E56 - Prenatal Cannabis Exposure #2 – Dr. Mishka Terplan

 

Is cannabis something to fear when it comes to prenatal health? The easy answer is yes, when we consider the universally acceptable care plan of all pregnancies are best lived following a healthy diet, doing appropriate exercise, and consuming no unnecessary drugs or medications. With cannabis becoming more widely used as a medicine and consumed recreationally by a growing population, it is important to fully understand how cannabis affects human development and family health. In their second episode discussing Prenatal Cannabis Exposure, Kirk and Trevor explore the implications of cannabis use in pregnancies with Virginia Commonwealth University’s Dr. Mishka Terplan of the Department of Obstetrics and Gynecology and Psychiatry. It may surprise you to discover how care giver behaviours and social policy may actually be more harmful to a family’s health and wellbeing than the mother using cannabis during pregnancy. What does current research actually say about the threat of prenatal cannabis exposure to the unborn child? How can understanding the bigger picture of women and family health help change our current policies on prenatal health?
 

Episode Transcript

Kirk: Hey, how's it going, Trevor?

Trevor: Kirk, I'm doing really well. I'm annoyed at you, though.

Kirk: You're annoyed with me.

Trevor: I am. You, Dr. Terplan interrupted a really nice cycle around Saskatoon. Saskatoon has some really nice bike trails all up and down the river.

Kirk: Right.

Trevor: And I was listening to this interview while doing that. My daughter is going to school there. We're looking for an apartment, yadda, yadda. But I was going for a bike ride in the morning, beautiful bike ride, beautiful trails. And I had to stop like every five minutes to mark down some really interesting stuff you guys were talking about.  A bike ride interrupted.

Kirk: I listened to the interview again today, and it really got into a nice discussion and a very long goodbye. I mean, I was like I had a second interview as I was saying goodbye to him.

Trevor: Well, I was just amazed with. So, here's a guy who goes off, becomes an OBGYN. And then gets into addictions medicine. And then gets into cannabis, we'll call advocacy. And you are looking to do a series of things on pregnancy in Canada. So couldn't hard to find a better person.

Kirk: Yeah, no kidding. Right. No kidding. How do you not get a better qualified person to talk to us? And again, you know, you've said this over and over again. How amazing it is that people return our phone calls. I mean, I think it's fantastic. And then when you start talking to these people, you know, I have I have a little simple question. Can you tell me about cannabis and pregnancy? And I'm talking to a man of that caliber. And, yeah, I really liked the interview. I love the way he talked about cannabis as an old medicine and how cannabis was mostly a female medicine and.

Trevor: Yeah, I had no idea.

Kirk: Yeah. Yeah. Well you know, as you were saying and I said to myself, you know, I've seen that over and over again. You and I are working on a course for how to live, how to live well with cannabis, aging well with cannabis. And in that research for that course, we're going to teach. I was noticing how every time I got into the old cannabis use, female health is there. Menstrual cramps. Cleopatra apparently used it. Queen Victoria apparently used it. So, I mean, cannabis has been used by women for a millennium. And here we've got an OBGYN that gets that.

Trevor: I don't and I don't want to give too much away, but I think this is like step two in your many part series in tracking down things from the Jamaican study because it came up again.

Kirk: I'm going to eventually talk to Dr. Dreher. That study, you know, I was talking about that study, I'm sure in episode zero in episode one I was talking about that study. I found that study years ago. And so, yes, someday I think we'll probably get to talk to her. There's also the other thing we should remember to acknowledge, Trevor, that once again, we're two men interviewing another man about female health.

Trevor: Yes. So, obviously, we are doing it sort of a step removed from people who actually experience things like pregnancy and childbirth.

Kirk: Yes. Yes, we are as researchers and question askers. But I want to start this, this is the second of a series of episodes I want to do with maternal health and mom and baby and Cannabis. So, I want to preface this by saying, as a nurse, as a human being, I understand that women have choices and it's a woman's body. As a nurse, I'm very concerned about the prenatal patient for the life of the baby. Right. So, there's two patients in this and there's always societies debate about the right of the unborn child. I do not want to get into that in this episode.  Except to say as a nurse, public health nurse with community health experience and practice caring for the unborn child as part of my responsibility. So understanding how cannabis affects a prenatal mom, a woman, it's almost it's almost redundant to see a prenatal woman or a pregnant woman right. A pregnancy. I want to understand it because I've seen it. I practiced it. I've had patients come in under the influence of alcohol and under the influence of other drugs and cannabis as prenatal patients. So damned if I did not chat with a man who's probably a top expert in America for what he does. Addictions. OBGYN. So I want to preface the conversation by saying that, right, ladies have a right, but it's the unborn child. So does cannabis affect the unborn child Trevor?

Trevor: Let's listen to someone much smarter us talk about that. Let's go to Dr. Terplan.

Kirk: OK, let's do that because, let's listen its a good story.

Trevor: It is.

Dr. Terplan: Thank you for having me. My name is Mishka Terplan. I'm a physician. I am trained as an obstetrician gynecologist and also an addiction medicine provider. So my work really has been along the intersections of reproductive and behavioral health, which includes taking care of people who are pregnant, who use drugs. I am currently the associate medical director of a drug research think tank and adjunct faculty at University of California, San Francisco, where I'm a clinician on their national clinical consultation substance use.

Kirk: Perfect. So, you specialize in obviously women's health, babies delivering babies and addictions. So those are the three branches of your practice?

Dr. Terplan: Yeah, I would say that is where my interest and practice began. But as time has gone on and I spend almost now no time on labor and delivery. A little bit of footprint still in prenatal care. But most of my clinical research, advocacy work, involves it's centered around more, I would say, reproductive health rather than pregnancy specifically, and more and more in addiction medicine then in OBGYN. So, clinically, I do for the last, I don't know, at least five years also see men. And take care of people with addiction medicine. In addition to women with substance use, misuse, addiction, et cetera.

