Crossing the Line to Floyd’s

Marijuana / Cannabis Use During Pregnancy and Breastfeeding: Nurses translating the evidence to parents Montana ECHO. 10.12.21. Virtual

Maureen Shogan, MN, RNC

Copyright 2021 Maureen Shogan. Not to be reproduced or copied via any means- electronically digitally, or transmitted on the internet, without permission in writing from the author. Spokane, WA [email protected]

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Marijuana / Cannabis Use During Pregnancy and Breastfeeding:

Translating the evidence to parents Maureen Shogan, MN, RNC

Clinical Director National Institute on Drug Abuse (NIH) GOVERNMENT Contract NO. HHSN-271-201700021C Phase 2

Contract 75N95020C00020 ESC-iPadContract HHSN271201700021C NIDA Reference No. N44DA-17-1210; “Development of Primer

and Reference Tool to Assess Neonatal Abstinence Syndrome”

Spokane, WA

[email protected]

MT - ECHO

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• ObjectivesRelate the US Surgeon General, FDA, AAP, ACOG, ASAM, AWHONN, NANN and Breast Feeding Medicine recommendations regarding marijuana/cannabis use in pregnancy and breastfeedingDescribe the potential methods of ingesting THCDescribe potential outcomes for children exposed prenatally to cannabis

Not to be reproduced electronically or digitally without written permission. Maureen Shogan, MN, RNC 2

Disclosure statement Maureen Shogan is on the speakers’ bureau for

Mead Johnson Nutrition, a Reckitt Company.The presenter has no interest in cannabis or CBD products/ stocks.

There will be no discussion of off label or investigational drugs.

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Crossing the Line to Floyd’s

Not to be reproduced electronically without permission in writing Maureen Shogan, MN, RNC 4

Floyd’s

Pullman, WA(WSU)

Moscow, ID(U of Idaho)

8 miles

Big Sky Montana South →

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Break through COVID-19Risk of fully vaccinated SUD population7.8% CUD

6.8% TUD14.2% Cocaine UDNon SUD population3.6%

After controlling for adverse SE determinant of health and co-morbid medical conditions, risk for breakthrough no longer differed in SUD EXCEPT for CUD

HR 1.5


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Volkow,ND et al (2019) JAMA 6

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mailto:[email protected]




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Ko, JY……Grant, AM (2020). 2017 PRAMS, MMWR, 69 (32), 1058, Aug 14.

Reasons for marijuana use during pregnancy 8 states - PRAMS

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Fallon, V et al (2021) J of Psychiatric Research, 136: 157-66Not to be reproduced electronically or digitally without written permission. Maureen Shogan, MN, RNC

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Post Partum women – Birth to 12 weeks

STAI score >40

EDPS score >13

PrePandemicPrePandemic

AnxietyDepression

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Pandemic Use Increased 25% in legal state

Maureen Shogan, MN, RNC 9

Young-Wolff, K et al (2021) JAMA 9.27.21. Kaiser, NoCal

8.14%

6.75%

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How to Counsel when moms say, “it must be safe since it is…………… ”

• Legal• Natural• Used as a medicine• Naturally occurring in the body and breast

milk• Used for nausea in pregnancy

© Copyright 2021 Maureen Shogan, MN, RNC. Not to be reproduced electronically or digitally without written permission. 10

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Where do Moms search for their Cannabis info?

Sought information from

Internet 90.8%HCP 34.7Pregnancy Groups 21.4Family or Friends 18.4Cannabis dispensaries 2%Bartlett, K et al (2020) J. ObGyn Canada, 42(11) 1346-50.


Colorado dispensaries recommended cannabis for morning sickness based upon personal opinion. Dickson et al (2018). ObGyn

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Do you think cannabis can pass through to the baby when you’re

pregnant?Sought info from

No Yes

HCP 11%Internet 33.3

Dispensaries 0 0.4%

Pregnancy Groups

11.1%

Family/friends 14.8%

Bartlett, K et al (2020) J. ObGyn Canada, 42(11) 1346-50. Hamilton, ON


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Marijuana / Cannabis Use During Pregnancy and BreasGeeding: Nurses translaHng the evidence to parents Montana ECHO. 10.12.21. Virtual



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Drug Molecular Weight

Nicotine 162Hydrocodone 299THCCBDOxycodone 315Insulin 6,000


https://pubchem.ncbi.nlm.nih.gov/compound/delta8-THC

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No amount of marijuana use during pregnancy or adolescence is known to be safe. ……the safest choice for pregnant women and

adolescents is not to use marijuana. Surgeon General Jerome Adams Advisory: Marijuana Use and the developing brain.August 28, 2019 14

What do the experts say?

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ACOGAmerican College of Obstetrics and Gynecology10.2017

Pregnant: discontinue marijuana use. Marijuana use during lactation … is discouraged.”

AAPAmerican Academy of Pediatrics9.2018

not be used during pregnancy.Maternal marijuana use while breastfeeding is discouraged……… encouraged to abstain from using any marijuana while breast feeding

Academy of Breastfeeding Medicine2015

Avoid further use or reduce their use as much as possible while breast feeding

American Society of Addiction Medicine (ASAM)10.20

Women who are pregnant or contemplating encouraged to avoid or discontinue cannabis use. Use during lactation and breastfeeding should also be discouraged.

