NASW Social Work Talks - EP 128: Cannabis Use in Pregnancy

Episode Date: April 2, 2025

In this episode of Social Work Talks, we discuss cannabis use and the impact it has on pregnancy and help social workers bring awareness to women who are pregnant and using cannabis. Joining us today is Dr. Roger Zoorob, the Richard M. Kleberg, senior Professor and chair of the Department of Family and Community Medicine at Baylor College of Medicine in Houston, Texas. And we have Dr. Mary Velasquez, Centennial Professor and Leadership for Community Professional and Corporate Excellence, and Director of the Health Behavior Research and Training Institute at the University of Texas at Austin, Steve Hicks School of Social Work.

This is Social Work Talks. I am your host, Makeba Royal, Licensed Clinical Social Worker and Senior Practice Associate at the National Association of Social Workers. In today's podcast, we will discuss cannabis use and the impact it has on pregnancy and help social workers bring awareness to women who are pregnant and using cannabis. Joining us today is Dr. Roger Zurab, the Richard M. Kleberg Senior Professor and Chair of the Department of Family and Community Medicine at Baylor College of Medicine in Houston, Texas. And we have Dr. Mary Velasquez, Centennial Professor in Leadership for Community, Professional, and Corporate Excellence and Director of the Health Behavior Research and Training Institute at the University of Texas

at Austin Steve Hicks School of Social Work. Before we begin, I will provide you with some background information about what they've done. Prior to joining Baylor, Dr. Zurab was the Frank S. Royal Professor and Chair of Family and Community Medicine at Meharry Medical College and Director of Family Medicine at Vanderbilt University in Nashville, Tennessee for 11 years. He is board certified in family medicine with over 30 years of experience in clinical practice and teaching. At Baylor, Dr. Zubab oversees the Center for Prevention and Population Health Research. The center aims to develop research and innovation for substance use disorders, alcohol screening

and brief intervention, tobacco cessation, cancer prevention and control, and antibiotic stewardship. Currently, Dr. Zurab is the Project Director on various Substance Abuse and Mental Health Services Administration grants. He is also the Principal Investigator for multiple grants awarded by the Cancer Prevention and Research Institute of Texas, CPRIT, which focuses on expanding the Lung Cancer Screening and Tobacco Control Network. Furthermore, Dr. Zurab has authored over 185 publications and book chapters and has presented

his work nationally and internationally. Dr. Velazquez brings over 25 years of experience in the design and implementation of federally and state-funded clinical research testing interventions to improve health behaviors and outcomes. She leads a team that specializes in training, supervision, and coaching motivational interviewing and evidence-based intervention and prevention approaches. Dr. Velazquez was a primary developer of the CHOICES intervention to prevent fetal alcohol spectrum disorders and principal investigator on three randomized clinical trials related to women at risk of alcohol and substance-exposed pregnancies. She is currently principal investigator on a federally funded grant to disseminate behavioral interventions

to social workers to prevent substance-exposed pregnancies. Dr. Velazquez is also the primary author on Women and Drinking, Preventing Alcohol-Exposed Pregnancies. Dr. Zurab and Velazquez, thank you for joining us today. Thank you for having us. Thank you for having us. Great. Thank you. Thank you for being here today. Let's get started. I do want to get some background information from both of you. If you don't mind, can you just let us know what made you get involved in the area of substance abuse or substance use? Yeah, I'll go ahead and get started. This is a good question, as sometimes things happen by chance for a good reason. My long-term interests were always in chronic disease management, including diabetes and other chronic diseases, but not the chronic disease as far as substance use disorders.

