This document summarizes a clinical track on maternal-fetal issues for physicians presented by various experts. It includes 3 learning objectives focused on describing an NAS treatment protocol that decreased treatment days and hospital stay, screening and counseling pregnant patients on prenatal marijuana use, and outlining changes to marijuana that may affect developmental outcomes. The track then provides details on an Ohio pilot study across 6 hospitals that established a stringent opioid weaning protocol, decreasing treatment and hospital days. It discusses the impacts of standardized guidelines for NAS treatment adopted across Ohio, including reduced opioid exposure and length of stay. The presentation aims to optimize non-pharmacological treatment and safety planning for infants with NAS and their families.

1. Clinical Track:
Maternal-Fetal Issues
for Physicians
Presenters:
• Scott L. Wexelblatt, MD, Regional Medical Director for Newborn Services,
Cincinnati Children’s Hospital Medical Center
• Susan Ford, RN, BSN, BEACON Quality Improvement Coordinator, Ohio
Perinatal Quality Collaborative
• Tamara D. Warner, PhD, Research Assistant Professor, Department of
Pediatrics, University of Florida
• Kay Roussos-Ross, MD, Director of Women’s Health, UF Shands Medical Plaza
Moderator: Carla S. Saunders, NNP-BC, Advance Practice Coordinator,
Pediatrix Medical Group, and Neonatal Nurse Practitioner, East Tennessee
Children’s Hospital, and Member, Rx Summit National Advisory Board

2. Disclosures
• Scott L. Wexelblatt, MD; Susan Ford, RN, BSN; Tamara D.
Warner, PhD; and Kay Roussos-Ross, MD, have disclosed no
relevant, real, or apparent personal or professional financial
relationships with proprietary entities that produce
healthcare goods and services.
• Carla Saunders – Speaker’s bureau: Abbott Nutrition

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Describe an NAS treatment protocol that has
decreased opioid treatment days and the length
of hospital.
2. Prepare physicians to screen and counsel
pregnant patients about prenatal marijuana use.
3. Outline changes in the potency and use of
marijuana during the past 30 years that may
affect the developmental outcomes of today’s
children with prenatal marijuana exposure.

5. Maternal-Fetal Issues for Physicians:
Optimal Care for Infants with
Neonatal Abstinence Syndrome
Scott Wexelblatt, MD
Susan Ford, RN, BSN

6. Disclosures
• Scott Wexelblatt, MD has disclosed no relevant, real or
apparent personal or profession financial relationship
with proprietary entities that produce health care
goods and services.
• Susan Ford, RN, BSN, has disclosed no relevant, real or
apparent personal or profession financial relationship
with proprietary entities that produce health care
goods and services.
• Disclaimer: The images of people used in this
presentation are for visual representations only.

7. Learning Objectives
• Describe an NAS treatment protocol that has decreased opioid
treatment days and the length of hospital.
– NAS diagnoses increased three-fold from 2002 to 2009, according
to a 2012 study in JAMA.
– In this session, clinicians will observe that an Ohio pilot study in
six children’s hospitals used a stringent weaning protocol to
decrease opioid treatment days and the length of hospital stay.
– This work, which was published in Pediatrics in August 2014, is
the largest published cohort of over 530 infants
pharmacologically treated for NAS.
– Fifty-two hospitals in Ohio now are incorporating this knowledge
for a quality improvement initiative and have a goal to reduce
the length of stay by 20 percent by June 30, 2015.

8. Neonatal Abstinence Syndrome

9. www.cdc.gov/nchs/nvss.htm.
* Per 100,000 population
How did we get here?
State by State Comparison 2008
Rate* of unintentional drug overdose deaths per 100,000

10. Updated 2010 data
Rate* of unintentional drug overdose deaths
per 100,000

11. Ohio had a 440% increase in unintentional drug
overdose from 1999 to 2011

12. Ohio Data:
~ 5 fold increase in opioid distribution

13. Ohio Data:
Unintentional Overdose Deaths by Specific Drug
Source: Ohio Department of Health Violence and Injury Prevention Program

