This is part of a series of posts commenting on a recent paper on cannabis and parenting. In these analyses, I offer my years of experience reading and writing scientific papers along with a perspective centered in mammalian physiology and harm reduction. This often results in an view that is different from the headlines that report the publishing of these papers.

This post is about the recent publication in Obstetrics and Gynecology (a leading ObGyn journal in the US), "Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. 1 "

You can read the paper here and I have also included my summary of the paper itself at the end of this blog post.

There is a lot I could say about this paper - but today I will discuss several of the thoughts this paper brought to the forefront for me.

My initial thought.

I understand that doctors, health care providers and public health officials want folks to know that using cannabis during pregnancy is a largely unknown science and the risks and benefits are still unclear. But to assert that dispensaries are offering personal opinion rather than medical evidence - and that is somehow different from the medical-legal-public health establishment - is a false claim. The medical establishment has a long way to go in their ability to offer unbiased, non-punitive, evidence-based care, most especially in maternity care. I would love to believe that this paper highlights the need for education on all sides, and I worry that it will simply end up being another assertion from the dominant paradigm that the marginalized narrative simply needs to “get in line.” (an assertion we see already, see this Westword article.)

Despite the fact that the liberalization of cannabis in Colorado has moved it from the margins to the center of attention, the idea of cannabis as an “illicit” substance still exists. More importantly, the reality of cannabis being scheduled as a controlled substance still impacts the dominant conversation dramatically in ways that prevent a harm reduction, nuanced approach. I would love to start talking about how to really bridge this gap between parents who use cannabis and their health care providers, but I am concerned that the opposite is true in Colorado right now. From where I stand, it often looks like the process of figuring out cannabis liberalization is widening the distance between pregnant/breastfeeding cannabis consumers and their health care providers, creating a climate of fear and retribution that will inhibit future conversations. This paper provides many examples of the way the gap is being forged, not bridged, by the research/medical/legal communities in Colorado.

1. The medical community is not seen as the best place to talk about medicinal cannabis use when you are pregnant. Though the paper places blame on the willingness of budtenders to give personal opinion, the truth is that the majority of health care providers are unwilling or unable to have a risk/benefit conversation about prenatal cannabis use.

As the authors noted early in the paper, women of reproductive age often feel uncomfortable talking with their health care providers about their cannabis use during pregnancy and parenting. This certainly reflects my experiences talking to pregnant and parenting cannabis users in Colorado over the past five years. In my experience (which, in this case, is also is backed by the scientific literature on this topic), almost no one starts using cannabis during pregnancy. And of the folks who continue using cannabis during pregnancy, many make a specific, explicit decision to do so based on their own best risk/benefit analysis. Much of the time these folks would be happy to consult a medical professional, but make the conscious decision to not talk about cannabis use with their health care providers. This decision not to talk to medical professionals about cannabis use is generally rooted in one of a few concerns, 1) an abstinence-only approach being the only available conversation, 2) fear of judgement, 3) fear of retribution of some kind.

Rarely do I hear a pregnant person feel like they have an MD who will work with them if they decide cannabis is the best medicinal choice, as ACOG recommends an abstinence-only approach with little information beyond a risk-centered analysis. And it isn’t because OBs are not able to have nuanced conversations - because they do find ways to have risk/benefit analyses about other medications. For example, SSRIs, a class of medication to treat depression, can result in respiratory challenges in the newborn at birth. Even with that risk, there are times when the risk of a woman who is both pregnant and depressed is greater than the risk of newborn respiratory challenges. And so OBs have an individualized conversation about the risk/benefit analysis with an eye for the wellbeing of the fetus and the gestating parent. This is not the kind of conversation the medical community is generally willing to have about cannabis.

The other problem I see with an abstinence-only conversation is the bias it must hold against someone who is, in fact, using cannabis during pregnancy. The fear of judgement by health care providers is real and drives pregnant folks to talk to someone other than their doctors about cannabis for morning sickness (like a dispensary). The fear of retribution is mentioned by the authors and is also a very real fear. Medical professionals are mandatory reporters - meaning they must report child abuse and neglect. In the state of Colorado, a positive test for exposure to cannabis in utero is defined as child abuse and neglect. I have spoken with many OBs, nurses and pediatricians who feel the tension of caring for a patient and being a mandatory reporter. These providers tell me that they feel that reporting prenatal substance use to the Department of Human Services is the most cautious approach to mandatory reporting and is, therefore, how they approach that element of their work. Unfortunately, this has the long-term effect of reinforcing the worry about personal and legal retribution from their health care providers, and it discourages pregnant and parenting folks from talking about their cannabis use.

