MARIJUANA IN No financial disclosures PREGNANCY: Now that it is - - PowerPoint PPT Presentation

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MARIJUANA IN No financial disclosures PREGNANCY: Now that it is - - PowerPoint PPT Presentation

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DISCLOSURES MARIJUANA IN No financial disclosures PREGNANCY: Now that it is legal June 7, 2018 42 nd Annual Antepartum and Intrapartum Management Lena H. Kim, MD MFM, Sutter Health, California Pacific Medical Center AUDIENCE RESPONSE

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SLIDE 1

MARIJUANA IN PREGNANCY:

Now that it is legal…

June 7, 2018 42nd Annual Antepartum and Intrapartum Management Lena H. Kim, MD MFM, Sutter Health, California Pacific Medical Center

DISCLOSURES

  • No financial disclosures

LEARNING OBJECTIVES

  • Current trends in marijuana use
  • Marijuana history

– Marijuana legalization

  • Medicinal use
  • Risks in pregnancy & lactation
  • Patient counseling

AUDIENCE RESPONSE QUESTION #1

What percentage of your pregnant patient population uses marijuana?

  • A. 0%
  • B. <10%
  • C. 10-20%
  • D. >20%
  • E. I don’t know

0% <10% 10-20% >20% I don’t know

2% 19% 10% 26% 44%

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SLIDE 2

MARIJUANA FACTS

  • Cannabis plant

– Tetrahydrocannabinol (THC)

  • 482 other compounds
  • ~65 other cannabinoids
  • Also known as cannabis, pot, weed…
  • Most commonly used illicit drug

– Smoke, vape, edible, extract

  • Self-reported prevalence of use in pregnancy

– 2-5%

  • 15-28% in young, urban, low SES women

– 34-60% of users continue in pregnancy

Van Gelder et al. Drug Alcohol Depend 2010 Beatty et al. J Addict Res Ther 2012

MARIJUANA USE INCREASING WITH LEGALIZATION

  • National Survey on Drug use and Health

– Trends in marijuana use 2002-2014 – Cross-sectional, nationally representative survey – In-person audio computer-assisted self-interviews

  • 200,510 reproductive age women

– 5.3% pregnant (n=10,587)

  • Adjusted prevalence past-month use in pregnancy

– Increased 62%

  • 2002 2.37%
  • 2014 3.85%

Brown et al. JAMA 2017

PATIENT VIEWS OF MARIJUANA USE IN PREGNANCY

  • Cross-sectional convenience sample survey

– Women presenting for prenatal care – 306 women

  • 35% current use

– 96% reported use for nausea – 34% planned to continue use in pregnancy

  • 70% acknowledged risks
  • 62% cited risk as reason to cut back or quit
  • 10% more likely to use in pregnancy if legalized

Mark et al. J Addict Med 2017

AUDIENCE RESPONSE QUESTION #2

Do you think that marijuana use in pregnancy is harmful?

  • A. YES
  • B. NO
  • C. MAYBE
  • D. I don’t know – that’s why I am here

Y E S N O M A Y B E I d

  • n

’ t k n

  • w

– t h a t ’ s w h y I . . .

58% 14% 23% 6%

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SLIDE 3

MARIJUANA EFFECTS

  • CNS effects via cannabinoid receptor type 1
  • Euphoria “high”

– Anxiety, paranoia, fear or panic

  • High potency (THC content) increasing
  • 1990

4%

  • 2014

12% (some as high as 37%)

  • Heightened sensory perception

– Impaired motor skills (MVA) – Decreased short term memory

  • Increased appetite

ORIGINS OF MARIJUANA

  • Cannabis plant Central Asia

– Africa – Europe – The Americas

  • 500 BC herbal medicine

– Asia

  • 800 AD hashish

– Middle East & Asia

LEGAL STATUS OF MARIJUANA IN THE UNITED STATES

  • 16th century cannabis cultivation in America

– Hemp fibers: textiles & rope – VA, MA, CT required farmers to grow hemp

  • Early 1900s recreational use introduced
  • 1931 cannabis outlawed in 29 states

– Prohibition 1920-1933

  • “Evil weed”

CRIMINALIZATION OF MARIJUANA

  • 1937 Marijuana Tax Act

– 1st Federal U.S. law to criminalize marijuana – Excise tax on sale, possession, transfer of all hemp products

  • Criminalization of all but industrial uses of marijuana

– 1st American jailed was a farmer

  • Hemp needed throughout WWII

– 1957 last hemp fields planted in Wisconsin

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SLIDE 4

WAR ON DRUGS

  • Controlled Substances Act of 1970

– Marijuana grouped with heroin & LSD – Schedule I drug

  • High potential for abuse
  • 1972 “The Shafer Commission” ignored

– “Marijuana: A Signal of Misunderstanding” – “Partial prohibition” – Lower penalties for small amounts of marijuana

MEDICAL MARIJUANA LEGALIZATION

  • The Compassionate Use Act of 1996

– California 1st state to legalize medical marijuana

  • Current count of legal medical use

– 29 states – District of Columbia – U.S. territories

  • Guam
  • Puerto Rico

RECREATIONAL MARIJUANA

  • 2012 Colorado & Washington 1st states to legalize

recreational marijuana

  • As of January 2018

– 9 states

  • AK, CA, ME, MA
  • NV, VT, OR

– District of Columbia

  • U.S. federal law

– Still illegal

MEDICINAL MARIJUANA HISTORY

  • 1830s cannabis extracts in India

– Decrease abdominal pain/vomiting of cholera

  • Late 1800s in Europe & U.S.