14. Number of Deaths in Ohio

20. Ohio Children’s Hospital
NAS Consortium
• Organized in January 2012
• Chartered by Governor
Kasich to work together to
improve care of children
• Neo Inaugural Project:
NAS- launched Sept 2012

21. • Form longitudinal cohort of term infants with
narcotic abstinence syndrome.
• Infants admitted by 6 Ohio Children’s Hospitals to
total of 20 hospitals.
• Describe the maternal and neonatal characteristics
• Determine the “potentially better practice” for
narcotic abstinence treatment.
• Identify variation and areas for future research.
Consortium Objectives:

22. Maternal Descriptors:
n=553 (2012- 2013)
Mean Range
Maternal Age 26.7 y 17-44
Maternal Race:
White, Non-Hispanic ( %) 92%
Single 84%
Insurance:
Public
None
80%
10%
N= 553
Any Prenatal Care 89%
Hep. C 25.9%
Sexually Transmitted Disease 7%
HIV 0
Hep. B 1.0%

23. Maternal Drug Use
Site A Site B Site C Site D Site E Site F Total
N=102 N=183 N=187 N=29 N=32 N=14 N=547
Buprenorphine (%) 55.9 23.5 46.0 31.0 18.8 14.3 37.1
Heroin (%) 16.7 36.1 20.3 37.9 25.0 42.9 26.7 (30%)
Hydrocodone (%) 9.8 14.2 9.6 6.9 6.3 28.6 11.3
Hydromorphone (%) 4.9 2.7 2.1 3.5 0.0 0.0 2.7
Methadone (%) 10.8 41.5 18.7 41.4 31.3 35.7 27.2
Morphine (%) 2.0 3.8 0.0 3.5 0.0 7.1 2.0
Oxycodone (%) 27.5 25.7 44.9 24.1 28.1 42.9 33.1
Unspecified Opiates (%) 24.5 55.7 38.0 34.5 71.9 71.4 44.1
More than One Narcotic (%) 4.9 33.9 17.7 10.3 15.6 28.6 20.5
Polysubstance by Toxicology (%) 27.5 47.0 37.9 24.1 34.4 57.1 36.9
Illicit Narcotics (%) 23.5 57.9 36.9 37.9 43.8 71.4 42.8
Any Illicit Substance (%) 47.1 68.9 56.6 48.3 46.9 78.6 58.1

24. Needle exchange program…
Updated data through 994 mothers:
• Heroin use: 30% (n=298)
• Hepatitis C rate: 26% (n=257)
• Under current law, needle exchanges can be
created in Ohio only with a declared local
health emergency.
Prevention Not Permission
Portsmouth City Health Department

25. 0
50
100
150
200
250
300
350
NumberwithCo-Exposure
Tobacco
Marijuana
Cocaine
Alcohol
Amphetamine
Poly Exposures
82% by self report
95% by cord

26. Infant Treatment
Characteristic N=994
Symptoms Started (hours; Mean) 44
Treatment Length (days; Mean) 19
Hospital Stay (days; Mean) 22.5
Number of Drugs Used (Mean) 1.4
Drugs used:
Morphine
Methadone
55%
44%

27. Phase 1 Collaboration Data by Center
0
5
10
15
20
25
30
35
40
45
50
N=102 N=183 N=187 N=29 N=32 N=14 N=547
A B C D E F Total
Opiate Treatment days
Day of Life of Discharge

28. Phase 1 Collaboration Data
3 centers with weaning protocol in place prior to onset of OCHA
0
5
10
15
20
25
30
35
N=77 N=476
No Protocol Protocol
Opiate Treatment Days
Day of Life of Discharge
P=<0.0001 P=0.004

29. Phase 1 Collaboration Data by Group
Methadone n= 224, Morphine n= 276
0
5
10
15
20
25
Day of life discharged Days total opiate treatment
Morphine only
Methadone only
P=0.79P=0.9

30. Different levels of care
0
5
10
15
20
25
30
Total treatment days Day of life of discharge
Level 2 n=218
Level 3 n=330

31. 0%
10%
20%
30%
40%
50%
60%
70%
Home with mother Home with family
member other than
mother
Foster care / adoption
Disposition

