Effects of prenatal marijuana exposure on neuropsychological outcomes in children aged 1-11 years: A systematic review

Systematic Review and Meta-analysis of the Relationship Between Exposure to Parental Substance Use and Attention-Deficit/Hyperactivity Disorder in Children

Attention-deficit/hyperactivity disorder (ADHD) is characterized by persistent patterns of inattention, hyperactivity, and impulsiveness. Among US children and adolescents aged 3-17 years, 9.4% have a diagnosis of ADHD. Previous research suggests possible links between parental substance use and ADHD among children. We conducted a systematic review and meta-analysis of 86 longitudinal or retrospective studies of prenatal or postnatal alcohol, tobacco, or other parental substance use and substance use disorders and childhood ADHD and its related behavioral dimensions of inattention and hyperactivity-impulsivity. Meta-analyses were grouped by drug class and pre- and postnatal periods with combined sample sizes ranging from 789 to 135,732. Prenatal exposure to alcohol or tobacco and parent substance use disorders were consistently and significantly associated with ADHD among children. Other parental drug use exposures resulted in inconsistent or non-significant findings. Prevention and treatment of parental substance use may have potential for impacts on childhood ADHD.

Exploration of Differences between Women Who Do and Do Not Disclose Their Marijuana Use during Pregnancy

OBJECTIVE

 This study aimed to explore demographic and health-related factors that may differentiate women who do and do not disclose their marijuana use during pregnancy.

STUDY DESIGN

 The current study is a secondary analysis of data from a prospective cohort of pregnant women identified as using marijuana during pregnancy via a variety of assessment tools including self-report, urine screen, and obstetrics record abstraction. The cohort included a convenience sample of women recruited from several antenatal clinics at The Ohio State University Wexner Medical Center (OSUWMC). To be eligible, women needed to be within the first or second trimester of their pregnancy, 16 to 50 years of age, able to communicate in English, and intended to deliver at OSUWMC. Chi-square, independent samples t-tests, and logistic regression analyses were used to explore differences between those who did and did not disclose their use in relation to physical and mental health diagnoses, adverse experiences, use of other substances, and demographics.

RESULTS

 Women who used marijuana during their pregnancy and had mental/physical health data available comprised the current sample (n = 109). Women who attended college were more likely to disclose their marijuana use compared with women who did not attend college (p < 0.001). Women who experienced homelessness (p < 0.01) or self-reported alcohol use during pregnancy (p < 0.001) were significantly more likely to disclose their marijuana use.

CONCLUSION

 Findings, suggesting disclosure of other substance use and adverse experiences, such as homelessness, may increase the likelihood that pregnant women will voluntarily disclose their marijuana use to providers. Findings did not reflect racial differences nor significant differences in mental/physical health status among women based on their disclosure. Future research with larger datasets is needed to build on these findings by confirming results, as well as exploring additional factors, that may more effectively differentiate women who are unlikely to disclose their prenatal marijuana use from those who do disclose their use.

KEY POINTS

· Women with higher education were more likely to self-disclose their prenatal marijuana use.. · Women who experienced homelessness were more likely to self-disclose their prenatal marijuana use.. · Self-disclosure of prenatal alcohol use was related to self-disclosure of prenatal marijuana use.

Intentions to Use Cannabis Postpartum: A Qualitative Study of Pregnant Individuals Who Used Cannabis During Early Pregnancy

Objective: To examine plans for postpartum cannabis use among pregnant individuals who used cannabis during early pregnancy. Materials and Methods: Eighteen virtual focus groups were conducted from November 17, 2021, to December 17, 2021, with 23 Black and 30 White pregnant adults in Kaiser Permanente Northern California, who self-reported prenatal cannabis use during early pregnancy. Focus groups were recorded, transcribed, and analyzed using thematic analysis. Results: The sample (N = 53) had a mean age of 30.3 years (standard deviation = 5.2) at recruitment; 70% reported daily, 25% weekly, and 6% ≤ monthly cannabis use at entrance to prenatal care. Some participants viewed cannabis as critical for coping with postpartum mental and physical health challenges, while others questioned whether cannabis use would fit with their parental lifestyle, and some planned to abstain altogether. Most planned to use cannabis postpartum, but with lower frequency than before pregnancy, and in ways consistent with harm reduction (e.g., smoking outside to avoid secondhand or thirdhand smoke exposure). Many were motivated to abstain from cannabis while breastfeeding, and some desired more data on the safety of cannabis and breastfeeding, or intended to "pump and dump," believing it would reduce potential transfer of Δ9-tetrahydrocannabinol (THC) to their infant. Responses from Black and White participants were generally similar, but White participants were more likely to report plans to use cannabis while breastfeeding and to want information about cannabis and breastfeeding. Conclusions: Pregnant individuals with prenatal cannabis use had varied plans for cannabis use postpartum. Many were motivated to abstain or use cannabis less frequently than pre-pregnancy, especially during lactation.

Exploring the associations between serious psychological distress and the quantity or frequency of tobacco, alcohol, and cannabis use among pregnant women in the United States

Serious Psychological Distress (SPD) and prenatal exposure to substances are associated with adverse outcomes for pregnant individuals and their developing offspring. This study aims to examine the relationship between SPD and quantity, or frequency of substance use among pregnant women in the United States (US). Descriptive and negative binomial regression analyses of the 2015-2019 National Survey on Drug Use and Health (NSDUH) were conducted among 3373 pregnant women (18 to 44 years old) to examine the association between SPD and (1) average number of cigarettes smoked in the past 30 days, (2) number of days of binge drinking in the past 30 days, and (3) number of days of cannabis use in the past 30 days. About 6% of the study population experienced SPD in the past 30 days. Compared to pregnant women who did not report SPD, pregnant women experiencing SPD showed greater rates in the number of cigarettes smoked during the past 30 days (IRR = 2.1, 95%CI = 1.1, 4.5), the number of days of binge drinking in the past 30 days (IRR = 5.1, 95%CI = 1.7, 15.4), and the number of days of cannabis use in the past 30 days (IRR = 2.9, 95%CI = 1.3, 6.5). Our results extend findings from prior research by documenting an association between SPD and the quantity and frequency of substance use among pregnant women in the US. Individual and structural interventions addressing SPD and/or substance might help reduce the impact of these comorbid conditions on expectant parents and their offspring.

Exploring preferences for different modes of cannabis use during early pregnancy: A qualitative study

OBJECTIVE

Rates of prenatal cannabis use are rising, yet little is known about modes of cannabis use during pregnancy. This focus group study with pregnant individuals aimed to examine use patterns and perceptions regarding common modes of prenatal cannabis use.

METHOD

Kaiser Permanente Northern California pregnant adult patients who identified as White or Black and self-reported cannabis use during pregnancy were recruited to participate (N = 53; 40% Black, 60% White; Meanage = 30.3, SD = 5.2). Eighteen focus groups with race-concordant facilitators followed a semi-structured format that queried participants on their prenatal cannabis use, including preferred modes of use (e.g., vapes, blunts, dabs, joints, edibles, topicals, pipes). Focus group discussions were coded and analyzed using a general inductive approach.

RESULTS

A range of modes were preferred, with no single mode predominant. Participants' preferences aligned with four themes: perceived effects and benefits of cannabis, health and safety, convenience and familiarity, and partner and friend influences. Participants sought modes that were accessible and familiar, provided consistent and quick relief for pregnancy-related symptoms, were aligned with partners or friends, and minimized perceived risks while also providing symptom relief. Participants desired evidence-based information about mode safety to better inform mode selection during pregnancy.

CONCLUSIONS

A range of personal and social factors influenced mode preferences during pregnancy. Many participants desired to reduce harms and use cannabis more safely in pregnancy but received little mode-specific information to guide these preferences. Further research identifying mode-specific risks is needed to guide harm reduction approaches during pregnancy.

