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Exploring the Management of Cannabis Use Among Women and During

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Exploring the Management of
Cannabis Use Among Women and
During Pregnancy
Fares F. Alharbi, MBBS, SCC-Psych,*
and Nady el-Guebaly, MD, FRCPCwz
Abstract
Objective:
Exploring the potential management of cannabis
among women and during pregnancy, an expanding
public health issue.
Method:
A Medline search was conducted from 1982 to 2012
for articles highlighting drug abuse among women
and during pregnancy, with particular emphasis on
cannabis/marijuana use during pregnancy and deliv-
ery, its management, as well as the impact of the drug
on the fetus.
Results:
Cannabis is the most commonly used illicit drug
among youth and pregnant women in western soci-
eties. Historically, cannabis has been used to allevi-
ate nausea during pregnancy. On reviewing the
literature on the use of medication and on psycho-
social approaches in women and during pregnancy,
clinical guidelines as well as a research agenda
including prevalence estimates through urine
screening were seen to emerge. The implication
of a positive test should not be punitive. Clinical
trials on pregnant women should also be conducted.
The impact of D9-tetrahydrocannabinol and
other cannabinoids should be further investigated.
Particular support of the infant and developing
child born from a cannabis-consuming mother is
warranted.
Conclusions:
Compared with the preventive efforts targeting alco-
hol and tobacco use during pregnancy, the increas-
ingly common use of cannabis is relatively neglected
and in need of further specific investigations.
Key Words: cannabis and women, cannabis and
pregnancy, cannabis management, cannabis and
child development, cannabis
(Addict Disord Their Treatment
2014;13:93–100)
C annabis is the world’s most widely
produced, seized, and consumed
illicit drug.1 Cannabis sativa, or Indian
hemp plant, is the source of a number of
products known collectively as canna-
bis. In the literature, the term cannabis
comprises: marijuana, the cut, dried
flowering tops, leaves, and stems of
www.addictiondisorders.com
Original Article ADDICTIVE 93
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June 2014
the plant; sinsemilla, derived from the
buds and flowering tops of the female
plant; and hashish, the resin that coats
the leaves and the flowering heads of
the plant.2
Cannabis use causes significant
adverse effects. The acute effects of
cannabis include subjective feelings of
euphoria, relaxation, dream-like state,
altered sensory perception, slowing
of time, anxiety/paranoia, and increased
appetite. Users’ short-term memory and
attention, motor skills, reaction time,
and skilled activities are impaired
while they are intoxicated.3–5 Long-term
cannabis use has been associated
with impaired memory function.6 Can-
nabis, in rare instances, can induce hal-
lucination or psychosis.7 Probable
harmful consequences of cannabis use
include impaired respiratory function,
cardiovascular disease, and increased
risk of involvement in motor vehicle
accidents.8
The major active compound in all
cannabis products is D9-tetrahydrocan-
nabinol (D9-THC or simply THC),
also known by its international nonpro- From the *Department of
Psychiatry, King Saud bin
prietary name as dronabinol. THC rap-
Abdulaziz University for Health
idly crosses the placenta, such that the Sciences (KSAU-HS) Riyadh,
fetal plasma concentration of THC is Saudi Arabia; wDepartment of
equivalent to or even higher than Psychiatry, Division of Addiction,
the maternal one.9,10 However, cannabis University of Calgary; and
zAlberta Health Services,
is not a pure substance. Commonly Calgary, AB, Canada.
available marijuana varies in potency
and may have up to 400 chemicals or The authors declare no conflict
other substances admixed.11 Separating
out the effects of these chemicals, as well
as the effects of varying potencies, is a
of interest.
Reprints: Fares F. Alharbi, MBBS,
SCC-Psych, King Abdulaziz
confounder in any report or in the sta- Medical City, P.O. BOX 22490,
tistics that address marijuana use in Riyadh 11426, Saudi Arabia
pregnancy. (e-mail: faris137@hotmail.com).