32. OCHA Publication
Paper in Pediatrics August 2014
Neonatal Narcotic Abstinence Syndrome:
A Multicenter Cohort Study of Treatments and Hospital Outcomes
Eric S Hall, PhD1*, Scott L Wexelblatt, MD1*, Moira Crowley, MD2,
Jennifer L Grow, MD3, Lisa R Jasin, MSN, NNP-BC4, Mark A Klebanoff,
MD5, Richard E McClead, MD6, Jareen Meinzen-Derr, PhD1,7, Vedagiri K
Mohan, MD8, Howard Stein, MD8, and Michele C Walsh, MD, MS Epi2
on behalf of the OCHNAS Consortium

33. Impact of Ohio OCHA Weaning Protocol
• In July 2013 a standard “Potentially Better” weaning protocol was adopted by all six groups.
• We documented management of 462 infants prior to statewide adoption of the weaning
protocol, and 392 infants after adoption.
o We removed infants who completed therapy as an outpatient, as this center did not adopt
the protocol.
0
5
10
15
20
25
30
35
40
45
50
N=102 N=183 N=187 N=29 N=32 N=14 N=547
A B C D E F Total
Opiate Treatment days
Day of Life of Discharge

34. Phase 2
N DOT P LOS P
Adjuvant
Therapy N
Adjuvant
Therapy %
P
Existing Protocol Sites 357 17.5 0.2 23.3 0.2 146 40.90% 0.05
Protocol Adopting Sites 35 17.1 <.001 22.9 <.001 2 5.70% 0.01
Total 392 17.5 0.4 23.3 0.5 148 37.80% 0.6
Phase 1
N DOT LOS
Adjuvant
Therapy N
Adjuvant
Therapy%
Existing Protocol Sites 415 16.5 22.1 140 33.70%
Protocol Adopting Sites 47 33.7 39.9 14 29.80%
Total 462 18.2 23.9 154 33.30%
Impact of Ohio OCHA Weaning Protocol

35. Conclusions:
• Adoption of standard opioid weaning guidelines for
NAS reduced the duration of opiate exposure and
length of hospital stay.
• Outcomes among infants managed by providers with
existing explicit weaning protocols were sustained
after statewide adoption.
Impact of Ohio OCHA Weaning Protocol

36. 0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
NumberofDays
Infants Treated for NAS through 2014
Neonatal Abstinence Syndrome Length of Stay
2012-2014
length of treatment Avg length of stay Average length of treatment
Inter-observer
reliability began
Oct 2012
Decreased average
Length of treatment to
38 days
New treatment
protocol initiated
Decreased to average
length of treatment
17 days
Impact of Ohio OCHA Weaning Protocol

38. The OPQC NAS Project is funded
by The Ohio Department of
Medicaid

39. Social Media

40. Projects: OCHA & OPQC
OCHA:
Ohio Children’s Hospital Association
• September 2012 –
September 2014
• Six children’s hospitals and
their affiliates (20 total)
• 994 infants
• Included only infants that
required pharmacological
treatment for NAS
OPQC:
Ohio Perinatal Quality Collaborative
• January 2014-June 2015
• 52 sites:
– Cohort 1: Level 3 NICU’s and
their Level 2 affiliates
– Cohort 2: Remaining Level 2
Special Care Nurseries in OH
• Over 2100+ infants
• Includes infants that
received both non-
pharmacological AND
pharmacological treatment