Repeated Exposure to High-THC Cannabis Smoke during Gestation Alters Sex Ratio, Behavior, and Amygdala Gene Expression of Sprague Dawley Rat Offspring

Because of the legalization of Cannabis in many jurisdictions and the trend of increasing Δ9-tetrahydrocannabinol (THC) content in Cannabis products, an urgent need exists to understand the impact of Cannabis use during pregnancy on fetal neurodevelopment and behavior. To this end, we exposed female Sprague Dawley rats to Cannabis smoke daily from gestational day 6 to 20 or room air. Maternal reproductive parameters, offspring behavior, and gene expression in the offspring amygdala were assessed. Body temperature was decreased in dams following smoke exposure and more fecal boli were observed in the chambers before and after smoke exposure in dams exposed to smoke. Maternal weight gain, food intake, gestational length, litter number, and litter weight were not altered by exposure to Cannabis smoke. A significant increase in the male-to-female ratio was noted in the Cannabis-exposed litters. In adulthood, male and female Cannabis smoke-exposed offspring explored the inner zone of an open field significantly less than control offspring. Gestational Cannabis smoke exposure did not affect behavior on the elevated plus maze test or social interaction test in the offspring. Cannabis offspring were better at visual pairwise discrimination and reversal learning tasks conducted in touchscreen-equipped operant conditioning chambers. Analysis of gene expression in the adult amygdala using RNA sequencing revealed subtle changes in genes related to development, cellular function, and nervous system disease in a subset of the male offspring. These results demonstrate that repeated exposure to high-THC Cannabis smoke during gestation alters maternal physiological parameters, sex ratio, and anxiety-like behaviors in the adulthood offspring.

Neurodevelopmental outcomes in children after prenatal marijuana exposure

BACKGROUND

The effect of prenatal marijuana exposure (PME) on child neurodevelopment remains poorly understood. Prior studies have demonstrated inconsistent results.

OBJECTIVES

This study evaluated the association between PME and neuropsychological test scores in late childhood and early adulthood, accounting for a wide range of parental characteristics.

METHODS

This study evaluated participants from the Raine Study, a cohort of 2868 children born between 1989 and 1992. Children whose mothers provided information on marijuana use during pregnancy were included. The primary outcome was the Clinical Evaluation of Language Fundamentals (CELF) at age 10. Secondary outcomes included the Peabody Picture Vocabulary Test (PPVT), Child Behaviour Checklist (CBCL), McCarron Assessment of Neuromuscular Development (MAND), Coloured Progressive Matrices (CPM), Symbol Digit Modality Test (SDMT) and Autism Spectrum Quotient (AQ) scores. Exposed and unexposed children were matched by propensity score using optimal full matching. Missing covariate data were imputed using multiple imputation. Inverse probability of censoring weighting (IPCW) was used to adjust for missing outcome data. Linear regression within matched sets, adjusted by IPCW, evaluated score differences between exposed and unexposed children. As a secondary analysis, modified Poisson regression, adjusted by match weights and IPCW, evaluated the risk of clinical deficit in each outcome following PME.

RESULTS

Of the 2804 children in this cohort, 285 (10.2%) had PME. After optimal full matching and IPCW, exposed children scored similarly on CELF Total (-0.33 points, 95% confidence interval [CI] -4.71, 4.05), Receptive (+0.65 points, 95% CI -4.08, 5.38) or Expressive (-0.53 points, 95% CI -5.07, 4.02). PME was not associated with secondary outcomes or risks of clinical deficit in any neuropsychological assessments.

CONCLUSIONS

After adjusting for sociodemographic and clinical covariates, PME was not associated with worse neuropsychological test scores at age 10 or autistic traits at 19-20.

Prenatal alcohol and tetrahydrocannabinol exposure: Effects on spatial and working memory

Introduction

Alcohol and cannabis are widely used recreational drugs that can negatively impact fetal development, leading to cognitive impairments. However, these drugs may be used simultaneously and the effects of combined exposure during the prenatal period are not well understood. Thus, this study used an animal model to investigate the effects of prenatal exposure to ethanol (EtOH), Δ-9-tetrahydrocannabinol (THC), or the combination on spatial and working memory.

Methods

Pregnant Sprague-Dawley rats were exposed to vaporized ethanol (EtOH; 68 ml/h), THC (100 mg/ml), the combination, or vehicle control during gestational days 5-20. Adolescent male and female offspring were evaluated using the Morris water maze task to assess spatial and working memory.

Results

Prenatal THC exposure impaired spatial learning and memory in female offspring, whereas prenatal EtOH exposure impaired working memory. The combination of THC and EtOH did not exacerbate the effects of either EtOH or THC, although subjects exposed to the combination were less thigmotaxic, which might represent an increase in risk-taking behavior.

Discussion

Our results highlight the differential effects of prenatal exposure to THC and EtOH on cognitive and emotional development, with substance- and sex-specific patterns. These findings highlight the potential harm of THC and EtOH on fetal development and support public health policies aimed at reducing cannabis and alcohol use during pregnancy.

A systematic review of in utero cannabis exposure and risk for structural birth defects

Introduction

Cannabis use among pregnant women has increased over time. Therefore, there is a great public health need to understand the consequences of in utero cannabis exposure. While several meta-analyses and reviews have summarized the evidence of in utero cannabis exposure on adverse obstetric outcomes (e.g., low birth weight and preterm birth) and long-term offspring development, there has not been a focus on in utero cannabis exposure and risk for structural birth defects.

Methods

We conducted a systematic review using PRISMA guidelines to evaluate the association between in utero cannabis exposure and structural birth defects.

Results

We identified 20 articles to include in our review and focused on interpreting findings from the 12 that adjusted for potential confounders. We report findings by seven organ systems. Within the 12 articles, four reported on cardiac malformations, three reported on central nervous system malformations, one reported on eye malformations, three reported on gastrointestinal malformations, one reported on genitourinary malformations, one reported on musculoskeletal malformations, and two reported on orofacial malformations.

Discussion

Findings on associations between in utero cannabis exposure and birth defects reported in more than two articles were mixed (i.e., findings for cardiac, gastrointestinal, central nervous system malformations). Findings for associations between in utero cannabis exposure and birth defects reported in two articles (i.e., orofacial malformations) or in a single article (eye, genitourinary, and musculoskeletal) suggested that cannabis exposure was not associated with these types of malformations, but strong conclusions cannot be drawn from such sparce research. We review the limitations and gaps in the existing literature and call for more research to rigorously evaluate associations between in utero cannabis exposure and structural birth defects.

Systematic Review Registration

identifier CRD42022308130.

Associations between Prenatal and Postnatal Exposure to Cannabis with Cognition and Behavior at Age 5 Years: The Healthy Start Study

BACKGROUND

Prenatal exposure to cannabis may influence childhood cognition and behavior, but the epidemiologic evidence is mixed. Even less is known about the potential impact of secondhand exposure to cannabis during early childhood.

OBJECTIVE

This study sought to assess whether prenatal and/or postnatal exposure to cannabis was associated with childhood cognition and behavior.

STUDY DESIGN

This sub-study included a convenience sample of 81 mother-child pairs from a Colorado-based cohort. Seven common cannabinoids (including delta 9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD)) and their metabolites were measured in maternal urine collected mid-gestation and child urine collected at age 5 years. Prenatal and postnatal exposure to cannabis was dichotomized as exposed (detection of any cannabinoid) and not exposed. Generalized linear models examined the associations between prenatal or postnatal exposure to cannabis with the NIH Toolbox and Child Behavior Checklist T-scores at age 5 years.

