Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use

Trends in Cannabis Polysubstance Use During Early Pregnancy Among Patients in a Large Health Care System in Northern California

IMPORTANCE

Rates of prenatal cannabis use are increasing alongside perceptions that cannabis is a harmless therapeutic for pregnancy-related ailments, while rates of prenatal use of alcohol and tobacco are decreasing. It is important to examine whether cannabis use during pregnancy is increasing similarly among patients with and patients without co-occurring substance use.

OBJECTIVES

To examine trends in cannabis polysubstance use during pregnancy and to test differences in cannabis use over time among pregnant individuals who use only cannabis vs those who use cannabis and other substances.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional time-series study used data from 367 138 pregnancies among 281 590 unique pregnant patients universally screened for prenatal substance use as part of standard care in Kaiser Permanente Northern California from January 1, 2009, to December 31, 2018. Statistical analysis was performed from October 5, 2021, to April 18, 2022.

EXPOSURES

Time (calendar year).

MAIN OUTCOMES AND MEASURES

Use of substances during early pregnancy was assessed via universal screening with a self-administered questionnaire (for cannabis, alcohol, stimulants, and nicotine) and/or positive results of a urine toxicology test (for cannabis, alcohol, stimulants, and pharmaceutical opioids), and data were extracted from the electronic health record.

RESULTS

The study sample of 367 138 pregnancies from 281 590 unique pregnant patients (median gestation at time of screening, 8.6 weeks [IQR, 7.3-10.6 weeks]) was 25.9% Asian or Pacific Islander, 6.6% Black, 25.8% Hispanic, 38.0% non-Hispanic White, and 3.6% other race or ethnicity; 1.1% were aged 11 to 17 years, 14.9% were aged 18 to 24 years, 61.9% were aged 25 to 34 years, and 22.1% were aged 35 years or older; and the median neighborhood household income was $70 455 (IQR, $51 563-$92 625). From 2009 to 2018, adjusted rates of use of only cannabis during pregnancy (no other substances) increased substantially from 2.39% (95% CI, 2.20%-2.58%) in 2009 to 6.30% (95% CI, 6.00%-6.60%) in 2018, increasing at an annual relative rate of 1.11 (95% CI, 1.10-1.12). The rate of use of cannabis and 1 other substance also increased (annual relative rate, 1.04 [95% CI, 1.03-1.05]), but not as rapidly (P < .001 for difference), while the rate of use of cannabis and 2 or more other substances decreased slightly (annual relative rate, 0.97 [95% CI, 0.96-0.99]). Adjusted rates of prenatal use of cannabis and alcohol (1.04 [95% CI, 1.03-1.06]) and cannabis and stimulants (1.03 [95% CI, 1.01-1.06]) increased over time, while rates of prenatal use of cannabis and nicotine (0.97 [95% CI, 0.96-0.98]) decreased.

CONCLUSIONS AND RELEVANCE

In this cross-sectional time-series study, rates of prenatal cannabis use during early pregnancy increased significantly more rapidly among patients without co-occurring substance use, which could reflect increased acceptability of cannabis and decreased perceptions of cannabis-related harms. Furthermore, increased rates of use of cannabis with alcohol and stimulants warrant continued monitoring.

Impact of cannabinoids on pregnancy, reproductive health and offspring outcomes

Cannabis is the most commonly used federally illegal drug in the United States and world, especially among people of reproductive age. In addition, the potency of cannabis products has increased significantly in the past decade. This is concerning because the available evidence suggests an adverse effect from cannabis exposure on male and female reproductive health. Exposure to cannabinoids may have differential impacts on female reproductive health across a woman's lifespan, from preconception to pregnancy, throughout lactation, and during menopause. Even more, cannabis use has been associated an adverse effect on fetal outcomes, and longer-term offspring health and developmental trajectories. Despite the prevalence of cannabis use, there is limited available evidence regarding its safety, especially in regard to reproductive health, pregnancy and lactation. The biological effects of cannabis are mediated by the endocannabinoid system and studies have reported the presence of cannabinoid receptors in the male and female reproductive tract, on sperm and the placenta, suggesting the endocannabinoid system plays a role in regulating reproduction. Cannabis use can impact male and female fertility and has been associated with altered reproductive hormones, menstrual cyclicity and semen parameters. Use of cannabis in males has also been associated with erectile dysfunction, abnormal spermatogenesis, and testicular atrophy. In females, cannabis use has been associated with infertility and abnormal embryo implantation and development. The main psychoactive component of cannabis, delta-9-tetrahydrocannabinol (THC), can also cross the placenta and has been detected in breastmilk. Maternal cannabis use during pregnancy and lactation has been associated with adverse effects including small for gestational age infants, preterm birth, fetal neurodevelopmental consequences, and impaired offspring sociobehavioral and cognitive development. The prevalence of cannabis use to alleviate menopausal symptoms has also increased despite the limited information on its benefits and safety. As cannabis use is on the rise, it is critical to understand its impact on reproductive health and offspring developmental outcomes. This is an understudied, but timely subject, with much needed information to guide healthcare providers and those interested in conceiving, or that are pregnant and lactating, as well as those at the end of their reproductive time span.

How are Canadian cannabis dispensaries counselling breastfeeding consumers?

Objectives

This study aimed to identify recommendations given to breastfeeding individuals by Canadian cannabis dispensary employees, since the legalization of recreational cannabis in 2018.

Methods

This was a nationwide cross-sectional study conducted from November 2020 to January 2021. A mystery caller approach was used to identify recommendations given to breastfeeding individuals seeking a product for “relaxation.” This study was modelled on similar studies which assessed recommendations given to pregnant women looking for cannabis products to manage nausea and vomiting (Vastis V, Shea AK, Vincent S, Metz TD. 275: Are canadian cannabis dispensaries counselling pregnant women appropriately? Am. J. Obstet. Gynecol. 2020;222: S187.(Abst). Lusero I, Paltrow LM, Rosenbloom N. Recommendations from cannabis dispensaries about first-trimester cannabis use Obstet Gynecol 2018;132:781–2.). The primary outcome was the recommendation of a cannabis product. Secondary outcomes included stated benefits of cannabis, recommended discussion with health care provider, length of call, rationale for recommendation, and reported source of information on which the recommendation was based.

Results

The majority (79.4%) of employees of the 714 Canadian dispensaries contacted recommended against a cannabis product for “relaxation” while breastfeeding. The recommendations from dispensary employees were often (80%) provided without a specific reason, whereas a minority referenced published research (2%) and opinion (17.6%). Cannabis products were rarely (3.3%) classified as safe in breastfeeding. Approximately 76.6% of dispensary employees recommended contacting a health care provider, while 2.4% recommended against.

Conclusions

Although a high proportion of dispensary employees recommended against using a cannabis product during lactation, there were still 20.6% that did recommend use, which contrasts the current public health guidelines and is not supported by the paediatric and obstetric societies. These findings highlight the need for further education about the safety of cannabis products while breastfeeding.

The endocannabinoids anandamide and 2-arachidonoylglycerol modulate the expression of angiogenic factors on HTR8/SVneo placental cells

The interest on the endocannabinoid system (ECS) in human reproduction has grown due to its involvement in placenta development, which led to growing concerns over pregnant cannabis consumer's impact on pregnancy outcome. The endocannabinoids anandamide (AEA) and 2-arachidonoylglycerol (2-AG) modulate placental trophoblast proliferation and apoptosis. However, their role on other placentation events such as angiogenesis and invasion are unknown. Using the human extravillous trophoblast HTR-8/SVneo cells, a well-accepted model of first trimester extravillous trophoblast (EVT), this study aims to investigate whether AEA and 2-AG can modulate the expression of angiogenesis- and invasion-related factors. Transcript analysis of angiogenic factors of the vascular endothelial growth factor (VEGF) and matrix metalloproteinase (MMP) protein family demonstrated the ability of AEA to increase VEGF-C and VEGFR3 expression via cannabinoid receptors CB1 and CB2 while the placental growth factor (PlGF) was increased through CB1. Moreover, an increase in VEGFR1, sFLT1, VEGFR2, MMP-2 and TIMP-1 independent of cannabinoid receptor activation was verified. However, 2-AG only increased PlGF transcript through CB1/CB2 activation. Both endocannabinoids stimulated HTR8/SVneo endothelial-like tube formation. As for the wound healing assay, only 2-AG was able to increase the percentage of wound closure. Moreover, the data demonstrated that both AEA and 2-AG, via cannabinoid receptors, activated the STAT3 signaling pathway. Distinct effects were observed on transcription factor HIF-1α and AKT phosphorylation that decreased with both endocannabinoids. Although different angiogenic and migration factors are affected the results obtained in this work showcase once more the ability of the endocannabinoids to modulate key processes in placental physiology.

