Substance Use and the Social Fabric
I wrote this article to address a gap I sensed in cannabis-pregnancy literature. This is neither an authoritative position statement nor an exhaustive literature search. Just my take on one neat little study.
Conventional knowledge tells us that cannabis use in pregnancy is harmful to the developing fetus.
The purpose of this article is to consider one outlier study, done in rural Jamaica by a nurse-turned-anthropologist from Columbia University, which shows the opposite: cannabis use associated with improved health outcomes in babies.
I consider this study alongside the recent findings Janni Niclasen from the University of Copenhagen which associate low level drinking in pregnancy with improved mental and emotional health in children.
My take on the Jamaican outlier study and its Danish complement is that they demonstrate that the context in which a person uses substances is a powerful determinant of health.
Substance use which is associated with positive health outcomes is substance use that weaves people into the centre of a vibrant and plentiful social fabric. By social fabric I mean the resources, people, values, work, rhythms, and rituals which organize the society where someone lives.
A glass of wine enjoyed over a nutritious, slowly-prepared meal shared with a parter who makes good money and doesn’t beat you is a different beast when it comes to infant and child health than a blunt smoked alone in a basement suite before a night shift at a dead-end job. Conversely, as our Jamaica study suggests, a blunt enjoyed with work colleagues over lunch at a well-paid, highly-respected job is not equatable to having three beers in the evening after a day of working at a soul-crushing job or not being employed at all.
The first time I read the Jamaica study it bent my mind so much it was all I could talk about to anyone who would listen for weeks.
I think the Jamaica study blew me away because most of the drug research I read is all “what is the effect on the fetus” and tries to control for the messy fact of the birth parent’s existence with powerful tools like large sample size and multiple linear regression.
This study was the first time I read something that bothered to ask, “how is the substance using parent doing?” and used the answer as a starting point from which to consider infant and child health.
I hope that by blogging about the Jamaica study and explicitly stating the relationship between substance use and the social fabric I offer useful support to the idea that caring for the pregnant person in all their nuanced humanness is a powerful way to care for both babies and parents.
Caring for the parent first is a strategy that is the opposite of the popular cultural practice of limiting or controlling pregnant and potential-pregnant people‘s actions and pleasures for the theoretical safety of their fetus.
I also hope I can add my voice to the growing chorus of people cheering on the increase in qualitative research in medicine.
A lot of folks don’t have a “take it or leave it” relationship to substance use
As soon as I started working as a midwife it was clear that the guidelines on substance use in pregnancy – complete abstinence from alcohol and marijuana – weren’t much help in clinical practice and real life.
Everyone seemed to drink in pregnancy, especially educated white women. Lots of people used cannabis – our hospital postpartum unit reported at rounds that 10-40% of folks on the floor at any one time disclosed cannabis use in their pregnancy.
At work I felt like an idiot telling a woman who had recently immigrated from Jamaica that studies done in Colorado on a mostly white population showed that she should stop enjoying her afternoon blunt, which she made with stuff she grew on her balcony, and consider looking into SSRIs, for which she would have to see a doctor and pay out of pocket.
What drug science tells us
THE ENDOCANNABOID SYSTEM BUILDS THE FETUS, CANNABIS INHIBITS THE ENDOCANNABOID SYSTEM
As much as I felt like an idiot I also felt genuine worry for the well-being of my cannabis-using clients and their kids.
Theoretically, from a drug science perspective, cannabis messes your kid up no matter how you do it when you’re pregnant.
Smoke it, eat it, rub it, whatever; the fetus has an endocannaboid system that relies on neurotransmitters the same shape as CBD and THC to build the fetus, especially the fetus’ nervous system.
We think that when someone uses cannabis the CBD or THC molecules from cannabis flood the fetus’ endocannaboid system and inhibit the production of the actual neurotransmitters that build the fetus.
The resulting kid has a permanently stunted nervous system and is more likely to be hyperactive, less bright, less social, and more prone to the join the lonely spiral of drug use themselves.
(Off topic but cannabis is suspected to be extra unhelpful when paired with breastfeeding. You know how edibles rely on fat [butter, oil] to carry the THC? Breastmilk has lots of fat and is like a storage tank for THC and CBD — it accumulates and accumulates and can take weeks to leave. But we don’t have research telling us the effects of THC-loaded breastmilk on a baby — ethically it’s nearly impossible to study this.)
I DO A DEEP DIVE
I felt like an idiot for making recommendations that didn’t account for the cultural context of someone’s cannabis use but also I felt worried for my clients based on my understanding of the drug science. Faced with these ugly feelings I did what I always do: I put my head down and did a deep dive into the research.
