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McManus J, Halwes M, Abrantes A, Battle C. Cannabis conversations: suggestions for providers serving perinatal patients. HPHR. 2022;50. 10.54111/0001/WW8
Major medical organizations have issued statements discouraging cannabis use in the perinatal period to minimize the risk of potential adverse outcomes. However, many pregnant individuals may decide to continue to use cannabis, or they may wish to quit, but have trouble discontinuing, potentially because they use cannabis to alleviate symptoms such as nausea, pain, sleep difficulties, or anxiety. Patients may not feel comfortable disclosing cannabis use or discussing alternatives, due to perceptions of cannabis safety, stigma, fear of legal repercussions, or mistrust in providers. Healthcare providers from diverse specialties interact with perinatal patients who use cannabis, yet guidance for them is limited. In this commentary, we encourage attention to understanding patients’ motivations for cannabis use. We offer general considerations for engaging in conversations with patients on this topic, including using a nonjudgmental, empathetic, and patient-centered approach to care.
Despite limited, and at times conflicting, evidence regarding the impacts of (CU) on pregnancy and fetal development, empirical findings increasingly suggest potentially concerning risks to mother and baby associated with maternal use.1 In response, major committee opinions have been issued in the United States (US) to recommend against CU in pregnancy.2 As cannabis legalization and use increases across the US, a range of healthcare providers now find themselves in a position to counsel patients regarding CU and cessation in pregnancy. The range of institutional and legal policies can be difficult to navigate, particularly for providers who may work at several facilities or in a region where the legalization of cannabis is shifting. Providers who understand the extent of their confidentiality in relation to local laws and policies are better able to guide patients on whether they are a suitable provider with which to discuss cannabis use (and perhaps better able to direct patients to resources that are not mandatory reporters, if that is their desire). It is essential that information regarding CU in the perinatal period is widely understood by providers from diverse backgrounds, and, most relevant, by prenatal care (OB/GYNs, midwives, nurses, family physicians) as well as by mental healthcare providers (psychologists, psychiatrists, social workers, others). Unique challenges in discussing CU with perinatal patients should be considered. In this commentary, we provide an overview of perinatal CU patterns in the US, discuss patient motivations for engaging in CU during the perinatal period, and present general considerations for clinicians who wish to support their patients in decision-making about the use of cannabis during pregnancy and postpartum.
We encoureage the authors to differentiate from “cannabis use” and “cannabis use disorder” (CUD).
Cannabis use in the United States has steadily risen throughout the 21st century, with reported overall use increasing from 10.4% to 18.7% between 2008 and 2021.3,4 During this time, the potency of THC in cannabis products has grown both in the non-legal market and the legal recreational/medical market.5 Cannabis is the most commonly used drug in pregnancy, with 9.9% of all pregnant women in the 2021 National Survey on Drug Use and Health (NSDUH) reporting first-trimester use. Recent data suggest that the actual rate of CU may be higher than what women self-report, based on biological verification with umbilical cord sampling.6,7
Current data regarding outcomes associated with cannabis use in pregnancy and during breastfeeding suggest risk, though data remain inconclusive. Several studies point to increased risk for adverse outcomes such as shorter gestation,8 spontaneous preterm births,9,10 NICU admissions,11 and child neurobehavioral consequences including cognitive, learning, and behavioral problems.12–16 As a result, between 2015 and 2018, expert opinions were issued by several major medical organizations, including the American College of Obstetrics and Gynecology (ACOG),2 Academy of Breastfeeding Medicine (ABM),17 and the American Academy of Pediatrics (AAP)18 recommending against cannabis use in pregnancy and lactation.
Further, some states and hospitals mandate that providers notify child protective services (such as the Department of Children, Youth, and Families, DCYF) regarding cannabis use during pregnancy or delivery. Depending on the state and hospital policy, providers may be required to test patients in the prenatal period and/or at the time of delivery if CU is reported in pregnancy. In some instances, such testing and reporting policies may come as a surprise, leading mothers and family members to have distressing experiences with protective services, potentially contributing to disruptions in familial bonding, and downstream trust issues between patients and providers.19–22 It is also worth noting that the criminalization of cannabis stemming from the United States’ “War on Drugs” have fostered a justice system in which criminal charges related to cannabis and other substances have disproportionately impacted people of color.23 These larger systemic issues in the US criminal justice system may contribute to some people of color being further dissuaded from disclosing cannabis use, regardless of their perinatal status. It is important for providers to be aware of and work against their own implicit biases regarding race and substance use as they interact with patients.