Focus on Rural Adolescent Cannabis Use and Abuse: Ignored Epidemiologic Trends, Unique Risks, Long-Term Concerns, and Hope

Cannabis-related issues for adolescents and young adults are emerging from the shadow of rural opioid addiction and deaths. The rural pediatric population has multiple risk factors putting them at increased risk for adverse consequences with the expansion of cannabis legalization across the United States. Research in this area is rich but scattered across professional disciplines. Differences in demographics and cultures between rural and urban youth are gaining attention. Epidemiological factors relevant to rurality as a risk for cannabis and other substance use are considered for formulating clinical care, public policymakers, and future research. Race, culture, community stability, basic demographics of age, gender, educational status, and demands for more and better, accessible services for rural, nonmetropolitan areas comprise factors for consideration and are detailed. Research findings provide direction for policymakers and clinicians for prevention and intervention efforts to improve care for rural populations, validating and expanding upon insights gained to date.

Beliefs about marijuana use during pregnancy and breastfeeding held by residents of a Latino-majority, rural region of California

Marijuana use among pregnant and breastfeeding women is on the rise and carries risks for infant health and well-being. Decisions to use marijuana while pregnant and breastfeeding are motivated by beliefs that use poses minimal risk to infants and offers benefits to maternal users. Misperceptions and usage trend higher among disadvantaged populations. This study surveyed 401 community residents on beliefs about risks and benefits of marijuana use by pregnant and breastfeeding women. The study utilized techniques to enhance recruitment of Latino and disadvantaged residents of rural communities in California, a state where recreational marijuana use is legal. Analyses revealed substantial endorsement of beliefs about benefits and low risks of marijuana use while pregnant and breastfeeding, many of which run counter to current evidence. Misperceptions were particularly prevalent for cannabis users and male respondents. Trends in valid beliefs, while modest, were higher for Latinos and parents.

Healthcare professionals' and budtenders' perceptions of perinatal cannabis use

Background: While national guidelines state that cannabis should not be consumed during pregnancy, cannabis use during pregnancy continues to increase. Pregnant individuals have reported using healthcare professionals and budtenders (i.e., cannabis store retailers) as resources for information on cannabis use during pregnancy and postpartum.Objectives: To determine healthcare professionals' and budtenders' perceptions of risks and benefits of perinatal cannabis use.Method: A qualitative study, using semi-structured, open-ended questions, was conducted with ten healthcare professionals (predominantly nurses; 100% women) and ten budtenders (70% women) in a state where cannabis use is legal for adults 21 years of age and older. Data were interpreted using a qualitative description methodology to identify themes. Themes were generated from participant responses (implicit and explicit). We analyzed data separately and sequentially and present linked themes across samples. Data saturation, rigor, and trustworthiness were discussed and agreed upon by the analytic team.Results: Six themes arose from the healthcare professional and budtender data: 1) Perinatal customers and patients perceive cannabis to be medicinal, 2) Supporting perinatal people who use cannabis, 3) Spectrum of perceived impacts of perinatal cannabis use, 4) Comparison to use of other substances during pregnancy, 5) Perceived limited knowledge and training about cannabis regulation and product safety, and 6) Current trends of purchase and use.Conclusion: Participants reported that perinatal patients/customers perceived cannabis to be medicinal, and highlighted non-judgmental/harm reduction strategies for engaging patients/customers. Training is needed for healthcare professionals and budtenders to assist with patient/customer discussions about perinatal cannabis use.

Cannabis legalization and cannabis-involved pregnancy hospitalizations in Colorado

The primary objective of this study was to evaluate the association between presence of recreational cannabis dispensaries and prevalence of cannabis-involved pregnancy hospitalizations in Colorado. This was a retrospective cohort study of pregnancy-related hospitalizations co-coded with cannabis diagnosis codes in the Colorado Hospital Association from January 1, 2011, through December 31, 2018 (recreational cannabis began January 1, 2014). Our primary outcome was cannabis-involved pregnancy hospitalizations per 10 k live births per county. The primary exposure measure was county variation in the number of recreational dispensaries. We controlled for counties' baseline exposure to medical cannabis dispensaries and used Poisson regression to evaluate the association between exposure to recreational cannabis and hospitalizations. During the study period, cannabis-involved pregnancy hospitalizations increased from 429 to 1210. Mean hospitalizations per county (1.7 to 4.7) and per 10 k live births (13.2 to 55.7) increased. Overall, increasing recreational dispensaries were associated with increases in hospitalizations (1.02, CI: 1.00,1.04). When comparing counties with different densities of baseline medical cannabis market, low and high exposure counties had fewer hospitalizations than those counties with no exposure (low: IRR 0.97, CI: 0.96-0.99; high: 0.98, CI: 0.96-0.99). In Colorado, there was more than a two-fold increase in cannabis-involved pregnancy hospitalizations between 2011 and 2018. Counties with no baseline exposure to medical cannabis had a greater increase than other counties, suggesting the recreational market may influence cannabis use among pregnant individuals.

Marijuana use in Pregnant Women with Disabilities in the United States

OBJECTIVES

While perinatal marijuana use is increasing, limited research exists related to its use during pregnancy among vulnerable subpopulations of women with disabilities. The purpose of this study is to assess marijuana use in pregnant U.S. women with disabilities.

METHODS

The analytic sample using 2015-2019 National Survey on Drug Use and Health (NSDUH) data included 3657 pregnant women. Descriptive statistics were performed and adjusted logistic regression models estimated the size and direction of the association between the type of disability and marijuana use.

RESULTS

Approximately 13.0% of pregnant women with disabilities used marijuana in the past month, which was higher than pregnant women without disabilities (4.4%). The highest prevalence of past month marijuana use was observed among pregnant women with sensory disabilities (17.2%) followed by women with cognitive disabilities (14.6%) and daily living limitations (11.7%). Marijuana use was also associated with younger age (≤ 25 years old), Black non-Hispanic, high school education or less, non-married, and past month alcohol/tobacco use. Overall, pregnant women with any disability, and particularly those with sensory disabilities (AOR 2.32, 95% CI 1.21, 4.47), were significantly more likely (AOR 1.65, 95% CI 1.02, 2.69) to use marijuana than their counterparts without disabilities.

CONCLUSIONS

The higher prevalence of marijuana use among pregnant women with disabilities in this study supports the American College of Obstetricians and Gynecologists recommendations for universal screening of maternal substance use. Screening for marijuana use in vulnerable populations is crucial and it may require training of health care providers to administer such screenings to women with disabilities.

European epidemiological patterns of cannabis- and substance-related congenital cardiovascular anomalies: geospatiotemporal and causal inferential study

As prenatal and community cannabis exposures have recently been linked with congenital heart disease (CHD), it was of interest to explore these associations in Europe in a causal framework and space-time context. Congenital anomaly data from Eurocat, drug-use data from the European Monitoring Centre for Drugs and Drug Addiction, and income from the World Bank. Countries with rising daily cannabis use had in general higher congenital anomaly rates over time than those without (time: status interaction: β-Est. = 0.0267, P = 0.0059). At inverse probability-weighted panel regression, cannabis terms were positive and significant for CHD, severe CHD, atrial septal defect, ventricular septal defect, atrioventricular septal defect, patent ductus arteriosus, tetralogy of Fallot, vascular disruptions, double outlet right ventricle, transposition of the great vessels, hypoplastic right heart, and mitral valve anomalies from 1.75 × 10^-19, 4.20 × 10^-11, <2.2 × 10^-16, <2.2 × 10^-16, 1.58 × 10^-12, 4.30 × 10^-9, 4.36 × 10^-16, 3.50 × 10^-8, 5.35 × 10^-12, <2.2 × 10^-16, 5.65 × 10^-5 and 6.06 × 10^-10. At spatial regression, terms including cannabis were positive and significant for this same list of anomalies from 0.0038, 1.05 × 10^-10, 0.0215, 8.94 × 10^-6, 1.23 × 10^-5, 2.05 × 10^-5, 1.07 × 10^-6, 8.77 × 10^-5, 9.11 × 10^-6, 0.0001, 3.10 × 10^-7 and 2.17 × 10^-7. 92.6% and 75.2% of 149 E-value estimates and minimum E-values were in high zone >9; 100.0% and 98.7% >1.25. Data show many congenital cardiac anomalies exhibit strong bivariate relationships with metrics of cannabis exposure. Causal inferential modelling for the twelve anomalies selected demonstrated convincing evidence of robust relationships to cannabis which survived adjustment and fulfilled epidemiological criteria for causal relationships. Space-time regression was similarly confirmatory. Epigenomic pathways constitute viable potential mechanisms. Given exponential genotoxic dose-response effects, careful and astute control of cannabinoid penetration is indicated.