I joined a working group at the Canadian Association of Midwives that focused on connecting decent existing resources on cannabis in pregnancy to midwives and clients. I read everything, went to every lecture and rounds I could find, and cared for folks for whom cannabis was as commonplace as Diet Coke and red wine for me.
The most important thing I learned from my deep dive is this: while almost all studies suggest that substance use is associated with more harm than good in pregnancy — and after reading everything I feel extremely confident saying that cannabis and alcohol are, base case, harmful to the fetus — there are OUTLIERS that show the exact opposite.
These outlier studies show that people who smoke pot and drink and enjoy better neonatal outcomes, that is, healthier babies and kids.
The two outlier studies that explore substance use associated with positive health outcomes are Dreher, Melanie et al. “Prenatal Marijuana Exposure and Neonatal Outcomes in Jamaica: An Ethnographic Study” Pediatrics 1994 Feb; 93(2): 254 – 259 and Niclasen, Janni et al. “Prenatal exposure to alcohol, and gender differences on child mental health at age seven years” J Epidemiol Community Health. 2014 Oct;68(10): 224 – 232.
Dreher found that babies of pregnant people in rural Jamaica who used cannabis every day scored higher than their non-exposed peers in terms of physiologic stability and behaviour.
Niclasen found that kids of folks who drank a little bit in pregnancy – a glass of wine or two a week – were better off in all aspects of mental and emotional stability and wellbeing at age seven than their unexposed peers.
In both outlier studies, substance use that is associated with positive health outcomes is also substance use that ties people into a vibrant and plentiful social fabric.
Folks who enjoyed healthier babies while using substances used them in such a way that the substances were ritually woven into a lifestyle of community, work, health, and wealth. Importantly, the lifestyle of the substance-users was more resource-rich and community-centred than that of their non-substance using peers who had worse outcomes.
The Jamaica Study
To better understand what it means to have substance use tied to a vibrant and plentiful social fabric, consider Dreher’s study in detail.
Dreher studied 44 Jamaican neonates, half of whom were exposed to cannabis prenatally through ritual daily smoking and half of whom were not.
She had a (Harvard educated) nurse blindly score the baby’s neurodevelopment and behaviour at several intervals after birth.
She found that “the neonates of heavy-marijuana-using mothers had better scores on autonomic stability, quality of alertness, irritability, and self-regulation, and were judged to be more rewarding for caregivers.” (254)
Dreher is adamant that for her cannabis-using pregnant folks, cannabis formed one part of a larger lifestyle that focused on spiritual and physical wellness. Using cannabis was part of what located women in the centre of their communities, giving them access to more resources that their non-cannabis using counterparts.
Dreher explains the interconnectedness of cannabis and wellbeing in the rural Jamaican community as follows:
Rastafarians, members of a political-religious movement that endorses marijuana as a sacred substance, may smoke ritually on a daily basis. Marijuana is also known for its therapeutic and health-promoting functions. It is consumed as a tea by family members of all ages for a variety of illnesses and to maintain and promote health. Although the consumption of marijuana tea transcends class, age, and gender divisions, marijuana smoking traditionally has been an adult male, working class activity. The female marijuana smoker was a rarity and the few women who engaged in smoking were considered base and undignified ans often held in contemp by both men and women. Instead, women prepared marijuana for themselves and their families in the form of teas and tonics.
More recently, however, increasing numbers of women have begun to smoke marijuana regularly…Not only are such women now grudgingly tolerated by their communities, many of the heavy-marijuana-users, particularly if they were Rastafarians, have been given the commendatory tite of “Roots Daughter.” Roots Daughters are described as women “with a purpose” who can “think, reason and smoke like a man” and who are self-reliant and dignified. They smoke marijuana on a daily basis, in a manner not unlike that of their male counterparts, and continue to smoke during pregnancy and the breastfeeding period…
The responsibilities that accompany pregnancy and infant care in an unyielding economic environment are not trivial. The multigravidas [people with more than one kid], in particular, report that the feelings of depression and desperation attending motherhood in their impoverished communities were alleviated by both social and private smoking…
Conventional wisdom would suggest that mothers who are long-term marijuana users are less likely to create optimal caregiving environments for their neonates. In this area of rural Jamaica, however, where marijuana is culturally integrated, and where heavy use of the substance by women is associated with a higher level of education and greater financial independence, it seems that roots daughters have the capacity to create a postnatal environment that is supportive of neonatal development.”Dreher, Melanie et al. “Prenatal Marijuana Exposure and Neonatal Outcomes in Jamaica: An Ethnographic Study” Pediatrics 93(2) 1994 Feb; 93(2): 254 – 259
Dreher’s description of the interconnectedness between well-being, community, and cannabis in Jamaica is unlike anything I’ve seen in North America, where cannabis use is associated with the fringes of society and all the attending confounders of ill-health – smoking, addiction, polydrug use, poverty, mental illness, racism.
