Featured topic and speakers
OB-GYN and addiction medicine physician Tricia Wright, MD, MS, DFASAM, examines cannabis use during pregnancy, including why pregnant persons might use cannabis, the effects of prenatal exposure and how to talk with pregnant patients about cannabis use.
Speakers
- Tricia Wright, MD, MS, DFASAM, OB-GYN and addiction medicine physician, University of California San Francisco
- Michael Suk, MD, JD, MPH, MBA, professor and chair, Musculoskeletal Institute and the Department of Orthopedic Surgery, Geisinger Health System; chair, AMA Board of Trustees
- Jesse Ehrenfeld, MD, immediate past president, American Medical Association
Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Dr. Ehrenfeld: Welcome to Moving Medicine, a podcast by the American Medical Association. Today’s episode is part of the Cannabis Education series, brought to you by the AMA Cannabis Task Force.
I'm Dr. Jesse Ehrenfeld, senior associate dean, tenured professor of anesthesiology and director of the Advancing a Healthier Wisconsin Endowment at the Medical College of Wisconsin. I'm also the immediate past president of the AMA and co-chair of the AMA Cannabis Task Force. Michael, take it away!
Dr. Suk: Thanks, Jesse. I'm Dr. Michael Suk, professor and chair of the Musculoskeletal Institute and the Department of Orthopedic Surgery at Geisinger Health System. I'm chair of the AMA Board of Trustees and your co-chair of the AMA Cannabis Task Force.
Through expert discussions and insights, this podcast series features information that can help physicians of all specialties understand cannabis and the health effects of cannabis use.
Dr. Ehrenfeld: The AMA forms mission-specific task forces like this one to tackle current medical issues in our nation. Make your voice heard by becoming a member today. Visit ama-assn.org/more. And now, on to the show. Michael.
Dr. Suk: Joining me today to talk about cannabis use and pregnancy is Dr. Tricia Wright. Tricia Wright is a professor of clinical medicine and medical director of maternal mental health and addiction medicine in the department of obstetrics, gynecology and reproductive health at the University of California San Francisco where she works both as an OB hospitalist and addiction medicine provider. Previously, she was at the University of Hawaii and founded the PATH Clinic, a perinatal clinic specializing in the care of pregnant and parenting women with substance use disorders. She is board certified in both obstetrics and gynecology and addiction medicine, and a fellow of the American College of Obstetrics and Gynecology, as well as being a distinguished fellow of the American Society of Addiction Medicine.
She has published multiple papers on pregnancy and addiction as well as a textbook on opioid use disorders in pregnancy published in 2018 by Cambridge University Press. Dr. Wright completed her undergraduate degree in biological sciences from Stanford University, her MD from the University of Michigan, and she completed her residency in obstetrics and gynecology from the University of New Mexico and obtained a master's degree in clinical research from the University of Hawaii.
Her research and clinical interests lie at the intersection of substance use disorders, mental health and pregnancy. Dr. Wright, welcome.
Dr. Wright: Thank you for having me.
Dr. Suk: Well, it’s great pleasure to meet you and I'd like to start by discussing what we know about the epidemiology of cannabis use during pregnancy. Can you describe the trends in cannabis use while pregnant and what are some of the reasons why a pregnant person might use cannabis that physicians should consider?
Dr. Wright: Yes, definitely with the increased legalization of cannabis throughout the country. We know that 24 states plus the District of Columbia have fully legalized cannabis. With this increased legalization, we have seen that pregnant people and actually people in general, even when they're not pregnant, have increased their use. So, we know in 2018 that almost 14% of people with the capability of becoming pregnant reported cannabis use. And fortunately, only about half of those continue to use during pregnancy. And we know this rate did go down from 2017 to 2018, from seven to less than 5%.
So, some disturbing trends in overall use, but luckily the message is getting out to pregnant people that it's not necessarily a good thing. Some of the reasons that pregnant people use cannabis is for the treatment of a hyperemesis or just nausea and vomiting in pregnancy. Also, there's this perceived notion that because it is natural, it is safer than medications to treat nausea and vomiting.
Dr. Suk: Thanks Dr. Wright. And can you talk a little bit about when cannabis use tends to be more common during pregnancy, and potentially, some people may perceive it as perhaps less harmful than tobacco.
