Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use

Predictors for cannabis cessation during pregnancy: a 10-year cohort study

The aim of this study is to determine factors associated with cannabis discontinuation, to assess the impact of mental health and addiction interventions on cannabis discontinuation during pregnancy and to investigate the neonatal impact of cannabis discontinuation. This is a 10-year cohort study in a tertiary hospital in Barcelona, Spain, including women with self-reported cannabis use during pregnancy. Main outcome was cannabis discontinuation based on biological sample testing. Secondary outcomes were neonatal intensive care unit (NICU) admission, preterm birth, birth weight and bottle-feeding. When cannabis use was detected during pregnancy, 32 out of 81 (38.3%) discontinued cannabis during pregnancy vs. four out of 61 (6.6%) when detected at birth (p < .001). Multivariate binary logistic regression showed that null parity (OR: 6.95, p = .011), detection of cannabis use during pregnancy (OR: 5.35, p = .018) and early detection and referral to mental health care for counseling on cannabis cessation and interventions on the first trimester (OR: 25.46, p < .001) increased cannabis discontinuation. Risk for preterm birth <37 weeks (11.4% vs. 30.8%) and NICU admission (25.7% vs. 54.2%) were lower when discontinuation. Early detection of cannabis use during pregnancy, cessation counseling with mental health interventions, and null parity are predictors for cannabis discontinuation during pregnancy.

Prenatal cannabis exposure in the clinic and laboratory: What do we know and where do we need to go?

Coincident with the legalisation of cannabis in many nations, rates of cannabis use during pregnancy have increased. Like prior investigations on smoking and alcohol, understanding how prenatal cannabis exposure (PCE) impacts offspring outcomes across the lifespan will be critical for informing choices for pregnant people, clinicians, and policy makers alike. A thorough characterization of the life-long impacts is especially urgent for supporting all of these stakeholders in the decision-making process. While studies in humans bring forth the most direct information, it can be difficult to parse the impact of PCE from confounding variables. Laboratory studies in animal models can provide experimental designs that allow for causal inferences to be drawn, however there can be challenges in designing experiments with external validity in mirroring real-world exposure, as well as challenges translating results from the laboratory back to the clinic. In this literature review, we first highlight what is known about patterns of cannabis use during pregnancy. We then seek to lay out updates to the current understanding of the impact of PCE on offspring development informed by both human and nonhuman animal experiments. Finally we highlight opportunities for information exchange among the laboratory, clinic, and policy, identifying gaps to be filled by future research.

Cannabis Use During Early Pregnancy Following Recreational Cannabis Legalization

Importance

It is unknown whether state recreational cannabis legalization (RCL) is related to increased rates of prenatal cannabis use or whether RCL-related changes vary with cannabis screening methods or the local policy environment.

Objective

To test whether RCL in California was associated with changes in prenatal cannabis use rates, whether changes were evident in both self-report and urine toxicology testing, and whether rates varied by local policies banning vs allowing adult-use retailers post-RCL.

Design, Setting, and Participants

This population-based time-series study used data from pregnancies in Kaiser Permanente Northern California universally screened for cannabis use during early pregnancy by self-report and toxicology testing from January 1, 2012, to December 31, 2019. Analyses were conducted from September 2022 to August 2024.

Exposures

California state RCL passage (November 9, 2016) and implementation of legal sales (January 1, 2018) were examined with a 1-month lag. Local policies allowing vs banning medical retailers pre-RCL and adult-use retailers post-RCL were also examined.

Main Outcomes and Measures

Any prenatal cannabis use was based on screening at entrance to prenatal care (typically at 8-10 weeks' gestation) and defined as (1) a positive urine toxicology test result or self-report, (2) a positive urine toxicology test result, or (3) self-report. Interrupted time series models were fit using Poisson regression, adjusting for age, race and ethnicity, and neighborhood deprivation index.

Results

The sample of 300 993 pregnancies (236 327 unique individuals) comprised 25.9% Asian individuals, 6.4% Black individuals, 26.0% Hispanic individuals, 37.7% White individuals, and 4.1% individuals of other, multiple, or unknown race, with a mean (SD) age of 30.3 (5.4) years. Before RCL implementation, rates of prenatal cannabis use rose steadily from 4.5% in January 2012 to 7.1% in January 2018. There was no change in use rates at the time of RCL passage (level change rate ratio [RR], 1.03; 95% CI, 0.96-1.11) and a statistically significant increase in rates in the first month after RCL implementation, increasing to 8.6% in February 2018 (level change RR, 1.10; 95% CI, 1.04-1.16). Results were similar when defining prenatal cannabis use by (1) a toxicology test or (2) self-report. In local policy analyses, the post-RCL implementation increase in use was only found among those in jurisdictions allowing adult-use cannabis retailers (allowed RR, 1.21; 95% CI, 1.10-1.33; banned RR, 1.01; 95% CI, 0.93-1.10).

Conclusions and Relevance

In this time-series study, RCL implementation in California was associated with an increase in rates of cannabis use during early pregnancy, defined by both self-report and toxicology testing, driven by individuals living in jurisdictions that allowed adult-use retailers.

Predictors of perinatal cannabis use in colorado and the association with depression during pregnancy

PURPOSE

To evaluate the prevalence and predictors of cannabis use and reasons for use during and/or after pregnancy among Colorado birthing individuals. To determine the independent association of self-reported depression during pregnancy and cannabis used.

METHODS

Data from Health eMoms, a statewide perinatal longitudinal electronic surveillance system were analyzed. Perinatal cannabis use was defined as any use during and/or after pregnancy. Bivariate associations of birthing individual and infant characteristics with use were estimated using chi-square tests. Multivariable logistic regression was used to assess the independent relationship between depression and reported cannabis use versus no reported cannabis use.

RESULTS

A weighted sample of 117,812 birthing individuals was analyzed from survey responses between 2018-2021. Among the 15,585 (13.3%) who reported perinatal cannabis use, 35.5% reported use during pregnancy and 87.3% reported post-partum use. Individuals with depression during pregnancy had 2.2 times higher adjusted odds (95% CI: 1.5. 3.3) of any perinatal cannabis use compared to those without depression. Among those who had any perinatal cannabis use, reported use for medical reasons was 92% during pregnancy, while 43% cited this as the reason for use 12-14 months post-partum.

CONCLUSION

Self-reported cannabis use during the perinatal period in a state with legalized recreational use was over 1 in 10. Use varied significantly by demographics and social factors with inconsistent perinatal guidance provided by healthcare professionals. Depression during pregnancy was significantly associated with use, illustrating the need for comprehensive mental health screening and therapeutic evidence-based interventions to support these individuals.

Association between state-level medical marijuana legalization and marijuana use during pregnancy: A population-based study

BACKGROUND AND OBJECTIVES

Despite marijuana's association with adverse pregnancy and birth outcomes, its use during pregnancy increased over the last two decades. During this period, medical marijuana has been legalized in 38 states and the District of Columbia. States with legalized medical marijuana have observed increased marketing of marijuana and related products. This study aims to examine the association between state-level medical marijuana legalization and marijuana use during pregnancy in the United States.

METHODS

Using the 2015-2021 National Survey on Drug Use and Health, we evaluated the association between marijuana use in the past month among currently pregnant mothers (N = 4338) and legalized medical marijuana in their state of residence. Survey-weighted descriptive, bivariate, and multivariable logistic regression analyzes were performed.

RESULTS

About 5.7% of pregnant women reported using marijuana in the past month, and 59.0% lived in a state where medical marijuana was legalized across 2015-2021. Compared to those living in states without marijuana legalization, more pregnant women living in states with marijuana legalization reported using marijuana (4.6% vs. 6.5%). In the multivariable model, pregnant women residing in states with medical marijuana legalization were more likely to use marijuana than residents of states without legalization (adjusted Odds Ratio: 1.56; 95% Confidence Interval: 1.11-2.18).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This is the first known study to find that pregnant women living in states where medical marijuana is legalized are more likely to use marijuana during pregnancy. Pregnant women should be informed of adverse pregnancy and birth outcomes linked to marijuana use during pregnancy.

Cannabis and Pregnancy

PURPOSE OF REVIEW

We review recent evidence describing the effects of prenatal exposure to cannabis in pregnant individuals.

RECENT FINDINGS

In the context of changing cannabis policy, more pregnant individuals are using cannabis, despite profound risks. Recent studies show possible perinatal and longitudinal neurodevelopment risks associated with cannabis use during pregnancy and lactation. Healthcare providers are reluctant to discuss this topic with patients for a variety of reasons. With increased access to cannabis comes the possibility of increased adverse effects of cannabis upon pregnant individuals and their children. A concerted effort to educate pregnant individuals about the potential risks of cannabis might mitigate those potential effects.