RESULTS

In this study, 7% (n = 6) of the children had prenatal exposure to cannabis and 12% (n = 10) had postnatal exposure to cannabis, with two children experiencing this exposure at both time points. The most common cannabinoid detected in pregnancy was Δ9-THC, whereas the most common cannabinoid detected in childhood was CBD. Postnatal exposure to cannabis was associated with more aggressive behavior (β: 3.2; 95% CI: 0.5, 5.9), attention deficit/hyperactivity problems (β: 8.0; 95% CI: 2.2, 13.7), and oppositional/defiant behaviors (β: 3.2; 95% CI: 0.2, 6.3), as well as less cognitive flexibility (β: -15.6; 95% CI: -30.0, -1.2) and weaker receptive language (β: -9.7; 95% CI: -19.2, -0.3). By contrast, prenatal exposure to cannabis was associated with fewer internalizing behaviors (mean difference: -10.2; 95% CI: -20.3, -0.2) and fewer somatic complaints (mean difference: -5.2, 95% CI: -9.8, -0.6).

CONCLUSIONS

Our study suggests that postnatal exposure to cannabis is associated with more behavioral and cognitive problems among 5-year-old children, independent of prenatal and postnatal exposure to tobacco. The potential risks of cannabis use (including smoking and vaping) during pregnancy and around young children should be more widely communicated to parents.

Association of cannabis use during pregnancy with severe acute respiratory syndrome coronavirus 2 infection: a retrospective cohort study

BACKGROUND AND AIMS

Cannabis use is increasingly common among pregnant individuals and might be a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to test whether prenatal cannabis use is associated with increased risk of SARS-CoV-2 infection during pregnancy.

DESIGN

This is a retrospective cohort study.

SETTING

The study was conducted in California, USA.

PARTICIPANTS

A total of 58 114 pregnancies (with outcomes from 5 March 2020 to 30 September 2021) among 57 287 unique pregnant women aged 14-54 years who were screened for prenatal substance use, enrolled in Kaiser Permanente Northern California (KPNC) (a health-care system) and had not tested positive for COVID-19 prior to pregnancy onset.

MEASUREMENTS

We utilized data from the KPNC electronic health record. Cannabis use status (current, recently quit and non-user) was based on universal screenings during prenatal care (including urine toxicology testing and self-reported use on a self-administered questionnaire). SARS-CoV-2 infection [based on polymerase chain reaction (PCR) tests] was estimated in time-to-event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined differences in (a) SARS-CoV-2 testing rates and (b) SARS-CoV-2 infection rates among those tested.

FINDINGS

We observed 348 810 person-months of follow-up time in our cohort with 41 064 SARS-CoV-2 PCR tests and 6% (n = 2414) of tests being positive. At the start of follow-up, 7% of pregnant individuals had current use, 12% had recently quit and 81% did not use cannabis. Adjusting for covariates, current use was associated with lower rates of SARS-CoV-2 infection [adjusted hazard ratio (aHR) = 0.60, 95% confidence interval (CI) = 0.49-0.74 than non-use. Those who had recently quit did not differ from non-cannabis users in infection rates (aHR = 0.96, 95% CI = 0.86-1.08). Sensitivity analyses among patients who received a SARS-CoV-2 test also found lower odds of infection associated with current versus no cannabis use (aOR = 0.76, CI = 0.61-0.93).

CONCLUSIONS

Current cannabis use appears to be associated with a reduced risk of SARS-CoV-2 infection among pregnant individuals.

Prenatal cannabis use and its impact on offspring neuro-behavioural outcomes: A systematic review

Introduction

Cannabis is a widely used substance in pregnancy, yet there is a paucity of literature addressing the neuro-behavioural consequences for prenatally exposed children. Our systematic review synthesizes currently available data for the impact of prenatal cannabis use on offspring intelligence and cognitive functioning.

Methods

MEDLINE, EMBASE, PsychINFO, CINAHL, and Clinicaltrials.gov were searched. Observational studies comparing prenatal cannabis use to controls were included. Offspring neuro-behavioural outcomes were grouped in prespecified domains of (1) intelligence and (2) cognitive functioning. Random-effect models were performed for meta-analyses when at least three studies reported the same outcome. All others were summarized qualitatively. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework was used to assess evidence certainty.

Results

Of the 1982 reviewed studies (n = 523,107 patients), 28 were included. Significant heterogeneity and cohort redundancy limited meta-analysis. Very low-quality evidence from pooled analyses showed no significant associations between prenatal cannabis exposure and attention [standardized mean difference = -0.27 (95% CI = -0.60 to 0.07)], global intelligence quotient [-0.16 (-0.42 to 0.10)], reading [-0.05 (-0.29 to 0.20)], written comprehension [-0.09 (-0.40 to 0.22)], spelling [-0.04 (-0.26 to 0.17)], and mathematics [-0.01 (-0.15 to 0.13)]. No significant associations were found between prenatal cannabis exposure for all other outcomes. Individual studies reported significant differences between the heavy use groups and non-exposed, although this did not prove to be significant when outcomes were pooled.

Conclusions

The current review did not find a clear association between prenatal cannabis use and offspring neuro-behavioural outcomes. However, evidence was low quality and heterogenous. Further prospective investigation is needed to elucidate any potential association between prenatal cannabis use and long-term neuro-developmental outcomes.

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.

Pregnant individual's lived experience of cannabis use during the COVID-19 pandemic: a qualitative study

Introduction

Quantitative studies indicate that the COVID-19 pandemic has contributed to increased rates of prenatal cannabis use. However, little is known about how the pandemic has impacted cannabis use from the perspective of pregnant individuals themselves. Our objective was to characterize COVID-19-related changes in cannabis use among pregnant individuals who used cannabis during the pandemic.

Methods

We conducted 18 focus groups (from 11/17/2021 to 12/17/2021) with Black and White pregnant individuals aged 18+ who self-reported prenatal cannabis use during universal screening at entrance to prenatal care (at ~8 weeks gestation) in Kaiser Permanente Northern California. Virtual focus groups were transcribed and analyzed using thematic analysis.

Results

The sample of 53 pregnant individuals (23 Black, 30 White) was 30.3  years old (SD = 5.2) on average, and most (70%) self-reported daily versus weekly or monthly prenatal cannabis use. Major themes regarding the impact of the pandemic on cannabis use included increases in use (resulting from depression, anxiety, stress, boredom), and changes in social use (less sharing of smoked cannabis products), modes of use (from smoking to other modes due to respiratory concerns) and source (from storefront retailers to delivery).

Conclusion

Coping with mental health symptoms and stress were identified drivers of perceived pandemic-related increases in prenatal cannabis use in 2021. Pregnant individuals adapted their use in ways consistent with public health recommendations to decrease social contact and reduce or quit smoking to mitigate COVID-19 transmission and harms. Proactive, mental health outreach for pregnant individuals during future pandemic waves may reduce prenatal cannabis use.

Marijuana use and sleep quality during pregnancy

OBJECTIVE

Marijuana use among pregnant women is on the rise in part due to the perception that marijuana may improve problems related to pregnancy such as poor sleep. This study's objective was to examine associations between marijuana use and sleep quality among a sample of women during pregnancy.

MATERIAL AND METHODS

The sample included women seeking prenatal care at The Ohio State University Wexner Medical Center (2010-2015). Intake assessments included medical, demographic, and socioeconomic domains, as well as the Pittsburgh Sleep Quality Index. Marijuana use during pregnancy was determined using urine screens, chart abstraction, and self-report. Women completed standardized questionnaires regarding sleep quality, depressive symptoms, anxiety, stress, and discrimination at enrollment and each subsequent trimester. A linear mixed-effect model was used to assess the relationship between sleep variables and marijuana use adjusted for maternal race, education, household income, age, marital status, depressive symptoms, anxiety, stress, discrimination, and use of tobacco and other substances during pregnancy. Women completed the sleep quality assessments for a total of 294 pregnancies, which comprise the study population.