© Copyright 2021 Not to be reproduced electronically or digitally without written permission. Maureen Shogan, MN, RNC15

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AWHONNAssociation of Women’s Health, Obstetric, and Neonatal Nursing9.2018

“…remove stigma, discourage use

NANN 6.21National Association of Neonatal Nurse

recommends women abstain from marijuanaconsumption while breastfeeding or providing human milk for consumption.

AmericanHeart Association9.2020

“ All clinicians need greater exposure to and education on the various cannabis products and their health implications. Maternal Cannabis use while breast feeding is discouraged” Page et al (2020). Circulation, 142(10):e131-e152.

© Copyright 2021 Not to be reproduced electronically or digitally without written permission. Maureen Shogan, MN, RNC16

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FDA.gov 10.20.19 17

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Endocannabinoid System

Photo Image by NIDA Marijuana Feb 2018

© Copyright 2021 Maureen Shogan, MN, RNC Not to be reproduced electronically or digitally without written permission. 18

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https://srhd.org/media/documents/W2K-Baby-RackCards-3up-Pregnancy.pdf

Spokane Regional Health District – Spokane, WA

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https://www.cdc.gov/marijuana/pdf/Marijuana-Pregnancy-508.pdf20

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https://ACOG.orghttps://www.acog.org/legal/permissions-information

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Is there withdrawal from Sole Prenatal Cannabis Use?

Non SpecificMimics

hypoglycemiaNOWS

• Gunn, JK, Rosales, CB, Center, KE et al (2016). BMJ Open, 6:e009986

© Copyright 2021 Maureen Shogan, MN, RNC Not to be reproduced electronically or digitally without wriaen permission. Maureen Shogan, MN, RNC 22

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Newborn Outcomes after prenatally Cannabis ingestion

Outcome Risk compared to non using momsmom UA positive at birth. n=330Low Birth weightPreterm delivery. LPINICU admit

Bailey, Wood, Shah (2020) J. Perinatalogy

n=330More than doubledNearly doubledNearly doubled

SGA (3rd)SGA (10th) Preterm. LPI (34 - 36 6/7)NICU admit

Corsi, DJ et al (2019), JAMA

Nearly tripled. n=9437DoubledDoubled

Prematurity

Corsi, DJ (2020) Nature Medicine

Doubled n=3148


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Cannabis Use Disorder (CUD)Pregnancy

• 5 million California moms• 20,237 moms with CUD• Associagon

– SGA– Preterm birth– Death less than one year of age.

OR 1.35• No associaCon with admit to

NICU

• Shi, Y, Zhu, B & Liang,D (2021) Addic?on,4.22.21 doi:10.111/add.15467

• First legal recrea?on sales Jan 2018


2.8

6.9

0

1

2

3

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5

6

7

8

20012002200320042005200720082009201020112012

per 1000 Deliveries state of California

per 1000

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https://ACOG.org




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Watch for Brain data

• Arpana Agrawal and Cynthia Rogers – WA U. St. Louis

• NIDA. 120 prenatally exposed v control group


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Beststart.ca 2018Thinking abut using cannabis before or during pregnancy?

Neurotoxicol Teratol 1988;10:305-13. J Dev Behav Pediatr 1990;11:49-58. Neurotoxicol Teratol 1995;17:479-87. Neurotoxicol Teratol 1994;16;169-75. Drug Alcohol Depend 2011;118:470-4.

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Be CAREFULL interpreting these OLDER data!!

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hOps://srhd.org/media/documents/W2K-Baby-RackCards-3up-BreasVeeding.pdf

Spokane Regional Health District – Spokane, WA

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Baker,T……Hale,T (2018). Ob/Gyn

0

10

20

30

40

50

60

70

80

90

100

0 0.33 1 2 3 4

Ng/mL

Hours

Mean THC in Br Milk

THC in Br MilkMetaboli tes

Should we tell moms who use marijuana to pump and dump?

© Copyright 2021 Maureen Shogan, MN, RNC. Not to be reproduced electronically or digitally without wriaen permission. 28

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Not to be reproduced electronically or digitally without written permission. Maureen Shogan, MN, RNCBertrand, KA et al (2018) Pediatrics, 142 (3), e20181076

THC concentration in Human milk hours after Use

Median 9.4 ng/mL

88% daily use - Inhalation 65%

6 Days

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THC Breast Milk without PP ingestion

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DAYS

Wymore, EM et al (2021) JAMA Pediatrics, 3.8.21

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Inhaled versus Edible –Children at Risk

https://compassionatecleveland.com

10 12

Smoked 34 mg

Ingested 15 mg

© Copyright 2021 Maureen Shogan, MN, RNC. Not to be reproduced electronically or digitally without written permission. 31

1.2022. 10mgTHC/edible. 100mg/packageMT HB 701 Labeling??

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Potency of Cannabis

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1983 1986 1992 1997 1999 2002 2004 2007 2010 2014 2018 2021

Percentage THC

Law Enforcement Seizures to 2014

© Copyright 2021 Maureen Shogan, MN, RNC Not to be reproduced electronically or digitally without written permission.