– “Stomach problems” & other ailments

  • 1985 FDA approved Marinol

– Cancer: chemotherapy related nausea

  • 2016 FDA approved Syndros

– AIDS: appetite loss

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SLIDE 5

OTHER MEDICAL USES

  • Chronic pain management

– Decrease narcotic dependence

  • Can’t overdose

– Neuropathic pain – Migraines

  • Multiple sclerosis muscle spasms
  • Childhood epilepsy (oil CBD >> THC)
  • Traumatic brain injury?
  • Bipolar disease?
  • Alzheimer’s disease?

PREGNANCY & LACTATION

  • THC small & highly lipophilic

– Animal models

  • Crosses the placenta
  • Fetal plasma levels 10% of maternal

– Found in breast milk

  • 2.5% of maternal dose

– Long half-life 20-36hr (4-5d if chronic)

  • Up to 30d to completely excrete

Baker et al. Obstet Gynecol 2018 Moir et al. Chem Res Toxicol 2008

TERATOGEN?

  • No clear association between marijuana and birth

defects

– Timing of exposure in pregnancy not always known

  • Marijuana exposure 1st month of pregnancy

– Odds of anencephaly increased to 2.5 – Possible confounding

  • Less folic acid supplementation

Fergusson et al. BJOG 2002 Ostrea et al. Pediatrics 1997

ADVERSE PERINATAL OUTCOMES

  • Increased risk of low birth-weight

– ≥Weekly use of marijuana increased risk

  • 11.2% vs 6.7%
  • RR 1.90 (95% CI 1.44-2.45)
  • Increased risk of IUFD

– RR 1.74 (95% CI 1.03-2.93) – Not adjusted for tobacco use

Campolongo et al. Psychopharmacology (Berl) 2011 Warshak et al. J Perinatol 2015 Conner et al. Obstet Gynecol 2016

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SLIDE 6

SPONTANEOUS PRETERM BIRTH

  • Majority of studies – no association
  • Adverse effects of smoking tobacco

– Possibly synergistic or additive effect

  • ≥ 1x Weekly use of marijuana increased risk

– 10.4% vs 5.7% – RR 2.04 (95% CI 1.32-3.17)

Ko et al. Drug Alcohol Depend 2018 Warshak et al. J Perinatol 2015 Conner Obstet Gynecol 2016 Chabarria et al. Am J Obstet Gynecol 2016

EFFECTS OF FETAL EXPOSURE IN CHILDREN

  • Impaired neurodevelopment

– Lower test scores

  • Visual problem solving
  • Visual-motor coordination
  • Visual analysis
  • Decreased attention span
  • Behavioral problems

– Aggression

Fried et al. Neurotoxicol Teratol 2003 Chandler et al. Alcohol Clin Exp Res 1996 Goldschmidt et al. Neurotoxicol Teratol 2000

OTHER LONGTERM EFFECTS

  • Predictor of marijuana use by age 14
  • Depression, anxiety
  • Controversial effect on school performance

– Middle SES children age 5-12

  • No difference

– Urban, low SES

  • Poorer reading & spelling scores
  • Lower teacher-perceived school performance

Fried et al. Neurotoxicol Teratol 1997 Goldschmidt et al. Neurotoxicol Teratol 2004 van Gelder et al. Epidemiology 2009

PROBLEMS WITH THE DATA

  • Limited data

– Difficult to study an illegal drug

  • Many confounding exposures

– Polysubstance use

  • Tobacco, alcohol, other drugs

– Low SES

  • Malnutrition (folic acid)

– Intimate partner violence

  • Reporting & recall bias
  • Increasing potency over time

Alhusen et al. J Pediatr 2013 Mehmedic et al. J Forensic Sci 2010

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SLIDE 7

ACOG COMMITTEE OPINION #722

“Because of concerns regarding impaired neurodevelopment, as well as maternal and fetal exposure to the adverse effects of smoking, women who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use.” “There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.”

Updated 9/22/17 (replaces #637, 7/2015)

PATIENT CASE

  • 30yo G0 @10 weeks GA with a history of chronic

pain seeing you for a new OB visit.

PRENATAL CARE

  • Universal screening for tobacco, alcohol, & drug use

including marijuana

PATIENT CASE

  • 30yo G0 @10 weeks GA with a history of chronic

pain seeing you for a new OB visit.

– Uses medical marijuana daily to control her pain – In the past, used narcotics

  • Was not always prescription
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SLIDE 8

PROVIDERS’ COUNSELING RESPONSES

  • Content analysis of audio-recordings

– 468 patient-health care provider 1st prenatal visits

  • 90 (19%) of patients disclosed marijuana use

– 48% of the time, providers did not counsel

  • 86% of tobacco use disclosure  counseling
  • 47 counseling results

– 33 punitive (urine tox screening, CPS) – 34 supportive – 26 medical counseling of risks

Holland et al. Obstet Gynecol 2016

PATIENT COUNSELING

  • Reassure your patient

– Screening is NOT to punish or prosecute – Screening IS to identify, educate, help

  • Discuss with your patient

– Potential adverse health consequences

  • Shared decision-making

– Marijuana less risk than illegal narcotics? – Other medical options

KEY REFERENCES

  • ACOG Committee Opinion #722

– Updated 9/22/17, replaces #637 from 7/2015

  • Chabarria KC, Racusin DA, Antony KM, Kahr M, Suter MA, Mastrobattista JM,

et al. Marijuana use and its effects on pregnancy. Am J Obstet Gynecol 2016;215:506.e1-7

  • Conner SN, Bedell V, Lipsey K, Macones GA, Cahill AG, Tuuli MG. Maternal

marijuana use and adverse neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol 2016; 128:713-23

  • Metz TD, Stickrath EH. Marijuana use in pregnancy and lactation: a review of

the evidence. Am J Obstet Gynecol. 2015 Dec;213(6):761-78.

THANK YOU