Cannabinoid and substance relationships of European congenital anomaly patterns: a space-time panel regression and causal inferential study

With reports from Australia, Canada, USA, Hawaii and Colorado documenting a link between cannabis and congenital anomalies (CAs), this relationship was investigated in Europe. Data on 90 CAs were accessed from Eurocat. Tobacco and alcohol consumption and median household income data were from the World Bank. Amphetamine, cocaine and last month and daily use of cannabis from the European Monitoring Centre for Drugs and Drug Addiction. Cannabis herb and resin Δ9-tetrahydrocannabinol concentrations were from published reports. Data were processed in R. Twelve thousand three hundred sixty CA rates were sourced across 16 nations of Europe. Nations with a higher or increasing rate of daily cannabis use had a 71.77% higher median CA rates than others [median ± interquartile range 2.13 (0.59, 6.30) v. 1.24 (0.15, 5.14)/10 000 live births (P = 4.74 × 10^-17; minimum E-value (mEV) = 1.52]. Eighty-nine out of 90 CAs in bivariate association and 74/90 CAs in additive panel inverse probability weighted space-time regression were cannabis related. In inverse probability weighted interactive panel models lagged to zero, two, four and six years, 76, 31, 50 and 29 CAs had elevated mEVs (< 2.46 × 10³⁹) for cannabis metrics. Cardiovascular, central nervous, gastrointestinal, genital, uronephrology, limb, face and chromosomalgenetic systems along with the multisystem VACTERL syndrome were particularly vulnerable targets. Data reveal that cannabis is related to many CAs and fulfil epidemiological criteria of causality. The triple convergence of rising cannabis use prevalence, intensity of daily use and Δ9-tetrahydrocannabinol concentration in herb and resin is powerfully implicated as a primary driver of European teratogenicity, confirming results from elsewhere.

Maternal Cannabis Use in the Perinatal Period: Data From the Pregnancy Risk Assessment Monitoring System Marijuana Supplement, 2016-2018

OBJECTIVE

To estimate the prevalence of perinatal cannabis use (ie, before and/or during pregnancy); document the frequency, modes, and motivations for use; and identify predictors of perinatal cannabis use.

METHODS

Six states in the Pregnancy Risk Assessment Monitoring System, a state-specific, population-based surveillance system, administered a supplemental questionnaire on perinatal cannabis use in 2016-2018. Women with live births were surveyed 2-6 months postpartum about behaviors ≤ 3 months preconception and during pregnancy. Demographic, psychosocial, and behavioral characteristics were examined in relation to perinatal cannabis use using multinomial regression models. Those who: (1) never used cannabis, (2) only used in preconception period, and (3) used in both preconception and prenatal periods were compared.

RESULTS

Among 6428 respondents, 379 (5.8%) used cannabis pre-conceptionally only and 466 (4.4%) used in both the preconception and prenatal periods. Among those using prenatally, most reported smoking as their single mode (87.1%), with the two most common reasons being stress (83.8%) and nausea/vomiting (79.2%). Marital status, race/ethnicity, socioeconomic status, parity, and cigarette and alcohol use were significantly associated with perinatal cannabis use. Single (vs partnered) women were more likely to use cannabis prenatally (odds ratio = 2.4, 95% confidence interval: 1.5, 3.9) and non-Hispanic Black (vs White) women were less likely to use prenatally (odds ratio = 0.4, 95% confidence interval: 0.2, 0.8).

CONCLUSIONS

Using a population-based sample of US births in six states, several demographic, psychosocial, and behavioral characteristics were identified in relation to perinatal cannabis use. These data are valuable for counseling in prenatal care and investigations of health effects.

Association of Comorbid Behavioral and Medical Conditions With Cannabis Use Disorder in Pregnancy

IMPORTANCE

Prenatal cannabis use continues to increase, yet studies of the demographic, psychiatric, and medical characteristics associated with cannabis use in pregnancy are limited by size and use of self-report, and often do not consider cannabis use disorder (CUD) or concomitant substance use disorders (SUDs). Understanding the factors associated with CUD in pregnancy is paramount for designing targeted interventions.

OBJECTIVE

To examine the prevalence of co-occurring psychiatric and medical conditions of US pregnant individuals hospitalized with and without CUD by concomitant SUDs.

DESIGN, SETTING, AND PARTICIPANTS

The study analyzed restricted hospital discharge data from the 2010 to 2018 Healthcare Cost and Utilization Project State Inpatient Databases in 35 states. Data were analyzed from January to August 2021. Weighted linear regressions tested whether the prevalence of psychiatric and medical conditions differed between individuals with and without a CUD diagnosis at hospitalization. Inpatient hospitalizations of pregnant patients aged 15 to 44 years with a CUD diagnosis were identified. Pregnant patients aged 15 to 44 years without a CUD diagnosis were identified for comparison. Patients were further stratified based on concomitant SUD patterns: (1) other SUDs, including at least 1 controlled substance; (2) other SUDs, excluding controlled substances; and (3) no other SUDs.

EXPOSURES

CUD in pregnancy.

MAIN OUTCOMES AND MEASURES

Prevalence of demographic characteristics, psychiatric disorders (eg, depression and anxiety), and medical conditions (eg, epilepsy and vomiting).

RESULTS

The sample included 20 914 591 hospitalizations of individuals who were pregnant. The mean (SD) age was 28.24 (5.85) years. Of the total number of hospitalizations, 249 084 (1.19%) involved CUD and 20 665 507 (98.81%) did not. The proportion of prenatal hospitalizations involving CUD increased from 0.008 in 2010 to 0.02 in 2018. Analyses showed significant differences in the prevalence of almost every medical and psychiatric outcome examined between hospitalizations with and without CUD diagnoses, regardless of concomitant SUDs. Elevations were seen in depression (0.089; 95% CI, 0.083-0.095), anxiety (0.072; 95% CI, 0.066-0.076), and nausea (0.036; 95% CI, 0.033-0.040]) among individuals with CUD only at hospitalization compared with individuals with no SUDs at hospitalization.

CONCLUSIONS AND RELEVANCE

Considerable growth was observed in the prevalence of CUD diagnoses among individuals hospitalized prenatally and in the prevalence of depression, anxiety, nausea, and other conditions in individuals with CUD at hospitalization. This study highlights the need for more screening, prevention, and treatment, particularly in populations with co-occurring CUD and psychiatric disorders. Research on the determinants and outcomes associated with CUD during pregnancy is needed to guide clinicians, policy makers, and patients in making informed decisions.

Marijuana, Opioid, and Alcohol Use Among Pregnant and Postpartum Individuals Living With HIV in the US

Importance

Amid the opioid epidemic and evolving legal and social changes with marijuana, little is known about substance use among pregnant and postpartum people living with HIV.

Objectives

To evaluate trends in marijuana, alcohol, and opioid use during pregnancy and the first year postpartum among US people living with HIV and the differences in substance use based on marijuana legalization status.

Design, Setting, and Participants

Data from the Surveillance Monitoring for Antiretroviral Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study were analyzed. SMARTT-enrolled, pregnant people living with HIV at 22 US sites from January 1, 2007, to July 1, 2019, with self-reported substance use data available in pregnancy, 1 year postpartum, or both were assessed.

Exposures

Calendar year and state marijuana legalization status.

Main Outcomes and Measures

The prevalence of any use of each of the following substances was calculated by calendar year, separately for pregnancy and postpartum: marijuana, alcohol, opioid, and concomitant alcohol and marijuana. Log binomial models were fit using general estimating equations to evaluate the mean annual change, accounting for repeat pregnancies. The study also evaluated differences in substance use by state recreational or medical marijuana legalization status.

Results

Substance use data were available for 2926 pregnancies from 2310 people living with HIV (mean [SD] age, 28.8 [6.1] years; 822 [28.1%] Hispanic, 1859 [63.5%] non-Hispanic Black, 185 [6.3%] White, 24 [0.8%] of more than 1 race, 24 [0.8%] of other race or ethnicity [individuals who identified as American Indian, Asian, or Native Hawaiian or other Pacific Islander], and 12 [0.4%] with unknown or unreported race or ethnicity). Between 2007 and 2019, marijuana use during pregnancy increased from 7.1% to 11.7%, whereas alcohol and opioid use in pregnancy were unchanged. Postpartum alcohol (44.4%), marijuana (13.6%), and concomitant alcohol and marijuana (10.0%) use were common; marijuana use increased from 10.2% to 23.7% from 2007 to 2019, whereas postpartum alcohol use was unchanged. The adjusted mean risk of marijuana use increased by 7% (95% CI, 3%-10%) per year during pregnancy and 11% (95% CI, 7%-16%) per year postpartum. Postpartum concomitant alcohol and marijuana use increased by 10% (95% CI, 5%-15%) per year. Differences in substance use were not associated with recreational legalization, but increased marijuana use was associated with medical marijuana legalization.

