Translating evidence on cannabis, alcohol and reproduction Nancy Poole, PhD, Director, Centre of Excellence for Women’s Health Lorraine Greaves, PhD, Senior Investigator, Centre of Excellence for Women’s Health Natalie Hemsing, MA, Research Associate, Centre of Excellence for Women’s Health
42
Embed
Translating evidence on cannabis, alcohol and reproductionnorthamericancannabissummit.org/.../E3-221_GREAVES-POOLE-HEM… · Trauma informed ‒ Harm reduction oriented ... perinatal
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Translating evidence on cannabis, alcohol and reproduction
Nancy Poole, PhD, Director, Centre of Excellence for Women’s Health Lorraine Greaves, PhD, Senior Investigator, Centre of Excellence for Women’s Health Natalie Hemsing, MA, Research Associate, Centre of Excellence for Women’s Health
Overview
1. Evidence for use of brief intervention on cannabis, alcohol and other legal substances to educate and support change
2. Messaging about cannabis and alcohol
3. Knowledge exchange principles when doing brief intervention‒ Sex and gender informed‒ Trauma informed‒ Harm reduction oriented‒ Equity informed
Drawing on the following projects:
Presenter
Presentation Notes
This presentation builds on work we at CEWH have been doing with addiction and health/social care agencies across Canada, linking the realities of delivering prevention, brief intervention, harm reduction and treatment, with evidence on sex/gender specific effects of cannabis and other legal substances.
Evidence from a literature scan and 12 pan-Canadian dialogic sessions with health and social care professionals
Discussing substance use with girls, women and their support networks in the perinatal period
2019 North American Cannabis Summit 3
Brief Intervention
Brief Intervention
Dialogue + Action, Women and Substance Use Project
GoalTo facilitate health and social care providers to incorporate brief intervention on alcohol and other substance use in their daily practice with girls, women, and their partners in the preconception, interconception and perinatal periods
Activities1. An environment scan of
current practices and exchange of ideas about good practice through 13 regional consultations with 8 types of practitioners
2. A review and summary of existing evidence on brief intervention with girls and women, including strategies for engaging their partners and support networks
2019 North American Cannabis Summit 4
Financial assistance for this project came from the Public Health Agency of Canada. The views expressed herein do not necessarily represent those of PHAC
We invited and engaged 8 professions
Practice Approaches
Brief intervention does not need to be lengthy or intensive ‒ can be part of routine intake
and assessment,‒ part of care for a specific
issue, or ‒ integrated into health
promotion and wellness activities
‒ many women and girls make changes because they were asked about their substance use
Head Goes Here
2019 North American Cannabis Summit 7
Top to bottom:http://www.projectchoices.ca/http://www.bccewh.bc.cahttp://www.vch.ca/
Brief intervention can be expanded to address multiple substances or multiple health outcomes
Discussing multiple substances at the same time can lead to effective and engaging interventions
2019 North American Cannabis Summit 8
Risks for multiple health outcomes overlap and a combination approach recognizes how substance use can be connected with other health issues
Depression or experiences of violence may be barriers to changing substance use and require interventions that consider multiple concerns simultaneously
Many evidence based approaches to discussing substance use are already being used by practitioners in Canada
Evidence on brief interventions for practitioners Regular and ongoing conversations
about substance use reduce stigma and invite critical thinking Brief intervention can address
multiple substances or multiple health issues Brief intervention does not require
extensive time and resources The quality of the conversation can
influence success There are multiple practice
approaches that can be used for brief intervention
Successful brief interventions are collaborative, non-judgemental and recognize people as experts on their lives Child welfare practices and policies
can reduce barriers to successful brief interventions in perinatal period Brief intervention in the perinatal
period can include women’s partners and social networks in synchronous ways Brief intervention with Indigenous
girls and women should be culturally grounded
Download from http://bccewh.bc.ca/category/post/alcohol-fasd-prevention/
Giving accurate information, supporting critical thinking, contrasting substances, avoiding moral panic
For Best Start/Health Nexus we reviewed the literature on the effects of cannabis in the perinatal period Natalie Hemsing, MA
Lorraine Greaves, PhD
Nancy Poole, PhD
Rose Schmidt, MPH
http://bccewh.bc.ca/
For this presentation we added 8 new studies published since 2017 by searching CINAHL, AJOG, JOGNN
Presenter
Presentation Notes
For this presentation we added 8 new studies published since 2017 by searching CINAHL, AJOG, JOGNN for recent literature. There is a new study from the Generation R longitudinal study (Marroun et al 2018) that found increased externalizing issues in children 7-10 with preconception and maternal and paternal use. There were a couple of studies measuring THC in breast milk following use. And a number of studies adding to the mixed evidence on newborn health effects. polysubstance use - few studies specifically show health effects of co-use of tobacco and cannabis. The negative health effects are more clear with co-use, and exceed that of tobacco use alone.� two recent studies on fecundability - showing no effect of cannabis use by women and men on ability to conceive.
