Copyright MotherJourney/Laurel Wilson 2018 Handout – Top Takeaways Up In Smoke: The Potential Long Term Impact of Cannabis Use During Perinatal Period Laurel Wilson, IBCLC, RLC, BSc,CLE, CCCE, CLD www.motherjourney.com NOTES [email protected] For list of references/resources/additional information, please visit: http://motherjourney.com/marijuana-and-breastfeeding.html Objectives: • Identify the two active cannabinoids found in cannabis of potential concern during pregnancy and breastfeeding. • Identify two potential risks to the developing baby for prenatal and postpartum exposure to cannabis. • State at least two open ended questions to use when discussing marijuana use and breastfeeding with their clients/patients. Takeaways: Cannabis is the most commonly used illicit substance among pregnant women in Western societies. Legal use in 9 states, all but four states have some form of legalization. Use of Cannabis during Perinatal period: • 3.9% of pregnant women used in past month and 7.0% used in past 2-12 months marijuana* • Past year users 16.2% were daily users* • Self reported use 5.7% in pregnancy and 5% during lactation** Considered a Schedule 1 Substance Federally - A dangerous substance with a high potential for abuse and no valid medical purpose Should not be shared/duplicated without permission, [email protected] Copyright MotherJourney/Laurel Wilson 2018 However, The National Academy of Science, Engineering and NOTES Medicine found that: • There is conclusive or substantial evidence that cannabis or cannabinoids are effective: • For chronic pain in adults • Anti-emetics in the treatment of chemotherapy-induced nausea and vomiting • Multiple sclerosis spasticity symptoms • There is moderate evidence that cannabis or cannabinoids are effective for: • Improving short-term sleep outcomes • There is limited evidence that cannabis or cannabinoids are effective for: • Increasing appetite and decreasing weight loss associated with HIV/AIDS • Symptoms of Tourette syndrome • Anxiety symptoms • PTSD Two strains used for medicinal and recreational purposes: Cannabis Sativa and Cannabis Indica. Forms of Use: Dried Herb, Hashish, Marijuana Oil, Concentrates, Edibles, Salves Prescription Forms: Dronabinol (Synthetci THC), Marinol (Synthetic THC), Sativex (Synthetic THC and CBD) Do Not Confuse Cannabis with K2 or Spice – very dangerous Cannabis contains 421 chemical and @ 60 Cannabinoids (phytocannabinoids) including THC, CBD, CBN, CBG THC ∆9 -tetrahydrocannabinol • THC effects: Psychoactive, Euphoria, Analgesic, Antibacterial, Antiemetic, Anti-tumoral, Bronchodilator, Appetite Stimulant, Neuroprotective (medium doses), Sleep Inducing, Anticonvulsant, Muscle Relaxant, Immuno-modulating • THC - First 11 Hydroxy THC (psychoactive) first main metabolite of THC • Then Nor-9-Carboxy THC (non active)(Nonpsychoactive) • Carboxy THC stays in the body, is lipophilic • THESE ARE THE NON ACTIVE METABOLITES. Should not be shared/duplicated without permission, [email protected] Copyright MotherJourney/Laurel Wilson 2018 NOTES • Hangs out in body from days to up to 4 weeks • THC metabolized in blood, and Carboxy THC is excreted through urine (20-35%) and feces (60-85%) • Elimination life 20-38 hours, chronic users up to 4 days CBD- Cannabidiol • CBD Effects – Neuroprotection, Anticonvulsant, Analgesia, Sedation, Antiemetic, Antispasmodic, Anti-inflamatory, Antianxiety Major Concern- Pesticides • Many grow houses using pesticides approved only for outdoor use on indoor • Because EPA can only regulate federally approved substances, Cannabis is not included • Some states allow 75-200 pesticides • Five most common banned substances found in raids • Myclobutanil - “Bad Actor” • Imidacloprid - “moderately hazardous • Abamectin and the avermectin chemical family - “Bad Actor,” • Etoxazole • Spiromesifen Endocannbinoid System – CB1 and CB2 receptors • Impacts: Learning and memory, Anxiety, Depression, Addiction, Appetite, Neuro-protection When using THC: • Hypocampus/Hypothalamus • Hunger • Feelings of hunger • Hippocampus • Short term memory • Lack of memory • Cerebellum • Coordination • Lack of coordination • Amygdala • Learn to fear • Become Paranoid • Limbic System • Dopamine • Feel pleasure Should not be shared/duplicated without permission, [email protected] Copyright MotherJourney/Laurel Wilson 2018 Perinatal Use in Animal Studies: • Disrupts EC Signaling NOTES • Alters dopamine, seratonin, and opiod receptors • Disrupts Synaptogenesis Wang, 2004 • 42 postmortem fetal brain samples (from saline induced abortions) • Decrease in dopamine receptor (D2) mRNA expression in amygdala • Significant prevalence in males • Chronic use association with low mRNA levels Comparison of population studies: • OPPS • 