101
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Witek TJ. Please don't call it medical marijuana unless it is; but it probably isn't. Canadian Journal of Public Health 2020; 112:74-77. [PMID: 32557287 DOI: 10.17269/s41997-020-00333-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/28/2020] [Indexed: 11/17/2022]
Abstract
The drug development process of demonstrating an agent is safe, effective and pure has, with rare exception, proven an exemplary path in translational research. The basic science, the clinical trials and the chemistry, manufacturing and control have served public health well. This carefully regulated approach forms the basis of a drug label with data from these studies also used to convey risk and benefit to prescribing physicians through the channels of medical literature and drug promotion by the industry. The latter is also important to public health in that such promotion must be based in the approved indication, be truthful, not be misleading and be substantiated by sufficient evidence. Why then is the emergence of "medical marijuana" any different? While substantial evidence exists for some conditions and some related products have undergone careful investigation through to NDA approval, most claims are not substantiated by research but driven by misguided enthusiasm. While recreational use of marijuana is not at debate here, nor is the right of an individual patient to explore cannabis therapeutically; however, allowing broad unsubstantiated claims around medicinal cannabis to infiltrate the general public is a disservice. To distill the potential medical benefits through the pharmacologic understanding of the endocannabinoid system, cannabis should follow the traditional drug development process or one that improves upon it. Until then, claims should remain as stated hypothesis to accept or reject.
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Affiliation(s)
- Theodore J Witek
- Institute of Health Policy Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street (4th Floor), Toronto, ON, M5T 3M6, Canada.
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102
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Abstract
As more states legalize cannabis for medical use, people increasingly use cannabis to treat medical conditions. Well-documented harms of cannabis use include increased risk of fatal auto accidents, neurocognitive deficits, and increased risk of addiction. Observational data supports the use of cannabis for pain, nausea and vomiting related to chemotherapy, and multiple sclerosis spasticity symptoms. Given potential harms versus benefits of cannabis use, how should physicians counsel patients regarding their cannabis use? This paper briefly reviews the evidence supporting medical cannabis use for pain. We consider cannabis use as a harm reduction strategy for pain management. We encourage routine, longitudinal assessments of cannabis use among patients. We discuss the commercialization of cannabis for financial gain, contributing to potent and addictive cannabis. We highlight the concerning phenomena of cannabis dispensary workers as proxy clinicians. Finally, we present three strategies to reduce public harms associated with potent cannabis use including required testing and reporting of tetrahydrocannabinol/cannabidiol concentrations, rigorous study of high-potency cannabis available for purchase in dispensaries across the USA, and large-scale efforts to measure cannabis consumption in medical records so prospective, longitudinal studies can be conducted to correlate consumption measures with medical and psychiatric outcomes.
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103
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Costentin J. [Epigenetic effects of cannabis/tetrahydrocannabinol]. BULLETIN DE L'ACADEMIE NATIONALE DE MEDECINE 2020; 204:570-576. [PMID: 32296244 PMCID: PMC7158823 DOI: 10.1016/j.banm.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/26/2020] [Indexed: 11/21/2022]
Abstract
The almost pandemic spread of cannabis among adolescents and young adults, especially in France, justifies the attention given to the consequences, not only acute but also delayed, of this intoxication. In the latter case, epigenetic mechanisms occur. We will first recall various types of epigenetic modifications involving either chromatin histones, mainly methylations or acetylations, either DNA, by methylation of cytosines. Such modifications caused by the tetrahydrocannabinol/THC of cannabis can intervene: either at the level of gametes before procreation, or at different points of the life cycle. These epigenetic modifications are associated with an increase in vulnerability to drug addiction, involving dopamine D2 receptors in the nucleus accumbens, overexpression of enkephalin precursor synthesis, modifications of: CB1 receptors of endocannabinoids, glutamic acid receptors, GABA receptors, proteins involved in synaptic plasticity… These changes can also affect: immune system, cognitive activities, development of psychiatric diseases, related to disturbances of brain maturation. The knowledge that accumulates in this respect is the opposite of the ambient trivialization of this drug. They impose sending an alert to the public authorities and to the public, especially young people, warning on the risks associated with this drug use and abuse.
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Affiliation(s)
- J Costentin
- Académie nationale de médecine, 16, rue Bonaparte, 75006 Paris, France
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104
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Humphreys K, Shover CL. Recreational cannabis legalization presents an opportunity to reduce the harms of the US medical cannabis industry. World Psychiatry 2020; 19:191-192. [PMID: 32394570 PMCID: PMC7214949 DOI: 10.1002/wps.20739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Keith Humphreys
- Veterans Affairs Health Care System, Palo Alto, CA, USA
- Stanford University School of Medicine, Stanford, CA, USA
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105
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Zeiger JS, Silvers WS, Fleegler EM, Zeiger RS. Attitudes about cannabis mediate the relationship between cannabis knowledge and use in active adult athletes. J Cannabis Res 2020; 2:18. [PMID: 33526137 PMCID: PMC7819330 DOI: 10.1186/s42238-020-00023-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/02/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Little is known about how cannabis knowledge and attitudes impact cannabis use behavior. OBJECTIVE To test the knowledge-attitudes-behavior paradigm in active adult athletes. DESIGN The Athlete Pain, Exercise, and Cannabis Experience (PEACE) Survey, a cross-sectional survey study, used social media and email blasts to recruit participants and SurveyGizmo to collect data. PARTICIPANTS Self-defined active adult athletes (n = 1161). MAIN MEASURES Knowledge about cannabis was evaluated with four questions. Attitudes toward cannabis was evaluated with 11 questions. The attitudes questions were used in a TwoStep Cluster analysis in SPSS to assign group membership by attitudes. Chi-square was used to determine if there were differences in cluster membership by demographic factors and if knowledge about cannabis differed by cluster membership. Regression analysis was performed to determine if cannabis attitudes mediated the relationship between cannabis knowledge and cannabis use. KEY RESULTS A three-cluster solution was the best fit to the data. The clusters were named Conservative (n = 374, 32.2%), Unsure (n = 533, 45.9%), and Liberal (n = 254, 21.9). There was a significant difference among the clusters for all 11 attitudes items (all p < 0.001). Attitude cluster membership was significantly different by age (p < 0.001), primary sport (p < 0.05), and knowledge about cannabis (p < 0.001). Athletes in the liberal cluster answered the knowledge questions correctly most often. Attitudes mediated the relationship between cannabis knowledge and cannabis use [Never (32.4%), Past (41.6%), Current (26.0%)] with athletes in the liberal cluster showing more knowledge and greater likelihood to be a current cannabis user (p < 0.001). Among current cannabis users there were differential patterns of cannabis use depending on their attitudes and knowledge; liberal athletes tended to co-use THC and CBD and used cannabis longer. (p < 0.001). CONCLUSIONS Cannabis education needs to consider attitudes about cannabis, especially among those who might benefit from medical cannabis.
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Affiliation(s)
- Joanna S Zeiger
- Canna Research Group, 3996 Savannah Ct, Boulder, CO, 80301, USA.
| | - William S Silvers
- Canna Research Group, 3996 Savannah Ct, Boulder, CO, 80301, USA
- Division of Allergy and Clinical Immunology, University of Colorado Denver School of Medicine, 12700 E. 19th Ave., Room 10C03, Aurora, CO, 80045, USA
| | - Edward M Fleegler
- Canna Research Group, 3996 Savannah Ct, Boulder, CO, 80301, USA
- To-Life in Peace, LLC, 3812 Taft Court, Wheat Ridge, CO, 80033, USA
| | - Robert S Zeiger
- Canna Research Group, 3996 Savannah Ct, Boulder, CO, 80301, USA
- Kaiser Permanente Southern California, 7060 Clairemont Mesa Blvd, San Diego, CA, 92111, USA
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106
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Lee E, Pluym ID, Wong D, Kwan L, Varma V, Rao R. The impact of state legalization on rates of marijuana use in pregnancy in a universal drug screening population. J Matern Fetal Neonatal Med 2020; 35:1660-1667. [PMID: 32419547 DOI: 10.1080/14767058.2020.1765157] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective: To evaluate the effect of state legalization of rate on marijuana use in pregnancy in a population with universal drug screening.Methods: This is a retrospective cohort study from July 2016 to December 2018 of pregnant women who had universal drug screening of marijuana use before and after legalization of recreational marijuana in California on 1 January 2018. Maternal medical conditions and neonatal outcomes associated with usage were also evaluated. Student's t-test, Wilcoxon rank-sum test, and multiple linear regression were used for statistical analyses.Results: Of 466 women, initial marijuana usage in pregnancy confirmed by urine drug test increased after legalization from 6 to 11% (p = .05). Factors associated with marijuana usage included younger age, white or black race, single marital status, psychiatric disorders, intimate partner violence and concomitant tobacco and alcohol use. 73% of users in this study had cessation of marijuana use with subsequent negative UDT. There was no statistical difference in rates of preterm birth, small for gestational age, NICU admission, or Apgar scores, when adjusted for other risk factors. Conclusion: Rates of marijuana usage in pregnant women who underwent universal drug screening increased after legalization. There were no differences in neonatal outcomes between users and non-users.
