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Featured Clinical Article: Pandemic-Induced Anxiety Leads to Increased Cannabis Use in Pregnant Women

13 Apr 2022 10:15 AM | Anonymous

By: Brittany Heuay, PharmD Candidate 2022; St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis

Mentor: Kara Berges, PharmD; Mercy Pharmacy Wentzville

The COVID-19 pandemic has had far-reaching effects beyond the illness caused by the novel virus. The disruption and isolation brought on by the pandemic has increased the demand for mental health services as feelings of loneliness, loss, grief, and anxiety overwhelm those with and without pre-existing mental health illness1. In September of 2021, authors from The Journal of the American Medical Association (JAMA) reported a startling increase of cannabis use in pregnant women during the COVID-19 pandemic. Women report using cannabis as a way to relieve stress and anxiety brought on by both general stressors of pregnancy and those related to COVID, such as social isolation, financial and psychosocial distress, increased burden of childcare, changes in accessing prenatal care, and concerns about heightened risk of COVID-19 for both mother and baby2.

Data from Kaiser Permanente Northern California was pulled to test the hypothesis that prenatal cannabis use was increasing during the COVID-19 pandemic. Urine samples were screened using universal toxicology from January 1, 2019 through December 21, 2020 during standard prenatal care (approximately 8 weeks gestation). The pre-pandemic period was defined as tests conducted from January 2019 to March 2020, while the pandemic period included tests taken from April through December 2020. Urine samples from 100,005 pregnancies in 95,412 women with a mean age of 31 years were tested. Before the pandemic, prenatal cannabis use was reported in 6.75% of pregnancies; during the pandemic, the rate of prenatal cannabis use increased to 8.14% (95% CI, 7.85 – 8.43%), a 25% increase (95% CI, 12 – 40%)2.

The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the Academy of Breastfeeding Medicine (ABM) all advise against the use of cannabis during pregnancy and breastfeeding4-6. Cannabis use during pregnancy can lead to a multitude of adverse effects including low birth weight, disruption of normal brain development in the fetus, increased risk of stillbirth, and increased risk of preterm birth3. There was a significantly increased risk of adverse effects such as low birth weight (OR 1.27, 95% CI, 1.05 – 1.54) and small for gestational age (OR 2.14, 95% CI, 1.38 – 3.30) among cannabis users, but not preterm birth. Additionally, a dose-related effect was noted – heavy cannabis users, defined as weekly use or more, had twice the risk of delivering a low birth weight or small for gestational age baby compared to non-cannabis users7. Due to the risk of adverse effects to the fetus, pregnant women who are currently using cannabis to treat anxiety caused or exacerbated by the COVID-19 pandemic should be counselled by their pharmacists and physicians to quit and seek alternative treatment methods that are safer for both mother and baby.

However, weighing the benefits and risks of taking medication during pregnancy is an age-old conundrum that patients, pharmacists, and physicians have to continually battle. Treating medical conditions during pregnancy involves the patient’s healthcare team taking multiple factors into account, such as the severity of the condition and the risks to mother and baby if the condition goes untreated. Furthermore, health professionals must look at both pharmacologic and non-pharmacologic treatment options and whether there is evidence of detrimental fetal effects of any chosen medication. With rising anxiety levels fueled by the COVID-19 pandemic, it is important for clinicians to have recommendations ready for pregnant women that are safer than cannabis, which has not been extensively studied for safety or efficacy.

For mild anxiety, non-pharmacologic options may be sufficient for treatment and can ease a pregnant patient’s fear about potential risks medication may have on their unborn baby. Counselling, cognitive behavioral therapy, exercise, and meditation may be appropriate non-pharmacologic strategies to help pregnant women manage their anxiety over cannabis use9. For generalized anxiety disorder, the 2016 Psychopharmacology Algorithm Project at the Harvard South Shore Program recommended selective serotonin reuptake inhibitors (SSRIs) as first line treatment. Various research studies have identified potential areas of concern in the use of SSRIs during pregnancy including a small increase in birth defects such as congenital heart defects, neonatal abstinence syndrome, low birth weight, and preterm delivery9. Other medications such as buspirone and bupropion in particular seem to pose very low risks to the fetus when used for the treatment of anxiety in pregnant women based on current studies9. Since the potential for risk is still present when utilizing medication to treat anxiety during pregnancy, pharmacists and other clinicians must make sure pregnant women have all the facts made available to them. Leaving anxiety untreated also poses its own set of risks, as anxiety can interfere with the woman’s sleep and diet, can negatively impact her relationships with friends and family, or push them to use substances known to be harmful to both mother and baby, such as alcohol, tobacco, or illicit drugs to manage their anxiety8. In studies, moderate to severe maternal anxiety and depression have been linked to adverse effects such as miscarriage, preeclampsia, preterm delivery, and low birthweight.
This generation’s pregnant women are facing a unique challenge in managing their mental health during the COVID-19 pandemic, and pharmacists play a key role in helping pregnant women make safe, data-driven recommendations when it comes to treating anxiety. Staying up to date on the most current information is vital, and most data points to cannabis being an inappropriate treatment option for pregnant women experiencing anxiety. Non-pharmacologic treatment options remain the safest options for those patients whose symptoms are mild, while patients with more moderate to severe anxiety may find the benefits of medication such as SSRIs, bupropion, or buspirone may outweigh the rare fetal risk.

Resources

  1. Covid-19 disrupting mental health services in most countries, WHO survey. WHO. 5 Oct 2020. <https://www.who.int/news/item/05-10-2020-covid-19-disrupting-mental-health-services-in-most-countries-who-survey>
  2. Young-Wolff KC, Ray GT, Alexeeff SE, et al. Rates of prenatal cannabis use among pregnant women before and during the Covid-19 pandemic. JAMA. 2021;326(17):1745-1747.
  3. Cannabis and pregnancy. ACOG. Feb 2021. <https://www.acog.org/womens-health/faqs/cannabis-and-pregnancy?utm_source=redirect&utm_medium=web&utm_campaign=int>
  4. Committee Opinion No. 722: Cannabis use during pregnancy and lactation. Obstet Gynecol. Oct 2017;130(4):e205-e209.
  5. Ryan SA, Ammerman SD, O'Connor ME. Cannabis use during pregnancy and breastfeeding: Implications for neonatal and childhood outcomes. Pediatrics. Sep 2018;142(3):e20181889.
  6. Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. Apr 2015;10(3):135-41.
  7. Nguyen VH, Harley KG. Prenatal cannabis use and infant birth outcomes in the Pregnancy Risk Assessment Monitoring System. J Pediatr. Jan 2022;240:87-93.
  8. Conover EH, Forinash AB. How do I weigh the risks and benefits of taking an antidepressant medication during pregnancy? Teratology Primer. Jan 2018. <https://birthdefectsresearch.org/primer/antidepresant-risk.asp>
  9. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists. Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. Apr 2008;111:1001-20 

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