41. Promedica
Toledo Children’s
Miami Valley
Mercy Anderson
Aultman
Mt. Carmel EastOSU
UH Rainbow Babies
& Children’s
Bethesda North
Hospital
Nationwide
Dublin Methodist
Akron Children’s Summa
Cincinnati Children’s
Hillcrest Hospital
Fairview Hospital
Cleveland
Clinic
Dayton Children’s
Nationwide
Riverside
Methodist
Nationwide
Grant
Nationwide Mt. Carmel St. Ann’s
UH Cincinnati
Good Samaritan
Hospital
MetroHealth
Mt. Carmel West
Nationwide Doctor’s
Akron Children’s
Nationwide
Children’s
Mercy Children’s
Hospital
Atrium Medical Center
Fort Hamilton
Mercy Hospital Fairfield
Mercy Medical
Center Canton
The Christ Hospital
St. Rita’s
Medical Center
Southview Medical Center
Good Samaritan Hospital Dayton
Kettering
Mercy Health
West
Southern Ohio
Medical Center
Genesis Healthcare System
OhioHealth
MedCentral
Mansfield
Marion
General
Elyria Medical
Center -UH
Mercy Regional Medical
Center Lorain
ProMedica
Bay Park
Lima Memorial
Health System
Springfield Regional
Medical Center
Adena
Regional
Medical Center
Soin Medical Center
Upper Valley
Medical Center
Licking Memorial Health System
52 NAS Participating Sites 2014
1/2014 start Level 3 and Level 2 teams
Akron Children’s
St. Elizabeth
Health
Center/Mahoning
Valley
Trumbull
Memorial
4/2014 start; remaining Level 2 sites

42. Key Driver Diagram
Project Name: OPQC Neonatal NAS Leader: Walsh
SMART AIM
KEY DRIVERS
INTERVENTIONS
By increasing
identification of and
compassionate
withdrawal treatment for
full-term infants born with
Neonatal Abstinence
Syndrome (NAS), we will
reduce length of stay by
20% across participating
sites by June 30, 2015.
Improve recognition and non-
judgmental support for Narcotic
addicted women and infants
Connect with outpatient support
and treatment program prior to
discharge
Standardize NAS Treatment
Protocol
Optimize Non-Pharmacologic Rx
Bundle
• Initiate Rx If NAS score > 8 twice.
•Stabilization/ Escalation Phase
•Wean when stable for 48 hrs by 10% daily.
•Swaddling, low stimulation.
•Encourage kangaroo care
•Feed on demand- MBM if appropriate or
lactose free, 22 cal formula
•All MD and RN staff to view “Nurture the
Mother- Nurture the Child”
•Monthly education on addiction care
Attain high reliability in NAS
scoring by nursing staff
Partner with Families to Establish
Safety Plan for Infant
Fulltime RN staff at Level 2 and 3 to
complete D’Apolito NAS scoring training
video and achieve 90% reliability.
• Establish agreement with outpatient program
and/or Mental Health
•Utilize Early Intervention Services
Collaborate with DHS/ CPS to ensure infant
safety.
Prenatal Identification of Mom
Implement Optimal Med Rx
Program
Engage families in Safety Planning.
Partner with other stakeholders
to influence policy and primary
prevention.
Provide primary prevention materials to sites.
To reduce the number of
moms and babies with
narcotic exposure, and
reduce the need for
treatment of NAS.
GLOBAL AIM

43. Improve Consistency in
Modified Finnegan Scoring
• All sites use same tool
• Train RN staff to 90%
reliability in scoring using
D’Apolito Training System
• In Pilot work, we were able
to see drop in max score
when training completed
• OPQC has sent out
DVD’s to each site
Attain high reliability in
NAS scoring by nursing
staff
Intervention:
Fulltime RN staff at Level 2
and 3 to complete D’Apolito
NAS scoring training video
and achieve 90% reliability.

44. Non-Pharmacologic Management of
Infants with NAS
• Feeding on Demand
o Breast Milk Feeds
(contraindicated if Mom not in
Treatment program/still using
illicit drugs/HIV+)
o Low Lactose Formula
o 22 kcal/oz feeds
• Swaddling
• Low Stimulation
• Rooming In
Other interventions in the
literature:
 Skin-to-Skin/Kangaroo Care
 Rocker Beds
 Massage therapy
 Music therapy
 Aromatherapy (lavender,
mother’s scent)
 Color Therapy (B&W
more soothing?)
Optimize Non-Pharmacologic
Rx Bundle
Key Driver:

45. Key Driver:
Intervention:
Pharmacological Bundle
Standardize NAS Treatment Protocol
• Initiate Rx If NAS score > 8 twice.
•Stabilization/ Escalation Phase
•Begin wean when stable for 48hrs
•Discharge home after 48hrs
(Morphine) to 72hrs (Methadone)
Source: https://neoadvances.org
Source: https://abcnews.com

46. Key Driver:
Intervention:
Relationships with Support Services
•Establish agreement with
outpatient program and/or
Mental Health Services
•Utilize Early Intervention
Services
Connect with outpatient
support and treatment
program prior to discharge
Examples of organizations our hospital
teams have partnered with:
• County Drug Courts
• MAT Treatment Centers
• Homeless Shelters (gender specific)
• ADAMHS Board (Alcohol, Drug Addiction
and Mental Health Services) throughout
the state of Ohio
• Under Ohio law, the ADAMHS Board is one of
50 Boards coordinating the public behavioral
health system in Ohio.