Despite the widespread recommendations of cannabis cessation in pregnancy and during breastfeeding and legal risks to parents who use cannabis prenatally, there is surprisingly little guidance for pregnant patients seeking to change their use behavior. Additionally, there is little concrete advice available for providers who routinely interact with individuals who may be using cannabis during pregnancy and postpartum. Given the siloed nature of healthcare specialties, and the challenge and unpredictability of patient disclosure of prenatal cannabis use, providers across diverse fields and specialties should understand the reasons for CU and subsequent options for treatment. In addition, providers must learn how to effectively have conversations about cannabis with their pregnant and postpartum patients, using nonjudgmental, empathic, and patient-centered approaches to the conversation.
Patients may report CU to many providers, including obstetricians, midwives, family medicine doctors, psychiatrists, substance use counselors, and psychotherapists. Regardless of the providers to whom they disclose, pregnant patients deserve a supportive, non-judgmental approach when seeking advice and learning about treatment options to address cannabis use during pregnancy and postpartum. In the absence of fully integrated mental health treatment in most prenatal clinics, providers across a range of specialty areas must be aware of the complexity of patients’ decisions and how to connect patients with available treatment options and supports if they seek to discontinue or reduce the use of cannabis.
The social and legal context of CU in the United States is changing, and information about the risks of maternal use is emerging as more research is conducted and disseminated. Very few specialized services currently exist for patients seeking to change perinatal CU. In this evolving landscape, clinicians are charged with providing individualized care for their patients and helping each person navigate decisions relevant to them. Although general clinical recommendations may change as outcome data and policies evolve, we suggest the following considerations when providing care for perinatal patients with current or recent cannabis use histories. In addition, we encourage consideration of how patients’ motives for use and preferences for CU or cessation may be informative in guiding clinicians’ next steps.
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A possible barrier to effectively addressing cannabis use in pregnancy may be providers’ lack of understanding regarding patients’ reasons for use. Larger systemic issues, including mistrust in the healthcare system, limited access to education regarding potential risks of use, and perceived safety of cannabis, likely play a role. On an individual level, factors such as physical/psychological dependency may also contribute to continued use in pregnancy despite knowledge of risks. Available data show that women report using cannabis in pregnancy to treat myriad underlying physical and mental conditions.8 Preliminary research suggests that women who utilize cannabis in pregnancy most often cite nausea/vomiting, appetite, anxiety, relaxation, pain, sleep, recreational reasons, depression, and anger as reasons for use. It is necessary for providers to inquire about motivations for use to guide education and potentially offer effective alternative treatment for underlying conditions in cases where cessation is desired.
Given the consequences of reporting cannabis use in pregnancy (i.e., notification of child protective services), discussions regarding perinatal cannabis use can be tricky. Pregnant patients may underreport their use due to the stigma associated with the use and their fear of intervention, preventing providers from having the opportunity to counsel effectively. In establishing care during pregnancy or resuming care with a new pregnancy, it is essential to approach patients non-judgmentally and share local policy regarding substance use in pregnancy to inform patients adequately. Once rapport and trust are established, the patient and provider can work together to determine reasonable next steps. Greyson and colleagues (2021) state that patients may make decisions about cannabis use during the perinatal period.26 Below, we explore treatment for patients who do and do not desire cessation.
In the case that a pregnant patient desires to stop using cannabis, providers may need to first understand the extent and severity of cannabis use. Some patients may have more occasional CU that does not meet the criteria for a clinical disorder, whereas others may meet diagnostic criteria for cannabis use disorder (CUD) which entails a pattern of regular cannabis use contributing to distress and impairment. Changing substance use behaviors can be challenging in all cases, but treating cannabis use disorder can be particularly difficult. Results from clinical trials of pharmacotherapy and structured therapeutic approaches in non-pregnant individuals show moderate efficacy in reducing use, though the efficacy of interventions in achieving abstinence is limited.27 Patients presenting to a prenatal provider, who desire cessation and/or abstinence during pregnancy may require more intensive treatment with addiction medicine, psychiatry, or partial hospital level of care. Unfortunately, specialized programs for pregnant and postpartum women seeking to change substance use behaviors are not readily available in all areas; some women may be reluctant to enroll in treatment even when it is locally available.