The things that happened by chance is one of my faculty in the department have left a grant unattended when he left the department, which made me pick it up and take care of it. it was about alcohol use and prevention in pregnancy and FASD prevention. This opened my eyes towards a highly needed topic in primary care. And from there, I renewed this grant and got funded on several other federal grants related to substance use disorders and prevention, dissemination, and training in primary care of various substance use disorders. So while I did not have interest at first, I grew to love the topic and the service it provides in an area of great need and less expertise in primary care. And 20 years later, this is where I am still working diligently in the topic, both in the

research, teaching, and implementation. Great. Okay, and I became interested in this, but it's sort of a serendipitous way. when I was a young mother and I will admit that I was a cigarette smoker. And one day my children were, my mother was visiting, watching my kids. I had a sore throat, imagine that, and was laying in bed and I picked up a little throwaway paper. It's called the green sheet. I was living in Houston at the time. And there was an advertisement in there and it said, if you're a smoker and don't want to quit, call this number. So I was kind of bored. I wasn't that sick, but after all,

mom was there to help with the kids. So I called the number and somehow volunteered to be in a research study. And the study followed me as a smoker for a number of years. And I became really interested in it. And there was no intervention. It was just a lot of questions about smoking. When did I smoke? What was the temptation? So what happened was I ended up staying on with that study. And ultimately, I did quit, not necessarily as a result of the study, but I think it did increase my awareness, perhaps of my cues for smoking. So after that, I decided to go back and get a master's degree and ultimately my doctorate. And one of my professors said I should do some volunteer work. And I had written a paper about this model that was developed from this

study that I was in. And it was called the stages of change. Some of you might recognize that as the stages of the trans-theoretical model. And Carlo Di Clemente was the principal investigator on that. It was not long after he had finished his doctoral degree. And so ultimately, I volunteered, began working with him, and that really started my career in substance use disorders. I became very interested in all the aspects of the trans-theoretical model, kind of worked my way up from volunteering to becoming a project director. And then ultimately, in about 94, Dr. DiClemente left to become chair of the psychology department at the University of Maryland, Baltimore County. And I was left to continue running the projects. And they knew

that I was going to have to write some grants in order to fund myself. I was in a psychology department at the time. So looked at a call for proposals from the CDC. And one of the calls was asking us to look at, for researchers who would look at risk of alcohol-exposed pregnancy and locate some settings where women might be at risk. So we proposed, my colleague Kirk von Sternberg and I proposed to look at jails and treatment centers and some other folks, Linda Sabell, Mark Sabell, who many people know their work. They were in Florida. They looked at primary care clinics and Karen Ingersoll and Mary Nettleman in Virginia. And they looked at also some primary care clinics and other settings. So that got us started. We were all, all three of those sites

were funded. So it was Houston, Richmond, Virginia, and Florida, Fort Lauderdale area, Florida. So we did this study called CHOICES, funded by the CDC. It was quite successful. We developed an intervention that was four sessions, and I won't go into a lot of detail about that. But subsequent to that, we're funded by the CDC for follow-up on CHOICES, then by the NIH to do something called Choices Plus that included smoking. And then one that was called Choices for Health, funded by the NIH, that is called, what's called Choices for Health. And we look at marijuana use and we use a tablet intervention. We compared that to counselor-based interventions delivered in primary care settings and some of the very primary care settings in Houston that Dr. Zurab is in

charge of. This was in Harris Health. So that's kind of what part of it was out of necessity and part of it was just out of a real interest in what makes people change their behaviors, health behaviors specifically. Right. And it's interesting you said that because it's always, you know, interesting to find out how people land in the work that they do. And from what both of you have said, we have life experience and also being open to various different opportunities to help us, you know, further our professional endeavors. So thank you for providing your background. I want to ask Dr. Zurab a question next about a manuscript that you were a part of for the American Academy of Family Physicians, which focused on cannabis during pregnancy.