47. Key Driver:
Non-Judgemental Support and
Compassionate Care
Improve recognition and non-judgmental support for
Narcotic addicted women and infants

48. Collaborative Aggregate

49. Collaborative Aggregate

50. Collaborative Aggregate

51. Collaborative Aggregate

52. Collaborative Aggregate

53. Nuts and Bolts of QI

54. • 21 Outpatient OB Centers
• 48 NICU’s and Special Care Nurseries
• Centers for Disease Control and Prevention
• Ohio Department of Health
• Ohio Department of Medicaid
• Ohio Hospital Association
• Ohio Children's Hospital Association
• Ohio Child Welfare Training Program
• Government Resource Center
• State Board of Nursing
• State Board of Medicine
• State Board of Dentistry
• Graham's Foundation
• Ohio Department of Mental Health and Addiction
Services
• XIX Recovery Support Services
• North Carolina Perinatal Quality Collaborative
• First Step Home
• Brigid’s Path
• Lily’s Place
• The Turning Point Program
• Ohio Managed Care Organizations
• Ohio Collaborative to Prevent Infant Mortality

56. It’s Not Your Mother’s Marijuana:
Effects on Maternal-Fetal Health and
the Developing Child
Dr. Kay Roussos-Ross, MD
Director of Women’s Health, Dept. of Ob/Gyn
University of Florida
Dr. Tamara Warner, Ph.D.
Research Assistant Professor, Dept. of Pediatrics
University of Florida

57. Disclosures
Dr. Roussos-Ross and Dr. Warner have
no conflicts of interest to disclose.

58. Objectives
• Prepare physicians to screen and counsel
pregnant patients about prenatal
marijuana use.
• Outline changes in the potency and use
of marijuana during the past 30 years
that may affect the developmental
outcomes of today’s children with
prenatal marijuana exposure.

59. Clinics in Perinatology (December 2014) Vol. 41, Issue 4, pages 877-894.
DOI: http://dx.doi.org/10.1016//j.clp.2014.08.009

60. Part 1
Pro-Marijuana Advocacy Efforts and
Changes in Marijuana Potency and Use

61. Societal Shift in Attitudes About Marijuana

62. States Legalizing “Medical” Marijuana
1. Alaska
2. Arizona
3. California
4. Colorado
5. Connecticut
6. DC
7. Delaware
8. Hawaii
9. Illinois
10. Maine
11. Maryland
12. Massachusetts
13. Michigan
14. Minnesota
15. Montana
16. Nevada
17. New Hampshire
18. New Jersey
19. New Mexico
20. New York
21. Oregon
22. Rhode Island
23. Vermont
24. Washington

63. Pending Legislation in 2015
(as of 2/19/15)
1. Florida
2. Georgia
3. Indiana
4. Kansas
5. Kentucky
6. Missouri
7. Nebraska
8. North Dakota
9. Pennsylvania
10. South Carolina
11. Tennessee

64. States Legalizing Recreational Marijuana

65. Legal Status of Medical Marijuana?
• Marijuana is a Schedule I drug under the
Controlled Substance Act, a federal law that
preempts action taken by individual states to
legalize its use, cultivation and distribution.
• When used for medicinal purposes, marijuana
should be considered a pharmaceutical agent
governed by the Food Drug & Cosmetic Act
– Regulatory oversight including evaluation of its
safety & efficacy by the Food & Drug
Administration.

66. Does legalizing marijuana result in
higher marijuana use?
Higher use in states that:
• Allow home cultivation
• Allow legal dispensaries
Lower use (and treatment
admissions) in states that:
• Restrict broad access by
requiring annual
registration of patients
A: Yes, but it depends on the specific aspects
of state laws and policies.