Prenatal tetrahydrocannabinol and cannabidiol exposure produce sex-specific pathophysiological phenotypes in the adolescent prefrontal cortex and hippocampus

Clinical and preclinical evidence has demonstrated an increased risk for neuropsychiatric disorders following prenatal cannabinoid exposure. However, given the phytochemical complexity of cannabis, there is a need to understand how specific components of cannabis may contribute to these neurodevelopmental risks later in life. To investigate this, a rat model of prenatal cannabinoid exposure was utilized to examine the impacts of specific cannabis constituents (Δ9-tetrahydrocannabinol [THC]; cannabidiol [CBD]) alone and in combination on future neuropsychiatric liability in male and female offspring. Prenatal THC and CBD exposure were associated with low birth weight. At adolescence, offspring displayed sex-specific behavioural changes in anxiety, temporal order and social cognition, and sensorimotor gating. These phenotypes were associated with sex and treatment-specific neuronal and gene transcriptional alterations in the prefrontal cortex, and ventral hippocampus, regions where the endocannabinoid system is implicated in affective and cognitive development. Electrophysiology and RT-qPCR analysis in these regions implicated dysregulation of the endocannabinoid system and balance of excitatory and inhibitory signalling in the developmental consequences of prenatal cannabinoids. These findings reveal critical insights into how specific cannabinoids can differentially impact the developing fetal brains of males and females to enhance subsequent neuropsychiatric risk.

Effects of in utero exposure to Δ-9-tetrahydrocannabinol on cardiac extracellular matrix expression and vascular transcriptome in rhesus macaques

Delta-9-tetrahydrocannabinol (THC), the psychoactive component of cannabis, remains a schedule I substance, thus safety data regarding the effects on the cardiovascular and prenatal health are limited. Importantly, there is evidence showing prenatal cannabis exposure can negatively impact fetal organ development, including the cardiovascular system. THC can cross the placenta and bind to cannabinoid receptors expressed in the developing fetus, including on endothelial cells. To understand the impact of prenatal THC exposure on the fetal cardiovascular system, we used our rhesus macaque model of prenatal daily edible THC consumption. Before conception, animals were acclimated to THC (2.5 mg/7 kg/day, equivalent to a heavy medical cannabis dose) and maintained on this dose daily throughout pregnancy. Fetal tissue samples were collected at gestational day 155 (full term is 168 days). Our model showed that in utero THC exposure was associated with a decreased heart weight-to-body weight ratio in offspring, warranting further mechanistic investigation. Histological examination of the fetal cardiac and vascular tissues did not reveal any significant effect of THC exposure on the maturity of collagen within the fetal heart or the aorta. Total collagen III expression and elastin production and organization were unchanged. However, bulk RNA-sequencing of vascular cells in the umbilical vein, umbilical artery, and fetal aorta demonstrated that THC alters the fetal vascular transcriptome and is associated with upregulated expression of genes involved in carbohydrate metabolism and inflammation. The long-term consequences of these findings are unknown but suggest that prenatal THC exposure may affect cardiovascular development in offspring.NEW & NOTEWORTHY Prenatal cannabis use is increasing and despite the public health relevance, there is limited safety data regarding its impact on offspring cardiovascular health outcomes. We used a translational, nonhuman primate model of daily edible Δ-9-tetrahydrocannabinol (THC) consumption during pregnancy to assess its effects on the fetal cardiovascular system. THC-exposed fetal vascular tissues displayed upregulation of genes involved in cellular metabolism and inflammation, suggesting that prenatal THC exposure may impact fetal vascular tissues.

Regulatory Framework for Cannabis: A Position Paper From the American College of Physicians

Cannabis, also known as marijuana, is the dried flowers, stems, seeds, and leaves of the Cannabis sativa plant. It contains more than 100 compounds, including tetrahydrocannabinol, which has psychoactive effects. Federal law prohibits the possession, distribution, and use of cannabis outside limited research activities, but most states have legalized cannabis for medical or recreational use. However, research into the potential therapeutic and adverse health effects of cannabis has been limited, in part because of the drug's federal legal status. In this position paper, the American College of Physicians (ACP) calls for the decriminalization of possession of small amounts of cannabis for personal use and outlines a public health approach to controlling cannabis in jurisdictions where it is legal. ACP recommends the rigorous evaluation of the health effects and potential therapeutic uses of cannabis and cannabinoids as well as research into the effects of legalization on cannabis use. It also calls for evidence-based medical education related to cannabis and increased resources for treatment of cannabis use disorder.

DNA methylation, but not microRNA expression, is affected by in vitro THC exposure in bovine granulosa cells

BACKGROUND

A global increase in cannabis use has led to questions about its effects on fertility. The rise in consumption amongst women of reproductive age is a growing concern, as this group is vulnerable in terms of reproductive health. Ample evidence suggests that the psychoactive component of cannabis, Δ9-Tetrahydrocannabinol (THC), interacts with the endocannabinoid system (ECS), that helps regulate mammalian reproduction. This study aimed to research the epigenetic effects of THC in bovine granulosa cells (GCs) by (1) investigating global DNA methylation via measuring 5-mC and 5-hmC levels; (2) measuring key methylation regulators, including the methylating enzymes DNMT1, DNMT3a, DNMT3b and the demethylases TDG and TET1/2/3; and (3) assessing fertility-associated miRNAs key in developmental competency, including miR-21, -155, -33b, -324 and -346.

METHODS

Bovine GCs were used as a translational model for reproductive toxicity in humans. To determine THC effects, GCs were isolated from Cumulus-Oocyte-Complexes (COCs) from bovine ovaries, cultured in vitro for 7 days, or until confluent, and cryopreserved at passage 1 (P1). For experimentation, cells were thawed, cultured until passage 2 (P2), serum restricted for 24-h and treated for 24-h in one of five groups: control, vehicle (1:1:18 ethanol: tween: saline) and three clinically relevant THC doses (0.032, 0.32 and 3.2 μM). Global methylation was assessed by measuring 5-mC and 5-hmC levels with flow cytometry. To assess mRNA and protein expression of methylation regulators and miRNA profiles, qPCR and Western Blotting were utilized. Shapiro-Wilk test was used to determine normality within datasets. One-way ANOVA was applied to determine statistical significance using GraphPad Prism 6.0.0.

RESULTS

Results indicate a significant decrease (p = 0.0435) in 5-mC levels following low THC exposure, while no changes were observed in 5-hmC levels. A significant increase in DNMT1 following high THC exposure at the RNA level (p < 0.05) and a significant increase following low THC exposure at the protein level (p = 0.0048) were also observed. No significant differences were observed in DNMT3a/3b, TDG, TET1/2/3 mRNAs or in any of the miRNAs analyzed.

CONCLUSIONS

This research suggests that THC mainly affects DNA methylation, but not miRNA profiles, ultimately altering gene expression and likely impairing oocyte competence, maturation, and fertilization potential.

Young Adults' Experiences with Cannabis Retailer Marketing and Related Practices: Differences Among Sociodemographic Groups and Associations with Cannabis Use-related Outcomes

OBJECTIVES

Limited cannabis retail surveillance has been conducted, particularly assessing retailer practices in relation to consumer sociodemographic factors or use-related outcomes. This study examined young adults': exposure to promotions, health claims, warnings, and age restrictions at cannabis retailers; demographic correlates of retail exposures; and retail exposures in relation to use-related outcomes.

STUDY DESIGN

This study used the cross-sectional quantitative analysis.

METHODS

We analyzed 2023 survey data among 876 young adults in states with legal non-medical cannabis, reporting past-month cannabis use and past-year retailer visits.

RESULTS

In this sample (Mage = 27.1, 44.1% male, 31.7% sexual minority, 17.7% Black, 11.2% Asian, 25.1% Hispanic), 46.7% "at least sometimes" noticed free samples, 76.5% price promotions, 37.4% subpopulation-targeted promotions; 72.5% health claims on products/ads, 63.1% signage, and 70.5% from budtenders; 72.5% warnings on labels, 65.5% signage, and 38.9% from budtenders; and > 80% age verifications. Multivariable analyses identified sociodemographic correlates of exposure outcomes: greater promotion exposure was associated with Black race; greater health claim exposure with being heterosexual, Black, and less educated; less warning exposure with less education; and less age restriction exposure with being younger, male, and Black. Retail exposures were associated with use-related outcomes: more frequent cannabis use was associated with less health claim exposure; greater perceived social acceptability with greater promotion and age restriction exposure; greater perceived risk with greater warning and less age restriction exposure; more problematic use and driving after use with greater promotion and less age restriction exposure.

CONCLUSIONS

Cannabis retail exposure disparities and their associations with use-related outcomes highlight the importance of regulatory and prevention efforts.

Effects of prenatal THC vapor exposure on body weight, glucose metabolism, and feeding behaviors in chow and high-fat diet fed rats

BACKGROUND

4-20% of people report using cannabis during pregnancy, thereby it is essential to assess the associated risks. There is some evidence that prenatal cannabis exposure (PCE) may be associated with increased risk for developing of obesity and diabetes later in life, however this has not been well explored under controlled conditions. The aim of this study was to use a translational THC vapor model in rodents to characterize the effects of PCE on adiposity, glucose metabolism, and feeding patterns in adulthood, with focus on potential sex differences.

METHODS

Pregnant Sprague Dawley rats were exposed to vaporized THC (100 mg/ml) or control (polyethylene glycol vehicle) across the entire gestational period. Adult offspring from PCE (n = 24) or control (n = 24) litters were subjected to measures of adiposity, glucose metabolism and feeding behavior. Rats were then placed onto special diets (60% high-fat diet [HFD] or control 10% low fat diet [LFD]) for 4-months, then re-subjected to adiposity, glucose metabolism and feeding behavior measurements.