What inspired you and your team to focus on this topic? Yes, thank you so much. This is an important topic, and family physicians and primary care providers in general are not very knowledgeable about the subject and the effects of cannabis in pregnancy. Being what it is that cannabis is becoming more and more a legal entity in many states in various forms of legalities, the use of cannabis has been increasing in the young population especially including pregnant women or women who desire pregnancy depending on the stats or the data you look at 18 to 25 years old about 25 percent of them may use cannabis and even in pregnancy there are statistics that show seven to ten percent are estimated of pregnant women use

cannabis this is a huge percentage when you when you talk about medications in pregnancy considering cannabis as a medication or a medicine or a substance you consume in pregnancy so there is a rising demand and the use of of cannabis and pregnancy that we need to tackle and the expertise in family medicine is not very huge and as it relates to substance use disorders and it's it's although it is a big number of population do use the expertise is not available a short evidence-based review that we did in family practice management was really something that was hoped to address those issues first the increasing use especially whether legal or not legal

depending on the state you live in now of course federally cannabis is still not legal, plus the amount of people using it and the harm it produces, it made us develop this short, concise, evidence-based review so that family docs and busy practices would pick up that journal and read two, three pages and get the summary of important information as opposed to, you know, reading and reviewing long-term literature. When we write those reviews, we make them pertinent to primary care providers in general and concise enough with good evidence of references and support to support what's in the literature so that they will learn about it very fast.

also from a it will be from a reliable and trusted source which is the American Academy of Family Physicians although we take responsibility usually for that for what we write the the new thing on the block is also screening and brief intervention experts so it's kind of like okay we make family dogs aware of the risks of cannabis in pregnancy and the risk of cannabis in general for for younger and older population. But since this is pregnancy, we wanted to also make them aware of the screening tests available to them, including simple, fast ones they can use in the office. And then what can they do about it, you know, whether it's brief intervention or referral to

treatment, two important things a family physician can do in their busy practice. And hence, with all those reasons, we did develop that evidence-based short review. Okay, great. And so with the rise in use, I'm sure that you also found some information as it pertained to risk. So what are you able to tell me or tell the listeners about risk to the developing baby associated with cannabis use during pregnancy? Well, let me get started on this. And then as a physician, Dr. Zurab can fill in any holes that I leave here. So using cannabis during pregnancy poses a number of risks to the developing baby. And we're learning more and more as time goes on. And as Dr. Zurab said, cannabis use is increasing. But the issue is that there are

several risks to the baby as the active compounds, particularly THC, can cross the placenta and affect fetal development. So what we see oftentimes is low birth weight. So cannabis use during pregnancy is associated with delivering babies who are smaller, don't gain the right amount of weight during gestation. Preterm birth, so there's an increased risk of babies being born before 37 weeks of gestation when cannabis is used. Stillbirth, some studies suggest a higher risk of stillbirth associated with prenatal use. And neurodevelopmental issues, so exposure to cannabis in utero may lead to problems with memory, attention, and behavior in children as they grow. And this is a particular concern. As we know, we've learned a lot about alcohol exposure during

pregnancy. But again, we're learning that some of these effects can also be the result of cannabis use. Dr. Zurab, what have I forgotten here? Oh, we're talking still about the effect on the baby, right? Yeah, the developing baby. Yeah, I think, you know, you've covered it, Mary. I would just like to emphasize that the psychoactive ingredients of cannabis cross the placenta and can be detected in breast milk. So kind of to emphasize what you're saying, that this fact by itself would show that, you know, that in fact, by passing through the placenta, it will have an effect on the baby. And the studies are still going on the endocannabinoid system, which is important for regulating memory and emotional processing. It's a newer discovery in neuroscience. We still

have much to learn about this effect and like any new substance remembering alcohol in the 50s or 40s and and tobacco later how things evolve when we think it's safe at first and then as studies come up and more research is done we discover the true side effects and and on on the developing babies. So just a word of caution not to be in a hurry to use this substance, which is new in the block and legally for pregnant women before more research is out and we are certain of actual safety, like any other medication we use in pregnancy. Most obstetricians and family docs and other providers are very careful in choosing their medicines in pregnancy. So why cannabis should be different and why should be recommending to use it if we don't know the side effects and

the effect on the baby. On the baby, yeah. Are there also, I mean, I know you're talking about the developing baby, but are there any risks to the mother as well that people should be aware about? Well, studies have shown that, again, prenatal cannabis use is associated with an increased risk of gestational hypertension, so increased high blood pressure, preeclampsia during pregnancy, and abnormal gestational weight gain. And so studies are showing that sometimes marijuana leads to both insufficient weight and excessive weight gain. So either direction, that can lead to further health complications for both the mother and the baby. And then also research shows an association between prenatal cannabis use and an increased risk of placental abruption, which is a condition where the placenta detaches from the uterine wall before delivery.