67. Unintended Consequences of Pro-
Marijuana Advocacy Efforts?
• Growing pro-marijuana
advocacy efforts are taking
place in a very different
environment than the 1960s.
• In the absence of strong public health
messages about the possible dangers of
marijuana, marijuana use may increase among
pregnant women.

68. It’s Not Your Mother’s Marijuana
• The potency of marijuana has significantly
increased in potency during the past 40 years.
• The amount of marijuana consumed, on
average, among young adults also seems to
increasing significantly.
• Marijuana is perceived as relatively “safe”
and, in some areas, the cost is comparable to
tobacco.

69. Increased Potency of Marijuana
• Potency is measured by the percentage of Δ9-
tetrahydrocannabinol (THC), the most
psychoactive of the 70 cannabinoids found in
marijuana.
• From the 1970s to the 2000s, there has been
an estimated 6- to 7-fold increase in the
percentage of THC found in seized marijuana.

70. Increased Potency of Marijuana
“It is now possible to mass product plants with
potencies inconceivable when concerted
monitoring efforts started 40 years ago.”
-- Mehmedic et al. (2010)
Potency Trends of Δ9-THC and Other Cannabinoids in
Confiscated Cannabis Preparations from 1993 to 2008

71. Increased Potency of Marijuana
From 1993 to 2008, the percentage of high potency
THC (> 9%) increased from 3.23% to 21.47%.
Mehmedic et al. 2010 doi: 10.1111/j.1556.4029.2010.01441.x

72. Increased Potency of Marijuana
Potency of non-domestic samples is increasing
while domestic samples are relatively stable.
Non-domestic
All samples
Domestic

73. But There’s More
• There are more than 100 different cannabinoids
found in marijuana.
• Not all cannabinoids have psychoactive properties.
• Cannabidiol (CBD) is non-psychotropic and displays
many beneficial properties:
– Antipsychotic
– Antihyperalgesic
– Anticonvulsant
– Neuroprotective
– Antiemetic properties

74. The Ratio is Important, Too
• As the percentage of THC has been increasing,
the percentage of CBD has been decreasing.
• This is particularly true in
sinsemilla – the flowering tops
of unfertilized female plants
with no seeds, which is gaining
market share (commonly called
“skunk”)

75. The Ratio is Important, Too
• The higher ratio of THC/CBD likely makes the
marijuana even more potent & dangerous.
–Increased risk for cannabis dependence
–Increased treatment seeking for cannabis-
related problems
–Increased vulnerability to psychosis
–May predispose users to adverse psychiatric
effects

76. Amount of Marijuana Use
• Amount of marijuana
consumed, on average,
may be increasing among
younger adults, especially
minorities
• Growing popularity of blunts (marijuana-
filled cigars) compared to joints and pipes

77. Amount of Marijuana Use
• Blunts contain significantly
more marijuana
–1 blunt = 1.5 joints
–1 blunt = 2.5 pipes
• Blunts are often shared among several
people making it difficult to quantify
individual usage

78. FIGURE 6
Marijuana: Trends in Annual Use, Risk, Disapproval, and Availability
Grades 8, 10, and 12
Use
% who used in last 12 months
Risk
% seeing "great risk" in using regularly
YEAR
'74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14
8th Grade
10th Grade
12th Grade
PERCENT
0
20
40
60
80
100
YEAR
'74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14
Perceptions of Marijuana
• In general, there is less
stigma associated with
marijuana use.
• Among adolescents,
the perceived risk of
regular use has
declined sharply since
2005.
FIGURE 6
Marijuana: Trends in Annual Use, Risk, Disa
Grades 8, 10, and 12
Use
% who used in last 12 months
60
80
100
8th Grade
10th Grade
12th Grade
1

79. Perceptions of Marijuana
• One study of urban pregnant women found that
marijuana was perceived as “safer” to use during
pregnancy than cigarettes or alcohol.
• Misperceptions may be due to
the relative absence of strong
public health messages.
• Cost of marijuana was
comparable to tobacco; price
is no longer a deterrent.