This paper highlights how cannabis users do not feel there is an accessible, non-judgmental, non-punitive conversation to be had with their medical care providers. In fact, health care providers receive little support in promoting harm reduction, and public health agencies and professional organizations continue to center the potential risk of cannabis to a fetus being the reason for an abstinence-only approach. While the authors contend that budtenders are often not giving advice “informed by medical evidence,” I contend that the medical establishment is not either.

2. I wish we were talking about what we learned from the “crack baby epidemic.”

(Or, what happens when we focus only on the risk and harm of the particular substance being discussed or researched.)

Our scientific inquiry into the topic of prenatal cannabis exposure, both historically and currently, has been largely funded by organizations invested in demonstrating harm or risk associated with substance exposure in utero (ie. National Institutes of Drug Abuse, March of Dimes). There is great risk in this approach because of the bias that exists in such a situation - risk that has been documented since the “crack baby epidemic.”

The quest to show the harm of prenatal crack exposure to babies resulted in 30 years of funded research that primarily demonstrated the harm of poverty on the development of babies and children. The crack baby epidemic also allowed us to quantify the harm of the “null-hypothesis,” the idea that only papers that show differences between groups are selected for publication and/or presentation. If a study shows no differences between exposed and unexposed fetus’, infants or children, it rarely becomes a part of the scientific literature. Combined, these two elements can create a body of medical evidence that is centered only in harm/risk and is without a broader discussion of a risk/benefit analysis. In the case of cannabis, the literature is murky enough that most medical professionals are having an abstinence-only conversation based on the potential for risk. This is in stark contrast to conversations about alcohol, cigarettes and caffeine, all with known, demonstrated risk to the fetus. In the case of these substances, abstinence-only might be the starting point for the conversation, but the conversation often proceeds to a more nuanced, individualized risk/benefit analysis.

3. I am just plain tired of the language that characterizes pregnant women as either ignorant of the risks of certain substances or harming their babies on purpose - and both states require management from a medical professional.

I often wonder “What outcome do the authors or the public health campaign writers expect as a result of a scare tactic approach?” It seems they believe that if we just appropriately scare the pregnant folks with a clear explanation of the risks involved in prenatal substance use, we will educate the ones simply making a bad decision with bad information, and they will then make a good decision (to not expose their fetus to these risks). Problem solved. And the ones that keep using prenatal substances even with all of the properly scary information? Their bad, selfish decision-making will be revealed, making it clear they are the parents we should worry most about. This approach has not been successful with cigarettes or alcohol, yet his perspective drives much of the language I hear from the medical-legal discussion on prenatal substance use, and I think it is problematic.

I object to the phrase, “Future studies should focus on the effects of maternal cannabis use on maternal and neonatal outcomes in hopes of being able to provide guidelines to care for pregnant women.” (emphasis mine). If we are talking about the risk of cannabis exposure on the fetus, let’s not rephrase it as the risk of maternal cannabis use. It reduces pregnant women to incompetent incubators - instead of caring parents making a choice they believe is in the best interest of their entire family and all its members. It prioritizes the wellbeing of the fetus over that of the mother and sets up a dynamic where the medical-legal system takes the view that it is in the best interest of the baby to protect it from its mother. As a result, separation of mothers and babies at birth is common even though this is a practice known to cause harm to both parents and babies.

The other issue I have with this phrase is that it centers the conversation only on the risk to the fetus and not on the potential risk or harm of maternal substance use on the mother herself. What if we were concerned about BOTH the risks to the fetus AND the risks to the mother? Moreover, what if there were potential benefits of prenatal substance use for babies or mothers? Though it may sound counterintuitive that there could be benefits, that is only because our conversation is so centered on (potential) risks. Remember our SSRI example? Exposure to SSRIs have the benefit of not being gestated by a depressed mother. It turns out depression is more harmful than the medication.

The current abstinence-based conversation does not provide the nuance to hold concern for both the baby and the mother. And truth be told, neither does the research. The vast majority of the research on the “effects of maternal cannabis use” look only at fetal, newborn and child outcomes. I have not seen any papers from the longitudinal studies that examine and report the wellbeing of the parents or family.

I also object to the second part of this phrase, that future research should be done “in hopes of being able to provide guidelines to care for pregnant women.” This language reinforces the idea that the best use of our research dollars is to provide guidelines for the people caring for pregnant women. Be very clear, we are not looking to produce guidelines for the women to use themselves - so that they can make good decisions in consultation with their care providers. Instead, the research is designed by the care providers for the care providers and overlooks pregnant and parenting women as valid stakeholders altogether. The narrative of the power being in the hands of the “well-informed expert” who will manage the clinical situation over the person actually experiencing the pregnancy is endemic in the maternal-pediatric health system in the U.S. This narrative, and this power dynamic, displace the pregnant person as an expert in their own experience and ultimately strips pregnant and parenting folks of the authority and autonomy to make good decisions for their families.

