Marijuana in Pregnancy Kimberly Butt MD, FRCSC, MFM Fredericton, NB ASOG September 15,2017
Outline Background Biologic effects Legislation Concerns for pregnancy Concerns for breast feeding Summary
Disclosure I have no potential conflict of interest to disclose I am not an expert on marijuana
Cannabis vs. Marijuana Used interchangeably Cannabis often used/preferred by physicians and researchers Latin root Marijuana comes from Mexican/Spanish used a lot during the last century of prohibition THC active psychogenic metabolite, delta-9- tetrahydrocannibinol
Medical vs. Recreational if used to treat an underlying medical issue it is considered medical application lifestyle enhancement is considered recreational
Prevalence 10.6% Canadians 15 and older report pastyear use in 2013 (CTADS) 22.4% age 15-19; 26.2% aged 20-24 27% who use Cannabis in the last 3 months do so daily (Health Canada 2013) Conflicting information on the health risk associated with marijuana and emerging evidence supporting the use for specific medical purposes
Cannabis Most commonly used illicit drug in Canada Psychoactive drug from the Cannabis plant Main psychoactive ingredient is THCtetrahdrocannabinol 65 other cannaboids Can be smoked, vaporized, eaten in food and taken as an extract.
Pharmacology Highly lipid soluble Persists in body for a long period of time. THC can be found in the body for weeks and or longer depending on quantity particularly the lipid membrane of neurons Effects CB 1 (central CNS)and CB 2 (peripheral)receptors CB 1 receptor in the brain increases dopamine and the psychotropic effects (mood and cognition)
Testing Maternal urine, serum: 2-3 days in occasional users/ several weeks, chronic users Maternal hair: several weeks Meconium: positive result indicates second and third trimester exposure Neonatal hair: positive result indicates third trimester exposure
Effects Effects: high / stoned feeling euphoria, change in perception, increased appetite Side Effects: decreased short term memory, dry mouth, impaired motor skills, red eyes, and paranoia and anxiety. addiction, decreased mental ability (when started as a teen), behavioral problems.
Legislation Marijuana for Medicinal Purposes Regulation (MMPRs) Introduced in June 2013 by Health Canada Healthcare practitioners are responsible for providing a medical document (prescription) to authorize patient access to marijuana from a licensed supplier. Three forms of marijuana-based pharmaceutical drugs approved by Health Canada. Dronabinol(pill), nabilone(pill), and nabiximols(spray)
Licensed Producers/ Dispensary The only legal way to buy marijuana in Canada is through a licensed producer (LP). There are 38 and counting licensed by Health Canada to grow or sell to patients Once you have a valid prescription you register with an LP, place an order online or by phone and wait for delivery to your home. Dispensaries are not technically legal and operate with varying intentions
Physician Guidelines College of Family Physicians of Canada released guidelines in 2014. Agreement that: Evidence lacking on indications, dosage, interactions, risk and benefits First exhaust conventional treatments CFPC- consider only for neuropathic pain that has not responded to other treatments
Clinical Trials Information for Health Care Professionals: Cannabis and the Cannabinoids [Health Canada 2013] 138 pages. Reviews all the clinical trials at the time.
Potential Indications Palliative care Nausea/vomiting Wasting syndrome Loss of appetite with cancer/anorexia/aids MS, ALS, spinal cord injury Epilepsy Acute/chronic pain Arthritis Movement disorders Glaucoma Asthma Hypertension Psychiatric disorders Alzheimer/dementia Inflammation GI disturbance Anti-neoplastic properties
Legislation: Non-Therapeutic Use Proposed Cannabis Act Target date for implementation is July 2018 Hope to create a strict legal framework for controlling the production, distribution, sale and possession across Canada No person could sell or provide cannabis to those under age of 18. Over age 18 or older you could possess, share, purchase, grow make cannabis/products
Legislation Federal Government: set strict requirements for producers set industry-wide standards Provinces/ Territories: Oversee distribution and sales Could increase the minimum age Lower the possession limit Create additional rules for growing Restrict where it is consumed publicly
Sources of Information Provincial colleges New Brunswick Medical Society has developed It s Your Choice Campaign Legal Not Safe : Recreational Marijuana Doctors Nova Scotia has a statement on Legalizing Marijuana NL and PEI do not comment on the websites
Clearing the Smoke on Cannabis Maternal Cannabis Use during Pregnancy-An Update Prevalence 11% of women childbearing age use cannabis 5% admit illicit drug use in pregnancy (cannabis not specified) up to 25-30% in inner city populations Endocannabinoid system plays a significant role in many developmental processes in the embryonic brain (proliferation, differentiation, neuronal development, neurotransmitter and behavioral disturbances). Significant potential to influence postnatal development and behavior Porath-Waller, Director CCSA
Pregnancy Outcomes After controlling for tobacco, alcohol and other drugs and demographic characteristics: Not associated with preterm birth Not associated with miscarriage Not associated with physical abnormalities In the Ottawa Prenatal Prospective Study Mothers who use THC 6 or more x / week have approx 1 week reduction in pregnancy gestational age at delivery Porath-Waller, Director CCSA
Pregnancy Outcomes Report of increased hyper-telorism, severe epicanthus 5x increase in features of FAS Meta-analysis of over 10 studies found only weak evidence of association with reduction in birth weight and low birth weight. Porath-Waller, Director CCSA
Neurocognitive Functioning Maternal use has subtle effects on children s neurocognitive functioning. General intelligence does not appear to affected. Porath-Waller, Director CCSA
Neurocognitive Functioning 18 month Increased aggressive behavior Attention deficits (females) 3-6 years Verbal and perceptual skills Verbal, visual and quantitative reasoning Short term memory Hyperactivity Attention deficits Impulsivity Impaired vigilance 9-10 years Deficits in: abstract and visual reasoning Executive functioning Reading Spelling Hyperactivity Attention deficits Impulsivity Depressive and anxious symptoms
Neurocognitive Functioning 14-16 years Deficits in: Visual-cognitive functioning Academic achievement Information processing speed Visual motor coordination Delinquency 17-22 years Deficits in: Executive function Response inhibition Visuospatial working memory Smoking Substance use Early initiation of substance use
Behavioral Effects Less clear before the age of 6 yrs. After 6 years: More hyperactive Inattentive Impulsivity At 10 years: Increased hyperactivity Inattention Impulsivity Increased delinquency Externalizing problems Age 14: More frequent initiation and daily cigarette smoking, cannabis use
Other Mental health More depressive and anxious symptoms at age 10. An area that requires further research.