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Affiliation(s)
- Emily Lee
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ilina D Pluym
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Deanna Wong
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lorna Kwan
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Vanita Varma
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Rashmi Rao
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
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107
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Torres CA, Medina-Kirchner C, O'Malley KY, Hart CL. Totality of the Evidence Suggests Prenatal Cannabis Exposure Does Not Lead to Cognitive Impairments: A Systematic and Critical Review. Front Psychol 2020; 11:816. [PMID: 32457680 PMCID: PMC7225289 DOI: 10.3389/fpsyg.2020.00816] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/02/2020] [Indexed: 01/30/2023] Open
Abstract
Background: Despite limited data demonstrating pronounced negative effects of prenatal cannabis exposure, popular opinion and public policies still reflect the belief that cannabis is fetotoxic. Methods: This article provides a critical review of results from longitudinal studies examining the impact of prenatal cannabis exposure on multiple domains of cognitive functioning in individuals aged 0 to 22 years. A literature search was conducted through PsycINFO, PubMed, and Google Scholar. Articles were included if they examined the cognitive performance of offspring exposed to cannabis in utero. Results: An examination of the total number of statistical comparisons (n = 1,001) between groups of participants that were exposed to cannabis prenatally and non-exposed controls revealed that those exposed performed differently on a minority of cognitive outcomes (worse on <3.5 percent and better in <1 percent). The clinical significance of these findings appears to be limited because cognitive performance scores of cannabis-exposed groups overwhelmingly fell within the normal range when compared against normative data adjusted for age and education. Conclusions: The current evidence does not suggest that prenatal cannabis exposure alone is associated with clinically significant cognitive functioning impairments.
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Affiliation(s)
- Ciara A Torres
- School of Social Work, Columbia University, New York, NY, United States.,Department of Psychology, Columbia University, New York, NY, United States
| | | | - Kate Y O'Malley
- Division on Substance Use, Department of Psychiatry, New York State Psychiatric Institute, New York, NY, United States.,Department of Psychological Sciences, Swinburne University, Hawthorn, VIC, Australia
| | - Carl L Hart
- Department of Psychology, Columbia University, New York, NY, United States.,Division on Substance Use, Department of Psychiatry, New York State Psychiatric Institute, New York, NY, United States
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108
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Bromwich KA, Sokol NA, McCallum M, Nguyen C, Werner EF, Matteson KA, Vergara-Lopez C, Stroud LR. Preconception Marijuana Use in Rhode Island: Rates, Demographics, and Psychosocial Correlates. RHODE ISLAND MEDICAL JOURNAL (2013) 2020; 103:37-41. [PMID: 32357592 PMCID: PMC7275872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Rates of marijuana use in Rhode Island (RI) exceed the national average; prevalence during preconception and characteristics of users remain unknown. METHODS Prevalence of marijuana use in the 3 months preconception was assessed by a RI-based telephone survey of a diverse, low-income sample of pregnant women (n=1683). Sociodemographic characteristics, substance use, and mental health were compared between preconception marijuana users, tobacco users and non-users. RESULTS 25.1% of respondents reported using marijuana during preconception. Marijuana users were younger, poorer, and less educated than non-users (ps<0.001) and more likely to report alcohol use and mental illness (ps<0.001). Marijuana users were younger with fewer children than tobacco-only users (ps<0.001). CONCLUSIONS Rates of preconception marijuana use in RI exceed national rates of prenatal use. Preconception marijuana users have a distinct sociodemographic profile, with higher rates of concurrent mental health conditions and alcohol use. Understanding this characterization enables targeted screening and interventions.
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Affiliation(s)
- Kira A Bromwich
- Warren Alpert Medical School, Brown University, Providence, RI
| | - Natasha A Sokol
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI
| | - Meaghan McCallum
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Cynthia Nguyen
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI
| | - Erika F Werner
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI
| | - Kristen A Matteson
- Department of Obstetrics and Gynecology, Warren Alpert Medical School, Brown University, Providence, RI
| | - Chrystal Vergara-Lopez
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital; Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
| | - Laura R Stroud
- Centers for Behavioral and Preventive Medicine, The Miriam Hospital; Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
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109
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Siega-Riz AM, Keim-Malpass J, Lyons GR, Alhusen J. The association between legalization of recreational marijuana use and birth outcomes in Colorado and Washington state. Birth Defects Res 2020; 112:660-669. [PMID: 32352231 DOI: 10.1002/bdr2.1680] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/14/2020] [Accepted: 03/31/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify trends in birth outcomes that may be associated with legalization of recreational marijuana which occurred in 2013 using vital records from Colorado and Washington states for the period of 2008-2016. METHODS Data were from birth certificates of live births (between 22 and 44 weeks gestation) of which there were 576,369 singleton births included for Colorado and 771,547 for Washington State. Outcomes included preterm birth defined as <37 completed weeks of gestation; small for gestational age (SGA) defined using <10th percentile birthweight z-score; and birth prevalence of congenital anomalies defined using a variable from the birth certificate that indicated any major defect. The outcomes of interest were analyzed using a change-point approach to logistic regression adjusting for maternal socio-demographics, body mass index, smoking, and infant sex. RESULTS There was evidence of an increased birth prevalence of congenital anomalies in both Colorado and Washington State when comparing prevalence before and after legalization. Only in Colorado did we observe an increase in preterm births post legalization, and there was no association with fetal growth in either state. CONCLUSION This time trend analysis indicates that the birth prevalence of all congenital anomalies combined in Washington and Colorado has increased in parallel with the timing of legalization of marijuana in those two states. However, this finding can only generate hypotheses as no pregnancy exposure information for marijuana was available in this dataset. More research is needed on the effect of marijuana use on birth outcomes.
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Affiliation(s)
- Anna Maria Siega-Riz
- School of Nursing, University of Virginia, Charlottesville, Virginia, USA.,Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Jeanne Alhusen
- School of Nursing, University of Virginia, Charlottesville, Virginia, USA
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110
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Martin JH, Hall W, Fitzcharles M, Borgelt L, Crippa J. Ensuring access to safe, effective, and affordable cannabis-based medicines. Br J Clin Pharmacol 2020; 86:630-634. [PMID: 32128867 PMCID: PMC7098857 DOI: 10.1111/bcp.14242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/27/2020] [Accepted: 02/03/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jennifer H. Martin
- Centre for Drug Repurposing and Medicines ResearchThe University of NewcastleCallaghanNew South WalesAustralia
- The Australian Centre for Cannabinoid Clinical and Research ExcellenceHunter Medical Research InstituteCallaghanNew South WalesAustralia
| | - Wayne Hall
- Centre for Youth Substance Abuse ResearchThe University of QueenslandBrisbaneQueenslandAustralia
| | | | - Laura Borgelt
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraCOUS
| | - Jose Crippa
- Department of NeuroscienceUniversity of Sao PauloSão PauloBrazil
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111
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Tirado-Muñoz J, Lopez-Rodriguez AB, Fonseca F, Farré M, Torrens M, Viveros MP. Effects of cannabis exposure in the prenatal and adolescent periods: Preclinical and clinical studies in both sexes. Front Neuroendocrinol 2020; 57:100841. [PMID: 32339546 DOI: 10.1016/j.yfrne.2020.100841] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/15/2020] [Accepted: 04/19/2020] [Indexed: 10/24/2022]
Abstract
Cannabis is the most commonly used illicit drug among adolescents and young adults, including pregnant women. There is substantial evidence for a significant association between prenatal cannabis exposure and lower birth weight in offspring, and mixed results regarding later behavioural outcomes in the offspring. Adolescent cannabis use, especially heavy use, has been associated with altered executive function, depression, psychosis and use of other drugs later in life. Human studies have limitations due to several confounding factors and have provided scarce information about sex differences. In general, animal studies support behavioural alterations reported in humans and have revealed diverse sex differences and potential underlying mechanisms (altered mesolimbic dopaminergic and hippocampal glutamatergic systems and interference with prefrontal cortex maturation). More studies are needed that analyse sex and gender influences on cannabis-induced effects with great clinical relevance such as psychosis, cannabis use disorder and associated comorbidities, to achieve more personalized and accurate treatments.
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Affiliation(s)
- Judith Tirado-Muñoz
- Addiction Research Group, IMIM-Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
| | - Ana Belen Lopez-Rodriguez
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin 2, Ireland
| | - Francina Fonseca
- Addiction Research Group, IMIM-Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain; Institute of Neuropsychiatry and Addictions, Parc de Salut Mar, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Magi Farré
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol and Institut de Recerca Germas Trias (HUGTP-IGTP), Badalona, Spain; Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Marta Torrens
- Addiction Research Group, IMIM-Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain; Institute of Neuropsychiatry and Addictions, Parc de Salut Mar, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
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112
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Davis E, Lee T, Weber JT, Bugden S. Cannabis use in pregnancy and breastfeeding: The pharmacist's role. Can Pharm J (Ott) 2020; 153:95-100. [PMID: 32206154 DOI: 10.1177/1715163519893395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The recent legalization of cannabis use in Canada requires pharmacists to be able to support their patients with accurate knowledge of its known risks and benefits. Certain populations, such as pregnant and breastfeeding women and their developing children, may be at higher risk than other populations. Methods The authors independently searched the literature for clinical reports or reviews of the literature regarding the safety of cannabis use in pregnancy and breastfeeding using search terms such as cannabis, marijuana, pregnancy and breastfeeding. Results This review combines the relevant pharmacological, pharmacokinetic and clinical evidence for the effects of cannabis in this special patient population. The literature demonstrates that some of the constituents of cannabis can reach children in utero and through breastmilk. Given that Δ⁹-tetrahydrocannabinol can be present in breastmilk as quickly as 1 hour after consumption and last up to 6 days, it may not be possible to use cannabis and avoid infant exposure. There is evidence that this exposure may result in cognitive, social and motor defects. Some of these effects may be long term, lasting years. The pharmacist must be able to educate and screen patients regarding marijuana use in pregnancy and breastfeeding, with the ultimate aim of harm reduction.
