Tips for talking with patients about cannabis use in pregnancy

Key takeaways:

• Self-reported cannabis use among pregnant women increased from 2017 to 2020.
• Discussions about cannabis use in pregnancy should be patientcentered and judgment-free, according to a speaker.

SAN FRANCISCO — With rising rates of cannabis use and changing legalization throughout the United States, more and more patients and physicians have questions about cannabis use before, during and after pregnancy.

“Data show, at a national level, that cannabis use is going up in pregnancy, [and we don’t know] whether that’s because people feel more comfortable admitting cannabis exposure as it is more and more accepted and legalized,” Cresta W. Jones, MD, FACOG, FASAM, associate professor of maternal-fetal medicine at University of Minnesota Medical School, said during a presentation at the ACOG Annual Clinical & Scientific Meeting.

When it comes to cannabis and patient care, Jones stressed the importance of open dialogue and information-sharing in a patient-centered and judgment-free way.

Rising use in pregnancy

Recent data from the Substance Abuse and Mental Health Services Administration (SAMHSA) show a rise in cannabis use in recent years among both pregnant people and nonpregnant people with reproductive potential. In 2017, 161,000 pregnant women aged 15 to 44 years self-reported marijuana use in the previous month; this number increased to 164,000 pregnant women in 2020. Moreover, other data demonstrated growing cannabis use in pregnancy during the COVID-19 pandemic compared with before the pandemic, according to Jones.

“This is definitely something that is affecting more of our pregnant and parenting people,” Jones said.

Talking to patients about use

It is important to ask patients who are pregnant or are considering pregnancy about their cannabis use using a patient-centered and judgment-free approach, with screening before conception and at regular intervals, Jones said.

This is “not someone coming in and you ask them, ‘Are you using pot during your pregnancy? You’re not using pot, right?’ If I ask in that way, of course they are going to [think], ‘Oh, my doctor does not want me to answer that yes.’

“I say, ‘Different substances are used by different people during their pregnancy; I just want to make sure I know what kind of things you’re exposed to so I can keep you healthy and I can keep your pregnancy healthy,” she said.

To offer information in a nonstigmatizing and judgment-free way, Jones said perhaps the conversation sounds more like: “I’m interested in what role cannabis plays in your life; tell me what that looks like for you” or “How do you feel like cannabis is helpful for you?” or “Are there are other things that we can do or medications I can prescribe that will help you reduce your cannabis exposure, especially during pregnancy?”

The most commonlycited reasons for cannabis use during pregnancy are to relieve stress and anxiety and relief from nausea and vomiting, according to research.

“We do have other effective medications for [nausea and vomiting]. We also have cognitive behavior therapy and other treatments for stress and anxiety,” Jones said. “I think this is really important to note that most of the patients who are identifying use are identifying it to treat symptoms that we could potentially offer other solutions for.”

Jones said there is increasing public perception that “natural” or “legal” means “safer.”

“There is a lot of movement throughout the country for medical cannabis and ... we’ve seen a lot of states [that have] legalized recreational cannabis. These are things that more and more your patients are going to see as legal,” she said. “The substances that are legal — nicotine and alcohol — are two of the biggest players in adverse pregnancy outcomes. [There is] that perception that, ‘Oh, it’s legal, it must be safer. Why would someone legalize something that’s not good for my health?’”

It is known that cannabis is a lipophilic substance and its metabolites cross the placenta.

Metabolites have been found in fetal tissue and breast milk, Jones said, noting that she does “feel comfortable saying to patients: ‘If you have chronic cannabis exposure in pregnancy, your baby is probably not going to grow as well.’” Research has demonstrated that prenatal cannabis exposure can be associated with increased risk for outcomes including low birthweight, risk for preterm birth and need for NICU admission, decreased infant head circumference, and other growth issues. A recent study on the effects of prenatal cannabis use on fetal and neonatal development found increased neurobehavioral changes in childhood and abnormal developmental screening, among other outcomes.

For lactation, cannabis metabolites can be present in breast milk for up to a month later with chronic use. “It’s not like alcohol, where we can say, ‘You had a drink, it has been 2 hours, it’s safe to breast- or chestfeed your child,” Jones said. There are very limited data on neurodevelopmental outcomes and there are confounders, she said.

Overall, there is a lack of “really good, compelling, reproducible data” and there have been mixed and confounded results, she said. Much of the available data are from when THC concentrations were much lower, like in the single digits, whereas now concentrations are much higher, according to Jones. Further, most data are from smokable or combustible cannabis.

There are even fewer data on CBD and THC edibles and seltzers, which are growing in popularity, according to Jones. Jones referenced one small animal study that looked at chronic edible exposure before and after gestation that showed subtle molecular changes in fetal and neonatal brain signaling.

“What I tell patients is: ‘We do not have the data.’ This has been a chedule substance for a long time. There is potential discussion that that may change. But, if something is chedule , we don’t have the federal funding to do the research that we need on this. So, I can’t, in confidence, tell my patients, ‘Yes, this is something that is legal and I am sure it is fine.’ What I tell them is: ‘We just don’t have that information yet.’”

Jones pointed the audience to guidance from ACOG and other medical societies, which emphasize shared decision-making and attempts at cessation and/or reduction.

‘Ongoing conundrums’

There are “ongoing conundrums” to think about, Jones said.

• In U.S. states that have mandated substance reporting, how do you approach the use of state-legalized recreational cannabis use?
• How do we approach the use of legalized medical cannabis in pregnancy, without a lot of data?
• What does it mean for maternal-infant dyad with THC toxicology in states where prenatal substance exposure is considered child abuse and/or neglect, but cannabis is legal?
• How can you partner with patients with ongoing cannabis use and plans to breastfeed?