So, again, given these potential risks, it's advisable for pregnant women to avoid using it and, again, to consult their health care providers for safer alternatives. I also might add that a number of women have told us through the years that they've asked their health care provider if it's all right to use marijuana during pregnancy or cannabis during pregnancy to help with things like, you know, morning sickness or pain or sleeping issues. And sometimes the physician has said, yes, that's OK. We would rather have you use some cannabis. So that's why it's so important. The work that Dr. Zurab and colleagues are doing and the American Academy of Family Physicians and others, ACOG, are getting the word out that it, you know, two physicians, for example, the manuscript that you were just referring to, Makiba, and Dr. Zurab was commenting on, that's really important information for health care providers, especially those who might have been trained earlier and just really haven't had the exposure to some of the more harmful information articles about the more harmful effects. Yeah, and I know also, too, in addition to the nausea, I know you've mentioned also, Dr. Zurab, that with the increase, with the legalization for medicinal purposes and also recreational use, it seems as though individuals

are using other forms of cannabis, such as like CBD edibles, capsules, or topicals, or things like that. Are the risks the same when individuals use different forms of cannabis? Yeah, so let me just answer that after I comment a little bit about the effect on the mother. When we forget, we're talking about use in pregnancy. However, you have to think any young adult, whether a young woman who's not yet pregnant what's the effect of marijuana on them as an as an individual too i mean we we're talking about pregnancy but these are effects that can affect any any any person such as the lung effects you know causing cough emphysema from marijuana, there are toxic substances in the inhaled cannabis, and cardiac effects, arrhythmias, rapid heart rate,

that can affect the mother gestational diabetes that Mary alluded to a little bit, and the carcinogen potential of smoking. the the people who use one substance may use other substances too polysubstance abuse or use is is common and people who use marijuana may smoke at the same time may may use alcohol so an alcohol is proven with negative effects on the on the baby so the effects on the mother are tremendous additional to the effect on the pregnant mother basically and the effect on the women in general, which leads me to what you mentioned, the edibles basically, or other forms of use. When I mentioned toxic substances and contaminants in the inhalants, whether they are through smoking or vaping, to be honest with you, the effect on the body and the baby may still be

the same. On the mother, it will be the cardiac effects, the tachycardia. There may not be lung effect so some people will will say it's it's safer which could be true from that aspect but the general harmful effects on the baby itself are probably the same and the the effect on as far as the heart and the causing arrhythmias and rapid heart rate and what have you are still there in other forms. Other forms also are absorbed erratically slower and can last longer in the body so it's hard to predict the effect as well and they may be confused as candy by kids so locking them and making sure kids don't expose to them is another important thing to make sure of to avoid pediatric childhood children getting intoxicated by consuming edibles inadvertently.

So these are kind of in a short summation of the differences. While we don't endorse it in one form, we still don't endorse it in another form. And I don't know, Mary, if you want to add anything to those. No, I don't think so. I think you asked maybe about CBD. You know, oftentimes people think that CBD edibles, you know, because they don't contain THC or they contain very little THC, there's not much research on how CBD alone affects pregnancy, but we're starting to see some studies that suggest CBD may interact with liver enzymes and that the liver enzymes that process medications, so potentially altering drug metabolism. So again, you know, the advice is against using cannabis in any form during pregnancy

due to the potential risks. Yeah, I mean, you both mentioned two important things. It sounds like there's a safety concern. And also you talked about women before pregnancy, right? A lot of the times we think of, you know, women when they actually are pregnant. So it's good to think about this from a prevention perspective. When we talk about prevention, we definitely know that providers are extremely necessary in raising awareness and prevention. What role do you think social workers can play in preventing cannabis use during pregnancy? So, yes, you know, social workers are the largest behavioral mental health profession focusing on mental health. that makes them out there available to help people in this subject while we as primary care providers do try to do the same job we in busy practices of primary care where we see patients every 20 minutes sometimes we don't get to cover

