Abstract
Objectives
Assessment and counseling are recommended for individuals with prenatal cannabis use. We examined characteristics that predict prenatal substance use assessment and counseling among individuals who screened positive for prenatal cannabis use in prenatal settings.
Methods
Electronic health record data from Kaiser Permanente Northern California’s Early Start perinatal substance use screening, assessment, and counseling program was used to identify individuals with ≥1 pregnancies positive for prenatal cannabis use. Outcomes included completion of a substance use assessment and among those assessed, attendance in Early Start counseling only or Addiction Medicine Recovery Services (AMRS) treatment. Predictors included demographics and past-year psychiatric and substance use disorder diagnoses evaluated with GEE multinomial logistic regression.
Results
The sample included 17,782 individuals with 20,398 pregnancies positive for cannabis use (1/2011–12/2021). Most pregnancies (80.3%) had an assessment. Individuals with Medicaid, anxiety, depression and tobacco use disorders, compared to those without, had higher odds and those with greater parity, older age (≥35) and in later trimesters, had lower odds of assessment. Among 64% (n = 10,469) pregnancies needing intervention based on assessment, most (88%) attended Early Start counseling only or AMRS (with or without Early Start). Greater parity and later trimester assessment was associated with lower odds, while Medicaid was associated with higher odds of Early Start counseling. Nearly all diagnosed psychiatric and substance use disorders were associated with higher odds of AMRS treatment.
Conclusions
A comprehensive prenatal substance use program engaged most pregnant individuals with prenatal cannabis use in substance use assessment and counseling. Opportunities to improve care gaps remain.
Key Words: cannabis, pregnancy, early intervention
Cannabis use during pregnancy is increasing and in some US states, outpacing use of other high-risk substances (ie, tobacco, alcohol), with up to 20% of pregnant individuals reporting use at some point during pregnancy.1–5 Cannabis use during pregnancy is associated with increased risk of lower birth weight, preterm delivery, neonatal intensive care unit admission, neurodevelopmental changes, and childhood psychopathology.6–14 National recommendations advise against cannabis use during pregnancy.7,15
Individuals who use cannabis during pregnancy should be provided prenatal care that offers substance use counseling and treatment.16 However, access to such care is often complex, with unique barriers, including potential legal consequences (ie, incarceration, loss of parental rights), as well as stigma, financial hardship, and competing demands.17 Kaiser Permanente Northern California’s (KPNC) Early Start program, which offers universal substance use screening, assessment, and counseling as part of prenatal care,18 has been associated with reductions in adverse infant outcomes, including low birth weight, assisted ventilation at birth, intrauterine fetal demise, and preterm delivery.19
Not all individuals with prenatal substance use participate in Early Start, highlighting opportunities to address critical care gaps.19,20 Evidence suggests that individuals screened for substance use later in pregnancy, who have greater parity, and who only use alcohol or other drugs have lower odds of participating, whereas individuals who report cannabis use only are more likely to participate, along with those who are younger, have lower income, single marital status and comorbid mental health (ie, depression, anxiety) or substance use disorders (SUDs).4
However, little is known about the characteristics of pregnant individuals who use cannabis associated with engagement in substance use counseling or treatment. Recent findings indicate pregnant individuals with a history of psychiatric disorders or SUDs have elevated odds of using cannabis and using cannabis more frequently.21 However, whether these conditions impact engagement in substance use counseling or treatment for pregnant individuals who use cannabis has not been explored.
This current study uses electronic health record (EHR) data from KPNC’s Early Start program to understand, among pregnant individuals identified with prenatal cannabis use in prenatal settings, the patient characteristics, including sociodemographics, psychiatric disorders, and SUDs, that predict completion of a comprehensive Early Start substance use assessment. Furthermore, this study explores, among those assessed and recommended follow-up, the characteristics that predict subsequent engagement in substance use counseling or treatment.
METHODS
Study Setting
KPNC is a large, multispecialty healthcare system serving ~4.6 million diverse members representative of Northern California’s insured population. Since 2003, all KPNC prenatal clinics have offered Early Start, a comprehensive substance use program successfully integrated into standard prenatal care in prenatal settings (ie, obstetrics and gynecologic clinic settings). The program provides substance use screening, assessment, and counseling staffed by licensed counselors (ie, social workers, therapists, and psychologists). Universal prenatal substance use screening is offered at a first prenatal visit (~8–10 weeks gestation) through both a self-administered questionnaire and urine toxicology testing (most often same day). Compared to toxicology testing, the sensitivity of self-reported prenatal cannabis use is low (33.9%); thus, a combined screening approach is optimal.22 Patients consent to urine toxicology testing included within a standard panel of prenatal laboratory tests. Positive immunoassay results are immediately available and confirmed by additional testing (eTable 1, http://links.lww.com/JAM/A557).