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Affiliation(s)
- Erin Davis
- Memorial University School of Pharmacy, St. John's, Newfoundland
| | - Tiffany Lee
- Memorial University School of Pharmacy, St. John's, Newfoundland
| | - John T Weber
- Memorial University School of Pharmacy, St. John's, Newfoundland
| | - Shawn Bugden
- Memorial University School of Pharmacy, St. John's, Newfoundland
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113
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Abstract
Importance Marijuana is the most commonly used dependent substance in pregnancy. The main active chemical of marijuana (delta-9-tetrahydrocannabinol [THC]) readily crosses the placenta, and cannabinoid receptors have been identified in fetal brain and placenta. As a result, prenatal marijuana use could potentially have detrimental impact on fetal development. Objective This review aims to summarize the existing literature and current recommendations for marijuana use while pregnant or lactating. Evidence Acquisition A PubMed literature search using the following terms was performed to gather relevant data: "cannabis," "cannabinoids," "marijuana," "fetal outcomes," "perinatal outcomes," "pregnancy," "lactation." Results Available studies on marijuana exposure in pregnancy were reviewed and support some degree of developmental disruption, including an increased risk of fetal growth restriction and adverse neurodevelopmental consequences. However, much of the existing prenatal marijuana research was performed in the 1980s, when quantities of THC were lower and the frequency of use was less. Additionally, most human studies are also limited and conflicting as most studies have been observational or retrospective, relying primarily on patient self-report and confounded by polysubstance abuse and small sample sizes, precluding determination of a causal effect specific for marijuana. Given the paucity of evidence, it is currently recommended to avoid using marijuana while pregnant or when breastfeeding. Conclusion and Relevance There is a critical need for research on effects in pregnancy using present-day THC doses. Once the adverse perinatal effects of marijuana exposure are identified and well characterized, patient education and antenatal surveillance can be developed to predict and mitigate its impact on maternal and fetal health.
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114
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Cogan PS. The 'entourage effect' or 'hodge-podge hashish': the questionable rebranding, marketing, and expectations of cannabis polypharmacy. Expert Rev Clin Pharmacol 2020; 13:835-845. [PMID: 32116073 DOI: 10.1080/17512433.2020.1721281] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The concept of a cannabis 'entourage effect' was first coined as a hypothetical afterthought in 1998. Since then, multiple scientific reviews, lay articles, and marketing campaigns have promoted the effect as a wholly beneficial manifestation of polypharmacy expected to modulate the therapeutic effects of cannabis and its derivatives. There is reason to wonder at the authenticity of such claims. AREAS COVERED A broad definition of the entourage effect is presented, followed by brief summaries of the nature of cannabis polypharmacy and the commonly cited contributing phytochemicals, with special attention to their attendant adverse effects. A critical analysis is then offered of the primary literature that is often portrayed as suggestive of the effect in existing reviews, with further studies being drawn from PubMed and Google Scholar searches. A final discussion questions the therapeutic value of the entourage effect and offers alternate perspectives on how it might be better interpreted. EXPERT OPINION Claims of a cannabis entourage effect invoke ill-defined and unsubstantiated pharmacological activities which are commonly leveraged toward the popularization and sale of ostensible therapeutic products. Overestimation of such claims in the scientific and lay literature has fostered their misrepresentation and abuse by a poorly regulated industry.
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Affiliation(s)
- Peter S Cogan
- Department of Pharmaceutical Sciences, Regis University School of Pharmacy , Denver, CO, USA
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115
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Birth and early developmental screening outcomes associated with cannabis exposure during pregnancy. J Perinatol 2020; 40:473-480. [PMID: 31911642 PMCID: PMC7047636 DOI: 10.1038/s41372-019-0576-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/29/2019] [Accepted: 12/18/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare birth and early developmental screening outcomes for infants with and without in utero cannabis exposures. STUDY DESIGN Observational cohort of women receiving prenatal care within a large health system, live birth between October 1, 2015 and December 1, 2017, and at least one infant visit. Cannabis exposure was through routine urine toxicology screen. Preterm birth, small for gestational age (SGA) birth, birth defects, and early developmental screening outcomes were assessed from birth and electronic health record data. RESULTS Of 3435 women, 283 (8.2%) had a positive urine toxicology screen. In utero cannabis exposure was associated with SGA birth, adjusted rate ratio (aRR) 1.69 (95% confidence interval [CI]: 1.22-2.34). Abnormal 12-month developmental screens occurred in 9.1% of infants with in utero cannabis exposure vs. 3.6% of those with negative maternal screens, aRR 1.90 (95% CI: 0.92-3.91). Additional birth outcomes were not associated with in utero cannabis exposure. CONCLUSIONS Exposure to cannabis during pregnancy may adversely impact fetal growth.
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116
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Grigsby TM, Hoffmann LM, Moss MJ. Marijuana Use and Potential Implications of Marijuana Legalization. Pediatr Rev 2020; 41:61-72. [PMID: 32005683 DOI: 10.1542/pir.2018-0347] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Most states in the United States have legalized medical and/or recreational cannabis in response to public demand. Trends in states adopting such legislation demonstrate an increasing prevalence of cannabis use coincident to decreasing perceptions of risk of harm from cannabis products. When providing anticipatory guidance, pediatricians should be prepared to address childhood unintentional ingestion management and prevention, adolescent problem use, and cannabis as an alternative therapy for seizure disorders and other conditions.
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Affiliation(s)
- Tamara M Grigsby
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Laurel M Hoffmann
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Michael J Moss
- Utah Poison Center, University of Utah College of Pharmacy, Salt Lake City, UT.,Division of Emergency Medicine, University of Utah, Salt Lake City, UT
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117
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Young-Wolff KC, Gali K, Sarovar V, Rutledge GW, Prochaska JJ. Women's Questions About Perinatal Cannabis Use and Health Care Providers' Responses. J Womens Health (Larchmt) 2020; 29:919-926. [PMID: 32011205 DOI: 10.1089/jwh.2019.8112] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: Cannabis use is common among individuals of reproductive age. We examined publicly posted questions about perinatal cannabis use and licensed United States health care provider responses. Materials and Methods: Data were medical questions on perinatal cannabis use posted online from March 2011 to January 2017 on an anonymous digital health platform. Posters were able to "thank" health care providers for their responses and providers could "agree" with other provider responses. We characterized 364 user questions and 596 responses from 277 unique providers and examined endorsement of responses through provider "agrees" and user "thanks." Results: The most frequent questions concerned prenatal cannabis use detection (24.7%), effects on fertility (22.6%), harms of prenatal use to the fetus (21.3%), and risks of baby exposure to cannabis through breast milk (14.4%). Provider sentiment in responses regarding the safety of perinatal cannabis use were coded as 55.6% harmful, 8.8% safe, 8.8% mixed/unsure, and 26.8% safety unaddressed. Half of providers (49.6%) discouraged perinatal cannabis use, 0.5% encouraged use, and 49.9% neither encouraged nor discouraged use. Provider responses received 1,004 provider "agrees" and 583 user "thanks." Provider responses indicating that perinatal cannabis use is unsafe received more provider "agrees" than responses indicating that use is safe (B = 0.42, 95% CI 0.02-0.82, p = 0.04). User "thanks" did not differ by provider responses regarding safety or dis/encouragement. Conclusion: The data indicate public interest in cannabis use effects before, during, and after pregnancy. While most health care providers indicated cannabis use during pregnancy and breastfeeding is not safe, many did not address safety or discourage use, suggesting a missed educational opportunity.
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Affiliation(s)
- Kelly C Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kathleen Gali
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California
| | - Varada Sarovar
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Judith J Prochaska
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California
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118
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Ishida JH, Zhang AJ, Steigerwald S, Cohen BE, Vali M, Keyhani S. Sources of Information and Beliefs About the Health Effects of Marijuana. J Gen Intern Med 2020; 35:153-159. [PMID: 31637640 PMCID: PMC6957653 DOI: 10.1007/s11606-019-05335-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/29/2019] [Accepted: 07/30/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Marijuana is currently legal for recreational use in 10 states and Washington DC while a total of 34 states have implemented varying degrees of medical marijuana. The commercialization of marijuana has been accompanied by a proliferation of false claims regarding the therapeutic potential of marijuana, which are popularized by several different information sources. To date, no study has examined where US adults get their information regarding marijuana. OBJECTIVE To determine the sources of information associated with believing unsupported claims about marijuana. DESIGN Probability-based online survey PARTICIPANTS: 16,820 adults, with a response rate of about 55% (N = 9003) MAIN MEASURES: Most influential sources of information about marijuana and belief of statements consistent with misinformation, for example, smoking marijuana has preventative health benefits, secondhand marijuana smoke or use during pregnancy is completely or somewhat safe, and marijuana is not at all addictive. KEY RESULTS There were 9003 respondents (response rate 55%). Forty-three percent believed unsupported claims about marijuana. The most influential sources of information were health professionals, traditional media, friends/relatives, and social media/internet. Individuals reporting social media or the Internet (1.46 CI [1.30, 1.64]), the marijuana industry (e.g., advertisements, dispensaries) (2.88 CI [2.15, 3.88]), and friends or relatives (1.41 CI[1.26, 1.58]) as the most influential source of information about marijuana were more likely to believe any statement consistent with misinformation about marijuana in comparison with those who reported other sources as most influential. CONCLUSIONS Individuals reporting the most significant source of information regarding marijuana was from social media or the Internet, the marijuana industry, or friends or relatives were more likely to believe unsupported claims about marijuana. Public health campaigns to counter the misinformation about marijuana to the public are needed.
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Affiliation(s)
- Julie H Ishida
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, CA, USA
| | - Alysandra J Zhang
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA
| | - Stacey Steigerwald
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA
| | - Beth E Cohen
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA.,Department of Medicine, UCSF, University of California, San Francisco, San Francisco, CA, USA
| | - Marzieh Vali
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA
| | - Salomeh Keyhani
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA, 94121, USA. .,Department of Medicine, UCSF, University of California, San Francisco, San Francisco, CA, USA.