RESULTS

Among the study sample (n = 294), 93 women used marijuana and 201 women did not use marijuana during their pregnancies. Women who used marijuana (n = 93) were more likely to identify as African-American (73% vs 58%; p = .01), report government health insurance (98% vs 89%; p = .001), use tobacco during pregnancy (66% vs 33%; p < .001), report less household income (70% vs 43% < 10,000 annual household income; p < .001), and be unmarried (69% vs 49%; p < .001) compared to women who did not. Mean sleep quality was similar among women who did (µ = 7.6; SD = 4.0) and did not use marijuana during pregnancy (µ = 7.7; SD = 4.0), and both groups had a mean score worse than the conventional cutoff for poor sleep quality (>5). In fact, both groups reported worse sleep than is typically observed among cohorts reporting poor sleep, which have ranged from 5.3 to 6.3.

CONCLUSIONS

Current findings did not suggest differences in sleep quality between women who used and did not use marijuana during pregnancy. Findings are contrary to the perception that marijuana use alleviates sleep-related problems during pregnancy. Given well-documented adverse outcomes associated with prenatal marijuana exposure for children and the increase in women using marijuana during pregnancy, providers should be prepared to discuss possible harms associated with marijuana use during pregnancy as well as provide psychoeducational information and service referrals to those interested. Future studies could improve upon this design by assessing objective measures of sleep, such as actigraphy, as well as marijuana use repeatedly throughout pregnancy, which may be a more optimal strategy for illuminating potential relationships between marijuana use and sleep during pregnancy.

Cannabinoids and Their Role in Chronic Pain Treatment: Current Concepts and a Comprehensive Review

For decades, chronic pain was managed with an almost conventional approach of using a wide range of analgesic spectrum, surgical approaches and complex interventional pain techniques to modulate or even interrupt pain pathways. These different approaches carry many pharmacological hazards together with the lack of efficacy and safety of many interventional and surgical management techniques for chronic pain have mandated searching for other effective therapies including alternative treatments. Cannabinoids are naturally occurring substances that are derived from Cannabis sativa L. The usage of cannabinoids and their related synthetic chemical compounds has emerged as a choice in the management of different chronic pain conditions is being evaluated, however, the efficacy is still not consistently established. In the present investigation, therefore, we discuss the different aspects related to cannabinoids and their implications in the management of chronic pain conditions. This review will also discuss the safety profile of the cannabinoids together with the legal considerations that hinder their use in different countries.

Novel Implementation of State Reporting Policy for Substance-Exposed Infants

BACKGROUND

The Child Abuse Prevention and Treatment Act's provisions concerning hospitalist and child protective services response to infants with prenatal substance exposure (IPSE) were revised in 2016 to address the impact of the opioid epidemic. In 2019, Connecticut unveiled a statewide hospital reporting infrastructure to divert IPSE without safety concerns from CPS using a deidentified notification to CPS and a plan of safe care (POSC). Connecticut is the first state to implement a separate, deidentified notification system.

METHODS

We used notification and birth data to determine rates per 1000 births. We employed multinomial logistic regression to understand factors associated with 3 mutually exclusive outcomes: (1) diversion with POSC, (2) report with POSC, or (3) report without POSC.

RESULTS

During the first 28 months of policy implementation, hospitalists submitted over 4700 notifications (8% of total Connecticut births). Over three-quarters (79%) of notifications included marijuana exposure, and 21% included opioid exposure. Fewer than 3% included alcohol exposure. Black mothers were disproportionally overrepresented among notifications compared with the state population, and all other race groups underrepresented. Over half of identified IPSE were diverted. Type of substance exposure was the strongest predictor of outcome, controlling for maternal age and race group.

CONCLUSIONS

Connecticut Child Abuse Prevention and Treatment Act diverted IPSE without provider safety concerns away from child protective services. Substance exposure type was associated with the dyad's outcome at hospital discharge. Nonuniversal screening practices may contribute to racial disproportionality in implementation.

An intergenerational lifespan perspective on the neuroscience of prenatal substance exposure

Prenatal substance exposure has the potential to impact a variety of domains, with neurobiological effects that last throughout the lifespan. Different substances may impact the brain in both specific and diffuse ways; however, the aberrant neural outcomes following exposure tend to coalesce in three areas: (1) sensorimotor development; (2) arousal, motivation, and reward; and (3) executive functioning, impulse control, and emotion regulation. This manuscript represents a summary and update of a previous review (Morie et al., 2019). We organize this piece by domain and summarize data from published neuroimaging studies that examine the neural correlates of prenatal exposure across developmental stages. While the published neuroimaging literature in the area of prenatal exposure has a range of sampling concerns that may limit generalizability as well as longitudinal prediction, the findings to date do point to domains of interest warranting further study. With this caveat, we synthesize the extant findings to describe ways in which prenatal substance exposure is associated with developmental psychopathology and implicated in potentially aberrant behavioral patterns beginning in infancy and persisting through childhood, adolescence, adulthood, and even parenthood. We also examine how substance abuse may impact parenting behaviors that in turn influences infant and child behavior in ways that may be additive or obscure the direct teratological effects of prenatal exposure. Given this observation, we offer an additional intergenerational lens through which prenatal substance exposure should be studied.

In-utero cannabis exposure and long-term psychiatric and neurodevelopmental outcomes: The limitations of existing literature and recommendations for future research

Given increases in cannabis use in pregnancy and animal model research showing effects of in-utero cannabis exposure, high-quality information on long-term consequences of in-utero cannabis exposure in humans is needed. While reviews have summarized findings from observational studies with humans, reviews have not focused on limitations of these studies and recommendations for future research. Therefore, we critically reviewed observational research on in-utero cannabis exposure and psychiatric and neurodevelopmental outcomes measured at or after age 3 and provided recommendations for future research. We used Web of Science, Google Scholar, and work cited from relevant identified publications to identify 46 papers to include in our review. Our review includes two main sections. The first section highlights the extensive limitations of the existing research, which include small and nongeneralizable samples, reliance on self-reported data, lack of detail on timing and amount of exposure, inclusion of older exposure data only, not accounting for important confounders, inclusion of potential mediators as covariates, not including outcome severity measures, and not assessing for offspring sex differences. The second section provides recommendations for future research regarding exposure and outcome measures, sample selection, confounder adjustment, and other methodological considerations. For example, with regard to exposure definition, we recommend that studies quantify the amount of cannabis exposure, evaluate the influence of timing of exposure, and incorporate biological measures (e.g., urine toxicology measures). Given that high-quality information on long-term consequences of in-utero cannabis exposure in humans does not yet exit, it is crucial for future research to address the limitations we have identified.

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

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

Understanding Relationships Between Fetal Health Locus of Control (FHLC) and Maternal Marijuana Use During Pregnancy

The objective of this study was to examine relationships between maternal perceptions of Fetal Health Locus of Control (FHLC) and perceived risk/benefit related to prenatal marijuana use with maternal marijuana use behaviors during pregnancy. The sample included women seeking prenatal care at The Ohio State University Wexner Medical Center (OSUWMC, Columbus OH) between 2010 and 2015, who participated in a follow-up study (2019-2020). Logistic regression models were run to estimate associations between maternal perceptions and prenatal marijuana use behaviors. Higher perceived benefit to mother (AOR = 1.53, 95% CI: 1.08-2.17) and lower perceived risk to children (AOR = 0.59, 95% CI: 0.45-0.78) were related to increased prenatal marijuana use, adjusted for confounders. In contrast, FHLC perceptions were not associated with maternal marijuana use; however, FHLC predicted women's perceptions of risk and benefit which in turn was associated with marijuana use during pregnancy. Understanding how maternal perceptions influence health-related risk behaviors during pregnancy is important because perceptions are feasible intervention targets.

Adverse childhood experiences and marijuana use during pregnancy: Findings from the North Dakota and South Dakota PRAMS, 2017-2019

BACKGROUND

Emerging research suggests that adverse childhood experiences (ACEs) may be a risk factor for prenatal marijuana use. This study is the first to use a representative sample from state surveillance systems to assess the connection between accumulating ACEs and marijuana use during pregnancy.

METHODS

Data are from the North Dakota and South Dakota Pregnancy Risk Assessment Monitoring System (PRAMS) from years 2017-2019 (N = 5399). The bivariate association between number of ACEs and marijuana use during pregnancy is assessed using a chi-square test. The multivariable association is assessed using linear probability modeling.