Pregnant individuals identified as using cannabis and other substances (based on self-report or toxicology testing) are offered an Early Start clinical assessment from a licensed counselor, which includes a detailed substance use interview, including Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for SUDs, brief medical history, patient education, brief counseling, and follow-up care plan. Individuals who are at increased risk of continued substance use during pregnancy and those who meet DSM-5 criteria for an SUD are offered Early Start substance use counseling. A variety of effective counseling techniques and therapeutic interventions, including motivational enhancement and cognitive behavioral therapies for cannabis use,23 are offered virtually or in-person, based on patient preference and clinician judgment, to support reductions or cessation of substance use throughout pregnancy. Clinicians may also refer some individuals, with severe SUDs, polysubstance use, or potential need for medications (eg, withdrawal management), to KPNC’s Addiction Medicine and Recovery Services (AMRS) to access intensive outpatient services, like day treatment (eg, partial hospitalization) or residential care. In California, clinicians are not mandated to report prenatal substance use to law enforcement or social services agencies, allowing for increased confidentiality.24
Data Source and Study Subjects
Using KPNC’s EHR data, we identified individuals with one or more pregnancies who 1) had KPNC membership two years prior to pregnancy, 2) were screened at their first prenatal care encounter (~8–10 weeks gestation) for cannabis use via a single-item on the questionnaire (ie, Since pregnancy, how often have you used marijuana? [never, monthly or less, weekly, daily]) and urine toxicology (January 2011–December 2019 and January 2021–December 2021), and 3) screened positive for prenatal cannabis use, reported as the frequency of use or urine toxicology positive for those who self-reported no use and had a positive toxicology test.22 All eligible pregnancies were included, with some individuals contributing more than one (Fig. 1). Data for 2020 were not included due to care changes early in the COVID-19 pandemic and an EHR system change that temporarily compromised data capture of self-reported substance use. During the study timeframe, 20,398 pregnancies among 17,782 individuals were positive for prenatal cannabis use. The KPNC Institutional Review Board approved this study and waived informed consent. This study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE reporting guidelines.25
Figure 1.
STROBE diagram of patient selection. LMP, last menstrual period; PSQ, prenatal screening questionnaire; UDAP, urine toxicology test.
Measures
Outcomes
We identified whether individuals who screened positive for prenatal cannabis use had documented completion of an Early Start substance use assessment within 6 months of their screening date. Individuals who completed the Early Start substance use assessment may have been identified as needing substance use counseling or treatment, which we identified from EHR discrete text fields: “follow-up/treatment plan,” “follow up PRN,” “follow at every prenatal visit,” or “follow up indicated but refused.” Among individuals identified as needing follow-up, we examined the type of intervention received, defined as Early Start counseling only, any AMRS treatment (which could include Early Start counseling), or neither (ie, no intervention). We did not evaluate individuals who attended AMRS only as few individuals meet criteria for AMRS.
Psychiatric Disorders and SUDs
Using ICD-9-CM and ICD-10-CM codes extracted from the EHR (eTable 1, http://links.lww.com/JAM/A557), we identified whether patients had a documented psychiatric or SUD diagnosis at an encounter from 1 year before pregnancy onset (based on date of last menstrual period) through the date of prenatal substance use screening. We created indicators for seven psychiatric disorders (attention deficit hyperactivity, anxiety, bipolar, depressive, personality, posttraumatic stress, psychotic disorders) and five SUDs (alcohol use, cannabis use, opioid use, stimulant use, and tobacco use disorders). Because burden of psychiatric disorders and SUDs is predictive of participation in substance use treatment,26 we generated counts of psychiatric disorders and SUDs (range 0–7 and 0–5, respectively), as well as type of comorbidity (psychiatric disorders only, SUDs only, both and neither).
Sociodemographic and Clinical Characteristics
From the EHR, we extracted the following baseline information as of pregnancy onset date: age (<18, 18–24, 25–34, >34 years old), self-reported race/ethnicity (Hispanic, non-Hispanic White, Asian/Pacific Islander, Black, and other/unknown/multiracial), neighborhood deprivation index (NDI; categorized into quartiles),27 insurance payor (Medicaid, non-Medicaid), and parity (number of births). Limited missing demographic data were coded as a separate category. Based on self-report data, we categorized frequency of prenatal cannabis use during early pregnancy as mutually exclusive categories of “none,” “monthly or less,” “weekly,” and “daily”; a category “urine toxicology positive, frequency unknown” was created to characterize individuals who self-reported no cannabis use but had a positive toxicology test. We also calculated trimester of pregnancy at time of screening and the initial Early Start assessment/counseling.
Statistical Analysis
We described the demographic and clinical characteristics of pregnancies among pregnant individuals who screened positive for prenatal cannabis by whether they completed an Early Start substance use assessment, and among individuals identified as needing substance use intervention by type of intervention (Early Start counseling only, any AMRS, or no intervention). Associations between patient demographics and clinical characteristics, including psychiatric disorders and SUDs, and completion of the Early Start substance use assessment were examined using generalized estimating equation (GEE) logistic models, clustered to account for nonindependence of multiple pregnancies from some individuals. Analyses were conducted in two steps. First, GEE logistic regression was used to estimate associations between sociodemographic and clinical characteristics (age, race and ethnicity, NDI, insurance, parity, trimester of pregnancy, frequency of cannabis use) and completion of an Early Start substance use assessment, accounting for length of pregnancy and calendar year. Next, for each psychiatric and SUD diagnosis, GEE logistic regression was used to estimate the adjusted odds ratios (aORs) of completion of the Early Start substance use assessment, adjusting for patient sociodemographic and clinical characteristics.