RESULTS

PCE did not influence maternal weight or food consumption but was associated with transient decreased pup weight. PCE did not initially influence bodyweight or adiposity, but PCE did significantly reduce the rate of bodyweight gain when on HFD/LFD, regardless of which diet. Further, PCE had complex effects on glucose metabolism and feeding behavior that were both sex and diet dependent. No effects of PCE were found on plasma leptin or insulin, or white adipose tissue mass.

CONCLUSIONS

PCE may not promote obesity development but may increase risk for diabetes and abnormal eating habits under certain biological and environmental conditions. Overall, this data enhances current understanding of the potential impacts of PCE.

A feasibility study to assess the recruitment and retention of pregnant patients who regularly use cannabis

OBJECTIVE

To assess first-trimester recruitment and retention of pregnant patients who regularly used cannabis, but not other substances, measured by willingness to participate in a research study, completion of self-administered electronic questionnaires, and willingness to provide urine samples during each trimester of pregnancy. We designed and launched a prospective feasibility study titled, Cannabis Legalization in Michigan (CALM) - Maternal & Infant Health (MIH), in two Michigan clinics after the recreational use of cannabis became legal for adults 21 years and older.

RESULTS

Over half (52%) of patients asked to participate in CALM-MIH were consented to the study. Two-thirds (66%) of screened patients initiated prenatal care during their first trimester of pregnancy and 50% used cannabis, of which the majority did not concurrently use other substances. Of those recruited into the prospective study, all participants completed the first-trimester questionnaire and provided urine samples. Study retention was 80% and all participants who completed follow-up assessments were willing to provide urine samples.

Changes in online marketing and sales practices among non-medical cannabis retailers in 5 US cities, 2022 to 2023

Objectives

Given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time.

Methods

In 2022 and 2023, researchers assessed website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies) among 175 randomly-selected cannabis retailers' websites across 5 US cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles [LA], California, n=∼35/city). Analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities.

Results

Similar to 2022, in 2023, 76.6 % required age verification for site entry, 85.1 % used social media promotion, and 90.9 % offered online sales (82.4 % of which required age verification and 34.6 % offered delivery). There were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4 % to 15.4 %), purchase limits (59.4 % to 47.4 %), health warnings (38.9 % to 29.7 %), health benefits (60 % to 47.4 %), and discounts/price promotions (92.6 % to 86.3 %). In 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90 % in Denver, Las Vegas, LA), allowed discounts/price promotions (100 % in Denver and Las Vegas), or required health warnings (48-60 % in Seattle and LA vs. < 20 % elsewhere). Despite all sites prohibiting youth-oriented content and all but Denver and Las Vegas prohibiting health claims, 30.3 % posted content targeting youth/young adults (LA = 8.1 % to Denver = 74.2 %) and 47.4 % health claims (Seattle = 27.0 % to Denver = 71.0 %).

Conclusions

Online cannabis retail presents risks for access and appeal to minors, emphasizes health benefits, and uses price promotions, regardless of restrictions, indicating need for greater regulatory efforts.

Dynamic Overrepresentation of Accumbal Cues in Food- and Opioid-Seeking Rats after Prenatal THC Exposure

The increasing prevalence of cannabis use during pregnancy has raised significant medical concerns, primarily related to the presence of Δ9-tetrahydrocannabinol (THC), which readily crosses the placenta and impacts fetal brain development. Previous research has identified midbrain dopaminergic neuronal alterations related to maternal THC consumption. However, the enduring consequences that prenatal cannabis exposure (PCE) has on striatum-based processing during voluntary reward pursuit have not been specifically determined. Here, we characterize PCE rats during food (palatable pellets) or opioid (remifentanyl)-maintained reward seeking. We find that the supra motivational phenotype of PCE rats is independent of value-based processing and is instead related to augmented reinforcing efficiency of opioid rewards. Our findings reveal that in utero THC exposure leads to increased cue-evoked dopamine release responses and an overrepresentation of cue-aligned, effort-driven striatal patterns of encoding. Recapitulating findings in humans, drug-related neurobiological adaptations of PCE were more pronounced in males, who similarly showed increased vulnerability for relapse. Collectively, these findings indicate that prenatal THC exposure in male rats engenders a pronounced neurodevelopmental susceptibility to addiction-like disorders later in life.

Perinatal Cannabis Use and Cannabis Use during Breastfeeding: the Role of Health Care Workers

OBJECTIVE

This study aimed to estimate the proportion of perinatal women reporting a health care worker (HCW) discussed cannabis use during pregnancy or breastfeeding with them and to evaluate the association between HCWs' discussions and perinatal cannabis use and cannabis use while breastfeeding.

STUDY DESIGN

Data from Health eMoms (a longitudinal, state-representative survey of Colorado mothers, collected from 2018 to 2020 [n = 3,193]) were utilized in logistic regressions assessing the relationship between HCW discussions about cannabis and perinatal cannabis use and cannabis use while breastfeeding at two time points postpartum, adjusting for sociodemographic factors.

RESULTS

A total of 5.8% of the sample reported cannabis use either during their most recent pregnancy or while breastfeeding at 3 to 6 months' postpartum. A total of 67.8% of the sample reported an HCW-discussed cannabis at prenatal visits. Women reporting perinatal use were more likely to report HCW discussing cannabis compared with nonusers (82.2 vs. 65.3%, p < 0.01). There was not a significant association between HCW discussions and cannabis use while breastfeeding at either time point postpartum. Compared with nonusers, women using perinatally were more likely to report cannabis Web sites (28.9 vs. 6.5%), cannabis stores (15.7 vs. 3.8%), or word-of-mouth (28.4 vs. 17.1%) as trusted sources of cannabis-related information.

CONCLUSION

HCW discussions about cannabis use during pregnancy or breastfeeding are not universally reported. This study highlights the need for further encouragement of universal HCW discussions of cannabis use during pregnancy and breastfeeding, strengthening of messaging around cannabis use during these periods, and improved delivery of reliable cannabis-related health information to this population.

KEY POINTS

· HCW discussions of perinatal cannabis use are not universally reported by women.. · Women reporting perinatal use were more likely to report HCW discussions of cannabis.. · Women reporting perinatal cannabis use were more likely to trust word-of-mouth or cannabis stores or Web sites..

Alcohol and cannabis use among women with infertility: associations with psychiatric symptoms, attempts to conceive, and engagement in fertility treatment

Little is known about substance use among women with infertility, yet substance use has implications for fertility and pregnancy. The purpose was to estimate the prevalence of substance use among women with infertility and examine whether substance use was associated with psychiatric symptoms, active attempts to conceive, and engagement in fertility treatments. Eligible patients were from a single healthcare system who received a female infertility diagnosis within the past 2 years. Participants (n = 188) completed an online questionnaire regarding substance use, psychiatric symptoms, attempts to conceive, and fertility treatments. The prevalence of hazardous alcohol use, any cannabis use, and hazardous cannabis use were 30.3%, 30.9%, and 8.5%, respectively. Hazardous alcohol use was not associated with psychiatric symptoms (p > .05). Those with any cannabis use were more likely to have higher depression scores than those without (p = .02). Those with hazardous cannabis use were more likely to have higher depression scores (p = .001) and higher anxiety scores (p = .03). Substance use was not associated with actively trying to conceive. Those pursuing fertility treatments had a lower percentage engaging in hazardous alcohol use compared to those not pursuing fertility treatments (19.0% vs. 36.3%, p = .02). Substance use among women with infertility is common. Hazardous cannabis use was associated with greater psychiatric symptoms, suggesting that cannabis may be used to cope with distress. Pursuing fertility treatments may serve as a protective factor for hazardous alcohol use. Clinicians treating patients with infertility may want to screen for substance use.

Maternal Cannabis Use during Lactation and Potential Effects on Human Milk Composition and Production: A Narrative Review

Cannabis use has increased sharply in the last 20 y among adults, including reproductive-aged women. Its recent widespread legalization is associated with a decrease in risk perception of cannabis use during breastfeeding. However, the effect of cannabis use (if any) on milk production and milk composition is not known. This narrative review summarizes current knowledge related to maternal cannabis use during breastfeeding and provides an overview of possible pathways whereby cannabis might affect milk composition and production. Several studies have demonstrated that cannabinoids and their metabolites are detectable in human milk produced by mothers who use cannabis. Due to their physicochemical properties, cannabinoids are stored in adipose tissue, can easily reach the mammary gland, and can be secreted in milk. Moreover, cannabinoid receptors are present in adipocytes and mammary epithelial cells. The activation of these receptors directly modulates fatty acid metabolism, potentially causing changes in milk fatty acid profiles. Additionally, the endocannabinoid system is intimately connected to the endocrine system. As such, it is probable that interactions of exogenous cannabinoids with the endocannabinoid system might modify release of critical hormones (e.g., prolactin and dopamine) that regulate milk production and secretion. Nonetheless, few studies have investigated effects of cannabis use (including on milk production and composition) in lactating women. Additional research utilizing robust methodologies are needed to elucidate whether and how cannabis use affects human milk production and composition.