RESULTS

Only 0.9% of women with zero ACEs reported marijuana use during pregnancy, compared to 11.7% of women with four or more ACEs. Findings from linear probability models showed that mothers reporting two ACEs (b =0.023, 95% CI =0.003,.043), three ACEs (b =0.042, 95% CI =0.014,.069), and four or more ACEs (b =0.053, 95% CI =0.035,.071) are more likely to report marijuana use during pregnancy relative to those with zero ACEs, net of demographic and socioeconomic control variables.

CONCLUSIONS

Accumulating maternal ACEs -especially four or more- is associated with increased likelihood of using marijuana during pregnancy. These findings demonstrate the early life trauma is a key social determinant of health over the life course and highlights how ACEs can contribute to intergenerational harm via the worsening of health behaviors during pregnancy.

Hypertensive disorders in pregnancy and child development at 36 months in the All Our Families prospective cohort study

Hypertensive disorders in pregnancy (HDP) are associated with increased risk of offspring neurodevelopmental disorders, suggesting long-term adverse impacts on fetal brain development. However, the relationship between HDP and deficits in general child development is unclear. Our objective was to assess the association between HDP and motor and cognitive developmental delay in children at 36 months of age. We analyzed data from the All Our Families community-based cohort study (n = 1554). Diagnosis of HDP-gestational or chronic hypertension, preeclampsia, or eclampsia-was measured through medical records. Child development was measured by maternal-report on five domains of the Ages and Stages Questionnaire (ASQ-3). Standardized cut-off scores were used to operationalize binary variables for any delay, motor delay, and cognitive delay. We calculated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using logistic regression, sequentially controlling for potential confounders followed by factors suspected to lie on the causal pathway. Overall, 8.0% of women had HDP and hypertension-exposed children had higher prevalence of delay than unexposed children. Hypertension-exposed children had elevated risk for developmental delay, but CIs crossed the null. The aRRs quantifying the fully adjusted effect of HDP on child development were 1.19 (95% CI 0.92, 1.53) for any delay, 1.18 (95% CI 0.86, 1.61) for motor delay, and 1.24 (95% CI 0.83, 1.85) for cognitive delay. We did not find a statistically significant association between HDP and developmental delay. Confidence intervals suggest that children exposed to HDP in utero have either similar or slightly elevated risk of any, motor, and cognitive delay at 36 months after controlling for maternal and obstetric characteristics. The observed direction of association aligns with evidence of biological mechanisms whereby hypertensive pathology can disrupt fetal neurodevelopment; however, more evidence is needed. Findings may have implications for early developmental monitoring and intervention following prenatal hypertension exposure.

Prenatal drug exposure and executive function in early adolescence

PURPOSE

Study of the relationship between prenatal cocaine exposure (PCE) and executive function (EF) has yielded inconsistent results. The purpose of the current study is to examine whether PCE, biological sex, environmental risk, and their interaction predicted EF in early adolescence.

METHODS

135 12-year-old adolescents (40.7% with PCE), who were followed prospectively from birth, attempted up to 8 Tower of Hanoi (ToH) puzzle trials of increasing complexity. The number of correctly completed puzzles served as the main outcome measure. Survival analysis was used to examine predictors of the number of successfully completed trials.

RESULTS

As trial difficulty increased, fewer adolescents were able to solve the TOH puzzle. Adolescents from high risk environments and with either prenatal alcohol or prenatal cannabis exposure completed fewer puzzles (p < .05). In addition, a hypothesized 3-way interaction of PCE x sex x environmental risk was found such that cocaine-exposed males with high environmental risk had the worst performance (p < .01).

CONCLUSIONS

The current findings are consistent with prior research indicating that males with PCE may be at particular risk of poorer functioning and highlight the potential importance of examining adolescent's sex and environmental risk as moderators of PCE effects.

Pregnant people's experiences discussing their cannabis use with prenatal care providers in a state with legalized cannabis

BACKGROUND

As cannabis legalization spreads, so do concerns about potential harms from use during pregnancy. Legalization may facilitate improved patient-provider interactions about cannabis use. Yet little is known about pregnant people's discussions of cannabis use with healthcare providers in an environment where recreational cannabis is legal.

METHODS

In May-August 2019, we conducted semi-structured in-depth interviews with 33 pregnant or postpartum people in California who used cannabis during pregnancy, and explored their discussions with healthcare providers about their cannabis use. We audio-recorded and transcribed interviews, and conducted thematic analysis using inductive and deductive methods.

RESULTS

Participants were diverse by age, race/ethnicity, and socio-economic position. Most reported daily cannabis use, both before and during pregnancy. Most participants did not disclose their cannabis use to their prenatal care providers, due to fears of being reported to child protective services (CPS), or fears of provider judgment. Participants reported that few providers initiated any discussions about cannabis use in pregnancy with them; some participants interpreted this omission as tacit endorsement of cannabis use in pregnancy. When participants and providers did discuss cannabis use in pregnancy, participants heard a wide range of sometimes-conflicting health messages, as well as some legal threats.

CONCLUSIONS

This study documents notable deficits in patient-provider interactions about cannabis. Pregnant patients' fears of being reported to CPS and separated from their children for cannabis use persist despite cannabis legalization. Providers' role as potential reporters to CPS appears to pose a significant barrier to comprehensive, compassionate counseling and education on cannabis use in pregnancy.

A Proteomic View of Cellular and Molecular Effects of Cannabis

Cannabis (Cannabis sativa), popularly known as marijuana, is the most commonly used psychoactive substance and is considered illicit in most countries worldwide. However, a growing body of research has provided evidence of the therapeutic properties of chemical components of cannabis known as cannabinoids against several diseases including Alzheimer's disease (AD), multiple sclerosis (MS), Parkinson's disease, schizophrenia and glaucoma; these have prompted changes in medicinal cannabis legislation. The relaxation of legal restrictions and increased socio-cultural acceptance has led to its increase in both medicinal and recreational usage. Several biochemically active components of cannabis have a range of effects on the biological system. There is an urgent need for more research to better understand the molecular and biochemical effects of cannabis at a cellular level, to understand fully its implications as a pharmaceutical drug. Proteomics technology is an efficient tool to rigorously elucidate the mechanistic effects of cannabis on the human body in a cell and tissue-specific manner, drawing conclusions associated with its toxicity as well as therapeutic benefits, safety and efficacy profiles. This review provides a comprehensive overview of both in vitro and in vivo proteomic studies involving the cellular and molecular effects of cannabis and cannabis-derived compounds.

Natural and Synthetic Cannabinoids: Pharmacology, Uses, Adverse Drug Events, and Drug Interactions

The purpose of this narrative review is to describe the current use environment of both natural and synthetic cannabinoids while providing context for cannabinoid chemistry and pharmacology. In addition to a long history of recreational and nonmedical use, natural cannabinoids are increasingly used as prescription products, through medical cannabis programs, and as consumer health products. Despite anecdotal safety evidence, cannabis and cannabinoids are pharmacologically complex and pose risks for adverse drug events and drug-drug interactions. Synthetic cannabinoids, particularly agonists of cannabinoid receptors, are more potent than natural cannabinoids and can lead to more severe reactions and medical emergencies. This review provides a summary of approved uses and an overview of mechanisms of action for adverse drug events with natural and synthetic cannabinoids. Clinical considerations for special populations that may be at heightened risk for drug-drug interactions and adverse drug events while using natural or synthetic cannabinoids are examined, and recommendations are provided.