Among individuals identified as needing substance use intervention, GEE multinomial logistic regression was used to examine associations between each psychiatric disorder and SUD with type of intervention, repeating the above-mentioned two steps. Similar analyses were also conducted to examine associations between counts of psychiatric disorders and SUDs, as well as type of comorbidity, with type of intervention. To characterize individuals who attend AMRS, post-hoc analyses assessed the prevalence of SUD diagnoses documented at Early Start assessment. All analyses were conducted in SAS 9.4. Two-sided P values <0.05 were considered statistically significant.
RESULTS
Among 299,496 pregnancies, 20,398 (6.8%) from 17,782 individuals were positive for prenatal cannabis use and included (Fig. 1), with 43.7% (n = 8,922) positive based on self-report and 56.3% (n = 11,476) based on urine toxicology testing. The sample was 36.8% non-Hispanic White, 27.9% Hispanic, 23.0% Black, 5.2% Asian/Pacific Islander and 7.1% other race/ethnicity, 46.4% aged 25–34, 25.9% with Medicaid insured, and 17.3% with parity ≥2 (Table 1). The most prevalent psychiatric disorders were anxiety (18.8%) and depressive (18.3%) disorders, followed by posttraumatic stress disorder (2.9%), bipolar (2.6%), attention-deficit/hyperactivity disorder (2.5%), personality (1.4%), and psychotic disorders (0.7%). The prevalence of SUD ranged from 0.9% for opioid use disorder to 13.5% for tobacco use disorder.
TABLE 1.
Patient Characteristics Associated With Completion of an Early Start Substance Use Assessment (n = 20,398)*
| Assessed | Not Assessed | Early Start Assessment† | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | aOR (95% CI) | P Value | |
| Age, yr | ||||||
| <18 | 567 | 3.5 | 111 | 2.8 | 0.97 (0.78, 1.20) | 0.755 |
| 18–24 | 6337 | 38.7 | 1412 | 35.2 | 0.96 (0.88, 1.05) | 0.350 |
| 25–34 | 7631 | 46.6 | 1825 | 45.5 | Ref | – |
| >34 | 1852 | 11.3 | 663 | 16.5 | 0.72 (0.65, 0.80) | <0.001 |
| Race and ethnicity | ||||||
| Asian/Pacific Islander | 843 | 5.1 | 214 | 5.3 | 0.95 (0.80, 1.11) | 0.497 |
| Black | 3788 | 23.1 | 904 | 22.5 | 1.04 (0.94, 1.15) | 0.423 |
| Hispanic | 4554 | 27.8 | 1127 | 28.1 | 0.99 (0.90, 1.08) | 0.786 |
| White | 6059 | 37.0 | 1453 | 36.2 | Ref | – |
| Other | 1143 | 7.0 | 313 | 7.8 | 0.89 (0.77, 1.02) | 0.090 |
| NDI quartile | ||||||
| 1st | 1881 | 11.5 | 476 | 11.9 | Ref | – |
| 2nd | 2961 | 18.1 | 714 | 17.8 | 1.05 (0.92, 1.20) | 0.460 |
| 3rd | 3915 | 23.9 | 977 | 24.4 | 1.02 (0.90, 1.16) | 0.759 |
| 4th | 5585 | 34.1 | 1503 | 37.5 | 0.94 (0.83, 1.06) | 0.327 |
| Missing | 2045 | 12.5 | 341 | 8.5 | 1.49 (1.27, 1.74) | <0.001 |
| Medicaid insured | ||||||
| Yes | 4267 | 26.0 | 1009 | 25.2 | 1.17 (1.08, 1.28) | <0.001 |
| No | 12,120 | 74.0 | 3002 | 74.8 | Ref | – |
| Parity | ||||||
| 0 | 8372 | 51.1 | 1716 | 42.8 | Ref | – |
| 1 | 4497 | 27.4 | 1212 | 30.2 | 0.77 (0.70, 0.84) | <0.001 |
| ≥2 | 2628 | 16.0 | 897 | 22.4 | 0.61 (0.55, 0.68) | <0.001 |
| Missing | 890 | 5.4 | 186 | 4.6 | 0.99 (0.84, 1.18) | 0.947 |
| Trimester at screening | ||||||
| 1st | 14,711 | 89.8 | 3551 | 88.5 | Ref | – |
| 2nd | 1478 | 9.0 | 350 | 8.7 | 1.00 (0.88, 1.14) | 0.987 |
| 3rd | 198 | 1.2 | 110 | 2.7 | 0.41 (0.32, 0.52) | <0.001 |
| Frequency of cannabis use | ||||||
| ≤Monthly | 3798 | 23.2 | 895 | 22.3 | Ref | – |
| Weekly | 1865 | 11.4 | 391 | 9.8 | 1.11 (0.97, 1.27) | 0.123 |
| Daily | 1616 | 9.9 | 357 | 8.9 | 1.07 (0.93, 1.23) | 0.343 |
| Unknown/positive urine‡ | 9108 | 55.6 | 2368 | 59.0 | 0.92 (0.84, 1.01) | 0.065 |
*All patient characteristics examined in one multivariable GEE logistic model.