Kirk: OK, so we have you on this interview because of your understanding of cannabis as a substance of addiction and its relation to prenatal health.

Dr. Terplan: Yes.

Kirk: Perfect. OK. Let's start from there, sir. From the very beginning. When did you first. When did this interest come to you? When did you decide, hey, I'd like to study people's addictions and how it relates to maternal health?

Dr. Terplan: Well, I think it was really interested in both and then bringing those worlds together. So when I was a medical student, I worked and volunteered in a syringe exchange. I set up a clinic for people who are homeless and people who were using drugs.  And a lot of that was just out of real interest and connection in working with people who use drugs. Then as a student turned out, I really liked obstetrics and gynecology. And so I went and did my residency in that and really my career as a resident and certainly thereafter was about bringing those two worlds together. How can I bring the world of substance use in alignment with my specific training in OBGYN? And so that began historically, as I mentioned, in working on pregnancy. But as time has gone on, it's been about a lot more about thinking about sexual and reproductive health as they relate to recovery and thinking about how we can sort of integrate better substance assessments, so to speak, in reproductive health care.

Kirk: But you are a medical doctor and have you formalized your education with a Masters or a PhD as well?

Dr. Terplan: Yeah, I have a I after my residency. So, in the United States medical school, followed by residency, I did a fellowship in clinical trials and epidemiology as part of that. I got a Master's in Public Health.

Kirk: OK, so you are a trained researcher, not just as a physician. So, can you talk to me about some of the research you've done with addictions and I guess specifically with cannabis?

Dr. Terplan: Yeah. So, one of the things some of the I think the original stuff we've done has been somewhat descriptive. In particular looking at both self-report and urine/drug test results during prenatal care.  And in looking at the number of people in etc. who tested positive for cannabis at a period and looking at how that changed over time. And so some of the early stuff that we looked at, we demonstrated that: One cannabis was actually the most common substance reported at the first prenatal visit, more common than tobacco, which by the national population health data is the most common substance during pregnancy. And the second thing we documented was that most people, in fact, almost everybody decreased use through the course of pregnancy. In among the almost 30% of people who had used in early pregnancy, there was less than one percent who are still using at the time of delivery. So, for me, those data sort of support the statement that all people who are pregnant are motivated to maximize their health, the health of their baby. People engage in behavioral change during pregnancy. And one common thing is people quit or cut back substance use, inclusive of cannabis.

Kirk: Now, these would be these would be women that are actually receiving prenatal care. So, they're getting a counseling.

Dr. Terplan: Correct.

Kirk: Encourages them to do this. Do you have any data that suggests without counseling, behaviors remain the same? I guess, or I guess the question is through counseling, there's an expectation of behavior change and you're finding that.

Dr. Terplan: Yeah, that's so this is you're sort of asking about the role of screening and brief intervention to some extent. So, this clinic is somewhat unique. Me and other people set up a system of as be as welcoming as possible for everybody who walks in through the door. And assessments are a routine part of care. So, it may or may not be representative of every single prenatal practice that exists. But the brief intervention piece, honestly, we the counseling was minimal and certainly not protocol or manualized or anything like that. So I see I interpret these data as less about the clinic and more about the patients, the people and their behavior change. That being said, the like the data for brief interventions are actually many forms of counseling and reducing substance use in general, much less in pregnancy is just not there. We see experts working to some extent for alcohol related emergency department visits, but we don't see it really working for other substance use. And in pregnancy, we have no data, don't support any psychosocial interventions. But that's not because they might not work. It's because that natural history of change that I mentioned, most people quitting or cutting back. To show an intervention that's greater than that is very, very difficult.

Kirk: OK, all right. So, let's focus on cannabis then. What have you learned about cannabis in your studies and your observations?

Dr. Terplan: Well, to me, cannabis is sometimes I say, endlessly fascinating. In particular around women's health and pregnancy. Historically, I know you know this like every single cultural, like pharmacopeia, lists cannabis as a medicine. And many of the utilizations relate directly to women's health. There are archeological evidence of obstructed labor where cannabinoids are either seeds, or it's unclear exactly how the cannabinoids were used, it appears from the archeological record for that. And then around the turn of the 20th century, the period of the so-called patent medicines, cannabinoids were sold under multiple different formulations with a focus on women's health.  They were prescribed for menstrual irregularities. Ovarian pain and et cetera, and things like this. And so, there's a historical sort of pre-modern medical utilization of cannabis for women's health in general and obstetric care in particular. So, that is interesting. That is different, then cocaine or then opioids, although they too have a gendered component to them to some extent in the historical record. So that's one context. The second context is in the United States, this changing regulatory environment that varies by state. Clearly over time, where the cannabis ranges from recreational legalized at the state level to non-punitive completely across the board, or these sort of hybrid medical of which there is multiple different types of medical cannabis that is only CBD and there's medical cannabis that that allows for THC and edibles.  So, there's a hugely heterogeneous environment and women are clearly getting pregnant and staying pregnant across the different states and stuff. And despite this sort of loosening and liberalization of cannabis policy, it still is at the state level and in particular in the world of child welfare, something that when people test positive for Child Welfare can get involved, does get involved. And one thing I didn't mention in the introduction is the work I've done with sort of legal groups and legal advocacy organizations around child welfare and substance use and pregnancy in particular. And I just keep seeing cases where people test positive for cannabis and the State begins foster care placement and child removal processes. That is unique.

Kirk: I like the fact that how you phrase that. We have cannabis in Western medicine and the eighteen hundreds. We have cannabis in European and Asian medicine thousands of years ago. And its only been the last, what, last 60 or 70 years ago that cannabis became bad. So, but yet we still have cannabis in our population. In Canada, as you know, Canada is legal and national. I know that your country is very jurisdiction with its legalization. But in your practice, you see cannabis quite readily. Right. And we and we've identified it in Canada as the probably the number one thing that pregnant women will use. Now, usually what the average woman finds out she's pregnant half way through or the latter part of the first trimester. And then they go into.

