Prenatal Cannabis Use and Maternal Pregnancy Outcomes.

Importance: Many studies have evaluated whether in utero cannabis exposure is associated with fetal and neonatal outcomes, yet little is known about whether prenatal cannabis use is associated with maternal health outcomes during pregnancy. Objective: To evaluate whether prenatal cannabis use is associated with maternal health outcomes during pregnancy. Design, Setting, and Participants: This population-based retrospective cohort study included pregnancies in Northern California from January 2011 to December 2019 that lasted 20 weeks or longer and were screened for prenatal cannabis use. Exposures: Prenatal cannabis use was defined as any self-reported use during early pregnancy or a positive toxicology test result based on universal screening at entrance to prenatal care (approximately 8-10 weeks' gestation). Self-reported frequency of use (daily, weekly, monthly or less, never, unknown), use defined only by self-report, and use defined only by toxicology test results were examined. Main Outcomes and Measures: Electronic health record data were used to define the following outcomes: gestational hypertension, preeclampsia, eclampsia, gestational diabetes, gestational weight gain greater and less than guidelines, placenta previa, placental abruption, placenta accreta, and severe maternal morbidity. Adjusted risk ratios (aRRs) were calculated using a modified Poisson regression. Results: The sample (n = 316 722 pregnancies; 250 221 unique individuals) included 84 039 (26.5%) Asian/Pacific Islander, 20 053 (6.3%) Black, 83 145 (26.3%) Hispanic, and 118 333 (37.4%) White individuals; the mean (SD) age was 30.6 (5.4) years. Overall, 20 053 (6.3%) screened positive for prenatal cannabis use; 2.9% were positive by self-report, 5.3% by toxicology testing, and 1.8% by both. The frequency of cannabis use was 1930 (0.6%) daily, 2345 (0.7%) weekly, 4892 (1.5%) monthly or less, and 10 886 (3.4%) unknown. Prenatal cannabis use was associated with greater risk of gestational hypertension (aRR, 1.17; 95% CI, 1.13-1.21), preeclampsia (aRR, 1.08; 95% CI, 1.01-1.15), weight gain less than (aRR, 1.05; 95% CI, 1.01-1.08) and greater than (aRR, 1.09; 95% CI, 1.08-1.10) guidelines, and placental abruption (aRR, 1.19; 95% CI, 1.05-1.36). The pattern of results was similar when defining prenatal cannabis use only by self-report or only by toxicology testing, and associations between the frequency of prenatal cannabis use and outcomes varied with outcome. Conclusions and Relevance: The results of this cohort study suggest that prenatal cannabis use was associated with several adverse maternal health outcomes during pregnancy. Continued research is needed to understand whether characteristics of prenatal cannabis use (eg, dose, mode, and timing) moderate these associations.

Intentions to Use Cannabis Postpartum: A Qualitative Study of Pregnant Individuals Who Used Cannabis During Early Pregnancy.

Objective: To examine plans for postpartum cannabis use among pregnant individuals who used cannabis during early pregnancy. Materials and Methods: Eighteen virtual focus groups were conducted from November 17, 2021, to December 17, 2021, with 23 Black and 30 White pregnant adults in Kaiser Permanente Northern California, who self-reported prenatal cannabis use during early pregnancy. Focus groups were recorded, transcribed, and analyzed using thematic analysis. Results: The sample (N = 53) had a mean age of 30.3 years (standard deviation = 5.2) at recruitment; 70% reported daily, 25% weekly, and 6% ≤ monthly cannabis use at entrance to prenatal care. Some participants viewed cannabis as critical for coping with postpartum mental and physical health challenges, while others questioned whether cannabis use would fit with their parental lifestyle, and some planned to abstain altogether. Most planned to use cannabis postpartum, but with lower frequency than before pregnancy, and in ways consistent with harm reduction (e.g., smoking outside to avoid secondhand or thirdhand smoke exposure). Many were motivated to abstain from cannabis while breastfeeding, and some desired more data on the safety of cannabis and breastfeeding, or intended to "pump and dump," believing it would reduce potential transfer of Δ9-tetrahydrocannabinol (THC) to their infant. Responses from Black and White participants were generally similar, but White participants were more likely to report plans to use cannabis while breastfeeding and to want information about cannabis and breastfeeding. Conclusions: Pregnant individuals with prenatal cannabis use had varied plans for cannabis use postpartum. Many were motivated to abstain or use cannabis less frequently than pre-pregnancy, especially during lactation.