In addition to the complex phar- Copyright r 2013 by Lippincott
macological actions of cannabis, addi- Williams & Wilkins
DOI: 10.1097/ADT.0b013e318293aecc
94 ADDICTIVE Alharbi and el-Guebaly
DISORDERS
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TREATMENT
Volume 13, Number 2
June 2014 tional blended effects of the use of alco-
hol, opioids, tranquilizers, and halluci-
nogens may result in an unpredictable
clinical picture, and the diagnosis is often
difficult.12
Cannabis is the most commonly
used illicit drug, especially among
young women in Western societies.13
Rose et al14 evaluated the prevalence of
marijuana use among young women,
aged 18 to 24, within a primary care
setting in Rhode Island. Of the 607
women who completed the screening
tests, 38.6% reported lifetime marijua-
na use, 8.4% used marijuana at least
monthly, and 1.7% reported using
marijuana daily. It is also reported to
be the most widely used recreational
drug during pregnancy.15 It has
been reported that at least half of all
pregnancies in North America are un-
planned.16 That, combined with the fact
that nearly 7% of American women of
child-bearing age (15 to 44 y) reported
past-month use of marijuana and hash-
ish, indicates the potential risk for the
offspring to be prenatally exposed to
cannabis.17
Although the health risks associ-
ated with tobacco and alcohol use dur-
ing pregnancy are well known to both
the general public and medical profes-
sionals, the same cannot be said con-
cerning cannabis. After the discovery of
their pregnancy, some users reduce or
stop cannabis consumption by them-
selves. But not all women know the
health risks of cannabis use during
pregnancy and its effect on children,
and many of them do not discuss the
use of cannabis with their doctor. In a
study including 396 women (mean age
24 y) from a community sample in the
northwestern United States, the authors
examined the association between
pregnancy or partner’s pregnancy and
month-by-month patterns of binge
drinking, daily smoking, and marijuana
use among young men and women.
They found that, among women who
used marijuana, 47% used during preg-
nancy at least once and 24% continued
to use marijuana throughout preg-
nancy; however, of the pregnant wom-
en who were binge drinkers, 33% drank
alcohol during pregnancy at least once
and only 8% continued to drink
throughout pregnancy. With regard to
r 2013 Lippincott Williams & Wilkins
daily cigarette smoking, the prevalence
decreased from >30% to approxi-
mately 20% after the first month of
pregnancy and continued to decline
gradually throughout pregnancy.18
In contrast, in a survey in France,
only one half of practitioners asked their
pregnant patients about illicit drug use,
and the most likely persons to make these
enquiries were midwives and obstetri-
cians. The questionnaire was sent to all
gynecologists, obstetricians, and mid-
wives in the district of Loire Atlantique
and to 20% of a randomized sample of
general practitioners.19 That means that
detection of cannabis use is often made
toward the end of pregnancy only.
In 1994, the National Institute on
Drug Abuse convened a conference to
address the wide gap in scientific knowl-
edge about addiction between sexes.20
It was deemed hard to conduct studies
on pregnant women. Reasons for this
were 2-fold. One, it was virtually impos-
sible for investigators to obtain permis-
sion to conduct prospective clinical
trials that would expose pregnant moth-
ers to cannabis. Two, because woman
often faced severe legal sanctions
(such as the loss of child custody or
incarceration) for admitting that they
used cannabis while pregnant, most
mothers refused to divulge such in-
formation, even to researchers conduct-
ing anonymous surveys years after the
incident.21
As a result, the published data
assessing the extent of maternal canna-
bis use and its health implications re-
main limited. Our aim is to assess the
knowledge base about management of
cannabis use among women and during
pregnancy in the literature.
METHOD
A Medline search for articles was
conducted from 1982 to 2012 highlight-
ing drug abuse in women and during
pregnancy, with particular emphasis on
cannabis/marijuana use during preg-
nancy and delivery, its management, as
well as the impact of the drug on the
fetus. Key words were cannabis man-
agement, cannabis and women, canna-
bis and pregnancy, and cannabis and
child development.
www.addictiondisorders.com
 Cannabis Use Among Women and During Pregnancy
RESULTS
Impact of Cannabis on the Female
Reproductive System
Animal research suggests that THC
exposure leads to abnormalities in re-
productive functioning. Studies on rats
have shown that administration of can-
nabinoids blocks the luteinizing hor-
mone surge that normally leads to
ovulation, thus abolishing the ovulatory
cycle.22 However, the research assessing
the effects of cannabis on human repro-
duction is not as clear. Mendelson and
Mello23 observed hormonal levels in a
group of female cannabis users and
failed to find any evidence that chronic
cannabis use affected sex hormones or
the duration of the cycle. A more recent
observational study of the outcomes
from in vitro fertilization and gamete
intrafallopian transfer found that wom-
en smoking >90 cannabis joints in their
lifetime had 27% fewer oocytes re-
trieved and 1 less embryo transferred
compared with those who had not
smoked cannabis.24 A case-control
study of female recreational drug users
with primary infertility showed that
women who smoke marijuana may have
a slightly increased risk of infertility due
to an ovulatory abnormality.25
Impact of Cannabis on Pregnancy
and Early Development
Although the use of cannabis by
pregnant women is common, the effects
of this use are still unclear. No pattern of
malformation has been observed that
could be considered a characteristic of
in utero cannabis exposure.19 However,
several publications have highlighted
the consequences of maternal cannabis
use on pregnancy and on the baby.