Dr. Terplan: Correct.

Kirk: Into prenatal care, and that's when they get some counseling. So that sort of segues me into your practice. So, how have you now studied cannabis? What have you learned about cannabis specifically in your practice. If the majority of the women are coming?

Dr. Terplan: Yes, so I think there's some of this is from my own clinical experience.  Some of this is from my knowledge of the published literature and some of it is from discussions with other providers who work in this space. To me, I think the there's a couple of things that mark cannabis as sort of unique or that I would focus attention on. One, is the utilization of cannabis as a medication or self-medication for people who are pregnant. And what that means and what that looks like and what we, these are more from national data, most people don't, when on surveys, don't say they exclusively use cannabis for medicinal purposes, but some people do. Roughly five percent of people who are pregnant and who among people who are pregnant and have used any cannabis, that five percent will say it's for medicinal purposes only.

Kirk: I'm sorry, is that a relatively new phenomenon in the last few years? People are identifying cannabis as medicinal use.

Dr. Terplan: Great question and we don't know the answer to that because it's only in the last five years or so that that question has been specifically asked in national level data. But I do think that it might be increasing. Now, whether there's there are cynical and I think somewhat judgmental perspectives where people would say, well, women are just saying that because they can. But I think that's somewhat dismissive of people's own motivations for use. But what we see is that people who say I use cannabis medicinally only actually don't change their use during pregnancy. They don't decrease.

Kirk: because they're using it as medicine.

Dr. Terplan: Exactly. The second thing that sort of, I think unique, it relates to this, the issue of child welfare. So, one thing in our clinic so we can talk through, if you want to, the literature on what are the sort of effects of cannabis on a pregnancy. But overall, to put it very simply, like the effects are minimal and the data are confounded by other factors such as tobacco and et cetera. And certainly, when you want if you want to compare substances in terms of birth outcomes, alcohol is the leading cause of intellectual disability in the United States. And I would assume in Canada as well. You know, tobacco is associated with small birth, low birth weight and NICU admissions, et cetera, and those, quote unquote harms are far greater than those described for illegal substances. It's unclear that the literature on cannabis changes over time, too, in part because cannabis has changed. Maybe so, like the data from the 80s or 90s showed basically hardly any differences in terms of birth outcomes. And more recent data shows some slight differences in terms of the neonatal intensive care unit admissions, anemia. Not sure exactly how that is, these are associations. These aren't necessarily causal linkages. And some people say that's because the THC concentration is increased over time. But it could be, which is a plausible hypothesis, but it's not established. But for me, the thing is. Go ahead.

Kirk: Well, what I'm finding in most of my reading, and you really have to read carefully, because the headline will say cannabis associated with low birth rates. But as you get into study, you start realizing there's one little sentence buried in the narrative. They haven't removed the causes action of tobacco. So, in all of these cases, we say that 100 percent of these women have had low birth rates, but 100% are also smoking tobacco. And it's like, well, what we know, tobacco causes low birth rates. Why are we associating cannabis with that? Why are we why is the headline Cannabis Causes Low Birth Weight and your study, yet your study eliminated that. Right? The one that I was looking at from. Can you explain that so what that that was 2015 you were able to actually remove the cannabis from the tobacco from the equation, right?

Dr. Terplan: Yes, I mean, I don't know, so statistically, you can, quote unquote, control for tobacco smoking and then you can see the quote unquote, residual effect of the cannabis. That is a standard way of doing this or a simple standard way of doing this sort of research. And honestly, when people do that, the data are mixed still. There's some data that still show a residual effect. And in some data where when you control for it, it goes away. For low birth weight. And I think, though, what we need to it's not just the outcome, but it's also the magnitude of the effect. Right. So, yes, you can statistically, there's some data where statistically, yes, cannabis use is associated with smaller birth weight infants. but the magnitude of the effect is about twenty-five or fifty grams. Now is that clinically significant. If that association is causal, is that difference clinically significant? Is that difference, could that difference be explained by other factors? You know, and I don't. And right now, most of what we're talking about is are cannabis that is smoked plant product and not, other formulations of cannabis or cannabinoids. So, I think there's one could design a better study that would look at cannabis as smoked. Cannabis as measured correctly and in a more modern medical formulation and look prospectively and RCT kind of situation. But we don't do those around substance exposures in pregnancy for obvious reasons. So we are left with these sort of messy, incomplete data which lend itself to these kinds of over interpretations that you describe.

Kirk: Yeah, it's fascinating in some studies, you know, you read that when you compare cannabis smokers with alcohol drinkers in university, you find that the cannabis smokers tend to have 50 years on or 20 years on. They tend to have better careers. I've seen that study, but I'm looking at your study at one of your papers. And it seemed like the cannabis was it was low socio economics. Right. This clinic, the university clinic, it's.

Dr. Terplan: Yes. Yeah.

Kirk: So low socio economics. I mean, we know that, again, that has contributing factors to prenatal care. And so, it's I guess it's I guess it's the study in the cohort as much as the substances that you're studying.

Dr. Terplan: Yeah, and so to kind of place this in the context of pregnancy, there are really, I mean, there's at least four prospective cohorts in the published literature that have followed the subsequent cannabis use in pregnancy. And then and then for varying lengths of time, you follow the kids. And the first one is from the nineteen eighties and was really more of a medical anthropology study in Jamaica where the women drank cannabis tea so not did not use inhaled plant. And what they found was actually that the birth outcomes were better among the moms who used who drank cannabis tea compared to moms who did not drink cannabis. And so for various reasons that lend themselves to a bit of conspiracy theory, the person who was involved with that research actually ended up losing her National Institute of Drug Abuse funding.