†Early start assessment measured 2 weeks before to 6 months after screening date
‡Includes individuals who had a urine toxicology screen positive for cannabis use and reported no prenatal cannabis use on the questionnaire.
aOR indicates adjusted odds ratio; NDI, neighborhood deprivation index.
Patient Factors Associated With Completion of Early Start Substance Use Assessment
Among pregnant individuals with prenatal cannabis use, 16,387 (80.3%) completed an Early Start substance use assessment within 6 months of screen date, with a median of 39 days (interquartile range: 20 and 72). Being Medicaid-insured was associated with higher odds (aOR 1.17 [95% CI 1.08–1.28]), while ages 35 and older (vs 25–34; 0.72 [0.65–0.80]), greater parity (vs no prior live births; aORs 0.77 [0.70–0.84] for 1 and 0.61 [0.55–0.68] for ≥2 births), and having been screened in the third trimester (vs first; aOR 0.41 [0.32–0.52]) were associated with lower odds of completing an Early Start substance use assessment (P values <0.001; Table 1). No significant differences were found by race/ethnicity, frequency of cannabis use, or use identified by urine toxicology.
Individuals with prenatal cannabis use and past-year history of anxiety and depressive disorders (vs without) had greater odds of completing an Early Start assessment (aORs 1.12 [1.01–1.24] and 1.13 [1.02–1.25], respectively; Table 2); those with tobacco use disorders also had higher odds of completing an Early Start assessment than those without (aOR 1.13 [1.00–1.27]). No other significant associations were found between the other psychiatric disorders and SUDs and completion an Early Start assessment
TABLE 2.
Patient Psychiatric and SUD Diagnoses Associated With Completion of an Early Start Substance Use Assessment (N = 20,398)*
| Assessed | Not Assessed | Early Start Assessment† | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | aOR (95% CI) | P Value | |
| Psychiatric diagnosis, yes vs no | ||||||
| ADHD | 433 | 2.6 | 82 | 2.0 | 1.28 (0.99, 1.66) | 0.056 |
| Anxiety disorder | 3,069 | 18.7 | 775 | 19.3 | 1.12 (1.01, 1.24) | 0.029 |
| Bipolar disorder | 430 | 2.6 | 105 | 2.6 | 1.17 (0.93, 1.49) | 0.186 |
| Depressive disorder | 3,016 | 18.4 | 719 | 17.9 | 1.13 (1.02, 1.25) | 0.023 |
| Personality disorder | 229 | 1.4 | 57 | 1.4 | 1.22 (0.87, 1.70) | 0.256 |
| PTSD | 480 | 2.9 | 112 | 2.8 | 1.25 (0.99, 1.59) | 0.063 |
| Psychotic disorder | 100 | 0.6 | 32 | 0.8 | 0.91 (0.59, 1.41) | 0.669 |
| SUD diagnosis, yes vs no | ||||||
| Alcohol use disorder | 376 | 2.3 | 78 | 1.9 | 1.24 (0.93, 1.65) | 0.136 |
| Cannabis use disorder | 1,139 | 7.0 | 289 | 7.2 | 1.03 (0.88, 1.20) | 0.734 |
| Opioid use disorder | 146 | 0.9 | 29 | 0.7 | 1.34 (0.86, 2.10) | 0.198 |
| Stimulant use disorder | 210 | 1.3 | 53 | 1.3 | 1.24 (0.87, 1.75) | 0.232 |
| Tobacco use disorder | 2,255 | 13.8 | 496 | 12.4 | 1.13 (1.00, 1.27) | 0.049 |
*Each psychiatric and SUD diagnosis examined in a separate multivariable GEE logistic model adjusted for age, self-reported race/ethnicity, neighborhood deprivation index, insurance payor, parity, length of pregnancy, calendar year, trimester at screening, and frequency of cannabis use.
†Early start assessment measured 2 weeks before to 6 months after screening date.
ADHD indicates attention-deficit/hyperactivity disorder; aOR, adjusted odds ratio; PTSD, posttraumatic stress disorder; SUD, substance use disorder.
Patient Factors Associated With Early Start Counseling or AMRS Treatment
Out of the 16,387 pregnancies with complete Early Start substance use assessment, 10,469 (63.9%) had indication of needing further substance use intervention. Among them, 9179 (87.7%) attended Early Start counseling and/or AMRS treatment: 9069 (86.6%) attended Early Start counseling only, 110 (1.1%) attended AMRS treatment (with a majority [96.4%] also having at least one Early Start counseling visit), and 1290 (12.3%) had neither Early Start counseling nor AMRS treatment. Among individuals who attended AMRS, 85% (93 of 110) had an SUD diagnosis documented at the time of assessment.