Conclusions and Relevance

In this cohort study, opioid use among pregnant people living with HIV remained stable, whereas marijuana use during pregnancy and postpartum increased over time and in states with legalized medical marijuana. These patterns of increasing marijuana use among pregnant and postpartum people living with HIV suggest that enhanced clinical attention is warranted, given the potential maternal and child health implications of substance use.

Cannabis Use in Pregnancy: A State of the Science Review

With a growing number of states legalizing recreational use, cannabis consumption during pregnancy is increasing. Population-based data and rigorous studies examining the association of cannabis use in pregnancy with perinatal outcomes are limited, but trends include preterm prelabor rupture of membranes, placenta previa, and an increased length of hospital stay. Neonates of pregnant persons who used cannabis during their pregnancy can be at increased risk of low birth weight, preterm birth, neonatal intensive care unit admission, neurocognitive deficits, and infectious and neurologic morbidity and mortality. This state of the science review examines the prevalence of cannabis use in pregnancy, its pharmacodynamics and how that is influenced by pregnancy, and associated adverse perinatal and neonatal outcomes. Implications for health care providers caring for pregnant persons using cannabis, especially in legalized states, are discussed.

Marijuana use in opioid exposed pregnancy increases risk of preterm birth

BACKGROUND

The prevalence of opioid use disorder has increased across the United States, but the rural population of Appalachia has been disproportionately impacted. Concurrently, the slow, but steady progress in the legalization of marijuana may be affecting perception of marijuana use in pregnancy. However, marijuana use in pregnancy has been associated with adverse perinatal outcomes. Concomitant use of opioids and marijuana in pregnancy has not been evaluated.

OBJECTIVE

The primary aim of the study was to evaluate the association between confirmed marijuana use in late pregnancy and preterm birth in opioid-exposed pregnancies.

METHODOLOGY

A retrospective chart review was conducted that included all births from July 2011 to June 2016 from 6 delivery hospitals in South-Central Appalachia. Out of 18,732 births, 2368 singleton pregnancies indicated opioid use and met remaining inclusion criteria, with 108 of these mothers testing positive for marijuana at delivery. Independent sample t-test and Chi-Square analyses compared marijuana and non-marijuana exposed groups on maternal and neonatal outcomes. Regression analyses controlled for confounding variables in predicting neonatal abstinence syndrome (NAS), NICU admission, preterm birth, small for gestational age, and low birth weight outcomes as shown in Table 1.

RESULTS

Neonates born to marijuana-positive women in opioid-exposed pregnancy were more likely to be born preterm, small for gestational age, have low birth weight, and be admitted to NICU. After statistically controlling for parity, marital status, tobacco and benzodiazepine use, preterm birth and low birth weight remained statistically significant with aOR of 2.35 (1.30-4.24) and 2.01 (1.18-3.44), respectively.

CONCLUSIONS

Maternal use of marijuana in any opioid-exposed pregnancy may increase risk of preterm birth and low-birth weight infants. Prospective studies need to examine the dose and timing of marijuana and opioid use in pregnancy to better delineate perinatal effects. Nonetheless, pregnant women using opioids, including recommended medication assisted treatment for opioid use disorder, should be educated about the risks of concurrent marijuana use during pregnancy and may need to be counseled to abstain from marijuana use during pregnancy for an optimal outcome.

Marijuana use and perinatal outcomes in obstetric patients at a safety net hospital

OBJECTIVE

To characterize the association between antepartum marijuana exposure and maternal and neonatal outcomes at our institution.

STUDY DESIGN

Retrospective chart review identified an obstetric cohort of singleton gestations. Women with self-reported marijuana use were compared with non-users. Demographic characteristics, risk factors, and maternal-fetal outcomes were evaluated. Associations between outcomes and marijuana use were assessed with regression analysis.

RESULTS

Of 2792 deliveries, 5.4% reported marijuana use. Compared to non-users, marijuana users entered prenatal care later, were younger, non-Hispanic, and used other illicit substances. Marijuana users had a higher rate of cesarean delivery (p = 0.01). After adjusting for confounders, marijuana use remained associated with 4.1-fold risk of delivering a small for gestational age (SGA) infant and 2.89-fold risk of neonatal oxygen use.

CONCLUSION

At a safety net hospital, antepartum marijuana use is significantly associated with cesarean delivery, SGA and supplemental oxygen use at birth. Healthcare disparities associated with marijuana use make this a population of critical interest.

Cannabinoid exposure as a major driver of pediatric acute lymphoid Leukaemia rates across the USA: combined geospatial, multiple imputation and causal inference study

BACKGROUND

Acute lymphoid leukaemia (ALL) is the commonest childhood cancer whose incidence is rising in many nations. In the USA, between 1975 and 2016, ALL rates (ALLRs) rose 93.51% from 1.91 to 3.70/100,000 <  20 years. ALL is more common in Caucasian-Americans than amongst minorities. The cause of both the rise and the ethnic differential is unclear, however, prenatal cannabis exposure was previously linked with elevated childhood leukaemia rates. We investigated epidemiologically if cannabis use impacted nationally on ALLRs, its ethnic effects, and if the relationship was causal.

METHODS

State data on overall, and ethnic ALLR from the Surveillance Epidemiology and End Results databank of the Centre for Disease Control (CDC) and National Cancer Institute (NCI) were combined with drug (cigarettes, alcoholism, cannabis, analgesics, cocaine) use data from the National Survey of Drug Use and Health; 74.1% response rate. Income and ethnicity data was from the US Census bureau. Cannabinoid concentration was from the Drug Enforcement Agency Data. Data was analyzed in R by robust and spatiotemporal regression.

RESULTS

In bivariate analyses a dose-response relationship was demonstrated between ALLR and Alcohol Use Disorder (AUD), cocaine and cannabis exposure, with the effect of cannabis being strongest (β-estimate = 3.33(95%C.I. 1.97, 4.68), P = 1.92 × 10^- 6). A strong effect of cannabis use quintile on ALLR was noted (Chi.Sq. = 613.79, P = 3.04 × 10^- 70). In inverse probability weighted robust regression adjusted for other substances, income and ethnicity, cannabis was independently significant (β-estimate = 4.75(0.48, 9.02), P = 0.0389). In a spatiotemporal model adjusted for all drugs, income, and ethnicity, cannabigerol exposure was significant (β-estimate = 0.26(0.01, 0.52), P = 0.0444), an effect increased by spatial lagging (THC: β-estimate = 0.47(0.12, 0.82), P = 0.0083). After missing data imputation ethnic cannabis exposure was significant (β-estimate = 0.64(0.55, 0.72), P = 3.1 × 10^- 40). 33/35 minimum e-Values ranged from 1.25 to 3.94 × 10³⁶ indicative of a causal relationship. Relaxation of cannabis legal paradigms had higher ALLR (Chi.Squ.Trend = 775.12, P = 2.14 × 10^- 112). Cannabis legal states had higher ALLR (2.395 ± 0.039 v. 2.127 ± 0.008 / 100,000, P = 5.05 × 10^- 10).

CONCLUSIONS

Data show that ALLR is associated with cannabis consumption across space-time, is associated with the cannabinoids, THC, cannabigerol, cannabinol, cannabichromene, and cannabidiol, contributes to ethnic differentials, demonstrates prominent quintile effects, satisfies criteria for causality and is exacerbated by cannabis legalization.

Metabolic Consequences of Gestational Cannabinoid Exposure

Up to 20% of pregnant women ages 18-24 consume cannabis during pregnancy. Moreover, clinical studies indicate that cannabis consumption during pregnancy leads to fetal growth restriction (FGR), which is associated with an increased risk of obesity, type II diabetes (T2D), and cardiovascular disease in the offspring. This is of great concern considering that the concentration of Δ9- tetrahydrocannabinol (Δ9-THC), a major psychoactive component of cannabis, has doubled over the last decade and can readily cross the placenta and enter fetal circulation, with the potential to negatively impact fetal development via the endocannabinoid (eCB) system. Cannabis exposure in utero could also lead to FGR via placental insufficiency. In this review, we aim to examine current pre-clinical and clinical findings on the direct effects of exposure to cannabis and its constituents on fetal development as well as indirect effects, namely placental insufficiency, on postnatal metabolic diseases.