Kirk: That was Melanie Dreher, is it not? That's her stuff. The famous Jamaican study. I've been trying to get ahold of her. I think she's now retired, but I've been trying to.

Dr. Terplan: Yes.

Kirk: I've been trying to hold of her.

Dr. Terplan: She did this remarkable research and lost funding. And the question and her career changed from that experience. And since then, you know, like the other the other cohorts are larger. They would be other a little bit more robust, statistically and et cetera. But don't necessarily, the magnitude, again the magnitude of the measured outcomes when different is small. It may not be, I'm not saying it's insignificant or meaningless. I'm just saying compared to the magnitude that we measure from legal substances, so-called legal substances. I know that's a changing landscape. Is smaller. And that's why I think you see those headlines.

Kirk: Put that in layman's term. What do you mean smaller? Like, what's the magnitude? Put that in layman's terms. What do you mean by that?

Dr. Terplan: Well, let's just look at birth outcome. Birth weight. And I'm generalizing numbers to a certain extent.  But cannabis birth weight changes plus or minus twenty-five or fifty grams. Tobacco smoke, birth weight changes more towards like five hundred grams.

Kirk: Right.

Dr. Terplan: So, both cause a change and both could have a "p" value that is likes to quote unquote statistically significant. But the magnitude of the effect on the birth weight, assuming that all those things are completely solid, which they are not exactly, is a lot greater for tobacco than it is for cannabis. And so, when we interpret data, we don't want to just look at what the "p" value, like significant or not significant and say, you know, cannabis causes low birth weight. We want to say what the magnitude of the effect is. What's the effect size? Because that really guides like that guides clinical interpretation a lot more. And that relates, I think, much more towards trying to assess what the population health outcomes are of things like this.

Kirk: So, in your study of the literature and from your experience, again, layman's terms, when isolating just cannabis as it's as a substance and relating to prenatal care, there is no significant concern? Is that the word?

Dr. Terplan: I would say: one, that we actually have a huge amount of data on this topical area. It's not like I hear oftentimes we don't really know. We actually know a lot. The problem is what we know is, is the results are mixed, right. Some showing no effect, some showing a slight positive effect. When we have a positive effect, the magnitude of the effect is relatively small compared to other substance exposures.  Sometimes uncertain significance. So, um, so my takeaway from that hope is when we don't have a... So, alcohol is like, for example, or even alcohol, which causes fetal alcohol syndrome and fetal alcohol spectrum disorders, we have a clear diagnosis or clear enough diagnosis that is causally attributed to alcohol. With most other substances don't have that relationship right. And in the absence of that relationship, instead of being sort of nuanced about our interpretation and how we talk to patients and how we read the literature, we say we just don't know because we're expecting, you know, it must have been illegal for a reason. And that reason must have been because it was so harm, is so harmful. Therefore, when the literature doesn't say that it's this categorical harm, we blame the literature rather than sort of think about how to think about it better.

Kirk: But isn't that interesting? That's cannabis's is... I mean, when you look at anything to do with cannabis and especially from the states and "the just say no" generation. I guess my partner Trevor always says, well, you know, medicine, what we do I'm a nurse, he's a pharmacist. What we do is Do no harm. Right. So, we know certain things. We know certain things about alcohol. We know certain things about smoking. We know that certain drugs are bad for pregnancy. Therefore, let's use a blanket statement, say no drugs during pregnancy. Even though someone might use cannabis as medicine. So, if you have a client that uses cannabis for nausea and she's using it throughout her pregnancy, how do you practice that? What is your clinician's approach to this?

Dr. Terplan: Yeah, great question. And so, I think there's two things. One is to talk about the nausea, and the second is to talk about cannabis. In the United States, in many places, I think it's simply speaking about child welfare. People are drug tested at the time of delivery. Drug tests that are positive, including for cannabinoid, cannabis metabolites, child welfare is notified and they may initiate an investigation and the investigation may culminate in removal of the child. So, I think it's very important as a provider to be transparent about that process and to tell pregnant people that they may be drug tested and these are the consequences of the drug test. I also tell them that regardless of what happens, I will remain your advocate. I will write letters. I would just disagree with removal and with that response. So that's a very more maybe more unique thing in the States. But I think that's very important to be transparent about what drug testing happens, what reporting is.

Kirk: And I don't want to cut you off. Is there a socio-economic issue there? Like if I show up with a BMW and, you know, and I'm a middle-class mother and I'm using cannabis and, you know, social welfare is not going to come to my suburb and take my kid away.

Dr. Terplan: So, there are some examples of middle class or upper middle-class white people being caught up in the child welfare system for cannabis in particular, but overwhelmingly the people who are reported, whose kids are removed, are poor and or people of color and or people with addiction or sort of marginalized. Quote unquote, populations of people that are adversely affected by the criminal justice system in general. There's a lot of parallels between who gets arrested, who goes to jail and who is reported to child welfare. In fact, there's a complete overlap between that. And that's yet another sort of critic of that system. The second thing is like the nausea. So, the data on nausea are interesting. There is just a couple of studies. There's some case reports showing the sort of cannabis hyperemesis syndrome in pregnancy. There are two. There's population level data that showed people who use cannabis. This is both from Hawaii, the data, as well as from Kaiser Northern California data, looking at either self-report that the Kaiser, the PRAM data or toxicology, that would be the Kaiser data and people who reported nausea and vomiting. People who use cannabis, reported nausea and vomiting more. Now, I can't say that's causal, but that's interesting. And then there are data from Canada actually looking more, it's smaller, and it's people who use cannabis during pregnancy because of nausea and vomiting. And those data show an improvement in nausea and vomiting, but only among those who were not cannabis naive. So, people haven't taken cannabis before and take it for the first time in pregnancy, maybe it doesn't work as well as people who are familiar with cannabis. So, I think that this is a long way of saying that although we know there are good data that cannabis is helpful for AIDS related nausea, vomiting and wasting. We don't see that the same level of benefit is not established for cannabis and nausea and vomiting in pregnancy.