Pregnancy complications found among
cannabis users are decreased gestation-
al periods, dysfunctional labor, precip-
itation of labor, and meconium
staining.9,26–28 Infants of women who
used cannabis during pregnancy have
been reported to have lower birth
weight and height. When other
confounding factors were adjusted for
(cigarette smoking, alcohol, tea, and
coffee consumption, maternal height
and weight, and the use of hard drugs
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ADDICTIVE 95
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Volume 13, Number 2
during pregnancy), there was an almost June 2014
significant but nonlinear association be-
tween the extent of cannabis use during
pregnancy and mean birth weight.29–31
In a recent prospective international
multicenter cohort study of 3184
healthy nulliparous women with a sin-
gleton pregnancy, investigators found
that marijuana is a strong risk factor for
spontaneous preterm birth.32 Children
born preterm or with lower birth weight
have an increased risk of infant mortal-
ity and long-term morbidity.33
At the age of 3, sleep disturbances
occurred in children of women who
smoked cannabis during pregnancy.34
Prenatal marijuana exposure in the first
and third trimesters predicted signifi-
cantly increased levels of depressive
symptoms at 10 years of ages compared
with unexposed controls.35 Exposure to
1 or more marijuana joints per day
during the first trimester predicted def-
icits in school achievement particularly
reading and spelling, whereas exposure
to alcohol during the same period of
pregnancy predicted poor ratings of
overall school performance by the
teachers.36 Goldschmidt and colleagues
also studied the effects of prenatal mar-
ijuana exposure on intelligence test
performance of 648 children at a 6-year
follow-up. They found that there was a
significant nonlinear relationship be-
tween marijuana exposure and child
intelligence. Heavy marijuana use (1 or
more joints per day) during the first
trimester was associated with lower ver-
bal reasoning scores on the Stanford-
Binet Intelligence Scale (SBIS). Heavy
use during the second trimester pre-
dicted deficits in the composite, short-
term memory, and quantitative scores
on SBIS. Third-trimester heavy use was
negatively associated with the quantita-
tive score on SBIS. Although there was
overlap between marijuana and alcohol
(75%), tobacco (64%), and cocaine
(6%), it was not complete.37 From the
age of 9 to 12 years, poorer visual prob-
lem-solving skills were identified in chil-
dren exposed prenatally to cannabis.38
Prenatal exposure to marijuana is a sig-
nificant predictor of marijuana use at age
14.39 The findings from brain imaging
studies of 18 to 22 year old individuals
linked prenatal marijuana exposure to
negative impacts on the neural circuitry
96 ADDICTIVE Alharbi and el-Guebaly
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Volume 13, Number 2
June 2014 involved in aspects of executive function-
ing, including visuospatial memory and
response inhibition.40,41
Management of Cannabis Use
Among Women
Pharmacotherapies
There is currently no accepted
pharmacological treatment specific to
cannabis use disorder. Vandrey and
Haney reviewed the extant research in-
vestigating medications of potential ther-
apeutic efficacy for the treatment of
cannabis dependence. They found that
dronabinol has been the most extensively
studied drug and appears to be the stron-
gest candidate medication to date.7 Four
studies were retrieved involving dronabi-
nol use in humans; the female partici-
pants in these studies were 0%, 15.2%,
16.7%, 25%, respectively.42–45 Sex differ-
ences were not analyzed.
There are currently 2 ongoing stud-
ies assessing the synthetic THC analog,
nabilone, for cannabis dependence.46–47
Haney also investigated a lower
dose of naltrexone (12 mg) in combina-
tion with THC in male (n = 10) and
female (n = 12) marijuana smokers. A
low-dose naltrexone blunted the intoxicat-
ing effects of a low THC dose (20 mg),
whereas it increased ratings of anxiety at
a higher THC dose (40 mg). There were
no sex differences in these interactions,
although men were more sensitive to
the effects of THC alone than were
women.48
Fluoxetine was associated with re-
duced cannabis use among depressed
alcoholics suggesting therapeutic po-
tential where women constituted 55%
of the participants.49 Initial studies of
buspirone, lithium, lofexedine, and qui-
tiapine have also indicated promise, but
the research completed to date is lim-
ited by small sample sizes and lack of
placebo control condition in open-label
studies. The occurrence of side effects
may also be limiting in the use of these
medications.7
Psychosocial Approaches
There are several effective psychoso-
cial treatments for women with addictions
including contingency management,
community reinforcement, behavioral
r 2013 Lippincott Williams & Wilkins
marital therapy, cognitive behavioral skills
training, motivational enhancement ther-
apy, 12-step approaches, and ‘‘Seeking
Safety’’ (a therapy designed for addicted
women with co-occurring posttraumatic
stress disorder).20
We reviewed 13 randomized psy-
chotherapy trials,50–63 as selected by
Benyamina et al,64 for relapse preven-
tion for cannabis. All were performed in
the United States and Australia. In only 1
study, the female participants (52%)
were more than the male participants.63
In this study, the authors investigated
school-based motivational enhance-
ment therapy (MET) intervention in
adolescents who smoked marijuana
regularly but were not seeking formal
treatment. They found that adolescents
could be attracted to participate in a
voluntary marijuana intervention that
holds promise for reducing problematic
levels of marijuana use. In other trials,
the percentage of women participants
ranged from 12% to 36%. The brief
interventions, psychotherapies associ-
ated with vouchers, vouchers combined
with cognitive behavioral therapy
(CBT), MET, multicomponent therapy
including CBT+ MET+ , and case man-
agement and relapse prevention model
were all effective therapeutic tools. In
the trials, no sex difference was elicited
or sex difference was not analyzed.