Factors Associated With Cannabis Use During the Reproductive Cycle: A Retrospective Cross-Sectional Study of Women in States With Recreational and Medical Cannabis Legalization

INTRODUCTION

Passage of cannabis laws may impact cannabis use and the use of other substances. The suggested association is of particular concern in pregnant women where exposure to substances can cause harm to both the pregnant woman and fetus. The present study contributes to the minimal literature on factors associated with cannabis use during the preconception, prenatal, and postpartum periods including state legalization status, concurrent use of tobacco and e-cigarettes and adequacy of prenatal care.

METHODS

We conducted a cross-sectional analysis using combined survey data from the 2016-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) collected from 36,391 women. Logistic regression was used to estimate the impact of state-legalization, adequacy of prenatal care, and other substance use on cannabis use during the preconception, prenatal, and post-partum periods.

RESULTS

In the preconception model, residence in a recreationally legal state (OR: 2.37; 95% CI, 2.04-2.75) or medically legal state (OR:3.32; 95% CI, 2.90-3.80) compared to a non-legal state was associated with higher odds of cannabis use. In the prenatal model, residence in a recreationally legal state was associated with higher odds of cannabis use (OR: 1.51; 95% CI, 1.29-1.79) whereas there was no association with residence in a medically legal state. Tobacco use including e-cigarettes and moderate prenatal alcohol use were also significantly associated with cannabis use.

CONCLUSION

Recreational cannabis legalization is associated with the use of cannabis prior to, during, and after pregnancy. Renewed clinical and policy efforts may be warranted to update prenatal substance use prevention programs, educational campaigns, and provider education as cannabis legalization evolves.

Teratogenic effects of maternal drug abuse on developing brain and underlying neurotransmitter mechanisms

The aim of this review is to highlight our knowledge of the various drugs of abuse that can prove potential teratogens affecting the brain and cognitive development in an individual exposed to maternal consumption of such agents. Among several drugs of abuse in women, we specifically highlighted the commonly used alcohol, nicotine, opioids, cannabis, cocaine and marijuana. These drugs can affect the fetal development and slow the cognitive maturation apart from physical disabilities. However, no known therapy exists to counter the toxic potential of these drugs. Several researchers used animal models of drug abuse to understand the underlying mechanisms affecting brain development and the relevant neurotransmitter system. Identifying such targets can potentially help in drug discovery research. We reported in depth analysis of such mechanisms and discussed the potential targets for drug development research.

The Cannabinoid Delta-9-tetrahydrocannabinol Disrupts Estrogen Signaling in Human Placenta

Cannabis consumption is increasing worldwide either for recreational or medical purposes. Its use during gestation is associated with negative pregnancy outcomes such as, intrauterine growth restriction, preterm birth, low birth weight, and increased risk of miscarriage, though the underlying molecular mechanisms are unknown. Cannabis sativa main psychoactive compound, Δ9-tetrahydrocannabinol (THC) is highly lipophilic, and as such, readily crosses the placenta. Consequently, THC may alter normal placental development and function. Here, we hypothesize alterations of placental steroidogenesis caused by THC exposure. The impact on placental estrogenic signaling was examined by studying THC effects upon the enzyme involved in estrogens production, aromatase and on estrogen receptor α (ERα), using placental explants, and the cytotrophoblast cell model BeWo. Aromatase expression was upregulated by THC, being this effect potentiated by estradiol. THC also increased ERα expression. Actions on aromatase were ERα-mediated, as were abolished by the selective ER downregulator ICI-182780 and dependent on the cannabinoid receptor CB1 activation. Furthermore, the presence of the aromatase inhibitor Exemestane did not affect THC-induced increase in ERα expression. However, THC effects on ERα levels were reversed by the antagonists of CB1 and CB2 receptors AM281 and AM630, respectively. Thus, we demonstrate major alterations in estrogen signaling caused by THC, providing new insight on how cannabis consumption leads to negative pregnancy outcomes, likely through placental endocrine alterations. Data presented in this study, together with our recently reported evidence on THC disruption of placental endocannabinoid homeostasis, represent a step forward into a deeper comprehension of the puzzling actions of THC.

Causal inference multiple imputation investigation of the impact of cannabinoids and other substances on ethnic differentials in US testicular cancer incidence

Background

Ethnic differences in testicular cancer rates (TCRs) are recognized internationally. Cannabis is a known risk factor for testicular cancer (TC) in multiple studies with dose-response effects demonstrated, however the interaction between ancestral and environmental mutagenic effects has not been characterized. We examined the effects of this presumed gene-environment interaction across US states.

Methods

State based TCR was downloaded from the Surveillance Epidemiology and End Results (SEER) website via SEERStat. Drug use data for cigarettes, alcohol use disorder, analgesics, cannabis and cocaine was taken from the National Survey of Drug Use and Health a nationally representative study conducted annually by the Substance Abuse and Mental Health Services Administration (SAMHSA) with a 74.1% response rate. Cannabinoid concentrations derived from Drug Enforcement Agency publications. Median household income and ethnicity data (Caucasian-American, African-American, Hispanic-American, Asian-American, American-Indian-Alaska-Native-American, Native-Hawaiian-Pacific-Islander-American) was from the US Census Bureau. Data were processed in R using instrumental regression, causal inference and multiple imputation.

Results

1975–2017 TCR rose 41% in African-Americans and 78.1% in Caucasian-Americans; 2003–2017 TCR rose 36.1% in Hispanic-Americans and 102.9% in Asian-Pacific-Islander-Americans. Ethnicity-based scatterplot-time and boxplots for cannabis use and TCR closely mirrored each other. At inverse probability-weighted interactive robust regression including drugs, income and ethnicity, ethnic THC exposure was the most significant factor and was independently significant (β-estimate = 4.72 (2.04, 7.41), P = 0.0018). In a similar model THC, and cannabigerol were also significant (both β-estimate = 13.87 (6.33, 21.41), P = 0.0017). In additive instrumental models the interaction of ethnic THC exposure with Asian-American, Hispanic-American, and Native-Hawaiian-Pacific-Islander-American ethnicities was significant (β-estimate = − 0.63 (− 0.74, − 0.52), P = 3.6 × 10^− 29, β-estimate = − 0.25 (− 0.32, − 0.18), P = 4.2 × 10^− 13, β-estimate = − 0.19 (− 0.25, − 0.13), P = 3.4 × 10^− 9). After multiple imputation, ethnic THC exposure became more significant (β-estimate = 0.68 (0.62, 0.74), P = 1.80 × 10^− 92). 25/33 e-Values > 1.25 ranging up to 1.07 × 10⁵. Liberalization of cannabis laws was linked with higher TCR’s in Caucasian-Americans (β-estimate = 0.09 (0.06, 0.12), P = 6.5 × 10^− 10) and African-Americans (β-estimate = 0.22 (0.12, 0.32), P = 4.4 × 10^− 5) and when dichotomized to illegal v. others (t = 6.195, P = 1.18 × 10^− 9 and t = 4.50, P = 3.33 × 10^− 5).

Conclusion

Cannabis is shown to be a TC risk factor for all ethnicities including Caucasian-American and African-American ancestries, albeit at different rates. For both ancestries cannabis legalization elevated TCR. Dose-response and causal relationships are demonstrated.

Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities

BACKGROUND

Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited.

METHODS

We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians.

DISCUSSION

The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Canadian Cannabis Consumption and Patterns of Congenital Anomalies: An Ecological Geospatial Analysis

OBJECTIVES

Cannabis is a known teratogen. Data availability addressing both major congenital anomalies and cannabis use allowed us to explore their geospatial relationships.

METHODS

Data for the years 1998 to 2009 from Canada Health and Statistics Canada was analyzed in R. Maps have been drawn and odds ratios, principal component analysis, correlation matrices, least squares regression and geospatial regression analyses have been conducted using the R packages base, dplyr, epiR, psych, ggplot2, colorplaner and the spml and spreml functions from package splm.

RESULTS

Mapping showed cannabis use was more common in the northern Territories of Canada in the Second National Survey of Cannabis Use 2018. Total congenital anomalies, all cardiovascular defects, orofacial clefts, Downs syndrome and gastroschisis were all found to be more common in these same regions and rose as a function of cannabis exposure. When Canada was dichotomized into high and low cannabis use zones by Provinces v Territories the Territories had a higher rate of total congenital anomalies 450.026 v 390.413 (O.R. = 1.16 95%C.I. 1.08-1.25, P = 0.000058; attributable fraction in exposed 13.25%, 95%C.I. 7.04-19.04%). In geospatial analysis in a spreml spatial error model cannabis was significant both alone as a main effect (P < 2.0 × 10) and in all its first and second order interactions with both tobacco and opioids from P < 2.0 × 10.