Legally sold

ElSohly MA…Church JC, (2016) Biol Psychiatry

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MT * cap

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Not to be reproduced electronically or digitally without written permission.

Maureen Shogan, MN, RNC34

[email protected]

Riverfront Park Clock Tower --Spokane, WA

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• ACOG Committee Opinion (2021). Breastfeeding challenges, Obstetrics and Gynecology, 137(2), e42-53.

• ACOG Committee Opinion (2017). Marijuana Use During pregnancy, Obstetrics and Gynecology, Number 722. 130(4). e205-e209.

• Bailey, BA, Wood, DL & Shah, D. (2020), Impact of pregnancy marijuana use on birth outcomes: results from two matched population-based cohorts, J Perinatology, doi.org/10.1038/s41372-020-0643-z.

• Barbosa-Leiker, C., Burduli, E., Lederhos-Smith, C., Brooks, O., Orr, M., & Gartstein, M (2020). Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis, J Addiction Medicine 14(6)

• Bartlett, K., Kaarid, K., Gervais, N., Vu, N., Sharma, S., Patel, T., & Shea, AK, (2020). Pregnant Canadians’ perceptions about the transmission of cannabis in pregnancy and while breastfeeding and the impact of information from health care providers on discontinuation of use, J Obstet Gynaecol Can, 42(11), 1346-50.

• Baker, T……Hale, T., (2018). THC in human milk, Ob/Gyn • Bertrand, KA, Hanan, N., Honerkamp-Smith, Best, BM., & Chambers, CD. (2018.) Marijuana

use by breastfeeding mothers and cannabinoid concentrations in breast milk, Pediatrics, 142 (3), e20181076

• Corsi, DJ et al (2020). Maternal cannabis use in pregnancy and child neurodevelopmental outcomes, Nature Medicine, doi.org/10.1038/s41591-020-10002-5.

• Corsi, DJ et al (7/2019) JAMA doi:10.1001/jama.2019.8734 Canada Better Outcomes Registry and Network (BORN)

• Corsi, DJ et al (2019). Trends and correlates of cannabis use in pregnancy: a population-based study in Ontario Canada from 2012 to 2017. Can. J. Public Health, 110, 76-84

• Dickson, B (2018). Recommendations from cannabis dispensaries about first trimester use of marijuana use. Obstetrics & Gynecology, doi: 10.1097/AOG.0000000000002619.

Not to be reproduced electronically or digitally without written permission.

Maureen Shogan, MN, RNC35

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• ElSohly, M, Mehmedic, Z, Foster, S., Gon, C., Suman, C & Church JC (2016). Changes in cannabis potency over the last two decades (1995-2014_ - Analysis of current data in the US, Biol Psychiatry, 79, (7)

• Fallon, V., Davies, SM., Silverio, SA., Jackson, L., De Pascalis, L, Harrold, JA. (2021), Psychosocial experiences of postnatal women during the COVID-19 pandemic. A UK-wide study of prevalence rates and risk factors for clinically relevant depression and anxiety, J Psychiatric Research, 136: 157-166.

• Ko, JY……Grant, AM (2020). Characteristics of marijuana use during pregnancy – 8 states, PRAMS, 2017 MMWR, 69 (32), 1058-63, Aug 14.

• PBS.org NOVA The Cannabis Question. 9.29.21

• Page, RL, Allen, LA, Kloner, RA, Carriker, CR, Martel, C Morris, AA, Piano, MR, Rana, JS & Saucedo, JF (2020). Medical marijuana, recreational cannabis, and cardiovascular health, Circulation. 142

• Shi, Y., Zhu, B., & Liang, D. (2021) The associations between prenatal cannabis use disorder and neonatal outcomes, Addiction, doi:10.1111/add.15467 (CA-CUD)

• Volkow, ND, Han, B, Compton, WM and McCance-Katz, EF (2019) Self-reported medical and nonmedical cannabis use among pregnant women in the US, JAMA , 320, 167-9.

• Wallman,C (2021) Marijuana, Breastfeeding, and the Use of Human Milk- NANN Position Statement, Advances in Neonatal Nursing, 21 (3), 176-7.

• Wang, L., Wang, Q.Q., Davis, PB., Volkow, ND and Xu, R (2021 in press). Increased risk for COVID-19 breakthrough infection in fully vaccinated patients with substance use disorders in the US between December 2020 and August 2021, Psychiatry World,

• Wymore, EM, Palmer, C., Wang, GS, Metz, TD, Bourne, DWA, Sempio, C., & Bunik, M (2021). Persistence of delta-9-tetrahydrocannabinon in human breast milk, JAMA Pediatrics, March 8

• Young-Wolff, KC., Ray, GT., Alexeeff, SE., Adams, SE., Does, MB., Ansley, D., & Avalos, Lyndsay, AA (2021). Rates of prenatal cannabis use among pregnant women before and during the COVID-19 pandemic, JAMA,9.27.21 online doi:10.1001/jama.2021.16328

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Crossing the Line to Floyd’s