1978 • Ottowa, CA • MJ and tobacco • Low Risk, Euro-Amer, Middle Class • Gest Age Red. • No diff in BW • MHPCD • 1982 • Pittsburg, PA • MJ and alcohol • High Risk, Mixed Ethnicity, Low socioeconomic • Birth length reduced after 1st tri exp • Inc. BW after 3rd Tri. Exp. • Gen R • 2001 • Netherlands • Many substances • Multiethnic, higher • socioeconomic class • Fetal growth reduced after from 2nd tri on • Reduced BW Infant Behavior • OPPS • Inc. startles and tremors • Red. habituation to light • 48 mo. Lower memory and verbal skills • MHPCD • No diff. in neonatal beh. • 36 Mo. Lower short term memory and verbal skills • Gen R Should not be shared/duplicated without permission, [email protected] Copyright MotherJourney/Laurel Wilson 2018 NOTES • 2001 • Netherlands • 36 mo. No differences Child Behavior • OPPS • More impulsivity and hyperactivity • Impaired visuo-perception func. • MHPCD • More impulsivity and hyperactivity • Inattention, delinquency • Gen R • Not yet examined Adult Behavior • OPPS • Response Inhibition • Alters neural functioning during visuo-spatial working memory processing • MHPCD • Not yet examined • Gen R • Not yet examined Ottowa Prenatal Prospective Study, OPPS Maternal Health Practices and Child Development Study, MHPCD Generation R Study, GEN R Gunn, 2016 • Infants were more likely to be anemic, have lower birth weight, and require placement in NICU • HOWEVER, insufficient evidence to support or refute a statistical association between maternal cannabis smoking and later outcomes in the offspring • Women used alcohol and/or tobacco during pregnancy. Thus it is not clear to what extent outcomes were related to marijuana use alone, or a combination of marijuana, alcohol, and tobacco Crume, 2018 • 50% increased risk of low birth weight (also tobacco users) • No increased risk for SGA, preterm birth, and NICU stay Should not be shared/duplicated without permission, [email protected] Copyright MotherJourney/Laurel Wilson 2018 NOTES 2014 Colorado TriCounty Survey • 5.9% WIC participants were Cannabis users • Depression/Anxiety/Stress 63% • Pain relief 60% • Nausea/Vomiting 48% • Fun and recreation 40% • Other 14% Dr. Baker and Hale Study 2018 • Abstained 24 hours • 0.1 g of containing 23.18% THC – with a new glass pipe Prezidential Kush Sativa • Smoked (3-4 hits over 10-20 minutes) and pumped at 20 minutes and 1, 2, and 4 hours • Relative infant dose 2.5% of maternal dose • Peaked at 1 hour, with a peak of 94 ng/mL (range 12.2– 420.3 ng/mL), and receded slowly over the subsequent 4 hours. Questions after study: • What is the plasma level in the breastfeeding infant? • What effect would repeated and continuous doses have on breast milk concentrations? • What about transfer with use of oral cannabis products? • What do cannabis products do to the endocannabinoid system? • What is the lasting effect of exposing developing infants to cannabis? Potential concerns for babies: • Increase risk SIDS if smoking • Positive urine screens (up to two weeks after exposure) • Potential double exposure • May cause epigenetic damage • Potential for exposure to other drugs. Marijuana not always “clean” What do Experts/Orgs/Journals Say? Academy of Breastfeeding Medicine Statement #9, 2015 • Counsel those who admit use • Strongly advise those with positive urine screen • Avoid or reduce use • Advise on long-term neurobehavioral risks • Avoid direct exposure of smoke to infant Should not be shared/duplicated without permission, [email protected] Copyright MotherJourney/Laurel Wilson 2018 NOTES • Take into careful consideration and counsel on the potential risks of exposure of marijuana and benefits of breastfeeding to the infant. • Careful consideration of the risks versus benefits of breastfeeding in the setting of moderate or chronic marijuana use • At this time, although the data are not strong enough to recommend not breastfeeding with any marijuana use, we urge caution. Obstet Gynecol 2013 • Due to the potential for breastfeeding to mitigate some of the effects of smoking and little evidence of serious infant harm, it appears preferable to encourage mothers who use marijuana to continue breastfeeding, but minimize infant exposure to marijuana smoke and reducing marijuana use. (Hill, 2013) Hill Reed 2017 • If a woman is going to smoke tobacco, she should be encouraged to continue breastfeeding. There is a lack of evidence to suggest that the recommendation to a mother who uses marijuana should be any different. AAP The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics • Revisions for the statement can no longer keep pace with the rapidly changing information available via the Internet, published studies, and new drug approvals. A more comprehensive and current database is