Vaporized Δ9-THC in utero results in reduced birthweight, increased locomotion, and altered wake-cycle activity dependent on dose, sex, and diet in the offspring

AIMS

Preclinical studies have found that chronic ∆9-tetrahydrocannabinol (THC) treatment is directly associated with weight gain when introduced during adolescence and adulthood, but the effect of prenatal THC is unclear. Clinical studies have demonstrated prenatal exposure to THC is a prospective predictor of increased health risks associated with obesity. Our study aims to examine prenatal THC impact on obesity risks in males and females throughout adolescence using a clinically relevant inhalation model.

METHODS

Pregnant rats were exposed to one of the following from gestational day 2 through birth: 10 mg THC, 40 mg THC, or air. Daily 10-min inhalations were conducted in each animal from 0900 to 1200. Offspring from each treatment group were given either a high-fat diet (HFD) or a normal diet (ND). Food and bodyweights were collected daily, while circadian activity, locomotion, and exercise were measured periodically (PND 21-60). Pregnancy weight gain and birth weight were collected to determine early-life developmental effects.

RESULTS

Rats prenatally treated with low-dose THC (LDTHC) generally had lower dark-cycle activity compared with control counterparts, but this altered activity was not observed at the higher dose of THC (HDTHC). In terms of open-field activity, THC doses displayed a general increase in locomotion. In addition, the LDTHC male rats in the ND showed significantly greater exploratory behavior. Prenatal THC had dose-dependent effects on maternal weight gain and birth weight.

CONCLUSIONS

Overall, our findings indicate there are some activity-related and developmental effects of prenatal THC, which may be related to obesity risks later in life.

The impact of recreational cannabis legalization on youth: the Colorado experience

Over the past two decades, cannabis policies have liberalized in the United States, culminating in the legalization of recreational cannabis in Colorado and Washington state in 2012. This review will focus on the impact of recreational cannabis legalization in Colorado. While the prevalence of past-year and past-month cannabis use has remained relatively steady among adolescents post-legalization, the prevalence of young adult use has continued to rise. Cannabis products with increased potency have become more prevalent and widely used. There are concerns that the use of products with increased potency will increase risk for cannabis use and comorbid mental health disorders, particularly cannabis-induced psychosis and suicidal behavior, although more research is needed to fully understand the impact of high-potency products. Since the legalization of recreational cannabis, numerous additional public health concerns have emerged: unintentional overdoses requiring acute care visits, electronic vaping-associated lung injury, increased motor vehicle collisions related to cannabis consumption, and higher rates of cannabis use during pregnancy. Lessons learned from the first decade of cannabis legalization emphasize the need for research efforts to provide evidence-based guidelines, inform prevention strategies, and implement selective interventions for at-risk populations including youth, individuals with comorbid mental health disorders, and individuals who are pregnant.

Integrating Mental Health Care in Ambulatory Obstetrical Practices: Strategies and Models

Perinatal mental health is recognized as a priority component of obstetrical care. Perinatal patients often turn to their obstetrician for help with mental health concerns as they view them as their primary health care provider. Unfortunately, obstetricians face challenges in providing adequate support due to time constraints and limited expertise. Integrated behavioral health care offers a collaborative and cost-effective solution to enhance patient care and clinician satisfaction. Integrated behavioral health clinicians possess fundamental skills to care for patients throughout the reproductive lifespan and assist obstetricians in identifying and managing common mood concerns.

The impact of recreational cannabinoid legalization on utilization in a pregnant population

Background

Marijuana potency and utilization both continue to increase across the United States. While the overall prevalence of cannabinoid utilization during pregnancy has been surveyed in various studies, the direct impact of changing governmental policies on pregnancy use is less characterized. Thus, we aimed to investigate how the legalization of recreational cannabinoid products impacted use during pregnancy in the state of New Mexico.

Methods

Participants who had a live birth during two study epochs were included: pre-legalization (Epoch 1: 1 January 2019-31 March 2021) and post-legalization (Epoch 2: 1 November 2021-30 November 2022). Participants were further divided into case group [prenatal cannabinoid exposure (PCE)] vs. control (no PCE), with cases being identified by documented self-report or a positive laboratory toxicology test for cannabinoid use during pregnancy.

Results

A total of 1,191 maternal/infant dyads were included in Epoch 1, and 378 maternal/infant dyads were included in Epoch 2. In Epoch 1, 788 dyads were controls with 403 cases, while Epoch 2 had 292 controls and 86 cases. Interestingly there was a significant decrease in self-report or positive laboratory toxicology tests in Epoch 2 compared to Epoch 1. Infants born following PCE in both Epoch groups were more commonly born via Cesarean section, had significantly smaller birth weight, length, and head circumference as well as significantly lower Apgar scores at 1 and 5 min.

Conclusion

The finding of decreased reported cannabinoid use in the post-legalization group is contradictory to previous studies which have shown increased rates of cannabinoid use after legalization. This could be due to multiple factors including changes in screening practices, the COVID-19 pandemic, and lack of commercialization of THC products. Additional studies are needed to further characterize how changing governmental policies impacts utilization during pregnancy.

Maternal Delta-9-Tetrahydrocannabinol Exposure Induces Abnormalities of the Developing Heart in Mice

Introduction: Cannabis is increasingly being consumed by pregnant women for recreational purposes as well as for its antiemetic and anxiolytic effects despite limited studies on its safety during pregnancy. Importantly, phytocannabinoids found in cannabis can pass through the placenta and enter the fetal circulation. Recent reports suggest gestational cannabis use is associated with negative fetal outcomes, including fetal growth restriction and perinatal intensive care, however, the effects of delta-9-tetrahydrocannabinol (THC) on fetal heart development remains to be elucidated. Materials and Methods: We aimed to determine the outcomes of maternal THC exposure on fetal heart development in mice by administering 0, 5, or 10 mg/kg/day of THC orally to C57BL/6 dams starting at embryonic day (E)3.5. Offspring were collected at E12.5 for molecular analysis, at E17.5 to analyze cardiac morphology or at postnatal day (PND)21 to assess heart function. Results: Maternal THC exposure in E17.5 fetuses resulted in an array of cardiac abnormalities with an incidence of 44% and 55% in the 5 and 10 mg/kg treatment groups, respectively. Maternal THC exposure in offspring resulted in ventricular septal defect, higher semilunar valve volume relative to orifice ratio, and higher myocardial wall thickness. Notably, cell proliferation within the ventricular myocardium was increased, and expression of multiple cardiac transcription factors was downregulated in THC-exposed E12.5 fetuses. Furthermore, heart function was compromised with lower left ventricular ejection fraction, fractional shortening, and cardiac output in PND21 pups exposed to THC compared to controls. Discussion: The results show that maternal THC exposure during gestation induces myocardial hyperplasia and semilunar valve thickening in the fetal heart and postnatal cardiac dysfunction. Our study suggests that maternal cannabis consumption may induce abnormalities in the developing heart and cardiac dysfunction in postnatal life.

Cannabis Retailer Communication About Cannabis Products, Health Benefits, and Risks: A Mystery Shopper Study of Licensed Retailers in Five U.S. Cities

OBJECTIVE

As the U.S. cannabis market expands, surveillance of retailer practices, especially product health claims and risks, is crucial to protect consumers. In this study, mystery shoppers (i.e., staff not explicitly identified as researchers) examined retail personnel communication regarding product recommendations, health benefits, safety, and/or risks among U.S. cannabis retailers.

METHOD

In Summer 2022, mystery shoppers audited 140 licensed cannabis retailers in 5 cities in states with established nonmedical (i.e., recreational) cannabis sales and diverse regulations (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive and bivariate analyses characterized retail personnel communication overall and across cities.

RESULTS

Common product recommendations for new users included edibles, pre-rolled joints, and bud/flower, and 8.6% offered free/inexpensive ways to sample products. Although Colorado, Washington, and Oregon explicitly prohibited health claims in advertising or labels, more than 90% of retailers there endorsed use for anxiety, insomnia, and/or pain. Whereas 54.3% endorsed use for pregnancy-related nausea (least common in Denver, 23.3%; most common in Seattle, 76.7%), 26.4% warned against use during pregnancy (most frequently in Denver, 46.7%; least frequently in Seattle and Portland, 13.3%). Overall, 52.1% warned against driving after use (most frequently in Denver, 80.0%; least frequently in Las Vegas, 20.0%). Almost all (≥90%) sold cannabidiol (CBD) products and endorsed their health benefits and safety, but few (<10%) sold or endorsed delta-8 tetrahydrocannabinol (THC), etc. (all of which were in Los Angeles).

CONCLUSIONS

Ongoing cannabis retail surveillance, particularly using protocols assessing factors outside those visibly observable, is needed to inform regulatory and enforcement efforts, especially related to health claims.

Impact of Cannabis Legalization on Adolescent Cannabis Use

Because of substantial limitations in available national data, such as inconsistencies among surveys and small sample sizes, the increased prevalence of cannabis use among adolescents since recreational legalization has not been directly observed. Nevertheless, both usage frequency and product potency have significantly increased, alongside alternative routes of delivery to smoking, such as vaping cannabis. Moreover, certain populations may be especially vulnerable to the effects of legalization. Regardless of differing state-level cannabis legalization status, the adverse consequences of cannabis on youth have clear negative impacts on mental health, medical symptoms, educational outcomes, and increased risk of addiction to other substances.