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119
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Montgomery L, Webb Hooper M. Gender Differences in the Association between Marijuana and Menthol Cigarette Use among African American Adult Cigarette Smokers. Subst Use Misuse 2020; 55:1335-1342. [PMID: 32253967 PMCID: PMC7281863 DOI: 10.1080/10826084.2020.1741633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Despite the strong relationship between marijuana and tobacco use, especially among African American individuals and males, very few studies have examined the association between marijuana and menthol cigarette use. This study was designed to identify the prevalence of past month, past year and lifetime marijuana use and marijuana dependence among menthol and non-menthol cigarette smokers, as well as the association between marijuana and menthol cigarette use among African American female and male cigarette smokers. Methods: Data were drawn from 1,173 African American adult cigarette smokers in the 2017 National Survey on Drug Use and Health. Results: Overall, 8.8%, 13.9% and 44.7% of African American menthol and non-menthol cigarette smokers reported past month, past year and lifetime marijuana use, respectively. Weighted multivariable logistic regression models revealed a significant interaction between gender and past month marijuana use on menthol cigarette use (AOR = 1.49, 95% CI: 1.21-2.42, p < .05). Past month marijuana use was associated with an increased odds of past month menthol cigarette use (relative to non-menthol cigarette use) among females, but a decreased odds of past of past month menthol cigarette use among males. Conclusions: When stratified by gender, marijuana use is differentially related to menthol cigarette use among African American adults. Given the prevalence of menthol cigarette use among this population, it is important to examine factors such as marijuana use that could be targeted in prevention and treatment interventions for African Americans, especially females, who are at risk for smoking or are currently smoking menthol cigarettes. Implications: This study found that marijuana use was associated with an increased odds of menthol cigarette use among African American females, while marijuana use was associated with a decreased odds of menthol cigarette use among their male counterparts. The impact of marijuana use on menthol cigarette smoking differs among females and males, highlighting the need for gender-tailored interventions that target marijuana use among African American individuals, especially females, who are at risk for smoking or are currently smoking menthol cigarettes.
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Affiliation(s)
- LaTrice Montgomery
- Department of Psychiatry and Behavioral Neuroscience, Addiction Sciences Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Monica Webb Hooper
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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120
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Young-Wolff KC, Adams SR, Wi S, Weisner C, Conway A. Routes of cannabis administration among females in the year before and during pregnancy: Results from a pilot project. Addict Behav 2020; 100:106125. [PMID: 31600645 DOI: 10.1016/j.addbeh.2019.106125] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/30/2019] [Accepted: 09/07/2019] [Indexed: 11/18/2022]
Abstract
Use of cannabis during pregnancy is on the rise, yet little is known about how women administer cannabis during the perinatal period. This study examined self-reported modes of cannabis administration among women in the year before and during pregnancy, and their association with self-reported cannabis use frequency using data from 585 women screened in 2018-2019 for cannabis use during standard prenatal care in two medical centers in Northern California. The prevalence of cannabis use was 12% before pregnancy and 3% during pregnancy. Among the 71 women who reported cannabis use before pregnancy and the 19 women who reported cannabis use during pregnancy, smoking was the most common mode of administration (58% and 42%), followed by edibles (27% and 16%), vaping (23% and 16%), lotions (11% and 5%), and other (10% and 0%). In the year before pregnancy and during pregnancy, monthly or less use was most common (56% and 58%), followed by weekly use (24% and 26%) and daily use (20% and 16%). Among cannabis users, 43% used more than one mode before pregnancy compared to 15% during pregnancy. Daily cannabis use was most common among women who reported smoking only or smoking in combination with other modes. These novel results indicate that while smoking is the most common mode of cannabis administration during the perinatal period, there is variation in use and co-use of alternative modes. Future studies are needed to understand the relative health effects associated with individual and combined modes of cannabis administration during pregnancy.
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Affiliation(s)
- Kelly C Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA.
| | - Sara R Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sharon Wi
- Early Start Program, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Amy Conway
- Early Start Program, Kaiser Permanente Northern California, Oakland, CA, USA
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121
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Co-use of alcohol, tobacco, and licit and illicit controlled substances among pregnant and non-pregnant women in the United States: Findings from 2006 to 2014 National Survey on Drug Use and Health (NSDUH) data. Drug Alcohol Depend 2020; 206:107729. [PMID: 31760250 DOI: 10.1016/j.drugalcdep.2019.107729] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/01/2019] [Accepted: 11/05/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The use, misuse and co-use of alcohol, cannabis, tobacco, and other licit and illicit controlled substances has increased in past decades leading to higher rates of morbidity, overdose, and mortality in women of reproductive age. Co-use compounds the adverse health effects of substance use compared to single-use of similar substances. Little is known about the full range of substance combinations used by pregnant and non-pregnant women. We sought to describe patterns of co-use of alcohol, tobacco, and controlled substances, and examine correlates of co-use in a nationally-representative sample of women. METHODS Cross-sectional study using self-reported survey data from 2006 to 2014 for women ages 18-49 years (N = 160,371) in National Survey on Drug Use and Health data. We use weighted proportions and 95% confidence intervals (CI) to report differences in substance use patterns in pregnant and non-pregnant women. Multivariate logistic regression models assessed association between characteristics and type of substance use pattern. RESULTS Prevalence of substance co-use among pregnant women is 5.1% and among non-pregnant women is 23.6%. Nearly all of the most frequent co-use patterns included alcohol, cannabis, or tobacco. Determinants of co-use among pregnant women included: younger age (18-25 years) compared to ≥ 26 years [AOR (95% CI): 1.81 (1.18, 2.80)]; and past year history of substance use [AOR 5.42 (3.59, 8.20)]. CONCLUSIONS Co-use of several substances, including and especially of tobacco, alcohol and cannabis, persists among pregnant women in the United States. Efforts that aim to improve maternal and child health should address the complexity of substance use during pregnancy, including and beyond opioids.
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122
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Nashed MG, Hardy DB, Laviolette SR. Prenatal Cannabinoid Exposure: Emerging Evidence of Physiological and Neuropsychiatric Abnormalities. Front Psychiatry 2020; 11:624275. [PMID: 33519564 PMCID: PMC7841012 DOI: 10.3389/fpsyt.2020.624275] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/14/2020] [Indexed: 12/22/2022] Open
Abstract
Clinical reports of cannabis use prevalence during pregnancy vary widely from 3% to upwards of 35% in North America; this disparity likely owing to underestimates from self-reporting in many cases. The rise in cannabis use is mirrored by increasing global legalization and the overall perceptions of safety, even during pregnancy. These trends are further compounded by a lack of evidence-based policy and guidelines for prenatal cannabis use, which has led to inconsistent messaging by healthcare providers and medically licensed cannabis dispensaries regarding prenatal cannabis use for treatment of symptoms, such as nausea. Additionally, the use of cannabis to self-medicate depression and anxiety during pregnancy is a growing medical concern. This review aims to summarize recent findings of clinical and preclinical data on neonatal outcomes, as well as long-term physiological and neurodevelopmental outcomes of prenatal cannabis exposure. Although many of the outcomes under investigation have produced mixed results, we consider these data in light of the unique challenges facing cannabis research. In particular, the limited longitudinal clinical studies available have not previously accounted for the exponential increase in (-)-Δ9- tetrahydrocannabinol (Δ9-THC; the psychoactive compound in cannabis) concentrations found in cannabis over the past two decades. Polydrug use and the long-term effects of individual cannabis constituents [Δ9-THC vs. cannabidiol (CBD)] are also understudied, along with sex-dependent outcomes. Despite these limitations, prenatal cannabis exposure has been linked to low birth weight, and emerging evidence suggests that prenatal exposure to Δ9-THC, which crosses the placenta and impacts placental development, may have wide-ranging physiological and neurodevelopmental consequences. The long-term effects of these changes require more rigorous investigation, though early reports suggest Δ9-THC increases the risk of cognitive impairment and neuropsychiatric disease, including psychosis, depression, anxiety, and sleep disorders. In light of the current trends in the perception and use of cannabis during pregnancy, we emphasize the social and medical imperative for more rigorous investigation of the long-term effects of prenatal cannabis exposure.
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Affiliation(s)
- Mina G Nashed
- Department of Anatomy and Cell Biology, University of Western Ontario, London, ON, Canada
| | - Daniel B Hardy
- Department of Physiology and Pharmacology, University of Western Ontario, London, ON, Canada.,Department of Obstetrics & Gynecology, University of Western Ontario, London, ON, Canada
| | - Steven R Laviolette
- Department of Anatomy and Cell Biology, University of Western Ontario, London, ON, Canada.,Department of Psychiatry, University of Western Ontario, London, ON, Canada
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123
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Corroon J, Sexton M, Bradley R. Indications and administration practices amongst medical cannabis healthcare providers: a cross-sectional survey. BMC FAMILY PRACTICE 2019; 20:174. [PMID: 31837706 PMCID: PMC6911295 DOI: 10.1186/s12875-019-1059-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/22/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The medical use of cannabis has been legislatively restricted for decades in the US and abroad. In recent years, changing local and national policies have given rise to a community of healthcare providers who may be recommending the medical use of cannabis without the benefit of formal clinical practice guidelines or sufficient training and education. In addition, a citizen science movement has emerged whereby unlicensed and untrained individuals are acting as healthcare provider proxies, offering cannabis-specific clinical care to "patients". This study sought to characterize the clinical practice characteristics of these provider groups. METHODS An anonymous, online survey was designed to describe levels of cannabis-specific education, practice characteristics, indications for medical use, dose, administration forms and adverse effects related to cannabis use. The questionnaire was disseminated via professional medical cannabis associations and by word-of-mouth. It was accessed between June 31-December 31, 2018. A self-selecting sample of respondents (n = 171) completed the survey. RESULTS Formal education or training in the medical use of cannabis was significantly more common among licensed respondents than unlicensed respondents (95.5% vs 76.9% respectively, OR, 6.3, 95% CI, 1.2-32.3, p = 0.03). The vast majority (n = 74, 83.15%) of licensed respondents reported having recommended cannabis as an adjunct to an existing prescription drug. Almost two-thirds (n = 64, 71.9%) reported having recommended it as a substitute. When delta-9-tetrahydrocannabinol (THC) is the principal therapeutic constituent of interest, vaporization is the most common method of administration recommended (n = 94 responses, 71.4% of respondents). In contrast, when cannabidiol (CBD) is the principal therapeutic constituent of interest, oral administration (sublingual or oromucosal absorption) is the most common method (n = 70 responses, 71.4% of respondents). CONCLUSIONS Individuals who recommend the medical use of cannabis appear to be self-generating a community standard of practice in the absence of formal clinical guidelines on dosing, interactions and other characteristics. Reducing barriers to clinical research on cannabis products is needed, not only to better understand their risks and benefits, but also to augment the evidence-base for informing clinical practice.