all subjects as we like to social workers can work very well collaboratively with primary care providers and other health professionals to promote substance free pregnancy they they they can have conversations with patients about any concern related to cannabis use which probably will will come up nowadays a lot being the increase having the increased use on legality the use in pregnancy or without pregnancy as my camera mentioned you you know, any any young woman may become pregnant. I mean, there's a lot of unplanned pregnancies if you look at the statistics. So if you if you if they are using or planning to become

pregnant or breastfeeding, you know, that discussion with social workers may be very helpful and outpatient mental health centers. They can also make sure to ask clients about about cannabis use and assess for polysubstance use, substance use disorders in general as well. It's very important that the training of, while family physicians are in tuned to dealing with substance use in an empathetic and non-judgmental matter, I also think social workers are ideal to approach all substance use, including cannabis, with a non-judgmental attitude and with empathy and create an environment for the pregnant woman to feel comfortable disclosing this use. These conversations are essential as research suggests that women's

concerns about how substances affect developing fetus can motivate them to abstain from substance use during pregnancy, including cannabis, and also to approach it without stigma as much as feasible and possible in order for women to feel comfortable talking to social workers in general as we collaborate with them. From my personal use and our practices here and other places I practiced in my long career in family medicine, I collaborate with social workers in our clinic here, in our private clinic, in our community health centers. We always have social workers, and they are an essential component in our daily practice, complements our work and actually augments it. So it goes without saying for cannabis in pregnancy or

without pregnancy or substance use in general, it's a very important topic for them and for us to work together to achieve a healthy baby and a healthy mother. Yeah, absolutely. Absolutely. I mean, you hit all of the, all of the target points. I mean, I think it's especially important for social workers to meet people where they are in this process, whether they are, you know, with child or not. And it's necessary to make sure that social workers are screening individuals on a regular basis too, right? Like we don't want to screen people one time a year, but if you're seeing someone, you know, frequently it would be, you know, best to kind of check in with individuals to see where they are. Because sometimes the use can change over the course

of time. So screening is definitely important. And also collaboration, which you did mention, right? Working with everyone within the person's life that you have consent to speak with to find out, you know, what kind of supports may be needed and what they may be seeing. So there's a lot of work that social workers can do with prevention. And more importantly, too, when you talk about treatment, because you did mention treatment, being aware of the type of treatment that's available to individuals in the community is extremely important. And just making sure that, you know, we stay knowledgeable about what's available to individuals when they need the services that they need is also important. Dr. Velasquez, do you have anything else you

want to comment on with that? Very, very good points, Makiba and Dr. Zorab. Thank you. No, I just want to mention that, speaking of social workers, we have an opportunity that we've put forth, and we will, again, if any social workers who are listening would like to become champions with us, well, actually, they're partners with us on preventing substance-exposed pregnancies. It's very little asked just to look at a presentation and read some things. So we'll be talking more about that at the upcoming NASW National Conference in June. I believe it will be in Chicago. So Anna Magnum, Diana Ling, and I will be doing a workshop there. And so anyone who is at that conference, we would invite you to join us. Or if you have interest in becoming a partner in our CDC NASW UT Austin collaborative project, we would love to hear from you.

Yes, we would. I do want to talk about screening too, because I know I brought that up as well as Dr. Zurab and Dr. Velazquez. Why is screening, brief intervention, and referral treatment an effective method for talking with women about cannabis use in pregnancy? Yeah. So, you know, I mean, we'll start first with screening. If you do not screen, you won't know right so and screening with a standardized method is the best way same like with alcohol the screening should be standardized and once you screen you know what you're dealing with so if we if we start with screening screening I I personally always like the one the single question screening and