Among individuals with prenatal cannabis use identified as needing intervention, those with Medicaid insurance compared to other insurance (aOR 1.30 [1.12–1.51]) and those with missing parity compared to no prior birth (aOR 1.40 [1.03–1.91]) had higher odds of Early Start counseling (Table 3). Completion of the substance use assessment in the 2nd or 3rd trimester (aORs 0.57 [0.49–0.66] and 0.16 [0.13–0.19], respectively), compared to first, and at least one prior birth compared to none (aOR 0.83 [0.71–0.97]) was associated with lower odds of Early Start counseling. Completion of the substance use assessment in the 2nd or 3rd trimester (aORs 0.42 [0.27–0.64] and 0.10 [0.04–0.25], respectively), compared to first, was also associated with lower odd of AMRS treatment. Compared to White, individuals with Asian/Pacific Islander or Black racial/ethnic background had lower odds of AMRS treatment (aORs 0.13 [0.02–0.99] and 0.56 [0.32–1.00], respectively). Compared to individuals who self-reported monthly or less use, those with positive urine toxicology test but no reported cannabis use also had lower odds of AMRS treatment (aOR 0.38 [0.22–0.64]).
TABLE 3.
Patient Characteristics Associated with Substance Use Counseling (Early Start) or Treatment (AMRS) Among Those Identified as Needing Substance Use Counseling or Treatment (n = 10,469)*
| Early Start Counseling (Only) | AMRS† | No Intervention | Early Start Counseling vs No Intervention | AMRS† vs No Intervention | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | aOR (95% CI) | P Value | aOR (95% CI) | P Value | |
| Age, yr | ||||||||||
| <18 | 326 | 3.6 | 3 | 2.7 | 37 | 2.9 | 1.12 (0.77, 1.62) | 0.567 | 0.91 (0.26, 3.20) | 0.881 |
| 18–24 | 3632 | 40.1 | 42 | 38.2 | 493 | 38.2 | 1.00 (0.86, 1.16) | 0.998 | 0.99 (0.61, 1.59) | 0.966 |
| 25–34 | 4141 | 45.7 | 52 | 47.3 | 584 | 45.3 | Ref | – | Ref | – |
| >34 | 970 | 10.7 | 13 | 11.8 | 176 | 13.6 | 0.86 (0.71, 1.06) | 0.152 | 0.84 (0.43, 1.62) | 0.598 |
| Race and ethnicity | ||||||||||
| Asian/Pacific Islander | 423 | 4.7 | 1 | 0.9 | 65 | 5.0 | 1.00 (0.74, 1.34) | 0.998 | 0.13 (0.02, 0.99) | 0.049 |
| Black | 2286 | 25.2 | 22 | 20.0 | 352 | 27.3 | 0.96 (0.80, 1.14) | 0.609 | 0.56 (0.32, 1.00) | 0.049 |
| Hispanic | 2486 | 27.4 | 25 | 22.7 | 360 | 27.9 | 0.99 (0.84, 1.18) | 0.926 | 0.65 (0.38, 1.10) | 0.108 |
| White | 3201 | 35.3 | 54 | 49.1 | 428 | 33.2 | Ref | – | Ref | – |
| Other | 673 | 7.4 | 8 | 7.3 | 85 | 6.6 | 1.07 (0.82, 1.40) | 0.608 | 0.80 (0.35, 1.82) | 0.597 |
| NDI quartile | ||||||||||
| 1st | 956 | 10.5 | 19 | 17.3 | 153 | 11.9 | Ref | – | Ref | – |
| 2nd | 1523 | 16.8 | 18 | 16.4 | 223 | 17.3 | 1.07 (0.84, 1.37) | 0.585 | 0.67 (0.33, 1.35) | 0.263 |
| 3rd | 2142 | 23.6 | 26 | 23.6 | 318 | 24.7 | 1.11 (0.89, 1.40) | 0.355 | 0.73 (0.37, 1.42) | 0.353 |
| 4th | 3251 | 35.9 | 35 | 31.8 | 479 | 37.1 | 1.14 (0.91, 1.43) | 0.263 | 0.73 (0.38, 1.41) | 0.344 |
| Missing | 1197 | 13.2 | 12 | 10.9 | 117 | 9.1 | 1.45 (0.78, 2.68) | 0.242 | 0.77 (0.13, 4.64) | 0.774 |
| Medicaid insured | ||||||||||
| Yes | 2549 | 28.1 | 25 | 22.7 | 342 | 26.5 | 1.30 (1.12, 1.51) | 0.001 | 1.05 (0.62, 1.77) | 0.869 |
| No | 6520 | 71.9 | 85 | 77.3 | 948 | 73.5 | Ref | – | Ref | – |
| Parity | ||||||||||
| 0 | 4609 | 50.8 | 60 | 54.6 | 571 | 44.3 | Ref | – | Ref | – |
| 1 | 2460 | 27.1 | 28 | 25.5 | 409 | 31.7 | 0.83 (0.71, 0.97) | 0.018 | 0.83 (0.51, 1.35) | 0.459 |
| ≥2 | 1461 | 16.1 | 18 | 16.4 | 256 | 19.8 | 0.83 (0.69, 1.01) | 0.069 | 0.96 (0.50, 1.85) | 0.897 |
| Missing | 539 | 5.9 | 4 | 3.6 | 54 | 4.2 | 1.40 (1.03, 1.91) | 0.032 | 0.76 (0.26, 2.21) | 0.620 |
| Trimester at ES assessment | ||||||||||
| 1st | 4249 | 46.9 | 63 | 57.3 | 455 | 35.3 | Ref | – | Ref | – |
| 2nd | 4136 | 45.6 | 41 | 37.3 | 551 | 42.7 | 0.57 (0.49, 0.66) | <0.001 | 0.42 (0.27, 0.64) | <0.001 |