Nausea and vomiting of pregnancy and prenatal cannabis use in a Michigan sample

BACKGROUND

Nausea and vomiting of pregnancy, also referred to as morning sickness, affects more than 70% of all pregnancies. Symptoms range from mild to severe and, in some cases, can be debilitating, resulting in a reduced quality of life. Moreover, prenatal cannabis use prevalence has doubled in the United States, and cannabis potency, measured by the concentration of delta-9-tetrahydrocannabiniol, has increased from 10% in 2009 to 14% in 2019. State-level recreational legalization of cannabis may contribute to the liberalization of its use and reduced risk perception. Furthermore, the relatively recent discovery of cannabinoid hyperemesis syndrome may contribute to the mischaracterization of morning sickness in individuals who use cannabis during pregnancy. Although cannabis has well-documented antiemetic properties, there is insufficient research on the topic. Therefore, it is essential to establish a tangible understanding of the association between nausea and vomiting of pregnancy and prenatal cannabis use.

OBJECTIVE

This study aimed to estimate the degree to which nausea and vomiting of pregnancy might be associated with prenatal cannabis use in a sample of pregnant people in Michigan, a state where recreational cannabis use became legal in December 2018.

STUDY DESIGN

This was a prospective study of participants from the Michigan Archive for Research on Child Health, a population-based pregnancy cohort that was recruited using a probability-based sampling approach. Participants were recruited from 22 prenatal clinics located throughout Michigan's lower peninsula. Cross-sectional analyses were performed for data available between October 2017 and January 2022.

RESULTS

Among this sample of Michigan pregnant people, 14% (95% confidence interval, 11%-16%) reported cannabis use. Participants who experienced increasing morning sickness severity had higher odds of using cannabis (adjust odds ratio, 1.2; 95% confidence interval, 1.1-1.2). When the sample was restricted to first-trimester morning sickness and cannabis use, the results remained statistically robust. When the direction of the association was reversed, an increase in morning sickness severity was detected among participants who used cannabis during pregnancy (ßadjusted, 0.2; 95% confidence interval, 0.1-0.2). Lastly, the association between prepregnancy cannabis use and first-trimester morning sickness was investigated. Study findings suggest an increase in morning sickness severity among people who used cannabis in the 3 months before pregnancy compared with those who did not use cannabis (ßadjusted, 0.1; 95% confidence interval, 0.003-0.200).

CONCLUSION

Study findings indicated a link between nausea and vomiting of pregnancy and prenatal cannabis use. Moreover, this study revealed that using cannabis in the 3 months before pregnancy is associated with first-trimester morning sickness severity. The strengths of our study contribute to the scant epidemiologic evidence in this area of research. More fine-grained, time-specific data on nausea and vomiting of pregnancy and prenatal cannabis use are necessary to draw inferences about cause-effect relationships. Our study might provide a basis to discourage cannabis use during pregnancy until more evidence is collected.

Patient Perceptions of Prenatal Cannabis Use and Implications for Clinicians

OBJECTIVE

To understand pregnant patients' reasons for prenatal cannabis use and perceptions of safety, desired and undesirable health care experiences, and desired information about prenatal cannabis use and secondarily to understand racial differences in these perceptions and preferences.

METHODS

We conducted a qualitative study including 18 semi-structured, race-concordant virtual focus groups with pregnant individuals who self-reported cannabis use at prenatal care entry in a large integrated health care system in Northern California from November 2021 to December 2021. The focus groups included semi-structured questions that were recorded, transcribed, and coded by the research team. Thematic analysis was used to analyze the data.

RESULTS

Overall, 53 participants were included; 30 self-identified, as White and 23 self-identified as Black. Participants averaged 30.3 years of age (SD 5.2 years) and were on average at 20.9 weeks of gestation at study enrollment; 69.8% reported daily cannabis use, 24.5% reported weekly cannabis use, and 5.7% reported monthly or less cannabis use at entrance to prenatal care. Although some participants quit cannabis use in early pregnancy because of concerns about potential health risks, many perceived a lack of scientific evidence or believed that prenatal cannabis use was safe. Many preferred cannabis to over-the-counter or prescription medications for treating mood, morning sickness, pain, and sleep. Participants valued open interactions with obstetricians that acknowledged their motivations for use, and they desired information about potential risks through conversations and educational materials. White and Black participants' perspectives were generally similar, but a few Black participants uniquely described concerns about racial bias related to their prenatal cannabis use.

CONCLUSION

Pregnant patients used cannabis to manage mood and medical symptoms, and many believed that prenatal cannabis use was safer than the use of prescription medications. Obstetrician-initiated, patient-centered conversations around prenatal cannabis use, advice to discontinue cannabis use during pregnancy, and exploration of willingness to switch to medically recommended interventions for pregnancy-related symptoms may benefit patients.

Combined exposure to alcohol and cannabis during development: Mechanisms and outcomes

Exposure to substances of abuse during pregnancy can have long-lasting effects on offspring. Alcohol is one of the most widely used substances of abuse that leads to the most severe consequences. Recent studies in the United States, Canada, and the United Kingdom showed that between 1% and 7% of all children exhibit signs and symptoms of fetal alcohol spectrum disorder (FASD). Despite preventive campaigns, the rate of children with FASD has not decreased during recent decades. Alcohol consumption often accompanies exposure to such drugs as tobacco, cocaine, opioids, and cannabis. These interactions can be synergistic and exacerbate the deleterious consequences of developmental alcohol exposure. The present review focuses on interactions between alcohol and cannabis exposure and the potential consequences of these interactions.

Cannabis retailer marketing strategies and regulatory compliance: A surveillance study of retailers in 5 US cities

As cannabis retail expands in the US, its surveillance is crucial to inform regulations and protect consumers. This study addresses this need by conducting point-of-sale audits examining regulatory compliance (e.g., age verification, signage), advertising/promotional strategies, products, and pricing among 150 randomly-selected cannabis retailers in 5 US cities (30/city: Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California) in Summer 2022. Descriptive and bivariate analyses characterized the retailers overall and across cities. Age verification rates were high (>90%). The majority of retailers had signage indicating restricted access (e.g., no minors; 87.3%), onsite consumption (73.3%), and distribution to minors (53.3%). Retailers were likely to post warnings regarding use during pregnancy/breastfeeding (72.0%), followed by health risks (38.0%), impacts on children/youth (18.7%), and DUI (14.0%). Overall, 28.7% posted health claims, 20.7% posted youth-oriented signage, and 18.0% had youth-oriented packaging. Price promotions were prevalent, particularly price specials (75.3%), daily/weekly/monthly specials (66.7%), and membership programs (39.3%). One-fourth had signs/promotions indicating curbside delivery/pick-up (28.0%) and/or online ordering (25.3%); 64.7% promoted their website or social media page. The most potent cannabis products were most often e-liquids (38.0%) or oils (24.7%); the least potent were often edibles (53.0%). The most expensive product was often bud/flower (58.0%); the least was joints (54.0%). The vast majority (≥81%) sold vaporizers, wrapping papers, and hookah/waterpipes/bongs, and 22.6% sold CBD products. Marketing strategies differed across cities, reflecting differences in state-specific regulations and/or gaps in compliance/enforcement. Findings underscore the need for ongoing cannabis retail surveillance to inform future regulatory and enforcement efforts.

Prenatal delta-9-tetrahydrocannabinol exposure is associated with changes in rhesus macaque DNA methylation enriched for autism genes

BACKGROUND

With the growing availability of cannabis and the popularization of additional routes of cannabis use beyond smoking, including edibles, the prevalence of cannabis use in pregnancy is rapidly increasing. However, the potential effects of prenatal cannabis use on fetal developmental programming remain unknown.

RESULTS

We designed this study to determine whether the use of edible cannabis during pregnancy is deleterious to the fetal and placental epigenome. Pregnant rhesus macaques consumed a daily edible containing either delta-9-tetrahydrocannabinol (THC) (2.5 mg/7 kg/day) or placebo. DNA methylation was measured in 5 tissues collected at cesarean delivery (placenta, lung, cerebellum, prefrontal cortex, and right ventricle of the heart) using the Illumina MethylationEPIC platform and filtering for probes previously validated in rhesus macaque. In utero exposure to THC was associated with differential methylation at 581 CpGs, with 573 (98%) identified in placenta. Loci differentially methylated with THC were enriched for candidate autism spectrum disorder (ASD) genes from the Simons Foundation Autism Research Initiative (SFARI) database in all tissues. The placenta demonstrated greatest SFARI gene enrichment, including genes differentially methylated in placentas from a prospective ASD study.

CONCLUSIONS

Overall, our findings reveal that prenatal THC exposure alters placental and fetal DNA methylation at genes involved in neurobehavioral development that may influence longer-term offspring outcomes. The data from this study add to the limited existing literature to help guide patient counseling and public health polices focused on prenatal cannabis use in the future.

Cannabis and Pregnancy: A Review

Importance

Prenatal cannabis use is rising and is a major public health issue. Cannabis use in pregnancy and during lactation has been associated with increased maternal and offspring morbidity and mortality.

Objective

This review aims to summarize the existing literature and current recommendations for cannabis use during pregnancy or lactation.