General risks of harm with cannabinoids, cannabis, and cannabis-based medicine possibly relevant to patients receiving these for pain management: an overview of systematic reviews

ABSTRACT

The growing demand for improved pain treatments together with expanding legalization of, and access to, cannabinoids, cannabis, and cannabis-based medicines has intensified the focus on risk-benefit considerations in pain management. Given limited harms data from analgesic clinical trials, we conducted an overview of systematic reviews focused on all harms possibly relevant to patients receiving cannabinoids for pain management. This PROSPERO-registered, PRISMA-compliant systematic overview identified 79 reviews, encompassing over 2200 individual reports about psychiatric and psychosocial harms, cognitive/behavioral effects, motor vehicle accidents, cardiovascular, respiratory, cancer-related, maternal/fetal, and general harms. Reviews, and their included studies, were of variable quality. Available evidence suggests variable associations between cannabis exposure (ranging from monthly to daily use based largely on self-report) and psychosis, motor vehicle accidents, respiratory problems, and other harms. Most evidence comes from settings other than that of pain management (eg, nonmedicinal and experimental) but does signal a need for caution and more robust harms evaluation in future studies. Given partial overlap between patients receiving cannabinoids for pain management and individuals using cannabinoids for other reasons, lessons from the crisis of oversupply and overuse of opioids in some parts of the world emphasize the need to broadly consider harms evidence from real-world settings. The advancement of research on cannabinoid harms will serve to guide optimal approaches to the use of cannabinoids for pain management. In the meantime, this evidence should be carefully examined when making risk-benefit considerations about the use of cannabinoids, cannabis, and cannabis-based medicine for chronic pain.

Cannabis use while trying to conceive: a prospective cohort study evaluating associations with fecundability, live birth and pregnancy loss

STUDY QUESTION

Is cannabis use assessed via urinary metabolites and self-report during preconception associated with fecundability, live birth and pregnancy loss?

SUMMARY ANSWER

Preconception cannabis use was associated with reduced fecundability among women with a history of pregnancy loss attempting pregnancy despite an increased frequency of intercourse.

WHAT IS KNOWN ALREADY

Cannabis use continues to rise despite limited evidence of safety during critical windows of pregnancy establishment. While existing studies suggest that self-reported cannabis use is not associated with fecundability, self-report may not be reliable.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was carried out including 1228 women followed for up to six cycles while attempting pregnancy (2006 to 2012), and throughout pregnancy if they conceived.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 18-40 years with a history of pregnancy loss (n = 1228) were recruited from four clinical centers. Women self-reported preconception cannabis use at baseline and urinary tetrahydrocannabinol metabolites were measured throughout preconception and early pregnancy (up to four times during the study: at baseline, after 6 months of follow-up or at the beginning of the conception cycle, and weeks 4 and 8 of pregnancy). Time to hCG-detected pregnancy, and incidence of live birth and pregnancy loss were prospectively assessed. Fecundability odds ratios (FOR) and 95% CI were estimated using discrete time Cox proportional hazards models, and risk ratios (RRs) and 95% CI using log-binomial regression adjusting for age, race, BMI, education level, baseline urine cotinine, alcohol use and antidepressant use.

MAIN RESULTS AND THE ROLE OF CHANCE

Preconception cannabis use was 5% (62/1228), based on combined urinary metabolite measurements and self-report, and 1.3% (11/789) used cannabis during the first 8 weeks of gestation based on urinary metabolites only. Women with preconception cannabis use had reduced fecundability (FOR 0.59; 95% CI 0.38, 0.92). Preconception cannabis use was also associated with increased frequency of intercourse per cycle (9.4 ± 7 versus 7.5 ± 7 days; P = 0.02) and higher LH (percentage change 64%, 95% CI 3, 161) and higher LH:FSH ratio (percentage change 39%, 95% CI 7, 81). There were also suggestive, though imprecise, associations with anovulation (RR 1.92, 95% CI 0.88, 4.18), and live birth (42% (19/45) cannabis users versus 55% (578/1043) nonusers; RR 0.80, 95% CI 0.57, 1.12). No associations were observed between preconception cannabis use and pregnancy loss (RR 0.81, 95% CI 0.46, 1.42). Similar results were observed after additional adjustment for parity, income, employment status and stress. We were unable to estimate associations between cannabis use during early pregnancy and pregnancy loss due to limited sample size.

LIMITATIONS, REASONS FOR CAUTION

Owing to the relatively few cannabis users in our study, we had limited ability to make conclusions regarding live birth and pregnancy loss, and were unable to account for male partner use. While results were similar after excluding smokers, alcohol use and any drug use in the past year, some residual confounding may persist due to these potential co-exposures.

WIDER IMPLICATIONS OF THE FINDINGS

These findings highlight potential risks on fecundability among women attempting pregnancy with a history of pregnancy loss and the need for expanded evidence regarding the reproductive health effects of cannabis use in the current climate of increasing legalization.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland (Contract numbers: HHSN267200603423, HHSN267200603424, HHSN267200603426, HHSN275201300023I). Jeannie G. Radoc has been funded by the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the National Institutes of Health and generous contributions to the Foundation for the National Institutes of Health from the Doris Duke Charitable Foundation (DDCF Grant # 2014194), Genentech, Elsevier, and other private donors. The authors report no conflict of interest in this work and have nothing to disclose.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT00467363.

Cannabis: A Toxin-Producing Plant with Potential Therapeutic Uses

For thousands of years, Cannabis sativa has been utilized as a medicine and for recreational and spiritual purposes. Phytocannabinoids are a family of compounds that are found in the cannabis plant, which is known for its psychotogenic and euphoric effects; the main psychotropic constituent of cannabis is Δ9-tetrahydrocannabinol (Δ9-THC). The pharmacological effects of cannabinoids are a result of interactions between those compounds and cannabinoid receptors, CB1 and CB2, located in many parts of the human body. Cannabis is used as a therapeutic agent for treating pain and emesis. Some cannabinoids are clinically applied for treating chronic pain, particularly cancer and multiple sclerosis-associated pain, for appetite stimulation and anti-emesis in HIV/AIDS and cancer patients, and for spasticity treatment in multiple sclerosis and epilepsy patients. Medical cannabis varies from recreational cannabis in the chemical content of THC and cannabidiol (CBD), modes of administration, and safety. Despite the therapeutic effects of cannabis, exposure to high concentrations of THC, the main compound that is responsible for most of the intoxicating effects experienced by users, could lead to psychological events and adverse effects that affect almost all body systems, such as neurological (dizziness, drowsiness, seizures, coma, and others), ophthalmological (mydriasis and conjunctival hyperemia), cardiovascular (tachycardia and arterial hypertension), and gastrointestinal (nausea, vomiting, and thirst), mainly associated with recreational use. Cannabis toxicity in children is more concerning and can cause serious adverse effects such as acute neurological symptoms (stupor), lethargy, seizures, and even coma. More countries are legalizing the commercial production and sale of cannabis for medicinal use, and some for recreational use as well. Liberalization of cannabis laws has led to increased incidence of toxicity, hyperemesis syndrome, lung disease cardiovascular disease, reduced fertility, tolerance, and dependence with chronic prolonged use. This review focuses on the potential therapeutic effects of cannabis and cannabinoids, as well as the acute and chronic toxic effects of cannabis use on various body systems.

The importance of psychology for shaping legal cannabis regulation

Different patterns of cannabis use can be traced directly back to different interactions between 2 types of variables: pharmacological and environmental. As legal cannabis expands in the U.S. and around the world, state and national regulatory agencies are gaining control over these variables. Specifically, regulatory agencies are increasingly capable of altering (a) the pharmacological properties of cannabis products and (b) the way these products are distributed to the population. Consequently, cannabis regulatory agencies are in a unique position to use evidence from psychological science to alter cannabis consumption patterns in ways that mitigate potential harm to public health. However, most state-level legal cannabis regulatory systems in the U.S. are not yet evidence-based or public health-oriented. This applied review and commentary draws on evidence from the psychological science literature to help regulators better understand the types of behaviors they must address and guide empirically supported regulation of THC-laden cannabis, whether used putatively for medical or recreational reasons. This review is organized into 3 parts that correspond to the 3 primary agents within the cannabis regulation ecosystem: (a) the cannabis consumer, (b) the cannabis industry, and (c) the cannabis regulatory agency. Within this structure, the review addresses critical psychological variables that drive cannabis consumer and industry behaviors and discusses how regulatory agencies can use this information to protect public health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Attitudes about marijuana use, potential risks, and legalization: a single-center survey of pregnant women

OBJECTIVE

There is an association between recreational marijuana use in pregnancy and legalization. As more states legalize marijuana, its use in pregnancy may increase. The objective of this study was to evaluate pregnant women's knowledge and opinions about marijuana use, potential risks, and legalization.