Marijuana in Pregnancy SOGC Position Statement (May 2017) Concern that it is most commonly used illicit drug in pregnancy Legalizing cannabis will result in increased use Evidenced based data shows: Adversely affect growth Adversely affect development Long-term learning and behavioral consequences Additional concern about maternal and fetal effects of smoking exposure Adverse effects can be life long
SOGC Women who are pregnant or considering pregnancy abstain from cannabis use during pregnancy HCP discuss potential adverse health effects and recommend to discontinue to those who are/or contemplating pregnancy Cannabis for medicinal purposes strongly discouraged in favor of other therapies Abstain during lactation and breastfeeding Further research Public education be funded
ACOG Review Marijuana use in pregnancy and lactation: a review of the evidence Summary: Growth - literature inconsistent Stillbirth - may be increased but needs further study because of possible confounding by tobacco use. Preterm birth - literature inconsistent (potential confounders). Congenital anomalies - literature does not support an association Neurodevelopment concerning pattern of altered neurodevelopment with early, heavy maternal use of marijuana Metz et al December 2015
ACOG Review Marijuana use in pregnancy and lactation: a review of the evidence Breast feeding: Amount the reaches infant 0.8% of maternal exposure In studies it is difficult to ascertain the difference in prenatal and lactation exposure as 84% of mothers did both. AAP statement says breast-feeding is contraindicated with illicit drugs. More information is needed. Metz et al December 2015
ACOG-Committee Opinion 2015 Recommendations: All women before or during pregnancy should be asked about use of tobacco, alcohol, marijuana and other drugs used for non-medical purposes Because of concerns regarding adverse neurodevelopment, adverse fetal effects of smoking, women who are pregnancy or contemplating pregnancy should be encouraged to discontinue use.
ACOG Ob-Gyn should be discouraged from prescribing or suggesting the use of marijuana for medical purposes during preconception, pregnancy and lactation. Alternative therapies with better pregnancyspecific safety data Marijuana use is discouraged during lactation and breastfeeding as there is insufficient data.
ABM Clinical Protocol #21 (2015) Carefully weigh the risks of not breastfeeding with the risks of continuing to breast feed wile using marijuana, while also considering the wide range of exposure. THC (the main compound in marijuana) is present in breast milk up to 8 x the level in maternal plasma Metabolites are found in infant feces indicating it is absorbed and metabolized by the infant.
ABM Clinical Protocol #21 (2015) It is rapidly distributed to the brain and adipose tissue It is stored in fat tissue for weeks to months It has a long half life (25-57 hours) Stays positive in urine for 2-3 weeks Evidence of THC exposure by breast feeding alone is sparse No data evaluating infant outcomes beyond 1 year. Potency has increased from 3% in 1980s to 12% in 2012. Concerns about infant sedation and maternal inability to care for infant under the influence remains a theoretical concern.
ABM Clinical Protocol #21 (2015) Endocannabinoid system plays a crucial role in the ontogeny of the CNS. THC exposure during critical periods of brain development can induce subtle long-lasting neurofunctional alterations (cognitive functions and emotional behaviors) Second hand smoke increases 2x risk for SIDS.
ABM Clinical Protocol #21 (2015) Summary A. Occasional/rare use: avoid or reduce use while breastfeeding. Advise of potential for adverse long term neurobehavioral effects and avoid direct exposure to THC and smoke. B. Advise women with a positive urine screen to discontinue exposure while breastfeeding C. Medicinal use. Review potential risks and benefits D. Moderate/chronic use: Abstaining from any marijuana use is warranted. Urge caution with any marijuana use.
Summary Information is limited, more research needed Neurobehavioral outcomes are concerning These effects may not be evident until the child is older Effects of smoking concerning Legalizing it will make use more prevalent in pregnancy Talk to your patients about it
References Porath-Walker, A. Clearing the Smoke on Cannabis. Maternal Cannabis Use during pregnancy-an update. Canadian Centrre on Substance Abuse, 2015. Metz, T. Marijuana use in pregnancy and lactation: a review of the evidence. AJOG December 2015. NBMS. Legal Not Safe: Recreational Marijuana. (https://www.nbms.nb.ca/leadership-andadvocacy/helping-newbrunswickers-live-healthier. Marijuana for Medical Purposes. CCSA. Policy Brief 2015 Marijuana. CCSA. July 2017.
References Wong S,et al. Substance Use in Pregnancy. SOGC CPG. April 2011. 367-80. Marijuana Use During Pregnancy and Lactation. ACOG. Committee Opinion, July 2015. Reece-Stremtan A, et al. ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, revised 2015. SOGC Position Statement: Marijuana Use during Pregnancy. May 9,201. What You Need to Know About Marijuana Use and Pregnancy. CDC 2017.
References Legalizing and Strictly Regulating Cannabis: The Facts. GOC. 2017. Information for Health Care Professionals: Cannabis and the Cannabinoids. Health Canada 2013. 138 pages.