MATERNAL AND NEWBORN HEALTH OUTCOMESOutcomes Significant Association No Significant Association
Maternal asthma Chabarria et al 2016
Maternal hypertensive disorders Metz et al 2017Maternal anemia Gunn et al 2016 Low birth weight Brown et al 2016; El Marroun et al
2009; Gunn et al 2016; Hayatbakhshet al 2012; NASEM 2017 ; Crume et al 2018
Conner et al 2015; Chabarria et al 2016; De Moraes et al 2006; Mark et al 2016; Schempf2008; Van Gelder et al 2010; Warshak et al 2015; Ko et al 2018
Preterm birth Hayatbakhsh et al 2012Leemaqz et al 2016
Conner et al 2015; Chabarria et al 2016; Mark et al 2016; Van Gelder et al 2010; Warshak et al 2015; Crume et al 2018; Metz et al 2017
Stillbirth Varner et al 2010; Coleman-Cowgeret al 2018
Conner et al 2015; Warshak et al 2015; Dotters-Katz et al 2016
Small for gestational age Brown et al 2016; Hayatbakhsh et al 2012; Warshak et al 2015; El Marrounet al 2009
Van Gelder et al 2010; Ko et al 2018; Crumeet al 2018; Metz et al 2017
NICU placement Hayatbakhsh 2012; Warshak 2015 Mark et al 2016; Crume et al 2018
Birth defects Van Gelder et al 2009 Warshak et al 2015
Presenter
Presentation Notes
mixed nature of evidence Majority US; retrospective cohort studies most substantial evidence is in regards to birth weight & small for gestational age; majority of significant findings associated with heavy use (MHPCD) Confounding substance use
CHILD DEVELOPMENT OUTCOMES
Chakraborty et al. 2015 New Zealand
frequent maternal use associated with better global motion perception
El Marroun et al 2010; 2018Holland: Gen. R
• no association with cognitive function/ behavioural problems age 3 (El Marroun et al 2010)
• preconception, maternal and paternal use associated with offspring externalizing problems at age 7-1-(El Marroun et al 2018)
Day et al. 2011; Goldschmidt et al 2004, 2008; Sonon et al 2015; Wilford et al 2010USA: MHPCD
• first trimester heavy use associated with subtle deficits in verbal reasoning scores at age 6
• offspring of heavier users more likely to report delinquent behavior at age 14
• subtle negative effects on school performance• subtle deficits in visual–motor coordination
Smith et al 2006; 2016Canada: OPPS
no differences on visuospatial task performance; observed differences in neural functioning/ blood flow on fMRI
Teyhan et al 2017Australia
Maternal & paternal use not associated with educational attainment
Zammit et al 2009, UK Maternal use not associated with psychotic symptoms at age 12
Presenter
Presentation Notes
3 Main longitudinal studies: OPPS (Ottawa), Generation R (Holland), MHPCD (Pittsburgh, USA) Many more papers have been published by these teams, but pre-date the scope of this report OPPS, Ottawa, middle-class, mostly Caucasian cohort. MHPCD: cohort of Caucasian (43%) and African American (57%) women of low SES, predominantly single (71%) in Pittsburgh, Pennsylvania, USA. The Gen R: ongoing, multi-ethnic prospective cohort in The Netherlands. Both OPPS and MHPCD: no association at preschool age, but subtle negative effects at later ages (from 3 years onwards) on cognitive and behavioral effects Again, largely associated with heavy use (>1 joint per day) these cohorts (OPPS, MHPCD) are from 25+ years ago; changes in potency and use should be considered (cross-breeding for more potent strains)
Effects of alcohol use in pregnancy
Risk of miscarriage or stillbirth
Risk of low birth weight or premature birth Risk of Fetal Alcohol Spectrum Disorder – brain
injury resulting in impairment in Motor skills, Neuroanatomy, Neurophysiology,Cognition, Communication, Academic Achievement, Memory, Attention, Executive Function, Affect Regulation,Adaptive Behaviour, Social skills, or Social Communication.
Higher risk in adults of auto-immune conditions, heart disease, sleep disorders, vision and hearing problems, endocrine disorders, digestive/intestinal problems, migraines, mental health problems . . .