Dreher doubts whether a North American study on cannabis can ever separate the effects of the substance from the effects of living on the margins:
With regard to the research context, it should be noted that virtually all the studies of perinatal exposure have been conducted in the United States and Canada where marijuana use is primarily recreational. This is in marked contrast to other societies, such as Jamaica, where scientific reports have documented the cultural integration of marijuana and its ritual and medicinal as well as recreational functions. Previous studies have had difficulty controlling possible confounding effects of factors such as polydrug use, antenatal care, mothers’ nutritional status, maternal age, socioeconomic status and social support… The legal and social sanctions associated with illicit drug use often compromise self-report data and render it almost impossible to obtain accurate prenatal exposure levels.” (254)Dreher, Melanie et al. “Prenatal Marijuana Exposure and Neonatal Outcomes in Jamaica: An Ethnographic Study” Pediatrics 93(2) 1994 Feb; 93(2): 254 – 259
I wonder about population bias in Dreher’s study — whether the better outcomes of the cannabis group are made more dramatic because of sheer poverty of the other group.
KIDS OF LIGHT DRINKERS HAVE BETTER MENTAL HEALTH
Similar to Dreher’s “Roots Daughters” who enjoyed better pregnancy outcomes because cannabis use situated them in a culture of work, wealth, and social connection, Niclasen’s light drinkers “did everything else right, in general; they exercised regularly, ate better, did not watch a lot of TV, had healthy BMIs, and were better educated.”
“The abstainers did the poorest in all outcomes. They were the poorest educated, smoked the most, did not exercise, and watched a lot of TV.”
Niclasen reviewed data on substance use collected from 37 000 Danish pregnant people. She followed up with the folks seven years later by having them fill out a standardized questionnaire on their child’s behaviour and mental health.
Like Dreher, Niclasen does not interpret her findings to suggest that substance use is in any way helpful to fetal development; rather, she comments on the limitations of conventional research methods to capture the nuances of context, the very context they are designed, through size and multiple linear regression, to make irrelevant.
To put it bluntly
Prenatal substance use that is associated with positive health outcomes in babies and kids is substance use that is weaves pregnant folks into a vibrant and plentiful social fabric.
The Jamaica study, lead by Melanie Dreher in 1994 and published in Pediatrics, found that daily prenatal cannabis use in a poor, rural part of Jamaica was associated with improved outcomes in babies and kids when compared to prenatal cannabis abstinence.
These findings do not align with what you would expect (poorer outcomes) given the suspected mechanism of action of cannabis on the fetus and the way that cannabis is used in North America (recreationally and on the periphery).
Dreher argues that in her population cannabis integrates folks into a supportive social network that includes better jobs and education and a spiritual practice. Notably, these cannabis-centric networks are more resource-rich than the networks of the study’s cannabis abstainers.
I have compared Dreher’s findings to those of the more recent study, done by Janni Niclasen at the University of Copenhagen, which showed that low level drinking in pregnancy is associated with improved health outcomes in kids at seven years of age.
Like Dreher, Niclasen attributes the better outcomes of kids whose parents drank a little to their lifestyle rather than any health benefits of alcohol itself.
One purpose of conventional research methods like multiple linear regression and large sample size is to eliminate the effect of someone’s social context on the outcome of interest. Dreher and Niclasen’s work invites us to bring the mess of humanness into research design.
By incorporating the cannabis-using parent’s social context into her interpretation of findings Dreher does a great job teasing out how caring for the pregnant person first, and treating their dignity and happiness as ends in and of themselves, is a more effective strategy to producing healthier kids than imposing limitations on pregnant people’s lives or trying to control their bodies for the theoretical safety of a fetus. (It’s never really about the fetus.)
It helps people make better decisions about substance use when we bring the messy nuance of the pleasure, support, and humanness to the conversation. When I was pregnant I looked at the research and decided that the pleasure I got from wine, coffee, and Diet Coke outweighed the risks. I drank a glass of wine with dinner three or four times a week, had coffee in the morning, and a Diet Coke at lunch. I declined diclectin to help with my nausea, thinking my kid might have a reason for telling me to avoid certain foods and to seek the freshest of fresh air (so much fresh air). I also didn’t use Advil (NSAIDS) knowing that they can mess up my kid’s heart in the third trimester.
It is my hope that by blogging about the Jamaica study and explicitly stating the relationship between substance use and the social fabric I can encourage folks to see caring for the pregnant person in all their nuanced humanness (rather than treating them as an incubator) as a powerful strategy for promoting the health of parents and babies.
I also hope I can add my voice to the growing chorus of people cheering on the increase in qualitative research in medicine.