CONCLUSION

These results show that the northern Territories of Canada share a higher rate of cannabis use together with elevated rates of total congenital anomalies, all cardiovascular defects, Down's syndrome and gastroschisis. This is the second report of a significant association between cannabis use and both total defects and all cardiovascular anomalies and the fourth published report of a link with Downs syndrome and thereby direct major genotoxicity. The correlative relationships described in this paper are confounded by many features of social disadvantage in Canada's northern territories. However, in the context of a similar broad spectrum of defects described both in animals and in epidemiological reports from Hawaii, Colorado, USA and Australia they are cause for particular concern and indicate further research.

Cannabis Retail Staff ("Budtenders") Attitudes Towards Cannabis Effects on Health and Experiences Interacting with Consumers - Washington State, USA

Cannabis legalization in Washington State has increased the availability, consumption, and potency of cannabis products for adults. Public health education promoting safe use for adult consumers has lagged behind these trends. This study assesses the potential of cannabis retail workers (budtenders) to engage in responsible use education with adult consumers at point of sale. Focus groups explored how budtenders perceive their professional role, including educating consumers about cannabis over intoxication, storage, and risks of use before driving and during pregnancy. Transcripts were analyzed to develop a coding scheme, which was then applied with an iterative review by the research team. Budtenders identified three main professional roles: creating a good experience for customers; being compliant with the state law and regulations, and educating customers on products. Budtenders did not believe their job involved discussing use during pregnancy or while driving or safe storage. They prioritized customers' autonomy over education on these topics, and they did not necessarily consider these behaviors to be harmful. Budtenders are committed to keeping minors outside stores and educating consumers on how to avoid over intoxication and exposure to cannabis contaminants. Future research could build on this to develop point-of-sale education to reduce cannabis use risks.

Mesolimbic dopamine dysregulation as a signature of information processing deficits imposed by prenatal THC exposure

Cannabis is the illicit drug most widely used by pregnant women worldwide. Its growing acceptance and legalization have markedly increased the risks of child psychopathology, including psychotic-like experiences, which lowers the age of onset for a first psychotic episode. As the majority of patients with schizophrenia go through a premorbid condition long before this occurs, understanding neurobiological underpinnings of the prodromal stage of the disease is critical to improving illness trajectories and therapeutic outcomes. We have previously shown that male rat offspring prenatally exposed to Δ⁹-tetrahydrocannabinol (THC), a rat model of prenatal cannabinoid exposure (PCE), exhibit extensive molecular and synaptic changes in dopaminergic neurons of the ventral tegmental area (VTA), converging on a hyperdopaminergic state. This leads to a silent psychotic-like endophenotype that is unmasked by a single exposure to THC. Here, we further characterized the VTA dopamine neuron and sensorimotor gating functions of PCE rats exposed to acute stress or a challenge of the D2 receptor agonist apomorphine, by using in vivo single-unit extracellular recordings and Prepulse Inhibition (PPI) analyses. At pre-puberty, PCE male rat offspring display a reduced population activity of VTA dopamine neurons in vivo, the majority of which are tonically active. PCE male progeny also exhibit enhanced sensitivity to dopamine D2 (DAD2) receptor activation and a vulnerability to acute stress, which is associated with compromised sensorimotor gating functions. This data extends our knowledge of the multifaceted sequelae imposed by PCE in the mesolimbic dopamine system of male pre-adolescent rats, which renders a neural substrate highly susceptible to subsequent challenges that may trigger psychotic-like outcomes.

Association of Cannabis Retailer Proximity and Density With Cannabis Use Among Pregnant Women in Northern California After Legalization of Cannabis for Recreational Use

This cross-sectional study examines the association of cannabis retailer proximity and density with cannabis use among pregnant women after legalization of cannabis for recreational use in California.

A geospatiotemporal and causal inference epidemiological exploration of substance and cannabinoid exposure as drivers of rising US pediatric cancer rates

BACKGROUND

Age-adjusted US total pediatric cancer incidence rates (TPCIR) rose 49% 1975-2015 for unknown reasons. Prenatal cannabis exposure has been linked with several pediatric cancers which together comprise the majority of pediatric cancer types. We investigated whether cannabis use was related spatiotemporally and causally to TPCIR.

METHODS

State-based age-adjusted TPCIR data was taken from the CDC Surveillance, Epidemiology and End Results cancer database 2003-2017. Drug exposure was taken from the nationally-representative National Survey of Drug Use and Health, response rate 74.1%. Drugs included were: tobacco, alcohol, cannabis, opioid analgesics and cocaine. This was supplemented by cannabinoid concentration data from the Drug Enforcement Agency and ethnicity and median household income data from US Census.

RESULTS

TPCIR rose while all drug use nationally fell, except for cannabis which rose. TPCIR in the highest cannabis use quintile was greater than in the lowest (β-estimate = 1.31 (95%C.I. 0.82, 1.80), P = 1.80 × 10^- 7) and the time:highest two quintiles interaction was significant (β-estimate = 0.1395 (0.82, 1.80), P = 1.00 × 10^- 14). In robust inverse probability weighted additive regression models cannabis was independently associated with TPCIR (β-estimate = 9.55 (3.95, 15.15), P = 0.0016). In interactive geospatiotemporal models including all drug, ethnic and income variables cannabis use was independently significant (β-estimate = 45.67 (18.77, 72.56), P = 0.0009). In geospatial models temporally lagged to 1,2,4 and 6 years interactive terms including cannabis were significant. Cannabis interactive terms at one and two degrees of spatial lagging were significant (from β-estimate = 3954.04 (1565.01, 6343.09), P = 0.0012). The interaction between the cannabinoids THC and cannabigerol was significant at zero, 2 and 6 years lag (from β-estimate = 46.22 (30.06, 62.38), P = 2.10 × 10^- 8). Cannabis legalization was associated with higher TPCIR (β-estimate = 1.51 (0.68, 2.35), P = 0.0004) and cannabis-liberal regimes were associated with higher time:TPCIR interaction (β-estimate = 1.87 × 10^- 4, (2.9 × 10^- 5, 2.45 × 10^- 4), P = 0.0208). 33/56 minimum e-Values were > 5 and 6 were infinite.

CONCLUSION

Data confirm a close relationship across space and lagged time between cannabis and TPCIR which was robust to adjustment, supported by inverse probability weighting procedures and accompanied by high e-Values making confounding unlikely and establishing the causal relationship. Cannabis-liberal jurisdictions were associated with higher rates of TPCIR and a faster rate of TPCIR increase. Data inform the broader general consideration of cannabinoid-induced genotoxicity.

Associations Between Prenatal Cannabis Exposure and Childhood Outcomes: Results From the ABCD Study

IMPORTANCE

In light of increasing cannabis use among pregnant women, the US Surgeon General recently issued an advisory against the use of marijuana during pregnancy.

OBJECTIVE

To evaluate whether cannabis use during pregnancy is associated with adverse outcomes among offspring.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, data were obtained from the baseline session of the ongoing longitudinal Adolescent Brain and Cognitive Development Study, which recruited 11 875 children aged 9 to 11 years, as well as a parent or caregiver, from 22 sites across the United States between June 1, 2016, and October 15, 2018.

EXPOSURE

Prenatal cannabis exposure prior to and after maternal knowledge of pregnancy.

MAIN OUTCOMES AND MEASURES

Symptoms of psychopathology in children (ie, psychotic-like experiences [PLEs] and internalizing, externalizing, attention, thought, and social problems), cognition, sleep, birth weight, gestational age at birth, body mass index, and brain structure (ie, total intracranial volume, white matter volume, and gray matter volume). Covariates included familial (eg, income and familial psychopathology), pregnancy (eg, prenatal exposure to alcohol and tobacco), and child (eg, substance use) variables.

RESULTS

Among 11 489 children (5997 boys [52.2%]; mean [SD] age, 9.9 [0.6] years) with nonmissing prenatal cannabis exposure data, 655 (5.7%) were exposed to cannabis prenatally. Relative to no exposure, cannabis exposure only before (413 [3.6%]) and after (242 [2.1%]) maternal knowledge of pregnancy were associated with greater offspring psychopathology characteristics (ie, PLEs and internalizing, externalizing, attention, thought and, social problems), sleep problems, and body mass index, as well as lower cognition and gray matter volume (all |β| > 0.02; all false discovery rate [FDR]-corrected P < .03). Only exposure after knowledge of pregnancy was associated with lower birth weight as well as total intracranial volume and white matter volumes relative to no exposure and exposure only before knowledge (all |β| > 0.02; all FDR-corrected P < .04). When including potentially confounding covariates, exposure after maternal knowledge of pregnancy remained associated with greater PLEs and externalizing, attention, thought, and social problems (all β > 0.02; FDR-corrected P < .02). Exposure only prior to maternal knowledge of pregnancy did not differ from no exposure on any outcomes when considering potentially confounding variables (all |β| < 0.02; FDR-corrected P > .70).