| 3rd | 684 | 7.5 | 6 | 5.5 | 284 | 22.0 | 0.16 (0.13, 0.19) | <0.001 | 0.10 (0.04, 0.25) | <0.001 |
| Frequency of cannabis use | ||||||||||
| ≤ Monthly | 1757 | 19.4 | 27 | 24.6 | 232 | 18.0 | Ref | – | Ref | – |
| Weekly | 1039 | 11.5 | 19 | 17.3 | 143 | 11.1 | 0.91 (0.72, 1.15) | 0.424 | 1.04 (0.55, 1.97) | 0.905 |
| Daily | 938 | 10.3 | 26 | 23.6 | 119 | 9.2 | 1.02 (0.79, 1.31) | 0.892 | 1.77 (0.98, 3.19) | 0.060 |
| Unknown/positive urine‡ | 5335 | 58.8 | 38 | 34.6 | 796 | 61.7 | 0.85 (0.72, 1.01) | 0.061 | 0.38 (0.22, 0.64) | <0.001 |
*All patient characteristics examined in one multivariable GEE multinomial logistic model.
†AMRS can also include Early Start counseling.
‡Includes individuals who had a urine toxicology screen positive for cannabis use and reported no prenatal cannabis use on the questionnaire
aOR indicates adjusted odds ratio; NDI, neighborhood deprivation index.
For each psychiatric disorder and SUD examined, no significant differences in odds of Early Start counseling were found between those with and without the condition (Table 4). For all psychiatric disorders, except personality or psychotic disorders, individuals with a diagnosis had at least two times the odds of having AMRS treatment compared to those without the condition. Pregnant individuals with any SUD diagnosis had greater odds of having any AMRS treatment compared to those without, with adjusted ORs (95% CIs) ranging from 4.3 (2.6–7.1) for cannabis use disorder to 70.6 (21.6–231.2) for opioid use disorder.
TABLE 4.
Patient Psychiatric and SUD Diagnoses Associated with Substance Use Counseling (Early Start) or Treatment (AMRS) Among Those Identified as Needing Substance Use Counseling or Treatment (n = 10,469)*
| Early Start Counseling (Only) | AMRS† | No Intervention | Early Start Counseling vs No Intervention | AMRS† vs No Intervention | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | aOR (95% CI) | P Value | aOR (95% CI) | P Value | |
| Psychiatric diagnosis, yes vs no | ||||||||||
| ADHD | 229 | 2.5 | 9 | 8.2 | 31 | 2.4 | 0.96 (0.66, 1.42) | 0.854 | 2.98 (1.39, 6.42) | 0.005 |
| Anxiety disorder | 1643 | 18.1 | 40 | 36.4 | 244 | 18.9 | 1.05 (0.89, 1.23) | 0.559 | 2.42 (1.58, 3.70) | <0.001 |
| Bipolar disorder | 210 | 2.3 | 13 | 11.8 | 33 | 2.6 | 0.83 (0.56, 1.22) | 0.344 | 4.10 (2.04, 8.27) | <0.001 |
| Depressive disorder | 1679 | 18.5 | 44 | 40.0 | 226 | 17.5 | 1.16 (0.98, 1.36) | 0.083 | 3.06 (2.02, 4.64) | <0.001 |
| Personality disorder | 111 | 1.2 | 3 | 2.7 | 16 | 1.2 | 1.01 (0.57, 1.76) | 0.985 | 1.82 (0.49, 6.77) | 0.370 |
| PTSD | 238 | 2.6 | 12 | 10.9 | 40 | 3.1 | 0.91 (0.63, 1.32) | 0.631 | 3.84 (1.89, 7.77) | <0.001 |
| Psychotic disorder | 50 | 0.6 | 1 | 0.9 | 10 | 0.8 | 0.78 (0.40, 1.54) | 0.477 | 1.20 (0.16, 9.22) | 0.859 |
| SUD diagnosis, yes vs no | ||||||||||
| Alcohol use disorder | 200 | 2.2 | 17 | 15.5 | 25 | 1.9 | 0.98 (0.63, 1.51) | 0.910 | 7.06 (3.60, 13.86) | <0.001 |
| Cannabis use disorder | 607 | 6.7 | 28 | 25.5 | 95 | 7.4 | 0.98 (0.77, 1.25) | 0.887 | 4.28 (2.58, 7.10) | <0.001 |
| Opioid use disorder | 66 | 0.7 | 19 | 17.3 | 4 | 0.3 | 2.75 (0.96, 7.92) | 0.061 | 70.64 (21.58, 231.17) | <0.001 |
| Stimulant use disorder | 103 | 1.1 | 14 | 12.7 | 15 | 1.2 | 1.16 (0.65, 2.08) | 0.617 | 13.71 (6.21, 30.27) | <0.001 |
| Tobacco use disorder | 1261 | 13.9 | 43 | 39.1 | 157 | 12.2 | 1.18 (0.97, 1.43) | 0.093 | 4.38 (2.86, 6.70) | <0.001 |
*Each psychiatric and SUD diagnosis examined in a separate multivariable GEE multinomial logistic model adjusted for age, self-reported race/ethnicity, neighborhood deprivation index, insurance payor, parity, length of pregnancy, calendar year, trimester at ES assessment, and frequency of cannabis use.