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Affiliation(s)
- Jamie Corroon
- The Center for Medical Cannabis Education, 428 8th Street, Del Mar, CA, 92014, USA.
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA.
| | - Michelle Sexton
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
| | - Ryan Bradley
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, CA, USA
- Australian Research Center on Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney, Ultimo, NSW, Australia
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124
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Reece AS, Hulse GK. Cannabis Consumption Patterns Explain the East-West Gradient in Canadian Neural Tube Defect Incidence: An Ecological Study. Glob Pediatr Health 2019; 6:2333794X19894798. [PMID: 31853464 PMCID: PMC6906350 DOI: 10.1177/2333794x19894798] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/23/2019] [Accepted: 11/19/2019] [Indexed: 12/18/2022] Open
Abstract
While a known link between prenatal cannabis exposure and anencephaly exists, the relationship of prenatal cannabis exposure with neural tube defects (NTDs) generally has not been defined. Published data from Canada Health and Statistics Canada were used to assess this relationship. Both cannabis use and NTDs were shown to follow an east-west and north-south gradient. Last year cannabis consumption was significantly associated (P < .0001; cannabis use-time interaction P < .0001). These results were confirmed when estimates of termination for anomaly were used. Canada Health population data allowed the calculation of an NTD odds ratio) of 1.27 (95% confidence interval = 1.19-1.37; P < 10-11) for high-risk provinces versus the remainder with an attributable fraction in exposed populations of 16.52% (95% confidence interval = 12.22-20.62). Data show a robust positive statistical association between cannabis consumption as both a qualitative and quantitative variable and NTDs on a background of declining NTD incidence. In the context of multiple mechanistic pathways these strong statistical findings implicate causal mechanisms.
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Affiliation(s)
- Albert Stuart Reece
- University of Western Australia,
Crawley, Western Australia, Australia
- Edith Cowan University, Joondalup,
Western Australia, Australia
| | - Gary Kenneth Hulse
- University of Western Australia,
Crawley, Western Australia, Australia
- Edith Cowan University, Joondalup,
Western Australia, Australia
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125
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Caulkins JP, Kilborn ML. Lower-Risk Cannabis Use Guidelines: Will Users Listen? Am J Public Health 2019; 110:71-72. [PMID: 31800288 DOI: 10.2105/ajph.2019.305420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jonathan P Caulkins
- Jonathan P. Caulkins is with the Heinz College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, PA. Michelle L. Kilborn is with Population, Public, and Indigenous Health at Alberta Health Services, Edmonton, AB, Canada
| | - Michelle L Kilborn
- Jonathan P. Caulkins is with the Heinz College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, PA. Michelle L. Kilborn is with Population, Public, and Indigenous Health at Alberta Health Services, Edmonton, AB, Canada
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127
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Cannabis-Based Medicines and Medical Cannabis in Rheumatic Diseases: A Treasure Chest or Pandora’s box. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00130-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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128
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Cook JL, Blake JM. Cannabis: Implications for Pregnancy, Fetal Development, and Longer-Term Health Outcomes. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:1204-1207. [PMID: 30268315 DOI: 10.1016/j.jogc.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Jocelynn L Cook
- The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON.
| | - Jennifer M Blake
- The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON
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129
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Almada M, Alves P, Fonseca BM, Carvalho F, Queirós CR, Gaspar H, Amaral C, Teixeira NA, Correia-da-Silva G. Synthetic cannabinoids JWH-018, JWH-122, UR-144 and the phytocannabinoid THC activate apoptosis in placental cells. Toxicol Lett 2019; 319:129-137. [PMID: 31730886 DOI: 10.1016/j.toxlet.2019.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/30/2019] [Accepted: 11/05/2019] [Indexed: 01/25/2023]
Abstract
The increasing use of synthetic cannabinoids (SCBs) in recreational settings is becoming a new paradigm of drug abuse. Although SCBs effects mimic those of the Cannabis sativa plant, these drugs are frequently more potent and hazardous. It is known that endocannabinoid signalling plays a crucial role in diverse reproductive events such as placental development. Moreover, the negative impact of the phytocannabinoid Δ9-tetrahydrocannabinol (THC) in pregnancy outcome, leading to prematurity, intrauterine growth restriction and low birth weight is well recognized, which makes women of childbearing age a sensitive group to developmental adverse effects of cannabinoids. Placental trophoblast turnover relies on regulated processes of proliferation and apoptosis for normal placental development. Here, we explored the impact of the SCBs JWH-018, JWH-122 and UR-144 and of the phytocannabinoid THC in BeWo cell line, a human placental cytotrophoblast cell model. All the cannabinoids caused a significant decrease in cell viability without LDH release, though this effect was only detected for the highest concentrations of THC. Moreover, a cell cycle arrest at the G2/M phase was also observed. JWH-018 and JWH-122 increased reactive oxygen species (ROS) production and THC, UR-144 and JWH-122 caused loss of mitochondrial membrane potential. All the compounds were able to induce caspase-9 activation. The involvement of apoptotic pathways was further confirmed through the significant increase in caspase -3/-7 activities. For UR-144, this effect was reversed by the CB1 antagonist AM281, for JWH-018 and THC this effect was mediated by both cannabinoid receptors CB1 and CB2 while for JWH-122 it was cannabinoid receptor-independent. This work demonstrates that THC and SCBs are able to induce apoptotic cell death. Although they may act through different mechanisms and potencies, the studied cannabinoids have the potential to disrupt gestational fundamental events.
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Affiliation(s)
- Marta Almada
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal
| | - Patrícia Alves
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal
| | - Bruno M Fonseca
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal
| | - Félix Carvalho
- UCIBIO, REQUIMTE, Laboratory of Toxicology, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal
| | - Cláudio R Queirós
- University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande, 1749-016, Lisboa, Portugal
| | - Helena Gaspar
- University of Lisboa, Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, Campo Grande, 1749-016, Lisboa, Portugal; MARE - Marine and Environmental Sciences Centre, ESTM, Instituto Politécnico de Leiria, 2520-641, Peniche, Portugal
| | - Cristina Amaral
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal
| | - Natércia A Teixeira
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal
| | - Georgina Correia-da-Silva
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira no 228, Porto, Portugal.
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130
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Singh S, Filion KB, Abenhaim HA, Eisenberg MJ. Prevalence and outcomes of prenatal recreational cannabis use in high-income countries: a scoping review. BJOG 2019; 127:8-16. [PMID: 31529594 DOI: 10.1111/1471-0528.15946] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND With expanding recreational cannabis legalisation, pregnant women and their offspring are at risk of potentially harmful consequences. OBJECTIVES To assess the prevalence of recreational cannabis use among pregnant women, health outcomes associated with prenatal recreational cannabis use, and the potential impact of recreational cannabis legalisation on this population. SEARCH STRATEGY Five databases and the grey literature were systematically searched (2000-2019). SELECTION CRITERIA Human studies published in English or French reporting on the prevalence of prenatal recreational cannabis use in high-income countries. DATA COLLECTION AND ANALYSIS Data on study characteristics, prenatal substance use, and health outcomes were extracted and qualitatively synthesised. MAIN RESULTS Forty-one publications met our inclusion criteria. The overall prevalence of prenatal cannabis use varied substantially (min-max: 0.24-22.6%), with the greatest use in the first trimester. In the three studies with temporal data available, rates of prenatal cannabis use increased across years. Only 7/41 and 5/41 studies provided information on gestational age of exposure and frequency of use, respectively. The concomitant use of alcohol, illicit drugs, and tobacco was higher among cannabis users than nonusers. Prenatal cannabis use was associated with select neonatal, but not maternal, health outcomes. There were insufficient data to compare prenatal cannabis use between the pre- and post-legalisation periods. CONCLUSION Cannabis use among pregnant women is prevalent and may be associated with adverse neonatal outcomes. Future studies should assess the gestational age and frequency of cannabis exposure, and usage patterns prior to and following legalisation. TWEETABLE ABSTRACT Women who consume cannabis during pregnancy could risk predisposing their newborns to poor birth outcomes.