A patient activation intervention in primary care for patients with chronic pain on long term opioid therapy: results from a randomized control trial.

BACKGROUND: Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy. METHODS: The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015-August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months. RESULTS: At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18-0.87); higher overall health (OR = 3.14, 95%CI 1.64-6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42-4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29-5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61-4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29-3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27-2.98). CONCLUSION: This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system. TRIAL REGISTRATION: The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223).

Agreement Between Self-reports and Urine Toxicology Measures of Illicit Methamphetamine and Cocaine Use During Early Pregnancy.

OBJECTIVE: This study aimed to assess agreement between self-report and urine toxicology measures assessing use of 2 illicit simulants (methamphetamine and cocaine) during early pregnancy. METHODS: This cross-sectional study of 203,053 pregnancies from 169,709 individuals receiving prenatal care at Kaiser Permanente Northern California between January 1, 2011, and December 31, 2019, assessed agreement ( κ , sensitivity, and specificity) between self-reported frequency and urine toxicology measures of methamphetamine and cocaine early in pregnancy. RESULTS: Prenatal use of the illicit stimulants was rare according to toxicology (n = 244 [0.12%]) and self-report measures (n = 294 [0.14%]). Agreement between these measures was low ( κ < 0.20). Of the 498 positive pregnancies, 40 (8.03%) screened positive on both measures, 204 (40.96%) screened positive on toxicology tests only, and 254 (51.00%) screened positive by self-report only. Relative to toxicology tests, sensitivity of any self-reported use was poor with 16.39% (95% confidence interval [CI], 11.75%-21.04%) of pregnancies with a positive toxicology test self-reporting any use in pregnancy. Relative to self-report, sensitivity of toxicology tests was also poor with 13.61% (95% CI, 9.69%-17.52%) of pregnancies who self-reported any use having positive urine toxicology tests. The sensitivity improved slightly at higher frequencies of self-reported use: daily, 17.50% (95% CI, 5.72%-29.29%); weekly, 25.00% (95% CI, 11.58%-38.42%); and monthly or less, 11.06% (95% CI, 6.89%-15.23%). Specificity was high (>99%), reflecting the high negative rate of use. CONCLUSIONS: Findings suggest that using self-report and toxicology measures in combination likely provides the most accurate information on methamphetamine and cocaine use in early pregnancy. Findings also highlight the need to provide supportive nonstigmatizing environments in which pregnant individuals feel comfortable disclosing substance use without fear of punishment.

Practice makes imperfect: stronger implicit interference with practice in individuals at high risk of developing Alzheimer's disease.

Early screening to determine patient risk of developing Alzheimer's will allow better interventions and planning but necessitates accessible methods such as behavioral biomarkers. Previously, we showed that cognitively healthy older individuals whose cerebrospinal fluid amyloid/tau ratio indicates high risk of cognitive decline experienced implicit interference during a high-effort task, signaling early changes in attention. To further investigate attention's effect on implicit interference, we analyzed two experiments completed sequentially by the same high- and low-risk individuals. We hypothesized that if attention modulates interference, practice would affect the influence of implicit distractors. Indeed, while both groups experienced a strong practice effect, the association between practice and interference effects diverged between groups: stronger practice effects correlated with more implicit interference in high-risk participants, but less interference in low-risk individuals. Furthermore, low-risk individuals showed a positive correlation between implicit interference and EEG low-range alpha event-related desynchronization when switching from high- to low-load tasks. This suggests that lower attention on the task was correlated with stronger interference, a typical phenomenon in the younger population. These results demonstrate how attention impacts implicit interference and highlight early differences in perception between high- and low-risk individuals.

Neonatal outcomes associated with in utero cannabis exposure: a population-based retrospective cohort study.