†AMRS can also include Early Start counseling.
AMRS indicates Addiction Medicine and Recovery Services; ADHD, attention-deficit/hyperactivity disorder; PTSD, posttraumatic stress disorder; SUD, substance use disorder.
Compared to those with none of the seven psychiatric disorders, pregnant individuals with two or more had two times the odds of AMRS treatment (aOR 2.15 [1.27–3.62]) rather than no intervention (eTable 2, http://links.lww.com/JAM/A557). Compared to those with none of the five SUDs, those with one disorder had two times the odds (aOR 2.21 [1.26–3.88]), and those with two or more had 10 times the odds (aOR 10.60 [5.84–19.22]) of having AMRS treatment rather than no intervention. Lastly, compared to those with neither psychiatric disorders or SUDs, those with only psychiatric disorders had two times the odds, those with only SUDs had four times the odds, and those with both types of disorders had almost eight times the odds of AMRS treatment rather than no intervention.
DISCUSSION
In this large, population-based study of pregnant individuals who screened positive for prenatal cannabis use, based on substance use screening offered as part of a universal, comprehensive prenatal substance use program within obstetrics and gynecology departments, 80% of individuals completed a substance use assessment. Moreover, among those identified as needing counseling or treatment, 88% had at least one follow-up visit, primarily to Early Start counseling. Individuals with anxiety, depression or tobacco use disorders, and Medicaid insurance were more likely to complete the substance use assessment, whereas individuals 35 years and older, those who screened positive for prenatal cannabis use later in pregnancy, and those with children had lower odds of completing the assessment, consistent with prior research among individuals with prenatal substance use.4 While no psychiatric or SUD diagnosis was predictive of attending Early Start counseling, nearly all were associated with higher odds of attending AMRS treatment, with greater number of comorbid of psychiatric disorders and/or SUDs associated with increasing odds of AMRS treatment.
The results found here highlight the considerable success of a population-based prenatal substance use program embedded in obstetrics and gynecology settings to engage pregnant individuals who use cannabis in substance use assessment and counseling. Greater than 80% of individuals were engaged at each step in the program, from receipt of assessment to attending substance use counseling or treatment. Most, even those with prenatal cannabis use identified through urine toxicology testing, attended a substance use assessment. When recommended, 88% followed through with at least one Early Start counseling or AMRS visit. Success of the Early Start program in engaging pregnant individuals with cannabis use can be attributed to universal substance use screening for all pregnancies, which reduces screening bias, and the program’s offer of unbiased access to substance use education, assessment, and counseling, especially early in pregnancy. Moreover, as a program fully integrated within prenatal care, Early Start reduces stigma and structural barriers to assessment and counseling. The small proportion of individuals with prenatal cannabis use who attended AMRS (and Early Start, in most cases) had a higher prevalence of most psychiatric disorders and SUDs as well as comorbid psychiatric or SUD diagnoses, underscoring the importance of specialized treatment programs, including detoxification, residential or rehabilitative facilities, and intensive outpatient programs, in serving patients with more complex SUDs.28,29 Overall, findings highlight the capacity of the Early Start program to address the majority of counseling or treatment needs of pregnant individuals with prenatal cannabis use.