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Affiliation(s)
- S Singh
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - K B Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - H A Abenhaim
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - M J Eisenberg
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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131
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Hurd YL, Manzoni OJ, Pletnikov MV, Lee FS, Bhattacharyya S, Melis M. Cannabis and the Developing Brain: Insights into Its Long-Lasting Effects. J Neurosci 2019; 39:8250-8258. [PMID: 31619494 PMCID: PMC6794936 DOI: 10.1523/jneurosci.1165-19.2019] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 12/24/2022] Open
Abstract
The recent shift in sociopolitical debates and growing liberalization of cannabis use across the globe has raised concern regarding its impact on vulnerable populations, such as pregnant women and adolescents. Epidemiological studies have long demonstrated a relationship between developmental cannabis exposure and later mental health symptoms. This relationship is especially strong in people with particular genetic polymorphisms, suggesting that cannabis use interacts with genotype to increase mental health risk. Seminal animal research directly linked prenatal and adolescent exposure to delta-9-tetrahydrocannabinol, the major psychoactive component of cannabis, with protracted effects on adult neural systems relevant to psychiatric and substance use disorders. In this article, we discuss some recent advances in understanding the long-term molecular, epigenetic, electrophysiological, and behavioral consequences of prenatal, perinatal, and adolescent exposure to cannabis/delta-9-tetrahydrocannabinol. Insights are provided from both animal and human studies, including in vivo neuroimaging strategies.
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Affiliation(s)
- Yasmin L Hurd
- Department of Psychiatry and Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York 10029,
| | - Olivier J Manzoni
- Aix Marseille University, Institut National de la Santé et de la Recherche Médicale, Institut de neurobiologie de la méditerranée, 13273 Marseille, France, and Cannalab, Cannabinoids Neuroscience Research International Associated Laboratory, Institut National de la Santé et de la Recherche Médicale, 13273 Marseille, France
| | - Mikhail V Pletnikov
- Department of Psychiatry and Behavioral Sciences, Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
| | - Francis S Lee
- Department of Psychiatry, Sackler Institute for Developmental Psychobiology, Weill Cornell Medical College, New York, New York 10065
| | - Sagnik Bhattacharyya
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, United Kingdom, and
| | - Miriam Melis
- Department of Biomedical Sciences, Division of Neuroscience and Clinical Pharmacology, University of Cagliari, 09042 Cagliari, Italy
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132
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Heard K, Monte AA, Wang GS. Another Perspective on Cannabis and Emergency Medicine in Colorado. West J Emerg Med 2019; 20:855-856. [PMID: 31738711 PMCID: PMC6860395 DOI: 10.5811/westjem.2019.8.44882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kennon Heard
- University of Colorado School of Medicine, Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado.,Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Andrew A Monte
- University of Colorado School of Medicine, Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado.,Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - George Sam Wang
- University of Colorado School of Medicine, Department of Emergency Medicine, Section of Medical Pharmacology and Toxicology, Aurora, Colorado.,Rocky Mountain Poison and Drug Center, Denver, Colorado.,University of Colorado School of Medicine, Department of Pediatrics, Section of Pediatric Emergency Medicine, Aurora, Colorado
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133
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Frau R, Miczán V, Traccis F, Aroni S, Pongor CI, Saba P, Serra V, Sagheddu C, Fanni S, Congiu M, Devoto P, Cheer JF, Katona I, Melis M. Prenatal THC exposure produces a hyperdopaminergic phenotype rescued by pregnenolone. Nat Neurosci 2019; 22:1975-1985. [PMID: 31611707 PMCID: PMC6884689 DOI: 10.1038/s41593-019-0512-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 09/11/2019] [Indexed: 12/21/2022]
Abstract
Increased legal availability of cannabis has led to a common misconception that it is a safe natural remedy for, amongst others, pregnancy-related ailments like morning sickness. Emerging clinical evidence, however, indicates that prenatal cannabis exposure (PCE) predisposes offspring to various neuropsychiatric disorders linked to aberrant dopaminergic function. Yet, our knowledge of how cannabis exposure affects the maturation of this neuromodulatory system remains limited. Here, we show that male, but not female, offspring of Δ9-tetrahydrocannabinol (THC)-exposed dams, a rat PCE model, exhibit extensive molecular and synaptic changes in dopaminergic neurons of the ventral tegmental area, including altered excitatory-to-inhibitory balance and switched polarity of long-term synaptic plasticity. The resulting hyperdopaminergic state leads to increased behavioral sensitivity to acute THC during pre-adolescence. The FDA-approved neurosteroid pregnenolone rescues synaptic defects and normalizes dopaminergic activity and behavior in PCE offspring, suggesting a therapeutic approach for offspring exposed to cannabis during pregnancy.
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Affiliation(s)
- Roberto Frau
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Vivien Miczán
- Momentum Laboratory of Molecular Neurobiology, Institute of Experimental Medicine, Hungarian Academy of Sciences, Budapest, Hungary.,Faculty of Information Technology and Bionics, Pázmány Péter Catholic University, Budapest, Hungary
| | - Francesco Traccis
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Sonia Aroni
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy.,Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Csaba I Pongor
- Nikon Center of Excellence for Neuronal Imaging, Institute of Experimental Medicine, Hungarian Academy of Sciences, Budapest, Hungary
| | - Pierluigi Saba
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Valeria Serra
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Claudia Sagheddu
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Silvia Fanni
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Mauro Congiu
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Paola Devoto
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy
| | - Joseph F Cheer
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - István Katona
- Faculty of Information Technology and Bionics, Pázmány Péter Catholic University, Budapest, Hungary
| | - Miriam Melis
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria, Monserrato, Italy.
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134
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Scheyer AF, Melis M, Trezza V, Manzoni OJJ. Consequences of Perinatal Cannabis Exposure. Trends Neurosci 2019; 42:871-884. [PMID: 31604585 DOI: 10.1016/j.tins.2019.08.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/10/2019] [Accepted: 08/21/2019] [Indexed: 12/17/2022]
Abstract
Cannabis exposure during the perinatal period results in varied and significant consequences in affected offspring. The prevalence of detrimental outcomes of perinatal cannabis exposure is likely to increase in tandem with the broadening of legalization and acceptance of the drug. As such, it is crucial to highlight the immediate and protracted consequences of cannabis exposure on pre- and postnatal development. Here, we identify lasting changes in neurons' learning flexibility (synaptic plasticity) and epigenetic misregulation in animal models of perinatal cannabinoid exposure (using synthetic cannabinoids or active components of the cannabis plant), in addition to significant alterations in social behavior and executive functions. These findings are supported by epidemiological data indicating similar behavioral outcomes throughout life in human offspring exposed to cannabis during pregnancy. Further, we indicate important lingering questions regarding accurate modeling of perinatal cannabis exposure as well as the need for sex- and age-dependent outcome measures in future studies.
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Affiliation(s)
- Andrew F Scheyer
- INMED, INSERM U1249, Marseille, France; Aix-Marseille University, Provence, France; Cannalab, Cannabinoids Neuroscience Research International Associated Laboratory, INSERM-Aix-Marseille University, Provence, France/Indiana University, Bloomington, IN, USA
| | - Miriam Melis
- Division of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, 09042, Monserrato, Italy; National Institute of Neuroscience, Cagliari, Italy
| | - Viviana Trezza
- Department of Science, Section of Biomedical Sciences and Technologies, University 'Roma Tre', Rome, Italy
| | - Olivier J J Manzoni
- INMED, INSERM U1249, Marseille, France; Aix-Marseille University, Provence, France; Cannalab, Cannabinoids Neuroscience Research International Associated Laboratory, INSERM-Aix-Marseille University, Provence, France/Indiana University, Bloomington, IN, USA.
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135
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Abstract
The prevalence and perceived safety of marijuana use in pregnancy are increasing with expanding legalization. Marijuana crosses the placenta and passes into breast milk, resulting in fetal and neonatal exposure. Many women cite medical reasons for prenatal marijuana use such as nausea and vomiting of pregnancy, anxiety, and chronic pain. The scientific literature regarding marijuana in pregnancy is mixed, resulting in confusion among practitioners as to how to counsel women about risks of use. In addition, there is a paucity of literature related to marijuana use and breastfeeding. Existing pregnancy studies are predominantly retrospective cohorts with a reliance on self-report for ascertainment of exposure, which underestimates use. Many studies fail to adjust for important confounding factors such as tobacco use and sociodemographic differences. Despite the limitations of the existing evidence, there are animal and human data suggesting potential harm of cannabis use. The harms are biologically plausible given the role of the endocannabinoid system in pregnancy implantation, placentation, and fetal neurologic development. Two recent systematic reviews and meta-analyses found an association between marijuana use and adverse perinatal outcomes, especially with heavy marijuana use. In addition, three longitudinal cohort studies demonstrate a possible effect of prenatal marijuana exposure on long-term neurobehavioral outcomes. Marijuana use may be associated with growth restriction, stillbirth, spontaneous preterm birth, and neonatal intensive care unit admission. Therefore, women should be advised to refrain from using marijuana during pregnancy and lactation.
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136
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137
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Priorities for a Comprehensive Post-Legalization Cannabis Research Agenda in Canada. CANADIAN JOURNAL OF ADDICTION 2019. [DOI: 10.1097/cxa.0000000000000057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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138
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The association between the legalization of recreational marijuana and both small for gestational age births and NICU admissions in Colorado. J Perinatol 2019; 39:1165-1174. [PMID: 31270431 DOI: 10.1038/s41372-019-0416-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/25/2019] [Accepted: 05/10/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the association between recreational marijuana legalization and both small for gestational age (SGA) births and neonatal ICU (NICU) admissions in Colorado. STUDY DESIGN Using interrupted time series analysis, we compared the incidence of SGA births and NICU admissions pre-/post-recreational marijuana legalization. Secondary analysis adjusted for marijuana outlet density (MOD) in maternal county of residence. RESULTS We analyzed 269,922 mother-infant dyads. SGA birth risk dropped 7% immediately post-legalization (p = 0.04), but there was no slope difference between cohorts. SGA birth risk for high MOD dyads was 1.4x that of dyads with no outlets (p < 0.001) and 1.2x that of low MOD dyads (p = 0.002). There was no immediate effect on NICU admission risk, but the slope increased 1%/month post-legalization (p < 0.001) including a 1%/month increase for low MOD and 3%/month for high MOD dyads. CONCLUSIONS Incidence of SGA births in Colorado did not change following recreational marijuana legalization. NICU admissions increased post-legalization.