This language - these particular phrases - are pervasive in medical-legal conversations about pregnancy substance use (which, by the way is generally considered synonymous with substance abuse), and I think there is harm in talking about this issue this way. We all know I am passionate about language and how it is a powerful tool. That is also true here.

4. We need to remember that we don’t evaluate the safety of most of the substances used and prescribed during pregnancy.

Near the end of the paper, the authors say, “expanding legalization may increase use among pregnant women and may be accompanied by increased perception of safety without data to assure safety.” Let me be very, very clear here. In the United States, we almost never collect prospective data on the safety of any drugs prescribed during pregnancy. That is not how scientific research works. We do not believe in experimenting on pregnant folks, so we do not collect data (aside from anecdotal data) to evaluate the safety of much of anything prescribed during pregnancy. The vast majority of drugs used in pregnancy - Zofran included, the most commonly prescribed drug for morning sickness despite never having been approved in the US or anywhere for use in pregnancy - have not been evaluated for their safety. In clinical trials, pharmaceutical drugs are generally tested for safety on white males, the results are extrapolated to the rest of us, and these drugs are then used by collective agreement (based on data that say that more than 60% of practices by ObGyns are based on community consensus2). The bar for “illicit,” whole plant medicines is much, much higher. Which is part of why the cannabis research is even more limited than pharmaceuticals prescribed in pregnancy.

5. If we are going to talk about risks and harms, let’s be thorough. The risks and harms involved in cannabis use during pregnancy or parenting involve not only medical risks and harms, but legal ones as well.

I know that doctors are not lawyers, but the myopic view that health risks should be the primary concern of pregnant families is just that, myopic and missing the bigger picture. In this country, we have decided to regulate and legislate actions of pregnant individuals with the idea that it protects children. In my view, what is missing in that perspective is that the vast majority of the time, when we resource parents with information and support, we resource kids as well.

There are real, harmful, legal risks to using cannabis when you are pregnant in Colorado. To talk about the potential health risks without also highlighting that one of the definitions of child abuse and neglect in Colorado law is a positive test for fetal exposure to cannabis at birth is irresponsible. I believe it is the responsibility of the doctors counseling and researching prenatal cannabis use to understand the legal implications as well.

And I don’t think this is too much to ask. Doctors and nurses already participate in the legal part of the medical-legal system. As mandatory reporters, they are already drawn into the medical-legal ways we manage pregnant people, though (in my experience) they are sometimes unsure how to navigate that intersection. They want to care for the health care of pregnant, laboring and parenting folks. But Colorado law requires they also be a site of investigation. This tension is felt by providers and consumers alike. Continuing to publish papers that ignore this tension serves no one.

6. The final statement of this paper is this: “Public health initiatives should consider collaborating with dispensary owners and other valuable stakeholders in conversations about standards for advice provided to pregnant women.”

I agree wholeheartedly! And I wish I felt this paper was a step in that direction. And I hope that this statement includes parents as stakeholders as well, not just agencies or organizations or retail operations.

But unfortunately, once again, this statement feels like the medical establishment asserting their superiority in the cannabis conversation. Positioning themselves as the experts over pregnant folks and dispensaries, both of whom might already be having more nuanced, harm reduction conversations based in evidence. Despite what the results of this study may indicate.

It makes me wonder sometimes, “What do doctors and agencies think will happen as a result of their abstinence-only position?” And in the case of this paper, “What does the medical-legal-public health establishment think parents who use cannabis will say when they invite them to a discussion that only includes the potential risks of perinatal cannabis use?” Do they believe they are bridging informational and emotional distance between practitioner and patient? Both consumers and dispensaries battle bias and discrimination from health professionals and agencies, making a non-punitive conversation between equal stakeholders out of reach. This research does not feel like a step towards including consumers or dispensaries in the conversation, rather a reminder that they don’t hold the “correct” information and are not to be considered equal stakeholders in a conversation about perinatal cannabis use.

For me, both the study design and presentation of the results of this paper feel like the medical establishment attempting to shame dispensaries and pregnant folks into talking to their doctors. This is unfortunate. In my experience, shaming techniques rarely work during prenatal care. The doctors who provide care for folks who use substances during pregnancy with a non-punitive, open and transparent relationship generally see the best results in improving the wellbeing of both the infant and their parent(s).

To close.

I am going to come full circle here and simply repeat what I said in the beginning. From where I stand, it often looks like the process of figuring out cannabis liberalization is widening the distance between pregnant/breastfeeding cannabis consumers and their health care providers, creating a climate of fear and retribution that will inhibit future conversations. This paper provides many examples of the way the gap is being forged, not bridged, by the research/medical/legal communities in Colorado.