80. Part 2
The Epidemiology of Marijuana Use
Among Pregnant Women: Who Uses?

81. Epidemiology of Marijuana Use Among
Pregnant Women
• Most commonly used illicit drug during
pregnancy.
• Estimated 115,000 pregnant women
annually.

82. Marijuana Use Among Pregnant Women

83. Marijuana Use Among Pregnant Women

84. Marijuana Use Among Pregnant Women

85. Epidemiology: Bottom Line #1
Teratogen = causes birth defects
• Cigarettes are the most commonly used
teratogen (15.9%)
• Alcohol is 2nd most commonly used teratogen
(8.5%)
• While marijuana is the commonly used illicit
drug, it is not the most common teratogen.

86. Epidemiology: Bottom Line #2
• Young adolescents (ages 15 to 17) have the
highest rate of marijuana use during
pregnancy (16.5%)
• Marijuana use is highest (10.7%) during the
first trimester then declines significantly.
• Use rebounds quickly after delivery.

87. Who Uses Illicit Drugs During Pregnancy?
• Pre-pregnancy BMI is
underweight
• No folic acid
supplementation
• Alcohol use
• Cigarette smoking
• Partners are drug users
• Intimate partner violence
• Lower levels of education
• Lower levels of income
• Higher rates of
unemployment
Common Factors

88. Who Uses Marijuana During Pregnancy?
• Excessive weight gain during pregnancy
• More likely to be nulliparous (no other children)
• More likely to have had an induce abortion in the
past
Possible Unique Factors*
Data from a population-based study using the National Birth Defects
Prevention Study with a small sample (n = 189).

89. Part 3
Issues Related to Marijuana Use
During Pregnancy

90. Recommendations
American Society of Addiction Medicine
• Prenatal education about all drugs for all pregnant women
• Universal screening to identify “at risk” women including
repeated follow-up assessments
• Culturally competence public prevention programs to
educate the public about realistic dangers of drug use in
pregnancy
• Education of health care providers in the care and
managements of women with evidence of drug use before,
during, and after pregnancy
• Women who are pregnant should receive priority
admission to substance treatment facilities.

91. Recommendations
American Society of Addiction Medicine
• Prenatal education about all drugs for all pregnant women
• Universal screening to identify “at risk” women including
repeated follow-up assessments
• Culturally competence public prevention programs to
educate the public about realistic dangers of drug use in
pregnancy
• Education of health care providers in the care and
managements of women with evidence of drug use before,
during, and after pregnancy
• Women who are pregnant should receive priority
admission to substance treatment facilities.

92. The CRAFFT Screening Interview
Begin: “I’m going to ask you a few questions that I ask all my patients. Please
be honest. I will keep your answers confidential.”
Part A
During the PAST 12 MONTHS, did you: No Yes
1. Drink any alcohol (more than a few sips)?
(Do not count sips of alcohol taken during family or religious events.)
2. Smoke any marijuana or hashish?
3. Use anything else to get high?
(“anything else” includes illegal drugs, over the counter and
prescription drugs, and things that you sniff or “huff”)
For clinic use only: Did the patient answer “yes” to any questions in Part A?
No Yes
Ask CAR question only, then stop Ask all 6 CRAFFT questions
Part B No Yes
1. Have you ever ridden in a CAR driven by someone (including yourself) who
was “high” or had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit
in?
3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
4. Do you ever FORGET things you did while using alcohol or drugs?
5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your
drinking or drug use?
6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CONFIDENTIALITY NOTICE:
The information recorded on this page may be protected by special federal confidentiality rules (42 CFR Part
2), which prohibit disclosure of this information unless authorized by specific written consent. A general
authorization for release of medical information is NOT sufficient for this purpose.
© CHILDREN’S HOSPITAL BOSTON, 2009. ALL RIGHTS RESERVED.
Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital
Boston. (www.ceasar.org)

93. CRAFFT

95. Part 4
The Developmental Effects of Prenatal
Marijuana Exposure

96. Longitudinal Studies
1. The Ottawa Prenatal Prospective Study
(OPPS) began in 1978 and enrolled a
predominantly middle-class, low-risk,
Caucasian sample from Ottawa, Canada
2. The Maternal Health Practice and Child
Development Study (MHPCD) started in 1982
and enrolled a high-risk, low socioeconomic
status mixed Caucasian and African-American
sample from Pittsburgh, Pennsylvania