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139
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Meinhofer A, Witman A, Murphy SM, Bao Y. Medical marijuana laws are associated with increases in substance use treatment admissions by pregnant women. Addiction 2019; 114:1593-1601. [PMID: 31106499 PMCID: PMC6684381 DOI: 10.1111/add.14661] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/15/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Between 2002 and 2014, past-month marijuana use among pregnant women in the United States increased 62%, nearly twice the growth of the general population. This growth coincides with the proliferation of state medical marijuana laws (MMLs) authorizing physicians to recommend marijuana for approved conditions. We estimated the association between MMLs and substance use treatment utilization among pregnant and non-pregnant women of reproductive age. We also examined whether the association varied across MML provisions, age groups and treatment referral sources to clarify potential pathways. DESIGN Nation-wide administrative data from the 2002-14 Treatment Episodes Data Set Admissions, and a difference-in-differences design that exploited the staggered implementation of MMLs to compare changes in outcomes before and after implementation between MML and non-MML states. SETTING Twenty-one MML and 27 non-MML US states. PARTICIPANTS Pregnant and non-pregnant women aged 12-49 admitted to publicly funded specialty substance use treatment facilities. MEASUREMENTS The primary outcome variable was the number of treatment admissions per 100 000 women aged 12-49, aggregated at the state-year level (n = 606). Admissions for marijuana, alcohol, cocaine and opioids were considered. The primary independent variable was an indicator of MML implementation in a state. FINDINGS Among pregnant women, the rate of marijuana treatment admissions increased by 4.69 [95% confidence interval (CI) = 1.32, 8.06] in MML states relative to non-MML states. This growth was accompanied by increases in treatment admissions involving alcohol (β = 3.19; 95% CI = 0.97, 5.410 and cocaine (β = 2.56; 95% CI = 0.34, 4.79), was specific to adults (β = 5.50; 95% CI = 1.52, 9.47) and was largest in states granting legal protection for marijuana dispensaries (β = 6.37; 95% CI = -0.97, 13.70). There was no statistically significant association between MMLs and treatment admissions by non-pregnant women. CONCLUSIONS Medical marijuana law implementation in US states has been associated with greater substance use treatment utilization by pregnant adult women, especially in states with legally protected dispensaries.
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Affiliation(s)
- Angélica Meinhofer
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY
| | - Allison Witman
- Cameron School of Business, University of North Carolina Wilmington, Wilmington, NC
| | - Sean M. Murphy
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY
| | - Yuhua Bao
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY
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140
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Reece AS, Hulse GK. Cannabis Teratology Explains Current Patterns of Coloradan Congenital Defects: The Contribution of Increased Cannabinoid Exposure to Rising Teratological Trends. Clin Pediatr (Phila) 2019; 58:1085-1123. [PMID: 31288542 PMCID: PMC6691650 DOI: 10.1177/0009922819861281] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Rising Δ9-tetrahydrocannabinol concentrations in modern cannabis invites investigation of the teratological implications of prenatal cannabis exposure. Data from Colorado Responds to Children with Special Needs (CRCSN), National Survey of Drug Use and Health, and Drug Enforcement Agency was analyzed. Seven, 40, and 2 defects were rising, flat, and falling, respectively, and 10/12 summary indices rose. Atrial septal defect, spina bifida, microcephalus, Down's syndrome, ventricular septal defect, and patent ductus arteriosus rose, and along with central nervous system, cardiovascular, genitourinary, respiratory, chromosomal, and musculoskeletal defects rose 5 to 37 times faster than the birth rate (3.3%) to generate an excess of 11 753 (22%) major anomalies. Cannabis was the only drug whose use grew from 2000 to 2014 while pain relievers, cocaine, alcohol, and tobacco did not. The correlation of cannabis use with major defects in 2014 (2019 dataset) was R = .77, P = .0011. Multiple cannabinoids were linked with summary measures of congenital anomalies and were robust to multivariate adjustment.
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Affiliation(s)
- Albert Stuart Reece
- University of Western Australia, Crawley, Western Australia, Australia
- Edith Cowan University, Joondalup, Western Australia, Australia
| | - Gary Kenneth Hulse
- University of Western Australia, Crawley, Western Australia, Australia
- Edith Cowan University, Joondalup, Western Australia, Australia
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141
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Young-Wolff KC, Sarovar V, Tucker LY, Conway A, Alexeeff S, Weisner C, Armstrong MA, Goler N. Self-reported Daily, Weekly, and Monthly Cannabis Use Among Women Before and During Pregnancy. JAMA Netw Open 2019; 2:e196471. [PMID: 31322686 PMCID: PMC6646980 DOI: 10.1001/jamanetworkopen.2019.6471] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE As the overall prevalence of prenatal cannabis use rises, it is vital to also monitor trends in the frequency of cannabis use in the period leading up to and during pregnancy because more frequent use may confer greater health risks for mothers and their children. OBJECTIVE To examine trends in the frequency of self-reported cannabis use among pregnant women in the year before and during pregnancy. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study using data from 367 403 pregnancies among 276 991 women 11 years or older who completed a self-administered questionnaire on cannabis use during standard prenatal care in Kaiser Permanente Northern California from January 1, 2009, to December 31, 2017. The annual prevalence of self-reported daily, weekly, and monthly cannabis use among women before and during pregnancy was estimated using Poisson regression with a log link function, adjusting for sociodemographics. Data analyses were conducted from February to May 2019. EXPOSURES Calendar year. MAIN OUTCOMES AND MEASURES Self-reported frequency of cannabis use in the year before pregnancy and during pregnancy assessed as part of standard prenatal care (at approximately 8 weeks' gestation). RESULTS Among the overall sample of 367 403 pregnancies among 276 991 women, 35.9% of the women self-reported white race/ethnicity; 28.0%, Hispanic; 16.6%, Asian; 6.0%, African American; and 13.5%, other. In the sample, 1.2% of the women were aged 11 to 17 years; 15.3%, 18 to 24 years; 61.4%, 25 to 34 years; and 22.0%, older than 34 years. Median (interquartile range) neighborhood household income was $70 472 ($51 583-$92 643). From 2009 to 2017, the adjusted prevalence of cannabis use in the year before pregnancy increased from 6.80% (95% CI, 6.42%-7.18%) to 12.50% (95% CI, 12.01%-12.99%), and the adjusted prevalence of cannabis use during pregnancy increased from 1.95% (95% CI, 1.78%-2.13%) to 3.38% (95% CI, 3.15%-3.60%). Annual relative rates of change in self-reported daily cannabis use (1.115; 95% CI, 1.103-1.128), weekly cannabis use (1.083; 95% CI, 1.071-1.095), and monthly or less cannabis use (1.050; 95% CI, 1.043-1.057) in the year before pregnancy increased significantly, with daily use increasing most rapidly (from 1.17% to 3.05%). Similarly, annual relative rates of change in self-reported daily cannabis use (1.110; 95% CI, 1.089-1.132), weekly cannabis use (1.075; 95% CI, 1.059-1.092) and monthly or less cannabis use (1.044; 95% CI, 1.032-1.057) during pregnancy increased significantly from 2009 to 2017, with daily use increasing most rapidly (from 0.28% to 0.69%). CONCLUSIONS AND RELEVANCE Results of this study demonstrate that frequency of cannabis use in the year before pregnancy and during pregnancy has increased in recent years among pregnant women in Northern California, potentially associated with increasing acceptance of cannabis use and decreasing perceptions of cannabis-associated harms.
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Affiliation(s)
- Kelly C. Young-Wolff
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry, University of California, San Francisco
| | - Varada Sarovar
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Amy Conway
- Early Start Program, Kaiser Permanente Northern California, Oakland
| | - Stacey Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry, University of California, San Francisco
| | | | - Nancy Goler
- Regional Offices, Kaiser Permanente Northern California, Oakland
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142
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Roberts BA. Legalized Cannabis in Colorado Emergency Departments: A Cautionary Review of Negative Health and Safety Effects. West J Emerg Med 2019; 20:557-572. [PMID: 31316694 PMCID: PMC6625695 DOI: 10.5811/westjem.2019.4.39935] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 04/02/2019] [Accepted: 04/08/2019] [Indexed: 11/11/2022] Open
Abstract
Cannabis legalization has led to significant health consequences, particularly to patients in emergency departments and hospitals in Colorado. The most concerning include psychosis, suicide, and other substance abuse. Deleterious effects on the brain include decrements in complex decision-making, which may not be reversible with abstinence. Increases in fatal motor vehicle collisions, adverse effects on cardiovascular and pulmonary systems, inadvertent pediatric exposures, cannabis contaminants exposing users to infectious agents, heavy metals, and pesticides, and hash-oil burn injuries in preparation of drug concentrates have been documented. Cannabis dispensary workers (“budtenders”) without medical training are giving medical advice that may be harmful to patients. Cannabis research may offer novel treatment of seizures, spasticity from multiple sclerosis, nausea and vomiting from chemotherapy, chronic pain, improvements in cardiovascular outcomes, and sleep disorders. Progress has been slow due to absent standards for chemical composition of cannabis products and limitations on research imposed by federal classification of cannabis as illegal. Given these factors and the Colorado experience, other states should carefully evaluate whether and how to decriminalize or legalize non-medical cannabis use.