In addition, providers may be able to directly assist patients who wish to stop using cannabis by understanding and addressing their underlying reason(s) for use. Nausea, commonly cited and regarded as a reason for cannabis use in pregnancy, is a specific concern given the possibility of cannabis contributing to worsened symptoms. ACOG recommends non-pharmacologic interventions as the first line – including nutrition interventions and P6 acupressure wrist bands, followed by vitamin and pharmacological interventions, such as converting prenatal vitamins to folic acid only, B6/doxylamine, and dopamine agonists.28 Pain, another commonly cited reason for cannabis use in pregnancy, can often be effectively treated by exercise, stretching, and acupuncture.29 Alternative pharmacological interventions include acetaminophen, baclofen, and gabapentin. Again, thorough risk/benefit discussions are necessary to assist patients in deciding alternative treatments in pregnancy. If the patient indicates underlying symptoms of depression or anxiety, providers may consider referral to psychotherapy, psychiatry, or higher levels of care (i.e., partial hospital program). Pharmacologic interventions, including SSRIs and other antidepressants/anxiolytics, may also be considered with patients following risk/benefit discussion.
Not all perinatal patients will desire to discontinue cannabis use, even when this is the recommendation of professional organizations and treating providers. Making sure that patients are supported as individuals and maintaining open lines of communication in the clinical setting between patient and provider is essential to ensure optimal care during the perinatal period, while also providing balanced information to patients about current recommendations, known risks, and local institutional and state policies relevant to cannabis use.
Harm reduction approaches in substance use are conceptualized as behaviors and strategies that help an individual reduce risk or harm to self and others. These may be considered by providers and pregnant patients who use cannabis if cessation or sustained abstinence in pregnancy is not perceived to be a realistic option or is not the patient’s goal. Given the concern for the dose-dependent relationship between cannabis use in pregnancy and poor outcomes, providers may consider supporting patients in developing a plan to reduce the dose/potency of THC in pregnancy. Additional harm reduction recommendations include educating patients about the importance of checking the potency and dosing of products they use, setting limits on use (i.e., only after a certain time or on a certain day), avoidance of situations that may trigger urges for use.30 It is also important to acknowledge that CU itself may be considered a harm reduction strategy by the patient if she is using it to prevent the use of other substances that may be harmful in pregnancy (i.e., alcohol, opioids, non-prescribed prescription drugs). The availability of additional empirical data will help delineate risk-benefit decision-making regarding harm reduction approaches for pregnant women, particularly data regarding the extent to which low levels of cannabis exposure are associated with adverse outcomes.
Breastfeeding among postpartum patients using cannabis can pose an additional risk of exposure for infants due to cannabis compounds in breast milk. Harm reduction approaches include recommending CU after breastfeeding and/or pumping and discarding breastmilk after use. Challenges with these harm reduction interventions include the limited evidence available for the overall risk of the use of cannabis in pregnancy and infancy.
Given nationwide trends of increased use of cannabis in pregnancy, clinicians across specialties must be familiar with how to provide targeted education, support, and treatment alternatives for cannabis use in pregnancy. Data regarding adverse outcomes associated with cannabis use during pregnancy and lactation are inconsistent and limited; it is currently recommended that women avoid cannabis use during pregnancy. However, due to the sole emphasis on cessation, women regularly using cannabis to treat underlying symptoms (e.g., anxiety, appetite problems, nausea, pain, and sleep issues) are often left without options. It is essential that providers not only screen for cannabis use in pregnancy, but also inquire about patients’ reasons for use, and discuss potentially effective alternatives for those interested in discontinuing cannabis during the perinatal period. This will increase the overall alliance between patients and providers and allow for shared decision-making with pregnant patients regarding cessation, alternative therapies, and/or harm reduction approaches.
Jenny McManus MD MPH is a second-year resident in emergency medicine in the Department of Emergency Medicine at the Warren Alpert Medical School at Brown University. She previously completed her psychiatry residency in the Department of Psychiatry Human Behavior at the Warren Alpert Medical School of Brown University, and is working towards dual board in psychiatry and emergency medicine.
Ms. Halwes is a Research Assistant working with Dr. Cynthia Battle at the Warren Alpert Medical School at Brown University. She recently completed her undergraduate training at Vanderbilt University with majors in Honors Psychology and Child Development.
Dr. Abrantes is Professor of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University and Co-Director of Behavioral Medicine and Addictions Research at Butler Hospital. Dr. Abrantes has extensive clinical and research experience in the development of interventions for individuals with substance use disorders. These research efforts have focused on testing health interventions (e.g., physical activity) using of technology-supported approaches such as wearable monitors (e.g., Fitbits, smartwatches), device-based interventions (e.g., tDCS), and smartphone app development and testing.
Dr. Battle is Professor of Psychiatry & Human Behavior at the Warren Alpert Medical School of Brown University and Associate Director of the Psychosocial Research Program at Butler Hospital. Her research focuses on women’s mental health, in particular developing and testing novel non-pharmacologic interventions for mental health conditions during pregnancy and the postpartum period. She received her Ph.D. in clinical psychology from the University of Massachusetts Amherst, and completed NIH funded postdoctoral training in treatment intervention research at Brown University.
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