BACKGROUND: The full spectrum of associations between in utero cannabis exposure and adverse neonatal outcomes is still unclear. OBJECTIVE: This study aimed to evaluate the associations between in utero cannabis exposure and neonatal outcomes. STUDY DESIGN: This population-based retrospective cohort study of singleton births among Kaiser Permanente Northern California members (January 1, 2011-July 31, 2020) included parent-infant dyads in which the pregnant parent was screened for cannabis use as part of standard prenatal care, generally upon entrance into care. Data were ascertained from electronic health records. Generalized estimating equation models were adjusted for sociodemographic characteristics, other non-cannabis prenatal substance use, medical and mental health comorbidities, and adequacy of prenatal care. In utero cannabis exposure was defined as self-reported use since becoming pregnant and/or a positive urine toxicology test for cannabis at any time during pregnancy (yes/no; primary exposure). Frequency of use was self-reported and categorized as daily, weekly, monthly or less, never, or unknown (secondary exposure). Neonatal outcomes included low birthweight, small for gestational age, preterm birth, neonatal intensive care unit admission, and infant respiratory support. RESULTS: Of 364,924 infants, 22,624 (6.2%) were exposed to cannabis in utero. After adjustment for potential confounders, including in utero exposure to other substances, in utero exposure to cannabis was associated with greater odds of low birthweight (adjusted odds ratio, 1.20; 95% confidence interval, 1.12-1.28), small for gestational age (adjusted odds ratio, 1.24; 95% confidence interval, 1.18-1.30), preterm birth (<37 weeks; adjusted odds ratio, 1.06; 95% confidence interval, 1.00-1.13), and neonatal intensive care unit admission (adjusted odds ratio, 1.06; 95% confidence interval, 1.01-1.11). There was a suggestive association with early preterm birth (<34 weeks; adjusted odds ratio, 1.11; 95% confidence interval, 1.00-1.23; P=.055), but no significant association with respiratory support (adjusted odds ratio, 1.07; 95% confidence interval, 0.97-1.18). Dose-response analysis found an increasing likelihood of low birthweight and small for gestational age with increasing frequency of prenatal cannabis use by the pregnant individual. Sensitivity analyses further supported an increased likelihood of low birthweight and small for gestational age, although associations with other outcomes did not reach statistical significance. CONCLUSION: In utero cannabis exposure was associated with increased likelihood of low birthweight, small for gestational age, preterm birth, and neonatal intensive care unit admission. Clinicians should counsel individuals who are pregnant or considering pregnancy about the potential adverse neonatal health outcomes associated with prenatal cannabis use.

Association between maternal prenatal cannabis use and missed child preventive care visits in an integrated health care delivery system in Northern California.

The periodicity of well-child visits recommended by the American Academy of Pediatrics emphasizes the importance of continuity of care in health management. Exposure to cannabis in utero has been associated with adverse development, and adherence to well-child visits is critical for earlier detection and intervention. To assess whether maternal prenatal cannabis use was associated with missed well-child visits in the first three years after birth we conducted a longitudinal cohort study in Kaiser Permanente Northern California of pregnant individuals and their children born between January 1, 2011 and December 31, 2018. Maternal prenatal cannabis use was defined as any self-reported cannabis use since becoming pregnant and/or a positive urine toxicology test for cannabis during pregnancy. Well-child visits were defined as an encounter for a well-child visit or physical exam and categorized into seven time periods from birth to 36 months. Modified Poisson regression models were conducted. Of the 168,589 eligible pregnancies, 3.4% screened positive for maternal prenatal cannabis use. Compared to no use, maternal prenatal cannabis use was associated with more missed well-child visits at every time period; (missed 12-month visit: adjusted relative risk (aRR): 1.43, 95%CI: 1.32-1.54; missed 3-year visit: aRR: 1.15, 95%CI: 1.11-1.20). Maternal prenatal cannabis use was also associated with missing two or more well-child visits through 36 months of age (35.8% among cannabis users vs. 23.0% among non-users, Χ2p < .001). Educating pregnant individuals who use cannabis on the importance of well-child visits may benefit children's health and development.

Patient Perceptions of Prenatal Cannabis Use and Implications for Clinicians.