CONCLUSIONS AND RELEVANCE

This study suggests that prenatal cannabis exposure and its correlated factors are associated with greater risk for psychopathology during middle childhood. Cannabis use during pregnancy should be discouraged.

Twitter Posts About Cannabis Use During Pregnancy and Postpartum:A Content Analysis

The prevalence of cannabis use has increased among U.S. pregnant women. Given this increase, and rapidly changing cannabis policies, it may be important to harness digital data sources to help capture trends and perceptions of cannabis use during pregnancy and postpartum. The objective of this study was to examine cannabis and pregnancy-related posts on Twitter over a 12-month period. Methods: Twitter posts from December 1, 2019 to December 1, 2020 that contained pregnancy and cannabis-related keywords were collected in this study (n = 17,238). A sample of 1,000 posts proportionally sampled by week and cannabis/pregnancy-related terms were selected for coding. Posts were classified by one or more of the following themes: 1) Safety during pregnancy i.e. mentions the safety of cannabis use during pregnancy, 2) Safety postpartum i.e. mentions the safety of cannabis use postpartum, and 3) Use for pregnancy-related symptoms i.e. mentions use of cannabis to help with morning sickness, nausea, vomiting, headaches, pain, stress, and fatigue. Results: Safety during pregnancy occurred in 36.00% of the posts and 2.30% posts asked about safety during postpartum. Use of cannabis for pregnancy-related symptoms occurred in 2.70% of posts. Discussion: Findings show that conversations about the risks and benefits of cannabis use during pregnancy and postpartum take place on Twitter. These findings suggests that health practitioners should discuss the risks of cannabis use (including CBD) during pregnancy and breastfeeding with their patients. Health communication planners may need to find ways to communicate risks with the public to prevent the spread of misinformation.

When Cannabis Use Goes Wrong: Mental Health Side Effects of Cannabis Use That Present to Emergency Services

Cannabis use is a modifiable risk factor for the development and exacerbation of mental illness. The strongest evidence of risk is for the development of a psychotic disorder, associated with early and consistent use in youth and young adults. Cannabis-related mental health adverse events precipitating Emergency Department (ED) or Emergency Medical Services presentations can include anxiety, suicidal thoughts, psychotic or attenuated psychotic symptoms, and can account for 25-30% of cannabis-related ED visits. Up to 50% of patients with cannabis-related psychotic symptoms presenting to the ED requiring hospitalization will go on to develop schizophrenia. With the legalization of cannabis in various jurisdiction and the subsequent emerging focus of research in this area, our understanding of who (e.g., age groups and risk factors) are presenting with cannabis-related adverse mental health events in an emergency situation is starting to become clearer. However, for years we have heard in popular culture that cannabis use is less harmful or no more harmful than alcohol use; however, this does not appear to be the case for everyone. It is evident that these ED presentations should be considered another aspect of potentially harmful outcomes that need to be included in knowledge mobilization. In the absence of a clear understanding of the risk factors for mental health adverse events with cannabis use it can be instructive to examine what characteristics are seen with new presentations of mental illness both in emergency departments (ED) and early intervention services for mental illness. In this narrative review, we will discuss what is currently known about cannabis-related mental illness presentations to the ED, discussing risk variables and outcomes both prior to and after legalization, including our experiences following cannabis legalization in Canada. We will also discuss what is known about cannabis-related ED adverse events based on gender or biological sex. We also touch on the differences in magnitude between the impact of alcohol and cannabis on emergency mental health services to fairly present the differences in service demand with the understanding that these two recreational substances may impact different populations of individuals at risk for adverse events.

Combined vapor exposure to THC and alcohol in pregnant rats: Maternal outcomes and pharmacokinetic effects

Cannabis is the most frequently used illicit drug among pregnant women, yet the potential consequences of prenatal cannabis exposure on development are not well understood. Electronic cigarettes have become an increasingly popular route of administration among pregnant women, in part to user's perception that e-cigarettes are a safer route for consuming cannabis products. Importantly, half of pregnant women who consume cannabis also report consuming alcohol, but research investigating co-consumption of these drugs is limited, particularly with current routes of administration. The purpose of this study was to establish a co-exposure vapor inhalation model of alcohol and THC in pregnant rats, to ultimately determine the effects on fetal development. Pregnant Sprague-Dawley rats were exposed to moderate doses of THC via e-cigarettes, alcohol, the combination, or vehicle daily from gestational days 5-20. Importantly, pharmacokinetic interactions of alcohol and THC were observed during pregnancy. Combined exposure consistently increased blood alcohol concentrations, indicating that THC alters alcohol metabolism. In addition, THC levels also increased over the course of pregnancy and THC metabolism was altered by alcohol. Alcohol, but not THC, exposure during pregnancy reduced maternal weight gain, despite no group differences in food intake. Neither prenatal alcohol nor THC exposure altered gestational length, litter size, sex ratio or birth weight. However, prenatal alcohol exposure delayed eye opening, and prenatal THC exposure decreased body weights during adolescence among offspring. These individual and synergistic effects suggest that this novel co-exposure vapor inhalation paradigm can effectively be used to expose pregnant dams, exerting some effects on fetal development, while avoiding nutritional confounds, birth complications, or changes in litter size. With this model, we have demonstrated that combining THC and alcohol alters drug metabolism, which could have important consequences on prenatal development.

Perinatal THC exposure via lactation induces lasting alterations to social behavior and prefrontal cortex function in rats at adulthood

Cannabis is the world's most widely abused illicit drug and consumption amongst women during and surrounding the period of pregnancy is increasing. Previously, we have shown that cannabinoid exposure via lactation during the early postnatal period disrupts early developmental trajectories of prefrontal cortex maturation and induces behavioral abnormalities during the first weeks of life in male and female rat progeny. Here, we investigated the lasting consequences of this postnatal cannabinoid exposure on synaptic and behavioral parameters in the adult offspring of ∆9-tetrahydrocannabinol (THC)-treated dams. At adulthood, these perinatally THC-exposed rats exhibits deficits in social discrimination accompanied by an overall augmentation of social exploratory behavior. These behavioral alterations were further correlated with multiple abnormalities in synaptic plasticity in the prefrontal cortex, including lost endocannabinoid-mediated long-term depression (LTD), lost long-term potentiation and augmented mGlu2/3-LTD. Finally, basic parameters of intrinsic excitability at prefrontal cortex pyramidal neurons were similarly altered by the perinatal THC exposure. Thus, perinatal THC exposure via lactation induces lasting deficits in behavior and synaptic function which persist into adulthood life in male and female progeny.

Cannabis Exposure During Critical Windows of Development: Epigenetic and Molecular Pathways Implicated in Neuropsychiatric Disease

PURPOSE OF REVIEW

Cannabis exposure during critical windows of development may have intergenerational physiological consequences disrupting epigenetic programming and marks. This review examines the literature relating to pre-gestational and prenatal cannabinoid exposure and its effect on genes and molecular pathways related to the development of psychiatric disease.

RECENT FINDINGS

Developmental cannabis exposure alters epigenetic processes with functional gene consequences. These include potentially heritable alterations in genes and molecular pathways critical for brain development and associated with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), schizophrenia, addiction, and other psychiatric diseases. Cannabis consumption and mental health illness in adolescents and young adults are increasing in the United States (U.S.), and recent studies suggest that cannabis consumption during critical periods of brain development could contribute to mental health illness through epigenetic mechanisms. These findings warrant future studies and consideration by regulators and health communicators.

Long-term effects of maternal cannabis vapor exposure on emotional reactivity, social behavior, and behavioral flexibility in offspring

The use of cannabis during pregnancy is a growing public health concern. As more countries implement legislation permitting recreational cannabis use, there is an urgent need to better understand its impact on fetal neurodevelopment and its long-term effects in exposed offspring. Studies examining effects of prenatal cannabis exposure typically employ injections of synthetic cannabinoids or isolated cannabis constituents that may not accurately model cannabis use in human populations. To address this limitation, we developed a novel e-cigarette technology-based system to deliver vaporized cannabis extracts to pregnant Long Evans rats. We used this model to determine effects of prenatal cannabis exposure on emotional, social, and cognitive endpoints of male and female offspring during early development and into adulthood. Dams were exposed to cannabis vapor (CAN_THC: 400 mg/ml), vehicle vapor (VEH), or no vapor (AIR) twice daily during mating and gestation. Offspring exposed to CAN_THC and VEH showed reduced weight gain relative to AIR offspring prior to weaning. CAN_THC offspring made more isolation-induced ultrasonic vocalizations (USVs) on postnatal day 6 (P6) relative to VEH-exposed offspring, which is indicative of increased emotional reactivity. Male CAN_THC offspring engaged in fewer social investigation behaviors than VEH-exposed male offspring during a social play test on P26. In adulthood, CAN_THC-exposed offspring spent less time exploring the open arms of the elevated plus maze and exhibited dose-dependent deficits in behavioral flexibility in an attentional set-shifting task relative to AIR controls. These data collectively indicate that prenatal cannabis exposure may cause enduring effects on the behavioral profile of offspring.

