SUBSTANCE USE DISORDERS
Public endorsement for potential benefits of the marijuana plant is at an all-time high. To date, 33 states and the District of Columbia have responded by legalizing “medical marijuana,” with 10 states also having legalized recreational use. The current practice is said to be ahead of science, as robust research has been hindered by strict regulations and most epidemiological studies point towards harmful associations. Yet the general population turns to this botanical while seeking self-remedies for various ailments and conditions for which other, evidence-based, treatment modalities exist. As physicians, we have seen some of the outcomes associated with use, particularly in vulnerable populations with underlying mental health and addictive disorders, as well as adolescents and—for the purpose of this article—pregnant individuals.
The Center for Disease Control (CDC) estimates that 16.2% of pregnant women between the ages of 18 and 44 are daily users and of all illicit cannabis is the most commonly abused by this population.1 Estimates also indicate that between 2009 and 2016 cannabis use among pregnant females has nearly doubled, with young age being positively correlated with use.2 Given the decreased perception of harm by the general public, women are certainly compelled to seek what they perceive as more natural self-management remedies.
Aside from continuation of use if already smoking at the time of pregnancy, some take up cannabis to manage morning sickness and overall nausea and vomiting. A study was recently done in Colorado where researchers identified as pregnant women and contacted dispensaries for guidance in managing pregnancy-related symptoms.3 Close to 70% of dispensaries contacted recommended products to treat symptoms particularly in the vulnerable first trimester, while 36% of theme also provided reassurance of the safety profile. Very few even encouraged a discussion with the physician.
Consumption of cannabis during pregnancy results in cannabinoid placental crossing and accumulation in the fetal brain, and other organs, where it interferes with neurodevelopment and the endocannabinoid system.4 Use during the postnatal period can also lead to secretion in breast milk for extended periods (up to a week) after last use. From retrospective studies, we know prenatal cannabis ingestion has been associated with anemia in the mothers as well as low birth weights, greater risk of preterm and stillbirths, as well as increased need for neonatal intensive care unit admissions.5
Although there is no phenotypic syndrome and no overt birth defects, a review of two longitudinal studies indicates the majority of the teratogenicity translates later in life, beyond the infant developmental stage. Children born to mothers who used during pregnancy have higher rates of impulsivity, delinquency, learning and memory impairment, as well as executive function deficits.6 There is also an increased association with psychosis proneness during middle childhood.7
Given that most human studies are observational and retrospective, we turn to animal studies in attempts to go beyond determinations of associations. Studies using rodent models hint at a variety of long-term neurobiological changes in a multitude of systems, particularly the neuroendocrine system, as well as the dopaminergic and glutamate neurotransmitter systems, resulting in behavioral impact later in life.8 Such behavioral consequences affect mnemonic processing and drug sensitivity but also to some extent emotional behavior and the development of locomotor activity.
The bottom line
In today’s era, it is important to be mindful of the increasing cannabis potency, as well as the different formulations and administration routes (ie. vaping), especially in light of the declining perceived risk among our patients. In 2018 the American College of Obstetricians and Gynecologists (ACOG) released guidelines advising physicians to screen for cannabis use in pregnant and breastfeeding women and encourage them to quit. This is a recommendation extended to all fields of medicine.
Furthermore, we shall not overlook the impact cannabis use can have on the mother during pregnancy, a stressful time at best. Cannabis use has been associated with increased incidence of anxiety, increased risk for developing depressive disorders, increased incidence of suicidal ideations and behavior, and increased symptoms of mania and psychosis in those with bipolar and schizophrenia spectrum conditions.9[PDF] Use of cannabis has also been linked to co-ingestion of other substances and alcohol, hence best practices would hint at screening for these as well in mothers who are using cannabis.
The author would like to acknowledge the contribution made by Karen Goodman, MSLIS, MA, medical librarian at the Dorothy M. Breene Memorial Library at New Hampshire Hospital, as she assisted with the literature search and procuration of the articles needed for this article.
Dr Stanciu is Assistant Professor of Psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH.
The author reports no conflicts of interest concerning the subject matter of this article.
1. Azofeifa A, Mattson ME, Schauer G, et al. National Estimates of Marijuana Use and Related Indicators - National Survey on Drug Use and Health, United States, 2002-2014. MMWR Surveill Summ. 2016;65:1-28. doi: 10.15585/mmwr.ss6511a1. https://www.cdc.gov/mmwr/volumes/65/ss/ss6511a1.htm. Accessed January 15, 2020.
2. Young-Wolff KC, Tucker LY, Alexeeff S, et al. Trends in Self-reported and Biochemically Tested Marijuana Use Among Pregnant Females in California From 2009-2016. JAMA. 2017;318:2490-2491. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5769923
3. Dickson B1, Mansfield C, Guiahi M, et al. Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. Obstet Gynecol. 2018;131:1031-1038. https://www.ncbi.nlm.nih.gov/pubmed/29742676
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5. Gunn JK, Rosales CB, Center KE, et al. Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis. BMJ Open. 2016;6:e009986. https://www.ncbi.nlm.nih.gov/pubmed/27048634.
6. Huizink AC, Mulder EJ. Maternal smoking, drinking or cannabis use during pregnancy and neurobehavioral and cognitive functioning in human offspring. Neurosci Biobehav Rev. 2006;30:24-41. https://www.sciencedirect.com/science/article/pii/S0149763405000953
7. Fine JD, Moreau AL, Karcher NR, et al. Association of Prenatal Cannabis Exposure With Psychosis Proneness Among Children in the Adolescent Brain Cognitive Development (ABCD) Study. JAMA Psychiatry. 2019;76:762-764. https://www.ncbi.nlm.nih.gov/pubmed/30916716
8. Schneider M. Cannabis use in pregnancy and early life and its consequences: animal models. Eur Arch Psychiatry Clin Neurosci. 2009;259:383-93. https://www.ncbi.nlm.nih.gov/pubmed/19572160
9. The Health Effects of Cannabis and Cannabinoids. Washington, DC: National Academies Press; 2017. https://www.nap.edu/resource/24625/Cannabis_committee_conclusions.pdf.