Evidence Acquisition

A PubMed, Cochrane Library, and Google Scholar literature search using the following terms was performed to gather relevant data: "cannabis," "cannabinoid," "delta-9-tetrahydrocannabinol," "THC," "cannabidiol," "fetal outcomes," "perinatal outcomes," "pregnancy," and "lactation."

Results

Available studies on cannabis use in pregnancy and during lactation were reviewed and support an association with increased risk of preterm birth, neonatal intensive care unit admission, low birth weight, and small-for-gestational-age infants.

Conclusion and Relevance

There is a critical need for research on the effects of cannabis use in pregnancy and during lactation. This is a necessary first step before furthering patient education, developing interventions, and targeting antenatal surveillance to ameliorate the adverse impacts on maternal and fetal health.

Up in Smoke: The Impacts of Marijuana During Pregnancy

Numerous drugs ingested during pregnancy can impact the developing fetus. Although some effects are apparent at birth as overt teratogenicity or profound neonatal withdrawal, others become apparent only after a careful long-term follow-up into childhood. Shifting legal and cultural attitudes toward marijuana have led to increased use during pregnancy. This shift should prompt health care providers to carefully consider the drug's mechanism of action, its interaction with the placenta, and the potential consequences of fetal exposure. The primary psychoactive compound in marijuana is Δ9-tetrahydrocannabinol (THC), which agonizes endogenous cannabinoid receptors. Cannabinoid receptors are present in the fetal brain early in gestation and appear to have an important role in the developing central nervous system. THC crosses the placenta in sufficient quantities to raise concerns about exogenous exposure during fetal development. Robust follow-up studies suggest that marijuana use during pregnancy contributes to suboptimal fetal growth. At school age, heavy prenatal marijuana exposure predicts challenges in executive function (specifically, memory and reasoning) and externalizing behavior (e.g., hyperactivity and inattention). Memory and behavioral problems persist into early adulthood. These challenges coincide with a higher risk of heavy marijuana use in offspring. In concert with a suboptimal environment, young adults may experience a higher risk of global cognitive impairment and/or delinquency. Importantly, these adverse outcomes appear to be mitigated by postnatal factors including home environment. Ongoing studies in the modern era will be vital to enhance our understanding of the mechanisms by which THC impacts the fetus and confirm or refute knowledge regarding long-term impact. This knowledge will inform both health care providers and parents in collaborative decision-making to optimize the outcome of children.

Cannabis use, cannabis use disorder and mental health disorders among pregnant and postpartum women in the US: A nationally representative study

BACKGROUND

Cannabis use and cannabis use disorder (CUD) are associated with mental health disorders, however the extent of this matter among pregnant and recently postpartum (e.g., new moms) women in the US is unknown. Associations between cannabis use, DSM-5 CUD and DSM-5 mental health disorders (mood, anxiety, personality and post-traumatic stress disorders) were examined among a nationally representative sample of pregnant and postpartum women.

METHODS

The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III was used to examine associations between past-year cannabis use, CUD and mental health disorders. Weighted logistic regression models were used to estimate unadjusted and adjusted odds ratios (aORs). The sample (N=1316) included 414 pregnant and 902 postpartum women (pregnant in the past year), aged 18-44 years old.

RESULTS

The prevalence of past-year cannabis use and CUD was 9.8% and 3.2%, respectively. The odds of cannabis use (aORs range 2.10-3.87, p-values<0.01) and CUD (aORs range 2.55-10.44, p-values< 0.01) were higher among women with versus without any past-year mood, anxiety or posttraumatic stress disorders or any lifetime personality disorder. aORs for the association of cannabis use with specific mood, anxiety or personality disorders ranged from 1.95 to 6.00 (p-values<0.05). aORs for the association of CUD with specific mood, anxiety or personality disorders ranged from 2.36 to 11.60 (p-values<0.05).

CONCLUSIONS

From pregnancy up to one year postpartum is a critical period where women may be particularly vulnerable to mental health disorders, cannabis use and CUD. Treatment and prevention are essential.

Cannabis for morning sickness: areas for intervention to decrease cannabis consumption during pregnancy

BACKGROUND

Cannabis use during pregnancy is increasing, with 19-22% of patients testing positive at delivery in Colorado and California. Patients report using cannabis to alleviate their nausea and vomiting, anxiety, and pain. However, preclinical and clinical data highlight harmful effects to offspring physiology and behavior following fetal cannabis exposure. This narrative review identifies potential areas for intervention to decrease cannabis consumption during pregnancy.

METHODS

A combination of keywords, including "cannabis", "cannabis", "weed", "pregnancy", "morning sickness", "child protective services", and "budtender" were searched in databases such as PubMed and Google Scholar, as well as in social media forums, governmental webpages, and other publicly available sources.

RESULTS

The literature search identified several areas for intervention to reduce cannabis use during pregnancy, including physician and pharmacist training, engagement with pregnant patients, regulation of dispensary workers, and the role of child protective services.

DISCUSSION

This comprehensive review identifies multiple areas for improvement to benefit pregnant patients. Recommendations are independent and can be implemented simultaneously by the identified groups. Limitations of this research includes the relatively limited availability of data focused specifically on cannabis consumption during pregnancy and the complexity of the sociopolitical field of substance use during pregnancy.

CONCLUSIONS

Cannabis consumption during pregnancy is increasing and causes harm to the developing fetus. To educate pregnant patients about these risks, we must address the gaps in education from multiple contact points.

The impact of timing of in utero marijuana exposure on fetal growth

Objective

To examine whether timing of in utero marijuana exposure independently and negatively impacts fetal growth, and if these effects are global or specific to certain growth parameters.

Study design

The two study groups were marijuana users (N = 109) and a randomly selected control group of biochemically verified non-users (n = 171). Study data were obtained via manual abstraction of electronic medical records.

Results

After control for significant confounders, regression results indicated significant (p < .05) decrease in newborn weight following first trimester marijuana exposure only (-154 g) and following marijuana exposure throughout gestation (-185 g) compared to controls. There were also significant deficits in head circumference following marijuana exposure in the first and second trimester only (-.83 cm) and marijuana exposure throughout pregnancy (-.79 cm) compared to controls. Newborn length was not significantly predicted by marijuana exposure.

Conclusions

Timing of marijuana exposure appears to play a key role in specific fetal growth deficits, with exposure throughout gestation most detrimental. However even first trimester exposure may result in decreased weight. Timing and amount of use could be confounded in this study as those who quit early in pregnancy may have been lighter users than those who continued throughout pregnancy. More research is clearly needed to better understand the role of amount and timing of in utero marijuana exposure in predicting different aspects of fetal growth, however, this study suggests that women should be encouraged to avoid marijuana use at any point in pregnancy.

Cannabinoids and the placenta: Receptors, signaling and outcomes

Cannabis use during pregnancy is increasing. The improvement of pregnancy-related symptoms including morning sickness and management of mood and stress are among the most reported reasons for its use. Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) are the most abundant cannabinoids found within the cannabis flower. The concentration of these components has drastically increased in the past 20 years. Additionally, many edibles contain only one cannabinoid and are marketed to achieve a specific goal, meaning there are an increasing number of pregnancies that are exposed to isolated cannabinoids. Both Δ9-THC and CBD cross the placenta and can impact the fetus directly, but the receptors through which cannabinoids act are also expressed throughout the placenta, suggesting that the effects of in-utero cannabinoid exposure may include indirect effects from the placenta. In-utero cannabis research focuses on short and long-term fetal health and development; however, these studies include little to no placenta analysis. Prenatal cannabinoid exposure is linked to small for gestational age and fetal growth-restricted babies. Compromised placental development is also associated with fetal growth restriction and the few studies (clinical and animal models) that included placental analysis, identify changes in placental vasculature and function in these cannabinoid-exposed pregnancies. In vitro studies further support cannabinoid impact on cell function in the different populations that comprise the placenta. In this article, we aim to summarize how phytocannabinoids can impact placental development and function. Specifically, the cannabinoids and their actions at the different receptors are described, with receptor localization throughout the human and murine placenta discussed. Findings from studies that included placental analysis and how cannabinoid signaling may modulate critical developmental processing including cell proliferation, angiogenesis and migration are described. Considering the current research, prenatal cannabinoid exposure may significantly impact placental development, and, as such, identifying windows of placental vulnerability for each cannabinoid will be critical to elucidate the etiology of fetal outcome studies.