Kirk: OK.

Dr. Terplan: The other thing, though, is the comparison group. And this is in terms of thinking about birth outcomes or even more developmental outcomes, right. So the real concern, I think, for people who study substance exposure in pregnancy is what does the developing fetus being exposed to these substances that are clearly psychoactive? What does that mean in terms of developmental outcomes? And we have as I mentioned, there's four prospective cohorts looking at children now adults sometimes who had been exposed in utero to cannabis. We have no prospective data looking at developmental outcomes of children and adults who were exposed in utero to medications for the treatment of nausea and vomiting. So the proper comparison group is not comparing people who, you know, whose mothers used cannabis during pregnancy for nausea and vomiting to everybody else. It's people who use cannabis versus people who used other prescribed medications. That's the appropriate comparison. That study has not been done, but I will say it has been funded and there are people going to be collecting those data.

Kirk: Interesting. Interesting. So, again, it's that whole naivete in the sense of what we know, what we don't know. We did it. We did an episode on Gabapentin and discovered that in Western medicine, we always hear doctors say we don't have enough studies, we don't have enough studies prescribing cannabis, we don't have enough studies. And I always bring gabapentin up. So how is it that you can prescribe Gabapentin for off label use when we don't have the studies for it? And.

Dr. Terplan: Yeah, yeah.

Kirk: So, how is it that we can justify one medication that we use off label and we can't justify the use of cannabis because it's illegal. Maybe. I don't know.

Dr. Terplan: Yeah. So, I think one is that. The distinction between legal and illegal is a social and legal distinction. It's not a biological or even historical distinction. And the category is a legal or illegal have changed over time. Yet, we attribute greater risk and greater harm to illegal substances than we do to legal ones. Despite preponderance of evidence. Like there are very few things that are teratogenic, i.e. cause birth defects. Alcohol does, but no other substance to which people develop addictions do. And there's a handful of medications that we that are prescribed that historically were prescribed like thalidomide, et cetera, that did.

Kirk: So know tobacco does.

Dr. Terplan: Tobacco. Yeah, it's. Yeah. I mean, so the term that people I think the term that makes the most sense to use might be like a neuroteratogen is the word. So, it doesn't cause a distinct physical manifestation of a birth defect. Like a face like faces or limbs or things like that.

Kirk: It's a whole spectrum. Tobacco is related to low birth rates. We know that, right?

Dr. Terplan: Yeah. So, whether that's a birth defect. A teratogenic is like...

Kirk: Ok.

Trevor: is more specific genre of harm. And things can cause harms or they can have outcomes that aren't birth defects. But that would be one of the pyramids of harm.  Like birth defect would be the top of the pyramid. And then there's other stuff as you kind of go down. But as I think that that's some of the reason why we just so we take this social lens and apply it to medical science in public health. But when I see when I see somebody who's using cannabis, let's say, for nausea and vomiting clinically. So, the couple of things. One, I'm an addiction medicine doctor. So, I look at everything through the lens of addiction, so I want to make sure that this person does not have a cannabis use disorder. The likelihood of them having cannabis use disorders some more, probably under 10 percent, but it's not zero. So, screening them for whether or not they have a cannabis use disorder. The second thing is like telling them, like I mentioned, about like what this testing means in terms of child welfare and then the clinically the more important thing saying, like, is it working, you know?

Kirk: Yeah, that's a good question to ask.

Dr. Terplan: You know, if it works, you know, and then telling them what we know and what we don't know about cannabis use. Then really more probably from the perspective of a question like do you have any questions about what your use of cannabis might mean for the health of your pregnancy and your child to be? And rather than lecturing, like soliciting people, that you brief, those motivational interviewing skills are central to clinical care.

Kirk: To do know of any studies right now, like are there any larger studies happening that are specific to cannabis and prenatal?

Dr. Terplan: Yeah, there's two that I know of. One is a prospective study. I think it's out of the University of Washington, which is looking at cannabis use during pregnancy for nausea and vomiting and will have a has a big sort of a follow up component that even involves, I think it is sort of brain imaging and stuff of newborns. And then the second one is from Kaiser, Northern California, which is using the Kaiser data, looking more back in time because they have a giant database. Looking at people who use comparing people who use cannabis during pregnancy and I don't know how specific they are around for nausea and vomiting or not, but comparing those people to people who use prescribed medications for nausea and vomiting during pregnancy. So those are the two. They are I think they're both RO1. So, these are five-year studies. They're both, I think, in their first or second year. So, it's going to be a while until those data are matured and published and available. But those are the two that I know of that I think will really help fill in some of the gaps.

Kirk: Wonderful.

Dr. Terplan: The other dimension that you haven't asked about relates to breastfeeding. Cannabis and breastfeeding. So, I do not know the status of this debate in Canada, in the United States, the American Academy of Pediatrics, as well as the American and whatever Academy of Breastfeeding it might be called, they both have issued guidance around breastfeeding, which more or depending how you read the guidance, really state at least caution in recommending or encouraging breastfeeding among people who are using cannabis. The concerns include transmission of metabolites in breast milk. As well as second or third hand smoke exposure to the infant. The I would say these guidance documents, especially the American Academy of Pediatrics are, when you read them, relatively nuanced. And but in practice, what this means is in many hospitals, if somebody tests positive at the time of delivery for THC metabolites, they are literally, quote unquote, prohibited from breastfeeding.

Kirk: Interesting.