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Affiliation(s)
- Brad A Roberts
- University of New Mexico, Department of Emergency Medicine, Albuquerque, New Mexico Partner, Southern Colorado Emergency Medicine Associates, Pueblo, Colorado
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143
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Cogan PS. On healthcare by popular appeal: critical assessment of benefit and risk in cannabidiol based dietary supplements. Expert Rev Clin Pharmacol 2019; 12:501-511. [DOI: 10.1080/17512433.2019.1612743] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Peter S. Cogan
- Department of Pharmaceutical Sciences, Regis University School of Pharmacy, Denver, CO, USA
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144
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Young-Wolff KC, Conway A, Goler N. Potential Adverse Effects of Marijuana Use in Pregnancy. Ann Intern Med 2019; 170:667. [PMID: 31060069 DOI: 10.7326/l19-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kelly C Young-Wolff
- Kaiser Permanente Northern California, Oakland, California (K.C.Y., A.C., N.G.)
| | - Amy Conway
- Kaiser Permanente Northern California, Oakland, California (K.C.Y., A.C., N.G.)
| | - Nancy Goler
- Kaiser Permanente Northern California, Oakland, California (K.C.Y., A.C., N.G.)
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145
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Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. Obstet Gynecol 2019; 133:1057. [PMID: 31022112 DOI: 10.1097/aog.0000000000003251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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146
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147
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Windle SB, Wade K, Filion KB, Kimmelman J, Thombs BD, Eisenberg MJ. Potential harms from legalization of recreational cannabis use in Canada. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2019; 110:222-226. [PMID: 30759307 PMCID: PMC6964625 DOI: 10.17269/s41997-018-00173-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/26/2018] [Indexed: 11/17/2022]
Abstract
With the recent legalization of recreational cannabis use in Canada, questions remain concerning optimal regulation to minimize harms and ensure public health and safety. Patterns of use are subject to change following legalization, and it is important to consider the potential adverse effects that this may have on public health. Important areas of consideration are methods of consumption (e.g., vaping, edibles) and product proliferation; acute and long-term health and behavioural effects (including impaired driving); and use in vulnerable groups, such as children and youth, pregnant women, individuals with mental illness, individuals with low socio-economic status, and Indigenous populations. To support harm reduction measures and evidence-based policy, there is a need to anticipate the potential ramifications that legalization of recreational cannabis use may have on public health in Canada.
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Affiliation(s)
- Sarah B Windle
- Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Kristina Wade
- Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Kristian B Filion
- Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Departments of Medicine and of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | | | - Brett D Thombs
- Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Departments of Medicine and of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Biomedical Ethics Unit, McGill University, Montreal, QC, Canada
- Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology, McGill University, Montreal, QC, Canada
| | - Mark J Eisenberg
- Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada.
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148
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Abstract
Cannabis has been cultivated by mankind for a multitude of uses over a period of thousands of years. This review explores how our relationship with the cannabis plant has evolved over this period of time, including the use of cannabis for recreational purposes and for its medicinal properties. The endocannabinoid system plays a complex role in the development of the fetal, infant and adolescent brain. Use of exogenous cannabinoids has the potential to result in supra-physiological stimulation and impact on normal central nervous system development. Cannabis is the most frequently used recreational drug in western societies and its use is common amongst pregnant women. This review summaries much of the evidence about what is known of the long term effects of in utero cannabis exposure. Further, the potential impact of use of medicinal cannabis products during pregnancy is considered and the implications to health professionals caring for pregnant women and their babies are explored.
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Affiliation(s)
- Philip Henschke
- Department of Paediatrics, Mercy Hospital for Women, Heidelberg, Victoria, Australia.
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149
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Young-Wolff KC, Sarovar V, Tucker LY, Avalos LA, Alexeeff S, Conway A, Armstrong MA, Weisner C, Campbell CI, Goler N. Trends in marijuana use among pregnant women with and without nausea and vomiting in pregnancy, 2009-2016. Drug Alcohol Depend 2019; 196:66-70. [PMID: 30711893 PMCID: PMC6392046 DOI: 10.1016/j.drugalcdep.2018.12.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/09/2018] [Accepted: 12/01/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cross-sectional studies indicate an elevated prevalence of prenatal marijuana use in women with nausea and vomiting in pregnancy (NVP). However, it is unknown whether differences in marijuana use by NVP status have persisted over time as marijuana becomes more acceptable and accessible and prenatal use increases overall. We compared trends in prenatal marijuana use by NVP status in the first trimester of pregnancy using data from Kaiser Permanente Northern California's (KPNC) large healthcare system. METHODS The sample comprised KPNC pregnant women aged ≥12 who completed a self-administered questionnaire on marijuana use and a urine toxicology test for cannabis during standard prenatal care from 2009 to 2016. The annual prevalence of marijuana use via self-report or toxicology by NVP status was estimated using Poisson regression with a log link function, adjusting for sociodemographics and parity. We tested for linear trends and differences in trends by NVP. RESULTS Of 220,510 pregnancies, 38,831 (17.6%) had an NVP diagnosis. Prenatal marijuana use was elevated each year among women with NVP. The adjusted prevalence of use increased significantly from 2009 to 2016 at an annual rate of 1.086 (95%CI = 1.069-1.104) among women with NVP, from 6.5% (95%CI = 5.7%-7.2%) to 11.1% (95%CI = 0.2%-12.0%), and 1.069 (95%CI = 1.059-1.080) among women without NVP, from 3.4% (95%CI = 3.2%-3.7%) to 5.8% (95%CI = 5.5%-6.1%). Trends did not vary by NVP status. DISCUSSION The prevalence of prenatal marijuana use has remained elevated over time among women with NVP. Clinicians should ask pregnant patients about their reasons for marijuana use and treat NVP with evidence-based interventions.
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Affiliation(s)
- Kelly C Young-Wolff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Varada Sarovar
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Lyndsay A Avalos
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Stacey Alexeeff
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Amy Conway
- Early Start Program, Kaiser Permanente Northern California, 1950 Franklin, Oakland CA 94612, USA
| | - Mary Anne Armstrong
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Nancy Goler
- Regional Offices, Kaiser Permanente Northern California, 1950 Franklin, Oakland CA 94612, USA
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150
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Chang JC, Tarr JA, Holland CL, De Genna NM, Richardson GA, Rodriguez KL, Sheeder J, Kraemer KL, Day NL, Rubio D, Jarlenski M, Arnold RM. Beliefs and attitudes regarding prenatal marijuana use: Perspectives of pregnant women who report use. Drug Alcohol Depend 2019; 196:14-20. [PMID: 30658220 PMCID: PMC6756431 DOI: 10.1016/j.drugalcdep.2018.11.028] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE With the increasingly permissive legal and social environments regarding marijuana, it is important to understand prenatal marijuana use from the perspective of women who use marijuana. Our objective was to qualitatively describe the marijuana use experiences, beliefs, and attitudes of women who used marijuana during pregnancy. METHODS We conducted semi-structured interviews with pregnant women who had either reported current marijuana use or had urine testing positive for marijuana. Interviews were transcribed verbatim and analyzed for patterns and themes. RESULTS Twenty-five pregnant women who used marijuana during their pregnancies participated in our study interviews. Main themes that emerged from the interviews were that women: 1) reported higher amounts of marijuana use prior to pregnancy and attempted to reduce their use once they realized they were pregnant; 2) used marijuana to help with nausea and appetite changes during pregnancy or to improve mood; 3) described marijuana as "natural" and "safe" compared to other substances such as alcohol, tobacco, other recreational drugs, and prescribed medications; 4) had conflicting opinions regarding whether marijuana was addictive; and 5) were uncertain but had some concerns regarding potential risks of prenatal marijuana use. CONCLUSION Pregnant women who used marijuana in pregnancy held contradictory beliefs about continued use; they reported trying to reduce usage and were worried about potential risks, but also felt that marijuana is more natural and safer than other substances, including prescribed medicines. These findings have implications for how practitioners address prenatal marijuana use and highlight the need for further research on developmental outcomes.
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Affiliation(s)
- Judy C Chang
- Magee-Womens Research Institute, 204 Craft Avenue, Pittsburgh, PA, 15213, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA; Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, Pittsburgh, PA, 15260, USA; Clinical and Translational Science Institute, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, USA.
| | - Jill A Tarr
- Magee-Womens Research Institute, 204 Craft Avenue, Pittsburgh, PA, 15213, USA; UPMC Hillman Cancer Center Clinical Research Services, 300 Halket Street--Room Islays 401, Pittsburgh, PA, 15213, USA
| | - Cynthia L Holland
- Magee-Womens Research Institute, 204 Craft Avenue, Pittsburgh, PA, 15213, USA; Department of Orthopaedic Surgery, UPMC Rooney Sports Medicine Concussion Program, University of Pittsburgh School of Medicine, 3858 S. Water Street, Pittsburgh, PA, 15203, USA
| | - Natacha M De Genna
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gale A Richardson
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Keri L Rodriguez
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, Pittsburgh, PA, 15260, USA; Center for Health Equity Research & Promotion (CHERP), Veterans Affairs Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA
| | - Jeanelle Sheeder
- Department of Obstetrics, Gynecology, & Pediatrics, University of Colorado School of Medicine, 13065 E. 17th Avenue, Aurora, CO, 80045, USA
| | - Kevin L Kraemer
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, Pittsburgh, PA, 15260, USA; Center for Research in Healthcare, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA, 15260, USA; Clinical and Translational Science Institute, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, USA
| | - Nancy L Day
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Doris Rubio
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, Pittsburgh, PA, 15260, USA; Center for Research in Healthcare, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA, 15260, USA; Clinical and Translational Science Institute, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, USA
| | - Marian Jarlenski
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA, 15261, USA
| | - Robert M Arnold
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, Pittsburgh, PA, 15260, USA; Center for Research in Healthcare, University of Pittsburgh, 4200 Fifth Avenue, Pittsburgh, PA, 15260, USA; Section of Palliative Care and Medical Ethics, Institute to Enhance Palliative Care, 230 McKee Place, Pittsburgh, PA, 15213, USA
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