METHODS

A cross-sectional survey of pregnant women at a regional perinatal center in New Jersey was performed from January-December 2019. Pregnant subjects were invited to complete a voluntary, anonymous 23-question survey about marijuana use in pregnancy, potential risks, and legalization. Subjects were excluded if they could not read in English or Spanish. Survey questions were based on a 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree). Likelihood of agreeing or disagreeing with potential risks, with neutral responses as the reference, were estimated based on the relative risk (RR) (95% confidence interval [CI]). Associations were examined with prior tobacco/marijuana use and education level.

RESULTS

During the study period, approximately 1133 consecutive patients were approached and 843 completed the study (74.4% response rate). The majority of participants were English-speaking, college educated, and employed. 204 (25.2%) reported prior marijuana use and 36 (4.5%) reported marijuana use during pregnancy. Overall, pregnant women had poor knowledge about potential risks of marijuana use in pregnancy. Although 234 (29.0%) patients were opposed to legalization, more than 90% of pregnant subjects indicated that they would be more likely to use marijuana in pregnancy if it were legalized. Associations of marijuana risks by prior tobacco use showed that nonsmokers had more awareness about risks. Nonsmokers had higher likelihood of agreeing that marijuana use may be harmful to a pregnancy (RR 1.41, 95% CI 1.12-1.76), may hurt the growth of a baby (RR 1.36, 95% CI 1.07-1.74), may cause preterm birth (RR 1.18, 95% CI 1.00-1.40), and may hurt a child's ability to learn (RR 1.20, 95% CI 0.95-1.51). Similar trends were observed for subjects who reported no prior marijuana use and for subjects with more than high school education.

CONCLUSIONS

The majority of surveyed pregnant women demonstrated poor knowledge about the possible risks of marijuana in pregnancy and indicated that they would be more likely to use marijuana in pregnancy if it were legalized. As the use of marijuana increases, providers should focus on educating their patients about potential risks associated with marijuana use in pregnancy while additional research is needed to clarify associated risks.

Perceived Risk of Weekly Cannabis Use, Past 30-Day Cannabis Use, and Frequency of Cannabis Use Among Pregnant Women in the United States

BACKGROUND

While accumulated evidence has shown that the prevalence of cannabis use among pregnant women in the US has increased in recent years, little is known about the specific subpopulations affected. The aim of this study was to estimate the prevalence and correlates of the perceived risk of weekly cannabis use, past 30-day cannabis use, and frequency of past 30-day cannabis use among US pregnant women.

METHODS

We analyzed data from 2,247 pregnant women 14 to 44 years of age surveyed in the 2015 to 2017 cross-sectional National Survey on Drug Use and Health. Analyses account for the sampling design. Primary outcomes included perceived risk of weekly cannabis use, past 30-day cannabis use, and frequency of cannabis use. We conducted multivariable logistic and negative binomial regression models to assess the associations between the primary outcomes and multiple correlates.

RESULTS

Among US pregnant women, 21.6% (95% CI=19.4, 23.8) did not perceive any risk associated with weekly cannabis use, 5.3% (95% CI=4.2, 6.5) used cannabis in the past 30 days, and among past-month users, the average number of days of use was 15.6 (95% CI=13.5, 17.7). Pregnant women living below the poverty line were both more likely to perceive no risk of weekly cannabis use (aOR=1.8; 95% CI=1.3, 2.5) and use cannabis more often in the past 30 days (aOR=2.9; 95% CI=1.5, 5.7) than pregnant women within an income bracket of more than two times the federal poverty threshold. Age, race, trimester of pregnancy, co-use of tobacco and/or alcohol were also associated with these outcomes.

CONCLUSION

Younger age, living in poverty, early trimester of pregnancy, and co-use of tobacco and/or alcohol increased the odds of cannabis use among pregnant women. As cannabis legalization spreads and cannabis use is increasingly perceived as safe, there is a growing need for research to determine the reasons why women in the identified at-risk subgroups are using cannabis during pregnancy.

Demographic Discrepancies in Prenatal Urine Drug Screening in Washington State Surrounding Recreational Marijuana Legalization and Accessibility

OBJECTIVES

This study evaluated demographic patterns related to prenatal cannabinoid urine drug screening (UDS) over a 5-year period during which recreational marijuana was legalized and became accessible in Washington State.

METHODS

Using electronic health record data, we performed a retrospective analysis for deliveries occurring over a 5-year period that encapsulated the transitions to marijuana legalization and legal access. For three cohorts of women delivering prior to legalization, between legalization and accessibility, and following accessibility, the UDS completion rate and screening demographic characteristics were assessed using Chi-squared tests and multivariate logistic regression.

RESULTS

25,514 deliveries occurred between March 2011 and March 2016. A significantly higher percentage of women underwent UDS post-accessibility (24.5%) compared to pre-legalization (20.0%, p < 0.001). A corresponding increase was not observed in the percentage of marijuana-positive UDS in tested patients (22.7% vs. 23.3%, p = 0.86). African American women had 2.8 times higher odds than Latinas of being tested, 2.1 times higher odds than Asian women, 1.7 times higher odds than White women, and 1.4 times higher odds than women of other races (all p < 0.001). Subsidized insurance status was also strongly associated with increased likelihood of testing (aOR = 3.5, p < 0.001).

CONCLUSIONS FOR PRACTICE

Prenatal UDS testing patterns changed as recreational marijuana possession and accessibility became legal. Demographic discrepancies in testing reveal biases related to race and insurance status, which may be a proxy for socioeconomic status. As such discrepancies are potential contributors to health outcome disparities, it is important for providers and health care systems to examine their practices and ensure they are being appropriately, equally, and justly applied.

Cannabis in Pregnancy and Lactation - A Review

Cannabis (marijuana) is now legal for either medicinal use or recreational use in 33 states with more states considering legalization for medicinal and/or recreational use. More women planning pregnancy, pregnant, or breastfeeding will present with exposure to marijuana. A familiarity with the pharmacology and potential effects for pregnancy and lactation is important for the obstetrical care provider to permit optimal counseling for the gravida. This paper provides a pertinent review of cannabis for the obstetrical care provider. The literature available for review concludes that no amount of marijuana and associated product use in pregnancy and lactation is safe. Cannabis and associated product use has the potential for adverse maternal, fetal, and long-term childhood development and its use should be discouraged during pregnancy and lactation.

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

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

Marijuana and the Pediatric Population

Cannabinoids, the psychoactive compounds in marijuana, are one of the most commonly used substances in the United States. In this review, we summarize the impact of marijuana on child and adolescent health and discuss the implications of marijuana use for pediatric practice. We review the changing epidemiology of cannabis use and provide an update on medical use, routes of administration, synthetic marijuana and other novel products, the effect of cannabis on the developing brain, other health and social consequences of use, and issues related to marijuana legalization.

