Original Article: Cannabis Essentials: Tools for Clinical Practice

Issue Date: December 2021

Available at: https://www.aafp.org/pubs/afp/issues/2021/1200/p598.html

To the Editor: We appreciated the thoughtful review by Dr. Sazegar on cannabis use. Rates of cannabis use in pregnancy are increasing because of the lessening of legal restrictions, changes in cultural norms, and the COVID-19 pandemic.¹ The review recommends that physicians advise against cannabis use in pregnancy in concordance with national guidelines.² Unfortunately, pregnant patients report receiving mixed messages about cannabis safety from their physicians. A study showed that one-half of physicians do not respond with any recommendations when a pregnant patient discloses cannabis use.³ Patients with questions about the safety of cannabis use in pregnancy report seeking answers from retail cannabis stores and the internet—sources that often normalize the use of cannabis for common issues during pregnancy, such as nausea and anxiety.⁴

Some patients are not comfortable discussing cannabis use during pregnancy because disclosure to a physician may trigger a referral to Child Protective Services (CPS). Depending on the state, the consequences of testing positive for an illegal substance can be severe, and, at the very least, a referral to CPS can feel like a rebuke of a person's parenting. The burden of test and refer policies is not shared equally across the population; Black parents are more likely to be referred to CPS.⁵ The American College of Obstetricians and Gynecologists recommends universal question-based screening for substance use during pregnancy but cautions that biologic drug testing should occur only after completing an informed consent process that includes reviewing the benefits, risks, and alternatives for testing.⁶ Although heavy use is almost certainly harmful, the criminalization of cannabis use in pregnancy is not solely based on evidence of harm because many common parenting behaviors that endanger the fetus and newborn do not trigger a CPS referral (e.g., tobacco use, co-sleeping, vaccine refusal).

Patients should be able to openly discuss the health risks of cannabis use with their physicians without fear of legal consequences. We propose using the WEED mnemonic to remember steps to address cannabis use in pregnancy: welcome questions about cannabis use; explore alternatives to cannabis for common pregnancy ailments such as anxiety and nausea; explain potential risks of cannabis use; deliver a harm-reduction message by recommending a decrease in the dose and frequency of use for patients who are not able or willing to stay abstinent during pregnancy.

In Reply: I would like to thank Drs. Frank and Morrison for furthering the discussion about cannabis use in pregnancy. Cannabis policy is not always aligned with cannabis science; criminalization that disproportionately affects minority populations is heartbreaking. The American Society of Addiction Medicine has officially recommended decriminalizing and rescheduling cannabis from Schedule 1 of the Controlled Substances Act to allow for further research into its medical uses, health risks, and impact on special populations.¹

Mixed messaging about cannabis use from physicians and lack of disclosure from patients are not unique to pregnancy.^2,3 One survey of Colorado primary care physicians and their patients showed that approximately one-half of physicians were unaware of cannabis use among patients who reported they used cannabis.² Population-level interventions to curb cannabis use in pregnancy should ideally involve dispensaries as stakeholders. A 2019 survey of legal dispensaries in Canada found that 93% of respondents advise against cannabis use for nausea and vomiting during pregnancy, whereas a study in Colorado found that 69% of dispensaries recommend cannabis for this use.^4,5 Interventions that encourage dispensaries to refer pregnant patients to their primary care physicians for a discussion about cannabis safety are worthy of consideration. I echo the sentiment that all patients (pregnant or not) need to feel safe discussing cannabis use with their physicians without fear of legal consequences. Conceptualizing cannabis use in the context of other harmful parenting behaviors, as highlighted by Drs. Frank and Morrison, can provide helpful talking points in advocacy work.

Establishing the safety of any drug in pregnancy is complex, and patients often value honesty about this uncertainty. In preconception and prenatal counseling, it can be helpful to frame the discussion in terms of the known adverse effects of cannabis on the developing brain, as discussed in my article. Discussing cannabis use with patients should ideally include a patient-centered, trauma-informed approach with motivational interviewing. I recommend starting the discussion with a nonjudgmental question such as, “Do you sometimes use cannabis (now that it's legal)?” and ending with a discussion about harm reduction. The take-home message for patients should be that cannabis use, in any form, is not recommended in pregnancy because of the absence of safety data, low-strength evidence of potential harm, and expert reviews that consider the known risks of cannabis to the developing brain.