And we've always used NIDA, how many times have you used illegal drugs or prescription medicines for not a medical reason, such as other non-therapeutic reasons for using any medication in the past year. However, what happens with that question now puts you in a bind. if I ask the person, how many times have you used illegal drugs in the past year, that in their mind, cannabis is no more illegal if it's in a state which is legalized. So we do not pick up properly the use of cannabis based on that single question. Please remember also there are other screening tests which are longer, such as the DAS, that can be used with multiple questions for more screening if needed. For family physicians, primary care

providers, a question like this is very friendly in a busy practice. That's all you need. It is a question that has been used forever and verified before. Hence, you know, I prefer using the NIDA question. Now, if you look at the literature as far as cannabis, there are other screening tools which are longer, but the single question for cannabis screeners called SIS-C, which is S-I-S-C, single item screen cannabis, it asks about how often in the past year did you use marijuana, and usually the answers are non daily or non yearly monthly weekly daily etc to give you a quick idea about this the use of cannabis and it's not as yet standardized but it's getting there there are few studies out there about it

and I think it makes sense if you don't want to use a longer screening test or you don't have time to do it in the primary care busy practice the what do you do after screening is really the brief intervention first so in prevention and mild disorders you you know a brief intervention of a few minutes they say two to three it may take a little longer that we used an alcohol effectively can prevent 20-30% of overuse of alcohol. So now it's being used in cannabis as well. And when you say, well, that's a small percentage, no, that's a huge percentage with such an intervention of response. However, you know, don't forget part of that is a referral

to treatment. So with severer cases, people not responding, you don't have time to do it, to do brief interventions or intervention in general, which is understandable, then you can have your referral network. So between consciously using standardized testing to screen your patient and attempting initial treatments and referral, you covered all bases for all stages of cannabis use or cannabis use disorder and that is why the screening and brief intervention is an important tool for the family medicine provider and for a social worker or for any mental health worker depending how deep you are into the subject and how much specialized you are. So the most important thing is you have standardized tools in your practice using them routinely

in a standard way to cover all your patients when you screen and in our practices we have standardized questionnaires that we use for all patients no matter what their problem is for new patients and yearly visits because you know people will ask you why are you asking me about marijuana about smoking about depression when you put them all together in one questionnaire and you normalize it and you say this is we ask everybody in our practices for wellness and prevention people are more aware and more accepting of such sensitive questions. Yeah. And it also sounds like it helps to reduce the stigma that may be associated with the two as well when you put it together and with other questions as well. So thank you for that. Well, I want to thank you both for the

information that you provided to our listeners today. Before we end, are there any final thoughts? I don't think so. I would just like to express thanks to you, Makiba, and to everyone at NASW and our partnership. We've had many years of successful collaboration, and we're very excited. UT Austin and I know Baylor College of Medicine and the CDC are very grateful for this opportunity. We think that social workers we know are the largest providers of mental and behavioral health services in all kinds of settings. And so the outreach is so important. And it's just a wonderful opportunity to reach women both for prevention in the pre-pregnancy, potentially pre-conception stage and during pregnancy and post-pregnancy. So thank you for this opportunity. Yes, I agree. Thank you for the opportunity, Makiba, and thank you, Mary, for the invite as

well. And my final thoughts would be, you know, marijuana is in the forefront of public use now and legalization. Let's treat it like any new drug or medicine as regards to pregnancy and cannabis. And take a deep breath and use more proven and safe medications for pregnancy. There is no safe dose for cannabis in pregnancy. It does cross the placenta. So let's wait out further research before we make the leap into using it for simple things like nausea or any other use in pregnancy. And again, thank you very much for this opportunity to participate. And thank you for sharing your time and your expertise, Dr. Zurab. We know it's very valuable and we really appreciate your being here today with us. Yes, yes, we certainly

appreciate both of you for being here today. This brings us to the end of the podcast. I want to thank you listeners for tuning into this episode of Social Work Talks as we engage in a conversation on what social workers should know about the impact cannabis can have on pregnancy. A link to the works of Dr. Zurab and Velazquez can be found in the show notes section of our website. You may google NASW Social Work Talks to find it. Again, thank you so much for listening.