Dr. Terplan: Yet so there's how I mean, he said so you asked about racial inequities in child welfare. And I said that there's some exceptions and this is a story of an exception. It was a woman in Colorado who fell down some stairs during around seven months pregnant. Injured her back. Went to the doctor. The doctor said, I'm going to prescribe you some opioids. This about five years ago or so she said, I'm not so sure about opioids. I've been hearing a lot of bad stuff about this.

Kirk: Ya think?

Dr. Terplan:  She's in Colorado, which is already legalized cannabis, and she's like, I'm going to use cannabis. Unclear if she had used it before or not. So, she uses cannabis for her pain. Pain is better. At the time of delivery, she tests positive. She's prohibited from breastfeeding. The case goes off the rails. She gets literally court ordered to not breastfeed. A judge's ruling that you're in violation of the court order because you're breast feeding. This is like messed up. This is a misunderstanding. What the drug test is. Misunderstanding, what the data on and even what the professional society recommendations are breastfeeding on and a complete violation of this woman's autonomy and bodily integrity. So, in practice, like these guidelines have really confused providers and it's not at all uncommon for people who use cannabis or people who have to stop using. But the test is still positive because those metabolites stick around for a very long period of time to be, quote unquote, prohibited breast feeding. Reported to child welfare when they take care of their kid in the way that we've been encouraging people for the right reasons to get out in our support, public health support of breastfeeding and etc. And to that, I will add yet what we don't know. And Dr. Marc, who is going to be on this podcast, who is unable to be here, like she has submitted a grant that did not get funded to look at this, which is we don't know how people metabolize cannabinoids in general, much less THC in pregnancy. And it's possible that the metabolites stick around a lot longer during pregnancy than they do, not during pregnancy. And so, our interpretation of what a positive drug test means that delivery is actually based on data from non-pregnant people. And it's flawed.

Kirk: So, so in review, because I think we're going to run out of time here with Zoom. In review, in your practice, in your research, looking at cannabis and pregnancy, there is nothing or how do I word this? The data is still out. We don't know. We can't correlate any direct causative harm to an infant. And later in life, if we just look at cannabis.

Dr. Terplan: Yeah, I would say let me I'll phrase this slightly differently. The main risk associated with using cannabis in pregnancy is the fact that it is illegal and when even so, that you have to engage in an illegal economy in order to get the cannabis, one. Two, you're not exactly always sure what you're getting. And that puts you and your family at greater risk than the chemical exposure does.

Kirk: Just entering the illegal market is more risky than consuming it.

Dr. Terplan: Yeah, yeah. Because you can, and in pregnancy, the risk the main risk is, is child welfare. And again, being investigated by child welfare, having your kid placed into foster care and all of the nonsense and injury that comes from that to you and to your family, that is the greatest risk of cannabis. It is the social response is the greatest risk. Now the medical risk. Go ahead.

Kirk: Well, I was going to let, the medical risks, I should let you finish that one, finish that thought please. The medical risk?

Dr. Terplan: So, the medical risk is not zero, but the magnitude of the risk is likely low. It's confounded by other things. And so, to me, what we want as clinicians and public health people is to support people to have the healthiest pregnancies possible. To raise their children in safe, stable environments devoid of violence. And so that means, one, making sure people don't have other conditions for which there's treatment, i.e. addiction or other diseases. And then really supporting people in the postpartum period. So, I think people, people who are healthy, have healthy babies and have healthier families. And so, it's about it's about health and wellness more than it is about legal illegal.

Kirk: So, let's think of utopia. Let's think of Canada. Utopia. So, we have legalized cannabis medicine and recreational in Canada. There is some thought that America is going to go that way in the next few years because the economy it offers, right. So, let's look at the utopian world that America is now legal for cannabis. So, how does that change your practice and your recommendations to women? Do you think there's still going to be the social stigma? Do you think that's still going to be social services?

Dr. Terplan: Yeah, I mean, I think it will depend. But, I think clearly from the experience of states like Colorado, which have legalized as much as they can at the state level cannabis. We still see pregnant people are treated differently. Right, both in terms of that, in terms of the breastfeeding stuff, in terms of especially child welfare. And that's an example, to me that's when we treat people differently based upon inherent conditions, i.e. pregnant or not, that's discrimination. So, I think that just the simple legalization blanket works for most people most of the time, but does not work in pregnancy. And so without specific attention to that, that sort of surveillance of and that an unequal surveillance that child welfare does will continue even under a regime of legalization. So that needs to be explicitly addressed. And the assumption that legalization will get rid of that is definitely won't happen. So that stuff needs to be, kind of like, cleared up. In terms, from the medical side of things, I mean, we will learn more. But to me, I think cannabinoids have therapeutic potential, without a doubt. You know, we know this from the historic record. We know this from recent data looking at cannabis and wasting and stuff like this. But I wouldn't call cannabis a medicine in the same way that, you know, Ondansetron or Phenergan are medicines, right. So what we need...

Kirk: Why, why is it not medicine that way?

Dr. Terplan: Well, because it's medicine in an old and I don't mean this at all as criticism in a premodern way. Right. It's plant based. And to a large extent, although this is changing like anecdotal. And that doesn't mean that it's wrong. It just means, when we think of medicine in the United States, I think of, you know, like a chemical compound that is studied in a randomized controlled trial fashion explicitly recorded.

Kirk: Spoken like a true Western doctor. There you go. I was looking for that one.

Dr. Terplan: Yes, exactly. So that and I think cannabinoids have incredible therapeutic potential and we need to study them. And the United States is still, you know, like, you know, it's so hard to study cannabinoids. There are cannabinoids in almost every single part of the human body except the brain stem and cannabinoid receptors throughout the reproductive system. And there are animal models of exogenous cannabinoids related to miscarriage and stuff like that. So that even from a women's health perspective, I think there's a great possibility of medications in the future. And yet we can't really...