97. Longitudinal Studies
3. The Generation R study started in 2010 and
recruited a multi-ethnic population-based
cohort in Rotterdam, The Netherlands

98. Difficult Research
• It is difficult to ascertain developmental effects
that are specific to prenatal marijuana
exposure.
• Why? Most pregnant women who use
marijuana also smoke cigarettes and/or drink
alcohol.
• Researchers are actually assessing the effects
related to polysubstance exposure.

99. Possible Pregnancy-Related Effects of
Prenatal Marijuana Use
• Decreased male fertility
• Decreased ovulation
• Altered hormones
– Prolactin, follicle-stimulating hormone, luteinizing
hormone, and estrogen
• Altered oviductal transport, embryo
implantation, and maintenance of pregnancy

100. Possible Pregnancy-Related Effects of
Prenatal Marijuana Use
• Altered placental blood flow
• Intrauterine growth restriction
• Decreased gestational age
• Decreased birth weight

101. Neonatal Period
• No neonatal withdrawal syndrome identified
• Neurobehavior – no consistent results during
first week of life

102. Minimal or No Effects on Child
Development
• Minimal, inconsistent effect on general
cognition
• Altered sleep patterns
• No effect on language
• Minimal effect on motor development
• Minimal effects on growth and pubertal
development

103. Consistent Negative Effects on Child
Development
• Poorer executive functioning skills and
attention (ages 3 to 16)
– Attention, impulsivity, problem-solving, reasoning
• Increased conduct and behavior problems
(ages 6 to 21)
– Greater risk of initiating cigarette smoking and
marijuana use during adolescence

104. Key Points
• Pro-marijuana advocacy may result in an
increase in the prevalence of marijuana use
during pregnancy.
• Today’s marijuana is 6- to 7-times more potent
than it just 20 years ago.
• Average marijuana consumption may be
higher owing to the growing popularity of
blunts compared to joints and pipes.

105. In the absence of strong public health messages
and the growing pro-marijuana movement,
marijuana use among pregnant women could
increase in coming years.
This may be particularly true among young
adolescents who already report the highest use
among all pregnant women.
Key Points

106. We Need to Get the Word Out

107. To date, the documented effects of prenatal
marijuana exposure on fetal outcomes and child
development have been minimal.
However, given the increased potency and
average use, the consequences of marijuana use
among pregnant women could be more
significant and serious than in past decades.
Key Points

108. Key Points
• Intersecting political forces and medical issues
mandate that physicians:
– Be knowledgeable about marijuana use by
their patients and
– Be prepared to counsel their patients about
the effects of prenatal marijuana use on
fertility, pregnancy, and exposed offspring

110. • Kay, I created the following 2 slides based on
the key points from our paper. I decided to
simply the messages into the 3 “Key Points”
slides. Keep or delete these – your choice!

111. Key Points
• Adverse fetal outcomes related to maternal
marijuana use remain unclear.
• Associations have been found with:
– Infertility
– Placental complications
– Fetal growth restriction

112. Key Points
• Long-term effects of prenatal marijuana use
on exposed offspring are difficult to ascertain
because polysubstance abuse is the norm
(cigarettes and alcohol).

113. Clinical Track:
Maternal-Fetal Issues
for Physicians
Presenters:
• Scott L. Wexelblatt, MD, Regional Medical Director for Newborn Services,
Cincinnati Children’s Hospital Medical Center
• Susan Ford, RN, BSN, BEACON Quality Improvement Coordinator, Ohio
Perinatal Quality Collaborative
• Tamara D. Warner, PhD, Research Assistant Professor, Department of
Pediatrics, University of Florida
• Kay Roussos-Ross, MD, Director of Women’s Health, UF Shands Medical Plaza
Moderator: Carla S. Saunders, NNP-BC, Advance Practice Coordinator,
Pediatrix Medical Group, and Neonatal Nurse Practitioner, East Tennessee
Children’s Hospital, and Member, Rx Summit National Advisory Board