Management of Cannabis Use
During Pregnancy: What do we
know?
Historical and Cultural Use
Historical references regarding the
use of therapeutic cannabis for a variety
of female medical conditions, including
difficult childbirth, date back to the sev-
enth century BC. Various parts of the
cannabis plant—including flowers and
seeds—were used by Chinese and
Persian societies to induce contractions,
prevent miscarriages, and reduce inci-
dences of postpartum hemorrhage.65
The historical use of cannabis for preg-
nancy-associated pain and other compli-
cations is also referenced in African,
Arab, Indian, and Southeast Asian cul-
tures. By the mid-19th century, the use of
cannabis tinctures became prevalent in
western cultures to hasten pregnancy
and reduce prepartum nausea (for more
www.addictiondisorders.com
 Cannabis Use Among Women and During Pregnancy
historical review, see Russo65). The use
of cannabis to treat nausea and increase
appetite during pregnancy remains
customary among women in southeast
Jamaica.66
Moreover, pregnant women may
use cannabis therapeutically by them-
selves to mitigate pregnancy-induced
nausea and vomiting. Data from a re-
cent survey reported that cannabis is
therapeutic in the treatment of both
morning sickness and hyperemesis
gravidarum, a potentially life-threaten-
ing condition characterized by severe
nausea and vomiting, malnutrition,
and weight loss during pregnancy. In a
survey of 79 pregnant female users of
medicinal cannabis, recruited through 2
compassion societies in BC, Canada, 51
(65%) reported using cannabis during
their pregnancies. Although 59 (77%) of
the respondents who were pregnant had
experienced nausea and/or vomiting, 40
(68%) had used cannabis to treat the
condition, and of these respondents, 37
(>92%) rated cannabis as ‘‘extremely
effective’’ or ‘‘effective.’’15
Withdrawal Symptoms
In the general population, with-
drawal symptoms include anger and
aggression, anxiety, depressed mood,
irritability, restlessness, sleep difficulty,
decreased appetite, weight loss, head-
aches, physical tension, sweating, stom-
ach pain, and general physical
discomfort.67,68 Most symptoms begin
within the first 24 hours of cessation,
peak within the first week, and last
approximately 1 to 2 weeks.69–71
In pregnant women, symptoms of
withdrawal from cannabis use are usu-
ally milder and may include sleep dis-
turbance, irritability, loss of appetite,
restlessness, nausea, and cramping.20,72
The sparse literature available recom-
mends that pregnant mothers be ad-
vised to quit cannabis use. Clinical
experience reports that for some wom-
en this may not be possible without
additional help.
Cannabis Urine Screening
The urine test is based on detection
of 11-nor-delta-9-tetrahydrocannabinol-
9-carboxylic acid (9-carboxy-THC), a me-
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ADDICTIVE 97
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Volume 13, Number 2
tabolite of D9-THC, which is the primary June 2014
pharmacologically active component of
marijuana. The breakdown products
of THC can be detected in the urine
days or even weeks after stopping its
use, depending upon whether a person
is an occasional or a regular marijuana
user.73,74
The urinary concentrations of
THC are very difficult to interpret be-
cause of variables such as dosage of THC
ingested, frequency of use, timing of
urine collection relative to last exposure
to marijuana, rate of release of stored
cannabinoids in fatty tissue, and an
individual’s hydration state. It is impor-
tant to appreciate that the detection of
THC metabolites in the urine is only an
indication of past marijuana use and is
not related to the degree of intoxication
or impairment.