Results also point to opportunities to improve linkage to Early Start substance use assessment and counseling. More than 4000 pregnant individuals identified with prenatal cannabis use over 10 years did not attend an assessment appointment. If they had engaged in assessment, upward of 2400 (60%), based on results here, may have been recommended for additional substance use counseling or treatment. Older individuals, those identified later in pregnancy (due to later engagement in prenatal care) and those with children were least likely to be assessed, consistent with previous findings among individuals with prenatal substance use.4 Moreover, individuals identified through urine toxicology testing, from Asian/Pacific Islander or Black racial/ethnic backgrounds, assessed later in pregnancy, or who had children were also least likely to attend counseling or treatment. Racial/ethnic inequities in prenatal SUD treatment likely underscore the need to address cultural and systemic barriers to treatment,30–32 while individuals who do not wish to report prenatal cannabis use may be less likely to attend treatment. Early Start screening is offered at entrance to prenatal care, suggesting that individuals who enter prenatal care later in pregnancy and those with children likely face other barriers (eg, lack of childcare, financial hardship, stigma, fear of impact on parental rights and custody).17 Efforts to engage these individuals may include providing childcare or flexible visit options. Despite California’s efforts to eliminate substance use-related consequences for pregnant individuals, public health messaging and preconception education may be warranted to reduce stigma and fear of consequences related to prenatal cannabis use and encourage early engagement with prenatal care.
Beyond integrated prenatal substance use programs, like Early Start, prenatal cannabis use prevention and treatment programs are limited.28,33 Outside of KPNC, nearly half of individuals with prenatal substance use do not receive appropriate care (ie, counseling, specialized inpatient or outpatient treatment) during pregnancy.34 For the small percent of pregnant individuals who do engage, the proportion identifying cannabis use as a reason for treatment has increased significantly in recent years,28 with medical cannabis laws associated with a 33% increase in substance use treatment for pregnant individuals.35 Ultimately, less than a third of pregnant individuals who engage complete treatment as recommended.33 However, successful engagement in substance use counseling or treatment for prenatal cannabis use has important implications for prenatal outcomes. In another study of this Early Start population, prenatal cannabis use was found to be associated with adverse neonatal outcomes.14 Although research demonstrating program effectiveness is needed, improving the reach of Early Start screening, assessment, and counseling for prenatal cannabis use could lead to reductions in maternal morbidity and negative birth outcomes, including preterm labor, placental abruption and stillbirth.19,20,36,37
Strengths and Limitations
This study took place within a large, integrated health care system in California, where prenatal substance use and infant exposure (without other safety concerns) are not mandated for reporting, and findings may not generalize to patients without insurance or to those outside of California. Even in a state without mandated reporting of prenatal cannabis use, the sensitivity of self-reported use is low and a majority of individuals with prenatal cannabis use were identified by toxicology testing.22 Although a combination of self-report and urine toxicology testing is optimal for identifying prenatal cannabis use,22 routine toxicology testing is not recommended in states (~20) with mandated reporting or in settings that penalize perinatal substance use.24,38 Prenatal cannabis use is often a continuation of use prior to pregnancy and our study was unable to determine whether cannabis use initiation came before or after development of psychiatric or SUDs. Moreover, the duration that cannabis is detectable in urine after last use varies depending on heaviness of use and may not represent use during pregnancy. This study is limited to EHR data and could not capture other patient factors that may contribute to participation in Early Start or whether individuals sought out care outside of KPNC. This study included 1 year of data post-COVID-19, which may not fully reflect current state of health care following unprecedented COVID-era changes. Study strengths include a large sample size of pregnant individuals identified with prenatal cannabis use, based on universal self-reported and toxicology screening as part of a comprehensive prenatal substance use program.
CONCLUSIONS
Among pregnant individuals with prenatal cannabis use, a comprehensive prenatal care substance use program that offers universal substance use screening, assessment and counseling, engaged most pregnant individuals in need of substance use assessment and intervention. However, opportunities to improve gaps in care remain.
Footnotes
Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.journaladdictionmedicine.com).
C.I.C. and M.B.D. have received support managed through their institution from the Industry PMR Consortium, a consortium of companies working together to conduct postmarketing studies required by the Food and Drug Administration that assess risks related to opioid analgesic use. The other authors report no conflicts of interest.
Supported by the National Institute on Drug Abuse (NIDA) grant K01DA043604 and the NIDA Clinical Trials Network grant UG1DA040314 (CTN 0140).
A NIDA-appointed protocol review board reviewed the design of the study, and the NIDA Clinical Trials Network Publications Committee reviewed and approved the manuscript for publication. The funding organizations had no role in the collection, management, analysis, and interpretation of the data; or decision to submit the manuscript for publication.
Reporting guidelines: STROBE.
Statement of adherence to preprint policy: This manuscript has not been posted to a preprint server.
Contributor Information
Felicia W. Chi, Email: Felicia.W.Chi@kp.org.
Kelly C. Young-Wolff, Email: Kelly.C.Young-Wolff@kp.org.
Deborah Ansley, Email: Deborah.R.Ansley@kp.org.
Carley Castellanos, Email: Carley.X.Castellanos@kp.org.
Monique B. Does, Email: Monique.Does@kp.org.
Asma H. Asyyed, Email: ASMA.ASYYED@kp.org.
Allison Ettenger, Email: Allison.Ettenger@kp.org.
Cynthia I. Campbell, Email: Cynthia.I.Campbell@kp.org.
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