Cook et al, FASD Guidelines for Diagnosis Across the Lifespan, December 2015
Polysubstance Use
Women who use cannabis during pregnancy more likely to smoke cigarettes and use alcohol (Ko et al 2018)
Dual maternal cannabis and tobacco use associated with poor infant self-soothing, effects more pronounced for daughters (Stroud et al 2018)
Co-use of tobacco and cannabis associated with increased risk of birth defects and small head circumference; not significant for cannabis use only (Coleman-Cowger et al 2018)
Methodological Challenges
Confounding factors‒ Tobacco, alcohol, other substances‒ Socio-demographics
Small samples of women who use prenatally Clinical trials unethical Self-reports Lack of data on quantity, potency, method of ingestion Interpreting animal studies
http://bccewh.bc.ca/
Presenter
Presentation Notes
Limitations: Confounders: SES, environmental factors, family, neighbourhood, polysubstance use cohorts with low incidence of prenatal cannabis; increase the risk for bias and confounding small effect sizes/ subtle differences, may not equate to clinically relevant deficits issues inherent to doing research on substance use during pregnancy: can’t conduct clinical trials/ expose pregnant women to cannabis self-report challenges (stigma; fear of child apprehension)… Research shows an association, and not causality - Chemical composition (THC, etc) varies from plant to plant, method of ingestion, chemistry of the person ingesting Changing potency, changing types of cannabis available animal data: dosing far exceeds human doses, not gradually escalated as in human use Funding bias and publication bias: marijuana illegal across USA until 1996; schedule 1 status Knowledge translation in the context of these limitations is a significant challenge
But we can still discuss cannabis use with women
Need for research on: ‒ amount, frequency, potency, method of ingestion, timing‒ medical/ therapeutic use; low to moderate use‒ paternal cannabis use
Interim action: Discuss what is known and not known
“Credibility … was enhanced by acknowledging uncertainty about the risk to the fetus with low to moderate alcohol exposure. Rather than undermine an abstinence-based message, this information served as a clear rationale for the recommendation. An honest and scientific framing of the message and delivery by an expert source were also shown to minimize counterargument and strengthen the message’s persuasiveness.” (France et al., 2013, p.8)
Head Goes HereBraiding together: evidence on brief intervention and perinatal cannabis/alcohol use, with broader equity oriented principles for practice
2019 North American Cannabis Summit 21
Locating communication about cannabis
and other substances
within broader promising practice
principles
Trauma Informed
Recognize that substance use may be related
to past and current
experiences of violence and
trauma. Create safety and
collaboration
Sex and Gender Discuss both the biological and social
issues affecting substance use. Support self determination, choices and
empowerment.Harm ReductionSupport girls and women to address immediate health and social goals, and consider their options for change in substance use
Equity informed & Culturally SafeHelp women address barriers to health such as povertyEngage in reciprocal and respectful discussion of culture
Principles for Practice and Policy
Perinatal Substance
Use
Approaches to include in brief interventions
Greaves, L., Poole, N., & Hemsing, N. (2019). Tailored Intervention for Smoking Reduction and Cessation for Young and Socially Disadvantaged Women During Pregnancy. Journal of Obstetric, Gynaecologic and NeontalNursing, 48(1), 90-98.
Presenter
Presentation Notes
BCCSU Guidelines on Treatment of Opioid Use Disorder During Pregnancy: “This guideline recommends a non-judgmental trauma-informed and culturally safe approach to care that accommodates pregnant patients’ individual choices and circumstances. Within this framework, the present document recommends a holistic and integrated care plan with appropriate use of the full range of available long-term treatment options and harm reduction services. “ Cultural Safety: “the aim with cultural safety is to build a relationship that is respectful and reciprocal, acknowledges differences and creates a safe way to interact.” FNHA’s Policy Statement on Cultural Safety and Humility, p. 2 http://www.fnha.ca/Documents/FNHA-Policy-Statement-Cultural-Safety-and-Humility.pdf
Sex/ Gendered Approach
2019 North American Cannabis Summit 23
How do sex and gender matterin substance use?
I. Mechanisms – differences in biological responses to drugs II. Consequences and Impacts – socioeconomic and legal
consequences of drug problems: employment, poverty, homelessness, gang activities, drug trafficking, sexual assault, domestic violence
III.Prevention Issues – differences in pathways, risk and protective factors, progression, transition and maintenance
IV.Treatment Issues – differences in access, readiness, retention, and outcomes
V. Reproduction/ Fertility / Parenting – different roles, biological concerns, social stigma, child custody
2019 North American Cannabis Summit 24http://grants1.nih.gov/grants/guide/pa-files/PA-03-139.html
There may be sex differences in the metabolism of cannabis, due to differences in muscle mass and fat distribution
Male and female users report differences in forms of ingestion, effects and withdrawal symptoms
Men who use cannabis are more likely to report dependence than women
Evidence regarding cannabis use and mental health is mixed; some studies report that depressive symptoms are greater among males, while other studies report an association with depression and anxiety only for females.
Cannabis use has been associated with decreased pain sensitivity in men, but not in women
The evidence regarding the effects of cannabis use during preconception, pregnancy and parenting is mixed
2019 North American Cannabis Summit 25
Canada’s Lower Risk Cannabis Use Guidelines do not yet provide sex specific recommendations
Sex gender and alcohol
interpersonal violence . . . Sex gender and alcohol
Gender influences on women’s drinking in pregnancy
- Partner drinking- Using alcohol to cope with
stress, poverty, interpersonal violence . . .
In health communication we often reinforce gender stereotypes, instead of challenging them
Gender transformative: a preferred approach
Gender transformative approaches have dual goals
Improving gender equity at the same time as achieving health
Often focus on‒engaging men and boys‒changing negative gender norms‒empowering women and girls at multi levels
Evaluation Framework Through collaborative discussions over several months, programs identified: Key issues for women at intake Theoretical approaches Key activities Outcomes for women