Dr. Wright: Yeah, we definitely see it most in the first trimester, especially before people know they're pregnant. Given that 50% of the pregnancies in this country are unplanned, it's not unusual given how high the cannabis use, especially among young people, 18 to 24 is. And that's when the unplanned pregnancy rates are highest also.
Patients think it is safer than tobacco because they're not as inhaling as often, they're not smoking as often as they would with tobacco, but unfortunately, the literature does not support that.
Dr. Suk: Thanks for that information. For a physician who has a patient who is pregnant or is considering becoming pregnant, what recommendations can you share for counseling and screening?
Dr. Wright: Thank you for asking that. I think the most important thing is to screen all patients for substance use during pregnancy using a validated screening test, such as the TAPS 1 and 2, or the 4Ps Plus, or CERP-P. There's a variety of tests out there. The important thing is to do it with a verbal screening in a nonjudgmental manner, not relying on urine and toxicology, which is not a good screening test at all. Then following it up with counseling that is evidence-based, really talking about the risks, not just the risks of child welfare involvement, but the risk to the pregnancy itself in, again, a non-judgmental way, but really giving the evidence behind why we don't recommend cannabis use in pregnancy, including some possible developmental effects.
Anytime the brain is developing rapidly, we know extrapolating from data around adolescent cannabis use that it can be very harmful. And the brain is developing very rapidly in utero. So, between 17 and 19 weeks is probably one of the most harmful times to ingest cannabis just because of the THC effects on the developing brain.
Dr. Suk: Thanks for that information and sharing your experience with implementing screening programs. We know that can be a challenge. What are some of the effects of prenatal exposure that we know? And why should physicians be concerned if a patient who is pregnant or thinking of becoming pregnant uses cannabis products?
Dr. Wright: Some of the associations that have been shown during studies is association with low birth weight, some preterm delivery and then other effects from inhaling. There's a few studies that have shown an increased risk of attention deficit and also decreased executive functioning.
Unfortunately, there are not great studies as far as the retrospective and not controlling from other, you know, such as genetic issues, such as maternal ADHD and other maternal characteristics. But that's the best information we have.
Dr. Suk: Dr. Wright, thank you for that information. And follow up, are there any risks of cannabis exposure during the postpartum period or in infancy?
Dr. Wright: Yeah, especially if patients are breastfeeding, we know that it is passed into the breast milk and can concentrate there, and it concentrates in fat tissues also. The levels are variable, and it just depends on when the last use was and the chronicity of use.
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Again, because the neonatal brain is developing very rapidly, exposure to THC during this time is not recommended. In addition, any environmental exposures from cannabis use in the home, if it's smoked versus ingested, could also affect the infant.
So, in general, the American College of Obstetrics and Gynecology and the American College of Pediatricians recommend to stop using cannabis while breastfeeding, but still encouraging breastfeeding for all people.
Dr. Suk: It seems like a lot of the information we have is both scientific but also in development. And so, we're learning more and more about the use of cannabis during pregnancy and in the postpartum period. We certainly want to thank you for your knowledge and experience on cannabis use in pregnancy. Do you want to share maybe a couple take home points for our audience that you'd like them to be familiar with?
Dr. Wright: Yeah, just that, you know, just because something is natural, doesn't mean that it's safe. There's a plant outside my house, oleander, that is beautiful and very natural and very poisonous. And so, and just because something is a medicine, doesn't mean that it can be good for everybody.
It's some interesting studies that were done about dispensary advice and just trying to get people, encourage people to use cannabis to prevent the nausea and vomiting or to treat the nausea and vomiting. One person said, well, it's an edible. It goes through your digestive tract, so the baby won't be affected. So, you have people like that giving advice.
So, I would give the advice to listen to your doctors and for doctors to give good, medically sound advice.
Dr. Suk: Dr. Wright, thank you for spending the time with us today on this topic. Your expertise and knowledge are really very welcome in this particular podcast.
Dr. Wright: Thank you for having me.
Dr. Ehrenfeld: Don’t miss the next episode in this series—be sure to subscribe to Moving Medicine on your favorite podcast platform. This content is for educational and informational purposes only and does not constitute medical or legal advice. The viewpoints expressed in this podcast are those of the participants and do not reflect the views and policies of the AMA, unless otherwise indicated.
Dr. Suk: And this has been Moving Medicine. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
