ACOG recommends universal cannabis screening

Key takeaways:

• ACOG recommends cannabis screening before, during and after pregnancy, citing growing use.
• Universal screening should include interviews rather than drug testing to prevent racial disparities.

Clinicians should screen their patients for cannabis use pre-pregnancy, during pregnancy and in the postpartum period, according to new guidance from ACOG.

The recommendation, which was released today, marks a “new and significantly updated clinical guidance,” according to a press release from ACOG. It offers evidence-based guidance for screening, counseling and strategies to reduce cannabis use before, during and after pregnancy.

“With increasing social acceptability, legalization of cannabis in many states, expanding accessibility, ACOG has decided to publish a new clinical consensus on this topic,” Melissa Russo, MD, FACOG, a co-author of the guidance told Healio. “There is also a perception in the public that cannabis is safe to use during pregnancy with minimal adverse effects.”

A 2019 research letter published in JAMA found that cannabis use among pregnant women in the U.S. more than doubled between 2002 to 2017. The adjusted prevalence of past-month cannabis use in pregnant women rose from 3.4% to 7%.

“The largest consumers of cannabis are reproductive-aged people, so we need to have these conversations with our patients and make sure that we educate them on the risks of cannabis use,” Russo said in the release.

People who use cannabis during pregnancy often report that it helps them manage their symptoms for preexisting conditions like chronic pain, insomnia, anxiety and depression, as well as pregnancy-related symptoms like weight gain, pain, stress, nausea and vomiting, according to the guidance.

“A lot of my patients have said that cannabis is a more natural way to treat their medical problems,” Russo said. “The most common reasons include mental health disorders such as anxiety, nausea, and appetite stimulation/weight gain.”

But there is no medical indication for cannabis use during pregnancy and postpartum.

“This document outlines that ACOG recommends against cannabis use in pregnancy and lactation period,” Russo said. “This document also outlines the potential adverse effects from cannabis use in pregnancy and the postpartum period, including low birth weight, small for gestational age, neonatal intensive care unit admission and perinatal mortality and postnatal neurocognitive and behavioral dysfunction (ADHD, memory challenges and intellectual disabilities).”

The guidance recommends clinicians help patients find alternative methods to address their health concerns, particularly when patients are using cannabis to cope with unmet mental or physical health needs. The guidance encourages clinicians to motivate behavioral change by talking with the patient about cannabis use and the associated risks, as well as their own personal priorities and any barriers to quitting.

“There are many safe alternative medications that can be given to treat nausea, anxiety and loss of appetite,” Russo said. “Additionally, it is important for a patient and provider to work together to determine alternative treatments and with mental health disorders medications, cognitive behavioral therapy and counseling can alternatively support a person in pregnancy and lactation period.”

For universal screening, the guidance specifically recommends self-reporting, validated screening tools or interviews, “as it helps to eliminate bias because it is required for all patients.”

But the guidance cautions against using drug testing as a way to assess cannabis use because this is not an accurate way to diagnose a substance use disorder, considering “limitations with assessing severity of use and the wide detection window.”

The release also noted that clinicians should recognize how “the disproportionate rates of drug testing and mandatory reporting to child protective services” among women in underrepresented racial populations — particularly Black women — have led to health inequities. They should remember these inequities when they counsel patients on the risks of cannabis use during pregnancy as well, according to the release.

“There are heterogenous policies at the state and institutional levels, reporting guidelines for exposed infants to child protective services, and drug testing in pregnant individuals that has led to disproportionate rates of drug testing and mandatory reporting in Black and minority birthing individuals,” Russo said. “A recent study at one institution showed that Black and Hispanic pregnant women were four to five times more likely to have drug testing for an indication other than reported substance use compared to white counterparts. These punitive policies have not led to better neonatal health outcomes.”

“For these reasons, ACOG recommends universal screening of all pregnant people during prenatal care for cannabis use by patient report,” Russo continued. “Biological testing should not be used as a screening test for cannabis use.”

References: