“Marijuana / Cannabis Use in Pregnancy” – with Dr. Torri Metz

Dr. Fox welcomes Dr. Torri Metz, an associate professor of OB-GYN and Maternal-Fetal Medicine at the University of Utah to the podcast to discuss cannabis use in pregnancy. Dr. Metz dives into her research encompassing this topic and her findings.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Torri Metz, thank you so much for coming onto the podcast. I really appreciate. How are you doing today, my friend?

Dr. Metz: I’m doing very well. Thanks for having me.

Dr. Fox: It is a pleasure. So, we’ve known each other for a while now, I guess, in our escapades through, I don’t know, the journey of MFMs in the country and various meetings and conferences and fellow retreats. It’s been a while.

Dr. Metz: Yes, we have. Hopefully, I’ll get to see you soon.

Dr. Fox: Yeah. I see you walking around in your bright orange Bronco jersey. Pick you out of a crowd. Yeah, no listen, it’s great. I feel like I’ve seen you grow up from a young fellow to, like, czar of the world in MFM. You’re a big honcho now.

Dr. Metz: Well, thank you, Natey. Honestly, it’s fun. It’s awesome to have a chance to do research in obstetrics, to teach young fellows in obstetrics, and, you know, practice clinical medicine and see my patients. It’s pretty great.

Dr. Fox: Good stuff. So, for our listeners, you are an associate professor of OB-GYN and maternal-fetal medicine at Utah. You are also a researcher. You are an editor of “The Green Journal, Obstetrics & Gynecology,” which is the top of the food chain journal for our field. And you are a Denver Broncos fan, if I’m correct.

Dr. Metz: Yes. All true. Although the last one is hard to admit to lately, but hopefully it’ll be better this year, but yes.

Dr. Fox: Well, you’ve had some good runs in your lifetime, which is…

Dr. Metz: It’s true.

Dr. Fox: …better than I can say is being a Bears fan. It’s been a long time for us. So, it’s all good. Give us a little bit of background about yourself, so, you know, where you’re from and how you made your way to where you are today, I guess either geographically, academically, however, you wanna put that together.

Dr. Metz: Yes. I grew up in Colorado and I did undergraduate at the University of Colorado Boulder, and medical school in Denver, and then did a residency also in Colorado. So, you can see why I am a Broncos fan. And then I did fellowship in Utah and, you know, practiced in Denver for a while and I’m now back in Utah. And that is mostly related to trying to do more clinical research and the opportunities that I had there. But I am an Intermountain West kind of gal, so it’s been good.

Dr. Fox: How did you get interested in medicine in the first place?

Dr. Metz: Oh, geez. I am one of those people, from the time of being able to articulate my career path, who said I was going to be a doctor. I can’t really tell you why, I don’t have doctors in the family. That was just something that I aspired to do. And knowing me for a while, you know that I work hard to achieve my goals. I guess I strayed away from it a little bit in undergrad, I would say, and considered maybe just, you know, doing chemistry in the lab, which is what my degree was in, and decided that, no, I really enjoyed humans too much for that, and I went back to the plan to go to med school. So, and OB-GYN was definitely not the plan initially. I had planned to do emergency medicine and just loved OB-GYN. I loved the combination of delivering babies, being able to operate, and having continuity with patients in a good way through some really joyful and sometimes some really sad times. And that’s what ended up eventually then pushing me into maternal-fetal medicine.

Dr. Fox: Well, I can’t see you in a lab. You really are a little too boisterous, I would say, to be cooped up in a lab. It would be…

Dr. Metz: Yeah, it’s true.

Dr. Fox: …a shame.

Dr. Metz: Yes. So, it was good I went back to medicine. I think it was a little bit of, “Oh geez, that’s a really long path it turns out. And can I really get into medical school?” More of, you know, life questions that were emerging when I was…whatever that is 1920. So, I’m glad I did it.

Dr. Fox: Cool. And how are you enjoying life in Utah?

Dr. Metz: It is great. We have an amazing division of MFM faculty there. And we are doing, I think, great work in the department and in our community. And I am doing a ton of research and have had a lot of opportunities both through grant funding and just, you know, opportunities through “The Green Journal” or “Obstetrics & Gynecology” that you mentioned to really just expand reach there. And I think hopefully make a big difference in how people are managed nationally and making sure that, you know, patients are getting the best care that they can.

Dr. Fox: Yeah. And then one of the things that you sort of pivoted to in recent years is you became really knee-deep in COVID in pregnancy. It was one of your big passions or maybe just responsibilities that got thrown at you. I don’t really know. What happened there? How did you get so ingrained in all of the…? I mean, it was everything. It was advocacy, it was research, it was, you know, just discussion about COVID. What happened there?

Dr. Metz: Yeah, I mean, I think that was really initially led by the fact that I was director of our labor and delivery unit at that time. And it was one of those things where as COVID started to be present in the United States, honestly, you know, predominantly initially in New York, as you know, we were just trying to learn about it and what people were doing about it and what we needed to do about it to keep our patients and staff safe. And there were just so many unknowns at that time that, you know, clinically I was working to take care of and administratively working to take care of our team. And so, that, you know, then inspired, “Well, we just need to know more about this so that we can educate people.” And that sort of launched the research aspect of that. So, I proposed a study to the National Institute of Child Health and Human Development or NICHD, Maternal-Fetal Medicine Units Network, which is the big clinical trials network to say, “You know, we as a group, since we’re established research, infrastructure established centers need to try to figure this out, so that we can provide information to our patients and we can provide information to clinicians out there.”

And, you know, they said, “Yep, we need to do that study.” And the NIH funded it and, you know, people then looked at me, “You know, Torri knows all the literature. She’s an expert in COVID.” And then I, you know, just sort of ramped up from there. I think people were looking for expertise in that area. People who had really delved into everything that was out there and knew how to take that information and try to put it into clinical policies and use it to think about how we were taking care of patients. And so, I think that just kinda became, you know, just the spiral. And then once we started doing that, you know, I received some other funding for a study that’s now ongoing where we’re looking at long-term outcomes of people who had COVID in pregnancy and both for them and their kids, their offspring. And so, that’s an ongoing study that was also funded through the NIH. And so, that’s kept me busy from sort of all ways from, you know, clinical work, research work, administrative work, for really a couple of years during the pandemic and is ongoing now. So, it took me away from my cannabis research for a little bit but…

Dr. Fox: Yeah. How much did you get roped in politically, in terms of either statewide or national-wide?

Dr. Metz: Yeah, I mean, I did a lot of public health messaging in the state as well as nationally. A lot, honestly, related to vaccination and pregnancy, about the concerns that pregnant people were getting very ill with COVID more so than non-pregnant people, which we see with the majority of viruses. That there was a lot of vaccine hesitancy from people who are pregnant just because it was a new vaccine type and pregnant people weren’t in the original trials of the vaccine. And so, for a lot of reasons, you know, patients were worried about being vaccinated, but even as we got information that said it was safe, we still saw a lot of hesitancy. So, I did a lot of outreach in our communities, was interviewed a fair amount nationally, just to talk to people about what we knew and what we didn’t know, you know, and encourage them that that was the safest thing for them.

Dr. Fox: It was it was pretty cool to see you quoted, see you on TV, see you on radio, see you in articles. I’m like, “I know her. I’ve known her for so long.” That’s [crosstalk 00:08:52.100]. It’s all good. I mean, obviously, you were highly capable and qualified to do it. It’s always just a treat though. And then the big…I guess my personal interaction with you as the COVID czar was every, like, four days I would get a Green Journal email from you saying, “Someone needs to review this and it needs to be done within two days.” I’m like, “Great, thanks.”

Dr. Metz: Yes. And I think that was actually sort of my…

Dr. Fox: Rapid reviews.

Dr. Metz: Yes. Yes. And we thank you for doing that, very much. And I think, you know, that was our effort to really get the information out as quickly as possible. You know, a lot of times with the scientific journals, you know, we receive information, we send it out for peer review, that takes a few weeks. We make a decision, the authors revise it. That takes a few weeks, it takes a while to get it to print. So, you know, it ends up being like ultimately several months from the time something happens until it appears, which is actually pretty fast in our journal actually compared to a lot of other journals. But we wanted it to be even faster with this. You know, get the information out. So, I was appointed as the, you know, ad hoc editor at that time to review all the COVID articles that were coming in because I did know what was new, what was important, you know, what do we need to get out quickly, what do we wanna send out for peer review now, and then fast track. And I thank you for being on the reviewing end of those things. I hope that it was helpful to, you know, the scientific community as well as all of the patients out there.

Dr. Fox: Well, yeah, I definitely wasn’t thinking altruistically. I’m like, “Man, if I’m doing this, I’m totally roping her into the podcast. She can’t say no now. All right, I’ll review this damn paper out of China, and you better come on the podcast.” So, first of all, I’m gonna ask you about the whole topic, but we were talking offline before, you know, the title of this podcast is talking about marijuana use in pregnancy. And you were saying that we really should try to pivot away from that. So, just tell me what, you know, we were talking about before. Tell our listeners, I guess, we were talking about before.

Dr. Metz: Yeah, I mean, I think there’s a strong movement in the research community as well as, you know, among substance use disorder experts who really want everybody to move to the term cannabis instead. And I think, you know, marijuana has been sort of a vague and stigmatized term in its history as this, you know, became a drug that a lot of people were using, especially sort of in the ’80s and ’90s kind of timeframe. And so, I think that now, you know, people are really trying to move towards using this term cannabis, which is what we’re talking about when we say marijuana more vaguely. So, that people can, you know, just use a more scientific term, a preferred term, rather than this, sort of, catchall, stigmatized term that existed previously.

Dr. Fox: Okay. So, in the podcast, we’re gonna refer to cannabis, but I mean, we’re talking about the same thing, essentially. It’s the same substance, but again, it could be smoked, it could be ingested. However, we’re gonna talk about all that, but we’re gonna use the term cannabis. Now, how did you get interested, I’m not gonna say in this, but in research on this? I’m not gonna ask about your personal life.

Dr. Metz: Yes.

Dr. Fox: Torri, tell me about your pattern through high school, if you don’t mind.

Dr. Metz: Yeah. I became interested in researching this, honestly, similarly to the way I became interested in looking at COVID. I mean, it’s things I was seeing in a clinical environment that then made me have questions, that then I really couldn’t answer when patients asked me about them in any kind of evidence-based way or based on any science. It just wasn’t available. And so, you know, when cannabis became legalized in Colorado, which was one of the first two states to legalize cannabis, I was there at that time practicing at Denver Health Medical Center and the University of Colorado Hospital. And a lot of patients just started to ask, “Is it okay to use cannabis during pregnancy, or use marijuana during pregnancy?” And I mean, I don’t know. I don’t really know the answer to that, and I don’t really know how to counsel you.

At that time, you know, there are data that were available, most of it from, sort of, that 1980s, 1990s timeframe. And at that time, you know, it looked like there was maybe an effect on fetal growth or, you know, growth of the baby in utero, but not really a lot else. There’s a lot of conflicting studies. You know, some said, “Yes, it was associated with pre-term birth.” Some said it wasn’t. People are really sort of still clinging to this “Jamaica study” that I’m sure people have heard about if they’ve looked at this literature at all, which is, you know, a really small study of 24 kids that were, sort of, selected in a very biased way, you know, without any kind of, sort of, adjustment for any of the other environmental factors that said, “Oh, yeah, their outcomes were the same or better when they were exposed to cannabis in utero.”

And so, it was just really hard to boil down all that literature that was out there. My former…well, now my current chair, but my mentor in fellowship, Bob Silver, called me up, and he was still in Utah at the time, and said, “Torri, I think you need to study cannabis in pregnancy.” And I’m like, “I don’t know, you know, Bob, that doesn’t really sound like, you know, what I necessarily wanna do. I’m not an expert in substance use.” And he’s like, “But like, we just don’t know the answers here. And, you know, this is gonna become legal everywhere.” And like many things, Bob was right. And I said, “Okay, you know, I’ll start looking into it.” And honestly, that’s how I started, you know, studying it.

And it just takes so long to do studies and there’s a lot of barriers to studying drugs and pregnancy, not surprisingly, right? Patients don’t wanna tell you about use in pregnancy. There’s a lot of stigmatization to that. There’s reporting laws that then, you know, require researchers to, you know, report them for drug use in pregnancy. And so, there’s just a lot of things that had to be worked through. So, honestly, the first few years I was studying this was a lot of just working with the IRB or the Institutional Review Board about how we can do human subjects research in this area. How can we do that and protect the participants and, you know, get the answers that we need? And so, it’s been a long ramp up because people know, that was like 10 years ago that that was legalized, why don’t we know everything now? Well, this is why. I mean, it just takes time to do the studies that we need to do to answer these questions.

Dr. Fox: Yeah. I mean, I think that for our listeners, it’s really important to sort of talk about that because, I mean, this is new, right? So, there was not a lot of research being done, but even just take things that have been around forever, right? Alcohol, smoking, various medications, you know, for whatever reason. It’s so hard even if they’re, like, prescribed by doctors, forget about, like, used generally, to know what the effects are in pregnancy precisely. Because the only way to really know for any substance, so let’s say for cannabis, is you have to make sure that it’s that substance versus something else going on in their lifestyle.

How do you do that in research? We take a lot, a lot, a lot of people, let’s say, you know, 20,000 and we randomly divide them into 2 groups, right? We don’t pick by anything that’s literally random like lottery. And half of you, we’re gonna give X amount of cannabis every day in pregnancy or during the first trimester or whatever we wanna study. And the other half we’re gonna give some sort of placebo, though I’m not really sure how you could not have people know what they got, but whatever. And then…yeah, wait, how do you feel? “Pretty damn good.” So, all right. And then after birth, you take the 20,000 babies or whatever it is and follow them until they’re like 18 and see how they do in neurodevelopmental scores and this and that and, you know, health and all that stuff. And then you go back and say, “All right, were the ones who were exposed to the cannabis better, worse, or the same than the others?” Like, that’s how you would have to do it. Now, obviously, that’s not been done. That’s never gonna be done.

Dr. Metz: It’s not, right?

Dr. Fox: Yeah, and listen, it’s basically true for alcohol. It’s true for most medications we use. It’s true for almost everything that we look at. And so, the only way to study it is to go backwards and say, “Okay, here’s 10,000 kids whose mothers did use it, and 10,000 kids whose mothers didn’t.” Then you’re like, “Well, are we really right?” Are the ones who didn’t do it, were they just lying? Like, maybe 10% of them were doing it didn’t tell us, or maybe the other group. And then was the group who was using cannabis also smoking more or drinking more, and were they telling you about this? And, you know, were the kids’ mothers used to test it more? There’s so much, you know, what we call, you know, in the research world, confounding. But, you know, you can call it, in general, noise in these studies to try to sift through that. And I don’t wanna say it’s impossible because it’s not impossible, but it makes it very challenging. And so, how do you get past that when you’re trying to come to an answer? Because people wanna know, just like, tell me, is it safe or is it not safe? And if it’s not safe, what are we talking about here, 1% risk, 50% risk? How do you try to even set something up that can answer a question like that?

Dr. Metz: Yeah, I mean, you did a great job of explaining all of the issues that really, sort of, plagued this research and our ability to clearly answer these questions. And I think that that leads to some frustration for patients, right? Well, why can’t you just give me a clear answer on this? And…

Dr. Fox: Because we’re doctors.

Dr. Metz: …this is why, right? Well, yeah, exactly. But this is why, I mean, it’s messy. The studies that are available are messy and we know that patients don’t report cannabis use like we’ve studied this, and so have others. And it probably underestimates use by at least two to threefold, in some studies as much as tenfold. And so, it’s really hard to even sort of classify participants and studies into groups like, “Yes, you were using cannabis, you weren’t.” Like, if we rely on them telling us it’s just not a reliable way to categorize.

So, you know, we’re working through that. We have some funding to look through that, which we can talk about more where we’re actually doing, you know, sort of, urine sampling on everybody in a de-identified way. So, it’s not harmful to anybody in terms of their broader life. But I think, you know, until we have those results, I think that, you know, the way that I counsel people is to sort of look at the totality of the information that we have out there. And there’s ways that we do that. You know, people do these assessments called systematic reviews where they look at all of the scientific literature that’s available, and they sort of summarize it. They go through each study and they say, “Yeah, this is a study that tries to answer this question. This is a good study or it’s a bad study,” which we call, you know, reading the degree of, sort of, bias.

And then we also look at, sort of, the differences between studies and, sort of, pool it all together in this meta-analysis, which is really a pooling of all the existing literature. And we say, “Yep, we think that based on everything that’s out there, the best answer right now is that this affects this outcome or that outcome.” And people have done that with cannabis use in pregnancy in a variety of different meta-analyses as well as, you know, the National Academy of Sciences has looked at this as one of their topics that they deeply investigated and did their own systematic review. And, you know, there are a few things that come out that say, “Yes, this bad outcome does seem like it’s associated with cannabis use in pregnancy.” And then I use that information really to counsel patients.

Dr. Fox: So, if you had to summarize…now, again, this is just our current understanding based on the available science, what would you tell people are the risks of using cannabis in pregnancy and, sort of, the magnitude of it? You know, like how likely is it, if you had to just like rattle them off in a way that could be maybe understandable?

Dr. Metz: Yeah. I mean, I think that, you know, the main risk, the one that seems to come up over and over and comes up in every meta-analysis and came up in the National Academy of Sciences report, is really that there seems to be an effect on fetal growth. And so, the growth of the baby in utero, and babies are smaller when they’re exposed to, you know, cannabis during pregnancy. And people may say, “Well, you know, why does that matter?” It’s really, sort of, a sign of how well the placenta is functioning. And it does make us concerned that there are, you know, potentially other adverse effects. We know that cannabis crosses the placenta, that is known. And so, metabolites, you know, when a mother ingests cannabis, they’re processed, they go into her bloodstream, they cross to the baby via the placenta.

And so, it’s definitely plausible that those metabolites would affect the placenta and would potentially affect the fetus. And so, we do see, you know, differences in fetal growth. There seems to be a signal for an increase in neonatal ICU admissions. Now, that one is a little bit more, I would say, new or burgeoning. I mean, that’s something that people hadn’t really looked at in the past, but there’s been several studies now that have shown an increased risk of neonatal ICU admission. Now, whether that’s related to pre-term birth or other complications, that honestly hasn’t really been teased out.

And then I think the other thing that people really worry about…well, there’s two. One is stillbirth. There’s a well-done study that shows an increased risk of stillbirth. That one actually twofold increased the risk of stillbirth. And that was a study that was done by the NICHD Stillbirth Research Network using, you know, biologic sampling data, so urine and…I’m sorry, actually, for that they used cord homogenate, so cord segments to look for cannabis metabolite. And they also sampled for tobacco, which is another big, as you mentioned, confounder, noise in these studies. You know, you wanna make sure that this isn’t a tobacco effect, that it’s a cannabis effect. But they said, “No, cannabis does seem to, you know, increase the risk of stillbirth.”

And then, you know, finally, people really worry about neurologic development. And I think, you know, you mentioned that earlier, you know, neurodevelopmental outcomes. And, you know, that’s something that people do worry about. I mean, we know that the metabolite crosses, we know that the endogenous cannabis system or the, you know, natural receptors for cannabis that exist, right? Everybody has these, that’s why it has an effect when people ingest it. Those are very active normally in the normal neurodevelopment of the fetus. And so, there’s concern that as these, you know, metabolites of cannabis from the outside come in and they interact with those receptors, they’re supposed to be doing something else that they can sort of interfere with this normal neurodevelopment.

And so, there’s been a lot of work, several large studies looking at neurodevelopment and whether cannabis has an effect on neurodevelopment. And those studies have shown that yes, they do. It does look like it does. But I will tell you that, you know, in the National Academy’s report, they said, “Well, but gosh…” now we talk about a lot of noise, right? “Where, you know, these kids are now 10 years old, there’s a million other things that have happened to them during that time, and how can we sort of tease out this cannabis effect?”

Dr. Fox: Yeah. That’s a tough one. Is there any evidence, at least with the NICU admission, that there’s any addiction or dependence of the newborns to this? Like, you know, you could have that with narcotics, obviously.

Dr. Metz: Yeah. There’s not much out there on like a syndrome or a described withdrawal, which is, you know, what we see with opioids, we see, you know, neonatal withdrawal. It doesn’t seem to be that. There are a couple of, sort of, very small observational cohorts that describe maybe a little bit more irritability, maybe a little more jitteriness, but, you know, that has not truly been fully teased out. And I think, you know, that’s where I say, that’s a little bit more of an emerging concept and why that would be…you know, there’s some controversy about that. But I think, you know, pretty solidly, you know, the concerns about growth are there, the stillbirth concern is there. And then these neurodevelopmental questions, I think, are really the three main areas that people worry about.

Dr. Fox: Now, how do you counsel people if they might ask you, “Well, all right, that’s what we have for all use, but is there any difference whether it’s someone smoking versus edibles? Is there any information on that or we just assume it’s the same?”

Dr. Metz: Yeah, I think, you know, people definitely ask that. I will tell you that the data, the majority is from the ’80s when people were smoking predominantly. I mean, edibles really weren’t available at that time. But I would also tell you that as I’ve studied this, the majority of people are still smoking. You know, I think it’s a smaller portion of the population that’s using these products as edibles. And the reality is that, you know, it’s all cannabis, right? It’s all THC that are giving people the high that they’re wanting. And it’s THC metabolite, whether you’re taking that as an edible product or you’re taking that as an inhaled product. Ultimately, you have metabolite in the bloodstream and that metabolite is crossing to the placenta. And so, you know, I think we can extrapolate and say it probably doesn’t really matter what form it is in now, in terms of the newer types of products and higher emphasis on CBD, and all of these things.

You know, the data that are out there really for THC, you know, which is the metabolite that makes people high, or the proportion of cannabis makes people high. And then the metabolite that we measure is, you know, a THC metabolite to look at levels, etc. And so, I think, you know, that the research really doesn’t delve into the CBD, but also, you know, the reality is that these CBD-only products are not CBD-only. You know, they’ve actually looked at that in places like Colorado where, you know, there are dispensaries and they’re pushing out CBD-only products and have found that they also have THC metabolite. And so, again, that gets messy. And yes, the majority of the data are from people who have inhaled cannabis products, but, you know, the metabolites end up being the same. And it seems like then biologically, you know, we’d expect to see the same effects from a pregnancy standpoint.

Dr. Fox: Yeah. I was gonna ask you for our uneducated listeners, how do you describe the difference between THC and CBD and where they might get one or the other? Not logistically, where they might get one. Not like, I don’t need a phone number.

Dr. Metz: Yeah. No, I mean, they’re just basically different components of the cannabis plant, and I think CBD has become more of a mainstream extracted component of cannabis because of the initial work related to Charlotte’s Web. Which I think, you know, a lot of people are familiar with where, you know, people began to investigate using the CBD component of cannabis plants to treat refractory seizure disorders. And this very specific seizure disorder is actually in children. You know, subsequently, there has been a lot of work, you know, looking at CBD for very various diseases. You know, a lot of neurologic disorders, and really, you know, the data are pretty darn mixed as to whether it works at all. And so, I think, you know, people still feel like perhaps it does for certain conditions, but that’s why you’re not seeing it more broadly in medical practice. We’re not prescribing CBD for all of these various ailments because as they’ve studied it with purified extract that has been, sort of, stamped by facilities that are certified to really get at that CBD component, we’re just really not seeing that same treatment effect that, you know, people were hoping to see.

Dr. Fox: It is interesting. And I was also curious from the studies, the studies that they’re looking at and saying, “It seems to do this, it seems to do that.” You can try to control for things like tobacco or alcohol or even maybe things like, you know, the age of the mother, maybe if you get her income, what ZIP code she lives in, you know, to try to get, sort of, some of what we call sociodemographic or other factors. But there just seems to be that unmeasured variable of someone’s using this for a reason, right? And so, again, not a reason like why, but there’s something about them that’s linked to them using it that could also confound or be noise in things like the size of the baby, the chance the baby [inaudible 00:29:18] neurodevelopmental. How do they try to tease that part out to know that this is real versus just noise? Because that seems to be the hardest.

Dr. Metz: Yeah, I mean, that comes up with all medications in pregnancy, right? I mean, whenever we study sort of the effects or potential adverse effects of a medicine in pregnancy, we have to consider why is the person using that medicine in the first place. You know, this comes up a lot with antidepressants. It also comes up with cannabis. And, you know, I’ll tell you, when I ask people in my practice, you know, who say, “Yeah, I’m using cannabis or I’m using marijuana.” You know, I query them as to what are they using it for. And, you know, in pregnancy it’s not typically because it’s fun or, you know, because they like to go up to parties. It’s usually because they perceive a benefit for something, and that’s often…anxiety, depression, nausea are the things that come up most often.

And so, I think it does become hard to tease those things out. And so, people have tried to look at this, they’ve tried to, what we say, you know, try to get rid of, sort of, this noise and really look specifically at the effect of the cannabis. But it is hard, and that’s why a lot of these studies are criticized, is that, “Well, you know, these groups of people are really just different.” People who continue to use cannabis during pregnancy versus those who don’t use cannabis in pregnancy are just different people. And it’s just really hard to adjust for all of those differences between them to really get at the effect of cannabis itself.

Dr. Fox: Yeah. Listen, it’s not easy. It’s really hard to get an answer here. And so, what are you trying to do moving forward to answer this? Like, what kind of research are you either doing or hoping to do to try to get to this?

Dr. Metz: Yeah. So, the study that we’re doing right now that we’re funded to do is taking biologic specimens, so urine specimens from people who participated in a large cohort study where we basically…they enrolled and kind of followed them across their pregnancy, and they weren’t following them to look at cannabis use. They were following them to look at their pregnancy outcomes and things that could influence pregnancy outcomes was the initial study. This was done nationally with 10,000 people who enrolled. And, you know, they gave urine samples, they gave blood samples, they gave placenta samples, they filled out all these questionnaires about, you know, their stress and their depression and their anxiety. And so, really tried to get just a comprehensive view of these patients’ lives, what their pregnancy looked like, and then all the sampling throughout that time to then be able to, sort of, investigate these questions about, well, what things do influence pregnancy outcomes when we account for all this other stuff?

And so, those samples are now de-identified, meaning that I don’t know who they belong to, which then allows me to study them and look for drug use among those participants that then won’t have, you know, ramifications for them. And I think that’s a key for doing any sort of substance use research is, you know, making sure that when we’re answering these questions, we’re also protecting participants. And so, now we have all these de-identified but linked data to be able to look at this and say, okay, we’re gonna sample the urine of these participants, which we are for any drug use, and then be able to look at, did that drug use influence outcomes when accounting for all this other stuff that we know about these participants?

And so, that’s the study that we’re doing now, and we can look for, you know, cannabis, other drugs, alcohol, tobacco. So, all of these things that contribute to the noise that we see in these studies, we’re hoping to be able to get a more clear answer as to whether, you know, cannabis use influences pregnancy outcomes. So, that’s exciting. You know, we have all of our data now and we’re starting to analyze it, and I’m hoping it’s gonna really contribute to our knowledge in this area.

Dr. Fox: That’s pretty cool. Now, I wanna ask you, so you’re talking to someone and they’re telling you that they’re using cannabis because specifically it’s the one thing that helps their nausea of pregnancy, or it’s the one thing that helps their chronic pain that they’ve had pre-pregnancy, right? So, when we look at something like alcohol, for example, and we look at the possible risks of alcohol, and the data’s pretty clear that at very, very low levels, there’s not really a lot of risk. But the reason, sort of the party line is don’t use it at all is because listen, there’s just no benefit. Like, there’s no upside. So, why take any risk on the downside? But if someone tells you that they have an upside to using cannabis for those things, how do you approach it with them? Do you say, “Listen, you really gotta stop?” Or, “You know, we’re gonna balance the risks to the benefits to you.” Or how do you go about that, because that’s a tough one?

Dr. Metz: Yeah, it is a tough one. I do think that for a number of the things that people tell me that they’re using cannabis to help, we do have, you know, medications or other treatments that have been studied in pregnancy that we have a little more clear data on regarding safety and efficacy that I would rather they try. And so, we just kind of talk through that, you know, especially for nausea. I mean, we have so much data on the drugs that we use, you know, as physicians that we prescribe for nausea and pregnancy, that I would much rather have a patient try one of those both for safety and efficacy than cannabis. I mean, we don’t have data saying that cannabis actually effectively treats nausea. You know, there’s cross-sectional studies that actually say, you know, patients who are using cannabis have much higher rates of nausea and vomiting.

Now, which one of those comes first, you know, it’s really bad. And so, then they use it versus they use it and then it’s really bad. It’s hard to sort out. But, you know, we do have data saying that you know, things like Diclegis and Zofran and Phenergan are actually helpful for nausea. And so, I try to have them use these other medications that we have more data on. Same thing with depression and anxiety. You know, I think a lot of patients suffer from depression and anxiety. I do hear a lot that they use cannabis to try to modulate that. And so, you know, talk to them about trying to use other medications that we have to treat that and psychotherapy and all the other tools that we have, you know, stressing the importance of improving maternal mental health in pregnancy. But, you know, that there may be other ways to do that other than cannabis.

And, you know, I would say it’s mixed. I mean, a lot of patients actually say, “Well, I didn’t know that we thought there were any risks to cannabis use in pregnancy.” And when I even just kind of bring that up with them, they’re willing to stop. You know, for other patients that’s harder. But I think at least as clinicians, it’s our job to at least start that conversation, offer safe alternatives, and really, you know, at least talk about, yeah, we think that there are risks in terms of fetal growth, stillbirth, and then potentially these longer-term neurodevelopmental effects.

Dr. Fox: Well, Torri, thank you so much. Really, that’s a tremendous amount of information in a short amount of time, and you’re easy to talk to and you explain things well, and it’s one of the reasons I like you, one of the many.

Dr. Metz: Thank you. Thank you for having me.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.