Kirk: This is a whole this is a whole new podcast that you just had a comment about the women's reproductive system. There's cannabinoid receptor cells in the uterus. Are these CBD1.

Dr. Terplan: And the fallopian tubes. Oh, yeah. Yeah.

Kirk: Are these CBD2 or CBD one receptors or.

Dr. Terplan: I think they're…  I don't know. I don't want to say the wrong thing.

Kirk: Okay.

Dr. Terplan: But I know that there are sort of animal models of a miscarriage, animal models that utilize, you know, exogenous cannabinoids that I think find to both. I don't but I honestly just don't know of the top of my head.

Kirk: So, it is a question. Just throw it out there. If our body has these receptor cells and we go back millennia, where plant medicine was practiced.  Is there a future for cannabis as medicine for women's health? I mean.

Dr. Terplan: Yeah, I mean, I think the historic record is so like cannabis really is more describe for women's health related stuff than any other medical condition historically and back like I don't mean just through the like one hundred and fifty years ago. I mean like as far back as there are pharmacopeia. And so yes, I think that is that would strongly suggest a therapeutic benefit of cannabinoids through this sort of modern quote unquote like regimen. The fact that we have cannabinoid receptors is that to me, the more similar substances are opioids that way too right. We have opioid receptors and historic like and the use of opioids like, you know, as far back as there are records of some parts of the world. And so to me, those are kind of like sort of similar things. It's just that we identified those compounds and isolated the receptor like a whole lot earlier for the opioid than we did for the cannabis. And cannabis got like in the United States, at least like lost in just the larger War on Drugs. Prohibition has not really been adequately separated from that despite the I mean, it's misclassified. Clearly, it's classified as something without medical benefit, which is that is it's clear that there is the possibility of medical, at least the possibility of medical benefit from cannabinoids so that classification system needs to change in the states.

Kirk: Dr. Terplan, I could talk to you for hours. Like, I just I already have lists of others issues I want to talked about. Is there any question I should have asked you, I forgot to ask you. Is there any topic you'd like to add to?

Dr. Terplan: Oh, I mean, I agree. I feel like we just sort skated on the surface. That's not a criticism and it's been a real pleasure. Thank you so much for reminding me. I don't have any questions at this moment.

Trevor: OK, Kirk, we're back out. So much going on there. I probably should listen to it a few more times, but one of the things because it's come up other places, what is cannabis hyperemesis syndrome?

Kirk: You know, I've never seen it, but in the literature and I have I have talked to practitioners that have seen it. It comes when somebody is consuming a lot of cannabis to the point that their body starts rejecting it and they start vomiting and they vomit aggressively. And it's very uncomfortable and nothing seems to settle it like the normal antiemetic don't seem to help. So, it's it seems to be out there. And I and I'm not sure if it's from too much ingestion or from smoking it too much.

Trevor: And the interesting thing, I know you and Dr. Terplan didn't get in and he would be into it, nausea and vomiting in pregnancy is relatively common. And there's even a small, tiny minority of women who vomit basically uncontrollably during pregnancy to the point that it's, you know, unfortunately vomiting during pregnancy, fairly normal, vomiting to the point that we worry about the electrolytes of the baby. Not but it does happen. And he was saying that they give cannabis hyperemesis syndrome does even happen sometimes in pregnancy. So, but onto the regular nausea bit, I thought it was fascinating and that sometimes cannabis might actually make the nausea and vomiting in pregnancy worse. So, what did you think about that bit?

Kirk: Well, again, I enjoyed chatting with him and it's funny being part of a conversation with somebody and you know, I'm trying to interview him. But as you can see, as the conversation started going, it just became a conversation. And there is some questions that I would like to have explored more. One that I found interesting was when it came right down to what he was saying is that we don't really know. Yeah, it goes it goes back to the conversation we had with covid, you know, covid episode. Cannabis can help the body, but a certain strain can also harm the body. So, again, when it comes to cannabis, there's no easy answer.

Trevor: No, because he did say that there are some people that the cannabis actually help their nausea and vomiting during pregnancy. And there were some that it didn't seem that it made worse. They think some of it had to do with whether or not your cannabis naive, if your cannabis naive in the first time you tried it was during pregnancy, might not be if you weren't. It might. And why I'm harping on this is we have a we have a pill called that we call diclectin that we prescribe, give to women when they're nauseous in pregnancy. And it's good.

Kirk: And it works really well.

Trevor: Well, here's the problem. There are people even to the standard drug, that is it indications nauseas and vomiting in pregnancy. There are researchers who would argue up and down that it's frankly no better than a placebo because the whole nausea vomiting in pregnancy is so hard to pin down. What's causing it, what's not. You know, just because you're nauseous this week in your pregnancy doesn't mean you're nauseous that week. And if you happen to have taken this, diclectin in between, you think that diclectin is the best thing ever. So, it just it was funny. You just reminded me using cannabis. And I'm not saying the cannabis is better or worse than diclectin, but it just reminded me from some of the readings we've done over the years on diclectin. Is it helping, is it's not? We don't really know.

Kirk: Isn't that interesting? So once again, medicine, medicine can be seen as hypocritical. So, we'll give somebody a pill we think might work. But we've got studies to say it doesn't work, but cannabis. Can't use cannabis.

Trevor: Yeah.

Kirk: And this is the part of the conversation I enjoyed with Dr. Terplan was essentially how he wove into his story is that we don't know a lot about cannabis. But what we do know about cannabis is it doesn't seem to do a lot of harm.

Trevor: No.

Kirk: You know, and that's and it seems like and that's another theme that sort of you can weave in all of our episodes when we when we've talked to experts, right. Experts of cannabis. This new plant that's been around for five years or 20 years in Canada that doesn't do much harm.