The metabolites of THC are stored
in fatty tissues of various organs and are
slowly excreted through the urine. That,
combined with the fact that women
generally have a higher percentage of
body fat than men,75 indicates the po-
tential for women to have THC detected
for longer periods of time. Urine tests
for THC are fairly accurate if careful
laboratory assessment is done, and
false-positive results are extremely rare.
Presence of other cannabinoids is rarely
tested.
Uncertainties
Medications: To our knowledge,
trials of medications to alleviate with-
drawal symptoms from cannabis use in
pregnant women have not been pub-
lished. To date, dronabinol has been
the medication most extensively
studied. Dronabinol has been assigned
by the Food and Drug Administration
to pregnancy category C, that is, animal
studies have revealed evidence of
decreased maternal weight gain and
decreased number of offspring, in-
creased fetal mortality, and early fetal
resorptions. Risk/benefit ratios of the
use of those medications are difficult
to quantify. For comparison purpose, a
number of psychotropic medications
are category C.
Psychosocial Approaches: CBT,
motivational enhancement, and contin-
gency management therapies have
98 ADDICTIVE Alharbi and el-Guebaly
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Volume 13, Number 2
June 2014 been demonstrated to be effective for
reducing marijuana use in women.
They have not been studied specifically
with pregnant users.
The Occasional Marijuana
Smoke: Safe for Moms or Not?: It is
difficult for anyone to state what a ‘‘safe
level’’ of cannabis use is. This is because
there is no way of knowing just how
much THC a person consumes each
time they use cannabis. The content of
THC in cannabis can vary from plant to
plant and differ when smoking different
parts of the plant. For example, canna-
bis plant ‘‘heads’’ have a naturally high-
er concentration of THC than the
leaves, and hydroponically grown can-
nabis is thought to have a higher THC
content than plants grown under nor-
mal conditions. Smoking through a
water pipe (or ‘‘bong’’) also has the
effect of concentrating the THC con-
sumed, when compared with smoking
a ‘‘joint.’’
Anesthetic Implications: The di-
verse clinical manifestations of mari-
juana combined with physiological
changes of pregnancy, and patho-
physiology of coexisting pregnancy-re-
lated disease, might lead to complications
and impact the management of labor
analgesia. Because most marijuana-abus-
ing parturients also use other illicit drugs,
the clinical picture could be very unpre-
dictable and diagnosis often difficult.12
Postpartum: Marijuana use in the
postpartum time period has not been
well studied. There is limited clinical
evidence to drive recommendations re-
garding counseling, intervention, or re-
habilitation. In the previously quoted
study, the investigators found that
the prevalence of marijuana use in-
creases steadily but gradually, returning
to prebirth rates at about 2 years after
birth.18
Breast Feeding: There are a few
studies about the effects of cannabis
consumption during lactation on infant
health and development. THC can ac-
cumulate in human breast milk to high
concentrations,76 and infants exposed
to marijuana through their mother’s
milk will excrete THC in their urine
during 2 to 3 weeks. Also, infants ex-
posed to marijuana through breast milk
show signs of sedation, reduced mus-
cular tonus, and poor suckling.77
r 2013 Lippincott Williams & Wilkins
CONCLUSIONS
With increase of cannabis use in
the population including women of
child-bearing age, increase of cannabis
use during pregnancy is expected, but
very little data are available about this
public health issue. Compared with the
systematic prevention campaigns tar-
geting the consumption of alcohol and
tobacco during pregnancy, the efforts
addressing the use of cannabis appear
negligible. The knowledge base about
prevention and management of canna-
bis use and abuse among women during
their child-bearing age remains limited.
An urgent research agenda
emerges. It includes the need for sys-
tematic screening of cannabis use
through urine testing as part of the first
prenatal checkups and quantitative es-
timates of the cannabis levels for the
mothers who pursue consumption. The
sociocultural variables moderating can-
nabis use among women and during
pregnancy should also be investigated.
Clinical trials are required to investigate
potential therapeutic uses of cannabis
during pregnancy rather than subjective
reports. The primary objectives of
screening and monitoring should be
supportive and therapeutic rather than
punitive. The loss of child’s custody
should be a last result measure.
Further investigation of the effect
of cannabinoids other than THC is also
required. This is of increasing impor-
tance as a range of synthetic cannabi-
noids marketed as ‘‘legal highs’’ are
becoming readily available.
Cannabis users may resist an ad-
monition to change their consumption.
The evaluation of targeted pharmaco-
logical and psychosocial interventions
during pregnancy is very limited and
needs to be promoted. Particular sup-
port of the infant and developing child
born from a cannabis-consuming moth-
er is warranted.
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