Sex differences in the interactive effects of early life stress and the endocannabinoid system

Sex differences in both the endocannabinoid system and stress responses have been established for decades. While there is ample evidence that the sexes respond differently to stress and that the endocannabinoid system is involved in this response, what is less clear is whether the endocannabinoid system mediates this response to stress differently in both sexes. Also, do the sexes respond similarly to exogenous cannabinoids (CBs) following stress? Can the administration of exogenous CBs normalize the effects of stress and if so, does this happen similarly in male and female subjects? This review will attempt to delineate the stress induced neurochemical alterations in the endocannabinoid system and the resulting behavioral changes across periods of development: prenatal, early neonatal or adolescent in males and females. Within this frame work, we will then examine the neurochemical and behavioral effects of exogenous CBs and illustrate that the response to CBs is determined by the stress history of the animal. The theoretical framework for this endeavor relates to the established effects of adverse childhood experiences (ACE) in increasing substance abuse, depression and anxiety and the possibility that individuals with high ACE scores may consume cannabinoids to "self-medicate". Overall, we see that while there are instances where exogenous cannabinoids "normalize" the adverse effects produced by early stress, this normalization does not occur in all animal models with any sort of consistency. The most compelling report where CB administration appears to normalize behaviors altered by early stress, shows minimal differences between the sexes (Alteba et al., 2016). This is in stark contrast to the majority of studies on early stress and the endocannabinoid system where both sexes are included and show quite divergent, in fact opposite, effects in males and females. Frequently there is a disconnect between neurochemical changes and behavioral changes and often, exogenous CBs have greater effects in stressed animals compared to non-stressed controls. This report as well as others reviewed here do support the concept that the effects of exogenous CBs are different in individuals experiencing early stress and that these differences are not equal in males and females. However, due to the wide variety of stressors used and the range of ages when the stress is applied, additional careful studies are warranted to fully understand the interactive effects of stress and the endocannabinoid system in males and females. In general, the findings do not support the statement that CB self-administration is an effective treatment for the adverse behavioral effects of early maltreatment in either males or females. Certainly this review should draw the attention of clinicians working with children, adolescents and adults exposed to early trauma and provide some perspective on the dysregulation of the endocannabinoid system in the response to trauma, the complex actions of exogenous CBs based on stress history and the unique effects of these factors in men and women.

Monitoring Perinatal Exposure to Cannabis and Synthetic Cannabinoids

PURPOSE

Drug use during pregnancy is a critical global challenge, capable of severe impacts on neonatal development. However, the consumption of cannabis and synthetic cannabinoids is on the rise in pregnant women. Obstetric complications with increased risks of miscarriage, fetal growth restriction, and brain development impairment have been associated with perinatal cannabis exposure, but data on synthetic cannabinoid use during pregnancy are limited.

METHODS

We reviewed studies that investigated the risks associated with cannabis and synthetic cannabinoid use and those that reported the concentrations of cannabinoids and synthetic cannabinoids in maternal (breast milk) and neonatal (placenta, umbilical cord, meconium, and hair) matrices during human pregnancy. A MEDLINE and EMBASE literature search to identify all relevant articles published in English from January 1998 to April 2019 was performed.

RESULTS

Cannabis use during pregnancy is associated with increased risks of adverse obstetrical outcomes, although neurobehavioral effects are still unclear. Analyses of cannabinoids in meconium are well documented, but further research on other unconventional matrices is needed. Adverse effects due to perinatal synthetic cannabinoid exposure are still unknown, and analytical data are scarce.

CONCLUSIONS

Awareness of the hazards of drug use during pregnancy should be improved to encourage health care providers to urge pregnant women to abstain from cannabis and, if cannabis-dependent, seek treatment. Moreover, substances used throughout pregnancy should be monitored as a deterrent to cannabis use, and potential cannabis-dependent women should be identified, so as to limit cannabis-fetal exposure during gestation, and provided appropriate treatment.

The cure model in perinatal epidemiology

In the statistical literature, the class of survival analysis models known as cure models has received much attention in recent years. Cure models seem not, however, to be part of the statistical toolbox of perinatal epidemiologists. In this paper, we demonstrate that in perinatal epidemiological studies where one investigates the relation between a gestational exposure and a condition that can only be ascertained after several years, cure models may provide the correct statistical framework. The reason for this is that the hypotheses being tested often concern an unobservable outcome that, in view of the hypothesis, should be thought of as occurring at birth, even though it is only detectable much later in life. The outcome of interest can therefore be viewed as a censored binary variable. We illustrate our argument with a simple cure model analysis of the possible relation between gestational exposure to paracetamol and attention-deficit hyperactivity disorder, using data from the Norwegian Mother, Father and Child Cohort Study conducted by the Norwegian Institute of Public Health, and information about the attention-deficit hyperactivity disorder diagnoses obtained from the Norwegian Patient Registry.

Women's Questions About Perinatal Cannabis Use and Health Care Providers' Responses

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.

Medicinal Use of Cannabis in Children and Pregnant Women

The increasing medicinal use of cannabis during recent years has largely overlooked children and pregnant women due to litigious and ethical concerns. However, over the last few years medicine has observed increasing numbers of children treated with cannabis for autism spectrum disorder (ASD) and fetal alcohol spectrum disorder (FASD), and pregnant women treated for hyperemesis gravidarum (HG). This review provides an account of major findings discovered through this research. Specifically, cannabis may offer therapeutic advantages to behavioral symptoms of autism spectrum disorder and fetal alcohol spectrum disorder, and to the severe nausea and vomiting in hyperemesis gravidarum. The use of medical cannabis in children and pregnant women should be further discussed and researched in this patient population.

The use of cannabis for Hyperemesis Gravidarum (HG)

Background

Hyperemesis Gravidarum (HG) responds only partially to standard antiemetic medications. Cannabis has been known to possess antiemetic effects and there are several medicinal cannabinoids used as anti -emetics for cancer chemotherapy. Its favorable use for HG has been described in social media, but not in the medical literature.

Methods

We evaluated 4 women with HG counseled by the Motherisk Program, before and following the use of cannabis. Using the validated Pregnancy Unique Quantification of Emesis (PUQE) scoring system and employing the Student’s paired t test, we compared changes in symptoms following initiation of cannabis.

Results

There was a highly significant improvement in symptoms: PUQE score improved from 14.5+/− 1 to 7.5+/− 0.58(p = 0.0004). Cannabis use was associated with a significant increase in the PUQE Quality of Life scale, from 2+/− 0.82 to 7+/− 0.82 (p = 0.0012).

Conclusions

The results suggest that cannabis may be effective for HG, and should be studied in appropriately powered, controlled studies, fully considering potential fetal risks.

Sex-specific behavioural deficits induced at early life by prenatal exposure to the cannabinoid receptor agonist WIN55, 212-2 depend on mGlu5 receptor signalling

BACKGROUND AND PURPOSE

Marijuana is the illicit drug most commonly used among pregnant and breastfeeding women. Different studies reported long-term adverse effects induced by in utero exposure to the main component of marijuana, Δ⁹ -tetrahydrocannabinol (THC), both in rodents and in humans. However, little is known about any potential sex-dependent effects of marijuana consumption during pregnancy on newborns at early developmental ages.

EXPERIMENTAL APPROACH

We studied the effects of prenatal exposure to the cannabinoid receptor agonist WIN55,212-2 (WIN; 0.5 mg·kg^-1 from GD5 to GD20) on the emotional reactivity and cognitive performance of male and female rat offspring from infancy through adolescence and tested the role of mGlu₅ receptor signalling in the observed effects.

KEY RESULTS

Prenatally WIN-exposed male infant pups emitted less isolation-induced ultrasonic vocalizations compared with male control pups, when separated from the dam and siblings and showed increased locomotor activity while females were spared. These effects were normalized when male pups were treated with the positive allosteric modulator of mGlu₅ receptor CDPPB. When tested at the prepubertal and pubertal periods, WIN-prenatally exposed rats of both sexes did not show any difference in social play behaviour, anxiety and temporal order memory.

CONCLUSIONS AND IMPLICATIONS

We reveal a previously undisclosed sexual divergence in the consequences of fetal cannabinoids on newborns at early developmental ages, which is dependent on mGlu₅ receptor signalling. These results provide new impetus for the urgent need to investigate the functional and behavioural substrates of prenatal cannabinoid exposure in both the male offspring and the female offspring.

Self-reported Daily, Weekly, and Monthly Cannabis Use Among Women Before and During Pregnancy

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.