Influence of prenatal cannabinoid exposure on early development and beyond

Public perception surrounding whether cannabis use is harmful during pregnancy often diverges greatly from the recommendations of doctors and healthcare providers. In contrast to the medical guidance of abstinence before, during, and after pregnancy, many women of reproductive age believe cannabis use during pregnancy is associated with little potential harm. Legalization and social cues support public perceptions that cannabis use during pregnancy is safe. Moreover, pregnant women may consider cannabis to be a safe alternative for treating pregnancy related ailments, including morning sickness. Compounding the problem is a lack of medical and federal guidance on safe, low, or high-risk levels of cannabis use. These issues mirror the continuing debate surrounding alcohol use and health, in particular, whether there are safe or lower risk levels of alcohol consumption during pregnancy. Clinical studies to date suffer from several limitations. First, most human studies are correlative in nature, meaning that causal associations cannot be made between in utero cannabis exposure and health and behavioral outcomes later in life. Due to obvious ethical constraints, it is not possible to randomly assign pregnant mothers to cannabis or other drug exposure conditions-a requirement needed to establish causality. In addition, clinical studies often lack quantitative information on maternal exposure (i.e., dose, frequency, and duration), include a small number of individuals, lack replication of outcome measures across cohorts, rely on self-report to establish maternal drug use, and suffer from unmeasured or residual confounding factors. Causal associations between maternal cannabis exposure and offspring outcomes are possible in preclinical cohorts but there is a large amount of heterogeneity across study designs and developmental differences between rodents and humans may limit translatability. In this review, we summarize research from human and preclinical models to provide insight into potential risks associated with prenatal cannabinoid exposure (PCE). Finally, we highlight gaps in knowledge likely to contribute to the growing divide between medical guidance and public attitudes regarding cannabis use during pregnancy.

Differences in cannabis use characteristics, routines, and reasons for use among individuals with and without a medical cannabis card

As recreational and medical cannabis use increases in the U.S., the proliferation of novel cannabis products is expected to continue. Understanding cannabis product preferences and use patterns may inform public health and policy decisions. This study investigated similarities and differences in cannabis use patterns, product preferences, and beliefs about cannabis' subjective effects and therapeutic benefits among individuals with and without a medical cannabis card (MCC). Participants with an MCC completed individual interviews (N = 25; 40% male). Participants without an MCC completed focus groups (N = 31; 6-7 participants/group; 72% male). All sessions followed a semistructured agenda. Participants were queried about their use routines, reasons for using cannabis, and perceptions and experiences of subjective cannabis effects. Thematic analysis of coded transcripts revealed that MCC participants had structured, daily cannabis use routines whereas non-MCC participants' use routines were less structured. Product information including strain and cannabinoid composition were important to MCC participants whereas non-MCC participants primarily evaluated quality based on perceptual (e.g., olfactory) cues. Regardless of MCC status, participants reported misconceptions about cannabis' therapeutic benefits and agreed that the two primary cannabis strains-Indica and Sativa-produced primarily sedative and stimulant effects, respectively. Results have clinical, public health, and policy implications surrounding cannabis recommendation guidelines and ways providers can relay accurate information to patients seeking medical cannabis. Future research assessing demographic and geographic differences in cannabis product preferences and beliefs about medical cannabis use is warranted. Further, quantitative research is needed to evaluate whether cannabis' therapeutic value differs across products. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The ethics and management of cannabis use in pregnancy following decriminalisation and licensing for medical use: narrative review

AIMS AND METHOD

As drug policies pertaining to cannabis use become more liberalised, the prevalence of cannabis use in pregnancy could increase. However, there is limited guidance available for clinicians. This paper presents a narrative review of literature published in the past 16 years (2006-2021) to (a) address the impact of legalisation and decriminalisation on the risks, ethics and support of women who use cannabis during pregnancy and (b) develop guidance for clinicians.

RESULTS

Both national and international trends suggest increased use of cannabis over the past decade, while the risks of cannabis use for recreational or medicinal purposes in pregnancy remain unmitigated.

CLINICAL IMPLICATIONS

This review confirmed that the recommendation of cannabinoid-based products for pregnant and breast-feeding women is currently premature. More research is needed to address safety concerns. We discussed navigating ethical concerns and suggest targeted management strategies for clinicians treating pregnant women who choose to use cannabis.

Sex-specific susceptibility to psychotic-like states provoked by prenatal THC exposure: Reversal by pregnenolone

Sociocultural attitudes towards cannabis legalization contribute to the common misconception that it is a relatively safe drug and its use during pregnancy poses no risk to the fetus. However, longitudinal studies demonstrate that maternal cannabis exposure results in adverse outcomes in the offspring, with a heightened risk for developing psychopathology. One of the most reported psychiatric outcomes is the proneness to psychotic-like experiences during childhood. How exposure to cannabis during gestation increases psychosis susceptibility in children and adolescents remains elusive. Preclinical research has indicated that in utero exposure to the major psychoactive component of cannabis, delta-9-tetrahydrocannabinol (THC), deranges brain developmental trajectories towards vulnerable psychotic-like endophenotypes later in life. Here, we present how prenatal THC exposure (PCE) deregulates mesolimbic dopamine development predisposing the offspring to schizophrenia-relevant phenotypes, exclusively when exposed to environmental challenges, such as stress or THC. Detrimental effects of PCE are sex-specific because female offspring do not display psychotic-like outcomes upon exposure to these challenges. Moreover, we present how pregnenolone, a neurosteroid that showed beneficial properties on the effects elicited by cannabis intoxication, normalizes mesolimbic dopamine function and rescues psychotic-like phenotypes. We, therefore, suggest this neurosteroid as a safe "disease-modifying" aid to prevent the onset of psychoses in vulnerable individuals. Our findings corroborate clinical evidence and highlight the relevance of early diagnostic screening and preventative strategies for young individuals at risk for mental diseases, such as male PCE offspring.

Impact of prenatal cannabis exposure on functional connectivity of the salience network in children

Cannabis use among pregnant people has increased over the past decade. This is of concern as prenatal cannabis exposure (PCE) is associated with cognitive, motor, and social deficits among offspring. Here, we examined resting-state functional connectivity (rsFC) of the salience network (SN)-a core neurocognitive network that integrates emotional and sensory information-in children with (vs. without) PCE. Using neuroimaging and developmental history data collected from 10,719 children (M ± SD = 9.92 ± 0.62 years; 47.9% female) from the Adolescent Brain Cognitive Development study, we assessed the impact of parent-reported PCE (before or after knowledge of pregnancy) on rsFC within and between the SN and five other core neurocognitive networks. We also evaluated whether SN rsFC mediated the association between PCE and child psychopathology. Results showed that PCE before (but not after) knowledge of pregnancy was associated with lower SN-ventral attention network (VAN) rsFC. Furthermore, psychotic-like experiences mediated the association between PCE and SN-VAN rsFC, and reversal of the model was also significant, such that SN-VAN rsFC mediated the association between PCE and psychotic-like symptoms. However, these mediation effects were no longer significant after the inclusion of covariates. Taken together, these findings suggest that developmental alterations in SN-VAN interactions may explain the previously reported association between PCE and elevated risk of child psychopathology.

The evolving culture of medical cannabis in Canada for the management of chronic pain

Although used therapeutically for millennia, cannabis has been a prohibited substance worldwide for most of the 20th Century. With revision of prohibitive regulations in many jurisdictions during the past 2 decades, cannabis is increasingly available to patients as a potential treatment option for various symptoms. Pain relief, sleep promotion and alleviation of distress, depression and anxiety are the most common reasons for cannabis use. Canada has been at the forefront of medical cannabis (MC) legislation revisions to enable and facilitate access for therapeutic use. Although initially viewed with caution and stigma, attitudes to cannabis in general have changed. Medical cannabis is identified as the herbal plant product sourced from a grower/producer and is not at present a regulated pharmaceutical product. Medical cannabis use is currently prevalent in Canada but has bypassed the rigorous study required for usual drug approval. Although uptake has been enthusiastic by patients, the medical community has voiced cautions and concerns. Access to medical cannabis is fairly easy once an approval document is obtained from a healthcare professional, but without obligation for medical or pharmacy oversight. The greatest concern is a dearth of sound clinical evidence for effects and harms. Emerging concerns include prevalent patient self-management with information based on personal research, an abundance of on-line information which may not always be accurate, the emergence of designated "cannabis clinics," potential risks to society due to accidents, and high cost of the legal medical product leading to access via the recreational market. With cannabis now entrenched in Canadian healthcare, physicians must be sufficiently knowledgeable to provide guidance that is evidence-based and will ensure personal and societal harm reduction. Examination of the changing culture of medical cannabis in Canada will provide insight for countries that may be anticipating similar revisions of cannabis regulations to allow cannabis access for their patient population and learn from the issues created by recreational legalization.

Impact of Cannabis Legalization on Adolescent Cannabis Use

Because of substantial limitations in available national data, such as inconsistencies among surveys and small sample sizes, the increased prevalence of cannabis use among adolescents since recreational legalization has not been directly observed. Nevertheless, both usage frequency and product potency have significantly increased, alongside alternative routes of delivery to smoking, such as vaping cannabis. Moreover, certain populations may be especially vulnerable to the effects of legalization. Regardless of differing state-level cannabis legalization status, the adverse consequences of cannabis on youth have clear negative impacts on mental health, medical symptoms, educational outcomes, and increased risk of addiction to other substances.

The impact of in utero cannabis exposure on fetal growth

BACKGROUND

The goal of this study was to examine if in utero cannabis exposure predicted reduced birth size and if these effects were evident in specific growth parameters as early as the second trimester.

METHODS

Eligible women had an initial prenatal visit between January 1, 2010, and March 31, 2020, completed an anatomy ultrasound between 18-24 weeks' gestation, and had no self-reported alcohol, tobacco, or other biochemically verified drug use. The two primary study groups were cannabis users (n = 109) identified through self-report and urine toxicology screens, and a randomly selected control group of non-substance users (n = 171). Medical records were manually reviewed for background and medical information, anatomy ultrasound results, and birth size parameters.