References:

1. Dickson, B. et al. Obstet. Gynecol. 131, 1031–1038 (2018), 2. Wright, J. D. et al. Obstet. Gynecol. 118, 505–12 (2011).

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The gist of the paper:

Two folks from Denver Health (the major public hospital in Denver, CO) called 400 dispensaries (medical, recreational and both), posing as a pregnant person, 8 weeks along, looking for relief from morning sickness. The majority (69%) recommended a cannabis product primarily (65%) based on personal opinion. The paper states that 82% of the budtenders suggested the “pregnant” caller talk with a medical professional, but many but only 32% mentioned a health care provider without being asked about it by the caller.

Introduction and primary objective:

The authors open the paper with the expected reference to the stance of the American College of Obstetricians and Gynecologists (ACOG), “obstetrician– gynecologists should be discouraged from prescribing or suggesting the use of marijuana for medicinal purposes during preconception, pregnancy, and lactation.” The authors follow with their concern that “expanding legalization may increase use among pregnant women and may be accompanied by increased perception of safety without data to assure safety.”

They acknowledge that “Pregnant women who are interested in using marijuana may refrain from seeking safety information from health care providers as a result of fear of legal repercussions and instead seek advice from cannabis retailers.” This concern leads to the study’s primary objective, “to estimate the proportion of cannabis dispensaries that recommended cannabis products to a caller posing as pregnant and experiencing nausea in the first trimester of pregnancy.”

What did they find?

The primary question of the paper asked how many dispensaries would recommend cannabis to a pregnant person for first-trimester nausea. Of the 69% dispensaries that recommended a cannabis product, 65% of the budtenders revealed that their recommendation was based on personal opinion. Medical dispensaries were most likely to base their recommendation on personal opinion (85%).

The secondary finding most highlighted by the paper and the subsequent press coverage was whether budtenders suggested the mystery caller talk to their health care provider. The study reports that, by the end of the call (which lasted about 2.5 minutes), 82% of the budtenders suggested the “pregnant” caller talk with a medical professional. The paper noted on several occasions that only 32% mentioned a health care provider without prompting; retail dispensaries were the least likely to mention a health care provider without prompting.

A few other statistically significant secondary findings were interesting. Nearly all (99%) dispensaries recommended a specific type of cannabis combination of THC and CBD with 26% recommending CBD-only products, 17% recommending THC only products and the remaining 56% recommending combination THC/CBD products. The finding that only 15% of budtenders warned the consumer of possible legal implications (medical dispensaries offered this warning more than other dispensaries) is not surprising, but is important. The legal implications of a newborn who tests positive for exposure to cannabis are a critical part of this public health conversation.

What did they conclude from these findings?

Pretty much what you would expect. They reiterated the professional organizational stance from the American College of Obstetricians and Gynecologists (ACOG): “given the concern for potential adverse effects on the fetus with maternal cannabis use, ACOG recommends against the use of cannabis products in women who are pregnant.” The authors went on to discuss the warning required by law on all cannabis products that says there “may be health risks associated with the consumption of this product for women who are pregnant, breastfeeding, or planning to become pregnant.” Still, the authors expressed concern this warning did not go far enough, saying, “Despite this warning, Colorado and other states that have legalized marijuana have refrained from prohibiting marijuana use during pregnancy….” and “there are currently no regulations about recommendations or advice that cannabis dispensaries can provide to customers in Colorado.”

The final paragraph reads, “This study prompts many questions about laws and regulations pertaining to cannabis dispensaries. As cannabis legalization becomes more common, women should be cautioned that advice from dispensary employees might not necessarily be informed by medical evidence. Future studies should focus on the effects of maternal cannabis use on maternal and neonatal outcomes in hopes of being able to provide guidelines to care for pregnant women. Public health initiatives should consider collaborating with dispensary owners and other valuable stakeholders in conversations about standards for advice provided to pregnant women.”

About me

I am a scientist, with a Masters in Biochemistry and a PhD in Molecular and Cellular Biology. I have worked in various aspects of Maternal/Child health for over 20 years, including clinical, human research, in-home postpartum care, and serving as the Director of Research at a midwife-led, freestanding birth center. My beliefs about birth and parenting are rooted in physiology, specifically mammalian physiology, and I believe birth is a biologic moment with lots of potential for long-term imprinting, both good and bad. The concept of harm reduction drives my work to promote evidence-based conversations that reduce the stigma of parental cannabis use to improve the wellbeing of parents and children. I advocate for less biased, less punitive conversations about parents who use cannabis but I do not consider myself a cannabis advocate.

The Circle Blog

My take on the recent paper, "Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use."