Are Canadian Cannabis Dispensaries Counselling Pregnant Women Appropriately?

Our objective was to examine the recommendations that Canadian dispensary employees are giving to women regarding cannabis use for nausea and vomiting of pregnancy (NVP) since the legalization of recreational cannabis in 2018. We conducted a nationwide cross-sectional study of licensed cannabis dispensaries in 2019, wherein a mystery caller stated they were 8 weeks pregnant and experiencing nausea and vomiting and asked for recommendations about cannabis. Our research was modeled after the primary study done in Colorado by Dickson and colleagues in 2018. An overwhelming majority of dispensaries (93%) in our study recommended against the use of a cannabis product for NVP, which contrasted significantly to the findings of the Colorado study, in which 70% of dispensaries recommended a cannabis product. These findings suggest that Canadian dispensary employees have been adequately educated about the dangers of cannabis use during pregnancy and are helpful from a public health lens.

Impact of tetrahydrocannabinol on the endocannabinoid 2-arachidonoylglycerol metabolism: ABHD6 and ABHD12 as novel players in human placenta

Cannabis use has been increasing worldwide for recreational and medical purposes. Consumption by pregnant women is associated with disturbances in pregnancy outcome, such as low birth weight, prematurity and intrauterine growth retardation, though the underlying biochemical mechanisms are unknown. The endocannabinoid system is involved in several reproductive events and the disruption of its homeostasis by ∆⁹-tetrahydrocannabinol (THC), the main psychoactive cannabinoid, may lead to a negative gestational outcome. In human placenta, THC impairs the levels of the endocannabinoid anandamide (AEA). The other major endocannabinoid, 2-arachidonoylglycerol (2-AG) also plays an important role on proper placentation and pregnancy success. However, THC impact on 2-AG homeostasis has never been addressed. Hence, the effects of THC in 2-AG levels and metabolic enzymes expression were explored. Long-term treatment impairs the expression of the main 2-AG synthetic and degradative enzymes. Curiously, with the highest concentration, despite the maintenance of diacylglycerol lipase alpha (DAGLα) and the decrease in monoacylglycerol lipase (MAGL) expression, 2-AG levels remain constant. Given the endocannabinoid signalling local tight regulation, we hypothesize the involvement of other 2-AG degradative enzymes. Indeed, THC increases the expression of the hydrolyzing enzymes alpha beta hydrolase domain-6 (ABHD6) and -12 (ABHD12), that we firstly describe in human placental tissues. The results show that THC, depending on time of exposure, induces alterations in 2-AG metabolic enzymes expression in placental explants, highlighting the importance of 2-AG regulation and endocannabinoid signalling in placental development. Alterations in this homeostasis may explain the negative pregnancy outcome related to cannabis consumption.

Perceptions of Marijuana Use for Glaucoma from Patients, Cannabis Retailers, and Glaucoma Specialists

PURPOSE

As marijuana's popularity continues to grow, patients with glaucoma will encounter conflicting opinions on marijuana's role in glaucoma therapy. This study seeks to define the differing perceptions among glaucoma specialists, medical marijuana dispensaries, and glaucoma patients in a state with legalized marijuana.

DESIGN

Cross-sectional study.

PARTICIPANTS

Medical marijuana dispensaries in Colorado, members of the American Glaucoma Society (AGS), and patients with glaucoma at the University of Colorado glaucoma clinic.

METHODS

First, medical marijuana dispensary employees were surveyed using a mystery call approach and a brief phone script. Dispensary employees were questioned as to whether marijuana was recommended and whether marijuana was safe and effective. Second, a self-administered survey was distributed to AGS members to determine the history of recommending marijuana and influencing factors for or against this recommendation. Third, the self-administered glaucoma patient survey assessed demographics, history of glaucoma, knowledge and rate of marijuana use, and perceptions of marijuana use. All surveys were conducted from October 2018 to March 2019.

MAIN OUTCOME MEASURES

The proportion of medical marijuana dispensaries and glaucoma specialists recommending marijuana for the treatment of glaucoma, and the proportion of patients with glaucoma using marijuana as a treatment for glaucoma.

RESULTS

A total of 203 of the 300 medical marijuana dispensaries called were successfully contacted (68%). Of these, 103 respondents (51%) recommended marijuana products for the treatment of glaucoma. The remaining 100 (49%) deferred making a recommendation or were unsure. Of the 1308 AGS members, 290 (22%) responded to the survey. Twenty-two respondents (7.6%) reported that they had recommended marijuana for the treatment of glaucoma, with the majority of these (86.4%) having done so infrequently. Among the 231 respondents with glaucoma, most (58.9%) had heard about the possible use of marijuana for glaucoma, but only 2.6% had used marijuana as a treatment for glaucoma.

CONCLUSIONS

Few glaucoma specialists have recommended marijuana as a treatment for glaucoma, and an even smaller percentage of patients report its use as a treatment for their glaucoma. In contrast, many marijuana dispensary employees endorse its use. As legal access and public acceptance of marijuana escalate, physicians should be aware of these perceptions when educating patients.

Update on the developmental consequences of cannabis use during pregnancy and lactation

There is a strong increase in prevalence trends for cannabis use during pregnancy and lactation as more states legalize use of this drug. Information on the teratogenic risk of cannabis is limited but some important themes can be gleaned. Studies have not found a unique phenotypic signature of prenatal exposure but an increased risk of congenital anomalies, particularly gastroschisis, has been reported. Changes in fetal growth have been described in some epidemiological studies but long-term patterns of physical growth appear unaffected. Prenatal exposure to cannabis is not generally associated with reductions in global IQ but specific cognitive skills, especially attention and memory, can be negatively impacted. Long-term impacts on psychological health include increased rates of depressive symptoms and anxiety as well as delinquency. Relatively little is known about the risk of maternal cannabis use during lactation but data suggest that infant exposure is relatively low compared to maternal exposure. As delta-9-tetrahydrocannabinol (THC) levels increase to meet consumer demand and routes of exposure diversify, there is a strong need for prospective birth-cohort studies that collect biological samples to quantify exposure. Data from such studies will be critical to overcoming the weaknesses of past cannabis research and are essential to establishing reliable information on the risks of maternal use. Until that time, health care providers should be encouraged to talk about the risks and benefits associated with cannabis use during pregnancy and lactation with their patients, emphasizing that fetal and neonatal risks cannot be excluded at this time.

Protection Versus Progress: The Challenge of Research on Cannabis Use During Pregnancy

A central tension in pediatric research ethics arises from our desire to protect children from harm while also allowing progress toward discoveries that could improve child health. A prime example of this tension is research on a controversial yet increasingly common practice: the use of cannabis by women to treat nausea and vomiting of pregnancy. Studies of cannabis use in pregnancy face a combination of ethical hurdles because of the inclusion of pregnant women and involvement of a schedule I controlled substance. Given the growing need for research on the safety and efficacy of cannabis for nausea and vomiting of pregnancy, we reflect on the multiple historical contexts that have contributed to the challenge of studying cannabis use during pregnancy and make a case for the ethical rationale for such research.

Role of Cannabis and Its Derivatives in Gastrointestinal and Hepatic Disease

Medical and recreational cannabis use has increased dramatically over the last decade, resulting from mainstream cultural acceptance and legalization in several countries worldwide. Cannabis and its derivatives affect many gastrointestinal processes via the endocannabinoid system (ECS). The ECS influences gastrointestinal homeostasis through anti-inflammatory, anti-nociceptive, and anti-secretory effects. Some gastrointestinal disorders might therefore be treated with cannabinoids. Despite numerous studies in cell lines and animals, few human studies have evaluated the therapeutic effects of cannabinoids. Cannabis' schedule 1 drug status has limited its availability in research; cannabis has been legalized only recently, in some states, for medicinal and/or recreational use. Cannabinoids can alleviate chemotherapy-induced nausea and emesis and chronic pain. Studies have demonstrated the important roles of the ECS in metabolism, obesity, and nonalcoholic fatty liver disease and the anti-inflammatory effects of cannabis have been investigated in patients with inflammatory bowel diseases. Despite its potential benefits, undesired or even detrimental effects of cannabis can limit its use. Side effects such as cannabinoid hyperemesis syndrome affect some users. We review the ECS and the effects of cannabis and its derivatives on gastrointestinal and hepatic function in health and disease.