RESULTS

After controlling for significant confounders, regression results indicated significant (p < .05) deficits in birth weight associated with cannabis exposure, with a trend for increasing weight effects beginning in the second trimester. A significant decrease in head circumference was evident as early as the second trimester, with differences remaining significant until birth. Significant overall length and specific bone length deficits were not predicted by cannabis exposure, at birth or earlier in gestation, after control for confounding.

CONCLUSIONS

Cannabis exposure predicted growth deficits at birth, with some effects evident as early as the second trimester. The biggest and earliest effects were seen for cranial size, with an adjusted deficit of more than 14 percentile points by birth. Overall weight was not impacted until at or near delivery.

Early pregnancy confirmation availability at crisis pregnancy centers and abortion facilities in the United States

OBJECTIVES

Crisis pregnancy centers (CPCs) seek to dissuade people from having abortions. Twenty-five states have policies supporting CPCs. We aimed: (1) to characterize access to early pregnancy confirmation at CPCs compared to abortion facilities nationwide and (2) to understand the role of state CPC policy in service access.

STUDY DESIGN

We conducted a national mystery caller study of 445 CPCs and geographically paired abortion facilities, posing as patients seeking pregnancy confirmation. Facility type (CPC vs abortion facility) was the primary exposure in Aim 1. Wait time to first available early pregnancy appointment was the primary outcome. In Aim 2, state-level CPC policy designation (supportive vs not supportive of CPCs) was the primary exposure. Difference in wait time ≥7 days to first available appointment between CPCs and paired abortion facilities was the primary outcome.

RESULTS

CPCs were more likely than abortion facilities to provide same-day appointments (68.5% vs 37.2%, p < 0.0001), and free pregnancy testing (98.0% vs 16.6%, p < 0.0001). The median wait to first available appointment at a CPC was 0 days (IQR 0,1), compared to 1 day at abortion facilities (IQR 0, 5), p < 0.0001. In states with supportive CPC policy environments, abortion facilities were less likely to have wait times exceeding their paired CPC by a week or more, compared to paired facilities in states with non-supportive CPC policy environments (p = 0.033). This remained true after adjusting for state abortion policy environment (p = 0.011).

CONCLUSIONS

Pregnancy confirmation is more accessible at CPCs compared to abortion facilities. Factors other than state-level CPC policies likely influence service accessibility. There is a need for improved access to pregnancy confirmation in medical settings.

IMPLICATIONS

Our findings demonstrating that pregnancy confirmation is more accessible at crisis pregnancy centers than at abortion facilities are predicted to be exacerbated in the wake of abortion clinic closures following the Dobbs v Jackson Women's Health Organization Supreme Court decision. This highlights the need for improved funding and support for pregnancy confirmation service delivery in medical settings, including abortion facilities.

Perceptions About Cannabis Following Legalization Among Pregnant Individuals With Prenatal Cannabis Use in California

IMPORTANCE

As rates of prenatal cannabis use increase and cannabis legalization spreads across the US, studies are needed to understand the potential impacts of legalization from the perspectives of pregnant individuals who use cannabis.

OBJECTIVE

To characterize pregnant individuals' perspectives on legalization of cannabis for adult use in California (effective in 2018) in relation to prenatal cannabis use behaviors and beliefs.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was conducted in Kaiser Permanente Northern California, a large health care system with universal screening for self-reported cannabis use at entrance to prenatal care. Eighteen semistructured focus groups were conducted from November 17 to December 17, 2021, using a secure video conferencing platform with Black and White pregnant participants who self-reported cannabis use during early pregnancy. Data were analyzed from March to June 2022.

MAIN OUTCOMES AND MEASURES

Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes.

RESULTS

Among 53 participants (mean [SD] age, 30.3 [5.2] years), 23 (43%) identified as non-Hispanic Black and 30 (57%) identified as non-Hispanic White; 16 participants (30%) reported continued cannabis use at the time of recruitment. Major themes regarding the perceived impact of legalization included easier access (via retailers and delivery), greater acceptance (including reduced stigma and more discussions about prenatal cannabis use with health care practitioners), and trust in cannabis retailers (including safety and effectiveness of diverse products sold and perceptions of cannabis retailer employees as knowledgeable, nonjudgmental, and caring). Responses were mixed about whether retailer marketing and advertising were associated with prenatal cannabis use and whether legalization resulted in reduced concerns about Child Protective Services involvement.

CONCLUSION AND RELEVANCE

The findings of this qualitative study suggest pregnant individuals perceive cannabis legalization as having reduced barriers to prenatal cannabis use and that legalization has created challenges and opportunities for supporting the health of pregnant individuals. The results of this qualitative study highlight key areas that can be further explored in future educational materials, public health campaigns, and policy adaptations to address increasing rates of prenatal cannabis use.

Chronic prenatal delta-9-tetrahydrocannabinol exposure adversely impacts placental function and development in a rhesus macaque model

Cannabis use in pregnancy is associated with adverse perinatal outcomes, which are likely mediated by the placenta. However, the underlying mechanisms and specific vasoactive effects of cannabis on the placenta are unknown. Our objective was to determine the impact of chronic prenatal delta-tetrahydrocannabinol (THC, main psychoactive component of cannabis) exposure on placental function and development in a rhesus macaque model using advanced imaging. Animals were divided into two groups, control (CON, n = 5) and THC-exposed (THC, n = 5). THC-exposed animals received a THC edible daily pre-conception and throughout pregnancy. Animals underwent serial ultrasound and MRI at gestational days 85 (G85), G110, G135 and G155 (full term is ~ G168). Animals underwent cesarean delivery and placental collection at G155 for histologic and RNA-Seq analysis. THC-exposed pregnancies had significantly decreased amniotic fluid volume (p < 0.001), placental perfusion (p < 0.05), and fetal oxygen availability (p < 0.05), all indicators of placental insufficiency. Placental histological analysis demonstrated evidence of ischemic injury with microinfarctions present in THC-exposed animals only. Bulk RNA-seq demonstrated that THC alters the placental transcriptome and pathway analysis suggests dysregulated vasculature development and angiogenesis pathways. The longer-term consequences of these adverse placental findings are unknown, but they suggest that use of THC during pregnancy may deleteriously impact offspring development.

State Trends of Cannabis Liberalization as a Causal Driver of Increasing Testicular Cancer Rates across the USA

BACKGROUND

The cause of the worldwide doubling-tripling of testicular cancer rates (TCRs) in recent decades is unknown. Previous cohort studies associated cannabis use with TCR including dose-response relationships but the contribution of cannabis to TCRs at the population level is unknown. This relationship was tested by analyzing annual trends across US states and formally assessed causality. Four US datasets were linked at state level: age-adjusted TCRs from Centers for Disease Control Surveillance Epidemiology and End Results database; drug use data from annual National Survey of Drug Use and Health including 74.1% response rate; ethnicity and median household income data from the US Census Bureau; and cannabinoid concentration data from Drug Enforcement Agency reports. Data was processed in R in spatiotemporal and causal inference protocols.

RESULTS

Cannabis-use quintile scatterplot-time and boxplots closely paralleled those for TCRs. The highest cannabis-use quintile had a higher TCR than others (3.44 ± 0.05 vs. 2.91 ± 0.2, mean ± S.E.M., t = 10.68, p = 1.29 × 10-22). A dose-response relationship was seen between TCR and Δ9-tetrahydrocannabinol (THC), cannabinol, cannabigerol, and cannabichromene (6.75 × 10-9 < p < 1.83 × 10-142). In a multivariate inverse probability-weighted interactive regression including race and ethnic cannabis exposure (ECE), ECE was significantly related to TCR (β-estimate = 0.89 (95%C.I. 0.36, 2.67), p < 2.2 × 10-16). In an additive geospatiotemporal model controlling for other drugs, cannabis alone was significant (β-estimate = 0.19 (0.10, 0.28), p = 3.4 × 10-5). In a full geospatial model including drugs, income and ethnicity cannabinoid exposure was significant (cannabigerol: β-estimate = 1.39 (0.024, 2.53), p = 0.0017); a pattern repeated at two spatial and two temporal lags (cannabigerol: β-estimate = 0.71 (0.05, 1.37), p = 0.0.0350; THC: β-estimate = 23.60 (11.92, 35.29), p = 7.5 × 10-5). 40/41 e-Values > 1.25 ranged up to 1.4 × 1063 and 10 > 1000 fitting causal relationship criteria. Cannabis liberalization was associated with higher TCRs (ChiSqu. = 312.2, p = 2.64 × 10-11). Rates of TC in cannabis-legal states were elevated (3.36 ± 0.09 vs. 3.01 ± 0.03, t = 4.69, p = 4.86 × 10-5).

CONCLUSIONS

Cannabis use is closely and causally associated with TCRs across both time and space and higher in States with liberal cannabis legislation. Strong dose-response effects were demonstrated for THC, cannabigerol, cannabinol, cannabichromene and cannabidiol. Cannabinoid genotoxicity replicates all major steps to testicular carcinogenesis including whole-genome doubling, chromosomal arm excision, generalized DNA demethylation and chromosomal translocations thereby accelerating the pathway to testicular carcinogenesis by several decades.