Trevor: And he had many sort of mind blowing statements. You know, pharmacists, talk to people, pregnant people about their, we'll call it drug use, but I'm talking about the medication, all the stuff they put in their body during pregnancy. I talk about that a lot and he kind of blew my mind with the no substance of abuse other than alcohol is transgenic now. Transgenic, it means causes a birth defect. We throw that around in pharmacy world, a lot transgenic is bad, causes a birth defect. So think thalidomide with the stumpy arm thing. That's our typical transgenic. My apologies to anyone with that birth defect.

Kirk: That was very visual.

Trevor: We talk about, you know, I have people who come into the pharmacy who use meth, who have used cocaine, who have used and and and and and and and and we were and and some percentage didn't get pregnant because they're people and people get pregnant. So, we worry about all of those things.

Kirk: You have addicted baby, you have crack babies.

Trevor: You know. Right, and I'm not saying it's good, if you are a crack baby. If you remember the 80s we talked about crack babies. That was literally a term. Yeah, but he's right now. I'm not saying it's good, don't get me wrong. But they certainly weren't born with three eyes. So, it's just. The things we're really afraid of, maybe aren't as bad?

Kirk: Yeah. Well, it goes right back to prohibition man. Prohibition of all drugs. Are drugs or crime or drugs a health issue? So, this this man, this doctor, he works with addictions you think you know right. He's seen it. So again, how does it affect my practice as a nurse when I'm dealing with prenatal patients and I do have active prenatal files where I work.  It's good insight for me to, you know, the whole fear thing. If you're going to do cannabis. Probably shouldn't. But, you know, alcohol or cannabis, alcohol or cannabis, harm reduction. Again, I don't want to get myself in trouble. The best diet is a balanced diet. No drugs.  But harm reduction right. Nursing is all about harm reduction. Cannabis. Well, I don't really think it does a lot of harm.

Trevor: Well, and for the stuff that does do harm you talking about prohibition, his story, his crazy story about, so you a lot of US hospitals, I'm sure this happens Canada, too, but he's in the US. So, the hospitals routinely test for cannabis and cannabis metabolites when he didn't give birth.

Kirk: Yes.

Trevor: So they tested it for this one woman in particular in a legal state. She started using it under doctor's direction for a back injury. While pregnant. They found metabolites. She's of course, I'm using it medicinally. And because of that, they wouldn't let her breastfeed. Now, Kirk, you do way more breastfeeding talking than I do. Kirk is breastfeeding good for babies?

Kirk: It's the best for babies. It's the best. I mean, I'm not a nipple Nazi, but breastfeeding, yeah, it's the best.

Trevor: Breastfeeding? Real, real good for babies, right?

Kirk: Real real good for babies. 

Trevor: So, the idea that you would not let a baby suckle from a mom who has some cannabis metabolites just kind of blows my mind.

Kirk: Yeah. Yeah. Yeah. It's.. Yeah. So, again, it's the harm reduction, right. We so obviously cannabis, cannabinoids are found in breast milk. So how is that going to affect the baby? Now here's the question I have. The Stuff in cannabis that is in the breast milk. Is it THC? Is it is it CBD? What is it? I mean, I don't know.

Trevor: We don't know. And, he made that point. We know so little about the metabolism of cannabis that we're not even sure whatever cannabinoid it got turned into. What it does like, you know, it's a little bananas that we don't know the effect of the metabolite, but we know for sure it's terrible for the infant.

Kirk: But do we, because all the studies, you know, when they start looking at the studies and start breaking down the factors and the causative effects and you isolate cannabis, well, we really haven't seen it do too much harm. You know, it's we don't want people doing it because we don't understand it. But as you said, you know, we'll give them medicine that we know doesn't really work because it works for people. So I don't know, Trevor. It's also wild and his enthusiasm for wanting to study cannabis, I bonded with him because it's, you know.

Trevor: Definitely infectious. He had many more mind-blowing things, but the last of his mind-blowing quotes that I just wanted to pull out because I had no idea what the numbers were. I like numbers. So he said, OK, so best as we can tell, birth weight reduction with cannabis 25 to 50 grams. Yeah. OK, so I hear that and go OK, that sounds significant. So, yeah, we can find that statistically significant. So, a real effect, not just by chance. It's OK. No, no, that's all right. We should be concerned about that pharmacist says yeah yeah. And he said but you compare that to tobacco, 500 grams less. Like a ten-fold more likely to cause harm with tobacco.

Kirk: A half a kilo right.

Trevor: It's a pound. It a pound for people who think in pounds. 454 but 500 grams is a pound.  You weight a pound less at birth and nobody yanks the baby away from, I'm not saying it's good, but no one yanks babies away from smoking mothers.

Kirk: But yeah, yeah, it's the cannabis stigma, right. It's back to that whole stigma, cannabis stigma. And it's and this is why I wanted to this series, you know, I want to I want to investigate this more in regards to how doctors are looking and nurses and how we're looking at cannabis for the health of people. So, series on prenatal exposure to cannabis Episode Two, I guess.

Trevor: Yeah, no, I'm I was a little leery when we first started the series, I'll be honest, because I didn't want us to sort of go over the edge into saying things that are going to get us professionally in trouble. But this has been this is this has been way more interesting and enlightening than I ever thought it was going to be. All right, Kirk, again, a fascinating, look. Dr. Terplan, thank you very much.

Kirk: Yes. music. I got to get back to him. He said he would give us some Turkish stuff from the 70s.

Trevor: All right, see everybody next time.

Rene: Hey, it's Renee here and I produced the Reefer Medness podcast. And I should interject here for a second and just explain. Recently at the end of each interview, Kirk or Trever, ask our guest if there's a particular song or style of music that they'd like us to play at the end of the episode. And Dr. Terplan had mentioned that he was a fan of Anatolian rock, which is Turkish rock, and so today's song at the end of this show is by arguably the king of Turkish rock. His name is Baris Manco and here's a song by him called Kol Basti. 

 

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