these limitations and obtain more accurate data.

Host: Yeah. Well, this has really been interesting. Congrats again on winning the Daniel M. Laskin Award. Before we wrap up, I'd like to get final thoughts from each of you on this. Dr. Kolokythas, let me start with you. Anything else you want to add or say about this research project or actually being named the Daniel M. Laskin Award winner?

Dr. Antonia Kolokythas: Thank you, Bill, for both. First of all, again, this is a very prestigious award, and I think at least my career, it's such a huge accomplishment, and you go join others in our specialty who hold this very special award. So we're very grateful for that.

But in regards to research, this is a topic that it's difficult to research, right? It has a lot of limitations and a lot of restrictions in how you design things. But topics such as recreational marijuana use that can become very charged when in an era where, you know, freedom of choice and, in general, habits are difficult to narrow down or pinpoint or investigate and how people react to questioning are so, you know, complex and challenging to navigate.

These are the areas where we absolutely have to put a lot of effort, which is very hard in a specialty where we have a significant, you know, membership into private practice where studies are difficult to conduct, right? But these kinds of studies require further pursuit and can change policies and approaches for us as a specialty, and then even go further into other specialties.

Host: Yeah, I like how you said this is challenging to navigate, but basically very important to pursue. Dr. Kolokythas, thank you for that. And Dr. Gangwani, final thoughts from you on the research project or being a recipient of the Daniel M. Laskin Award?

Dr. Pooja Gangwani: You know, I'm very grateful, like Dr. Kolokythas mentioned, it is a prestigious award. It feels very humbling to receive such a prestigious award and reinforces that we're on the right track. As Dr. Kolokythas mentioned, that it is difficult to study this topic. And I would like to add a few points if you don't mind that why understanding marijuana consumption is so difficult.

Marijuana consumption via inhalation may affect cardiopulmonary system differently compared to ingestion. Large variety of products are available in the market for consumption and so there is variability in that. And also, there is variability in the label accuracy. And so, exact dose of THC, which is the primary ingredient of marijuana, cannot be documented.

So, you know, these reasons might make it a bit difficult and somewhat challenging researching on this topic. But like Dr. Kolokythas said, we cannot give up. We have identified a question. We are passionate about it and so we will stay with it and we will not give up and continue to study further.

And lastly, engaging in clinical research is very exciting and gratifying. And I must express this, that it is a privilege to take care of patients to educate and train residents and collaborate with bright minds to contribute to this specialty through research. So, in and all, it's just a wonderful specialty to be a part of, and thank you.

Host: Yeah, you bet. Well, wonderful closing thoughts, Dr. Gangwani. You're right, a lot of variability there. But I like how you said we will not give up. So, I love hearing that. That is so great. So, Dr. Kolokythas and Dr. Gangwani, thank you so much for your time today.

Dr. Antonia Kolokythas: Thank you very much, Bill, for having us.

Dr. Pooja Gangwani: Thanks, Bill, for having us.

Host: Yeah. Pleasure talking with both of you. And once again, that is Dr. Antonia Kolokythas and Dr. Pooja Gangwani. And for more information on the study, just go to AAOMS.org/JOMS. Once again, AAOMS.org/JOMS. And if you enjoyed this podcast, please share it on your social media and make sure you subscribe so you don't miss an episode. Thanks for listening.