OBJECTIVE: To understand pregnant patients' reasons for prenatal cannabis use and perceptions of safety, desired and undesirable health care experiences, and desired information about prenatal cannabis use and secondarily to understand racial differences in these perceptions and preferences. METHODS: We conducted a qualitative study including 18 semi-structured, race-concordant virtual focus groups with pregnant individuals who self-reported cannabis use at prenatal care entry in a large integrated health care system in Northern California from November 2021 to December 2021. The focus groups included semi-structured questions that were recorded, transcribed, and coded by the research team. Thematic analysis was used to analyze the data. RESULTS: Overall, 53 participants were included; 30 self-identified, as White and 23 self-identified as Black. Participants averaged 30.3 years of age (SD 5.2 years) and were on average at 20.9 weeks of gestation at study enrollment; 69.8% reported daily cannabis use, 24.5% reported weekly cannabis use, and 5.7% reported monthly or less cannabis use at entrance to prenatal care. Although some participants quit cannabis use in early pregnancy because of concerns about potential health risks, many perceived a lack of scientific evidence or believed that prenatal cannabis use was safe. Many preferred cannabis to over-the-counter or prescription medications for treating mood, morning sickness, pain, and sleep. Participants valued open interactions with obstetricians that acknowledged their motivations for use, and they desired information about potential risks through conversations and educational materials. White and Black participants' perspectives were generally similar, but a few Black participants uniquely described concerns about racial bias related to their prenatal cannabis use. CONCLUSION: Pregnant patients used cannabis to manage mood and medical symptoms, and many believed that prenatal cannabis use was safer than the use of prescription medications. Obstetrician-initiated, patient-centered conversations around prenatal cannabis use, advice to discontinue cannabis use during pregnancy, and exploration of willingness to switch to medically recommended interventions for pregnancy-related symptoms may benefit patients.

Associations between Adverse Childhood Experiences (ACEs) and Prenatal Mental Health and Substance Use.

Adverse childhood experiences (ACEs) are common and increase the risk of poor health outcomes. Resilience may offer protection against the impacts of ACEs. This study examined the association between maternal ACEs and mental/behavioral health outcomes during pregnancy overall and by resilience. The sample comprised pregnant patients in two pilot studies screened for eight ACEs and resilience during standard prenatal care in Kaiser Permanente Northern California from 1 March 2016 to 30 July 2016 (Study 1, medical centers A, B) and from 1 April 2018 to 31 March 2019 (Study 2, medical centers A, C). Early pregnancy outcomes included anxiety and depressive disorders, depression symptoms, intimate partner violence (IPV), and substance use. Multivariable logistic regression was used in this cross-sectional study to examine associations between maternal ACEs (0, 1-2, ≥3) and mental/behavioral health outcomes overall and among those with low and high resilience. Patients (n = 1084) averaged 30.8 years (SD 5.1); 41.7% were non-Hispanic White; 41.7% experienced ≥1 ACE, and 40.3% had low resilience. Patients with 1-2 ACEs or ≥3 ACEs (versus 0 ACEs) had higher odds of anxiety and depressive disorders, depressive symptoms, IPV, and any prenatal substance use (OR 1.44-4.40, p < 0.05). Each individual ACE was associated with ≥2 mental/behavioral health outcomes. In stratified analyses, having ≥1 ACE (vs. 0) was associated with a greater number of mental/behavioral health outcomes among patients with low versus high resilience. ACEs were associated with prenatal mental/behavioral health conditions, particularly in the context of low resilience, highlighting the importance of trauma-informed prenatal care and the need to study resilience-building interventions during pregnancy.

Exploring preferences for different modes of cannabis use during early pregnancy: A qualitative study.

OBJECTIVE: Rates of prenatal cannabis use are rising, yet little is known about modes of cannabis use during pregnancy. This focus group study with pregnant individuals aimed to examine use patterns and perceptions regarding common modes of prenatal cannabis use. METHOD: Kaiser Permanente Northern California pregnant adult patients who identified as White or Black and self-reported cannabis use during pregnancy were recruited to participate (N = 53; 40% Black, 60% White; Meanage = 30.3, SD = 5.2). Eighteen focus groups with race-concordant facilitators followed a semi-structured format that queried participants on their prenatal cannabis use, including preferred modes of use (e.g., vapes, blunts, dabs, joints, edibles, topicals, pipes). Focus group discussions were coded and analyzed using a general inductive approach. RESULTS: A range of modes were preferred, with no single mode predominant. Participants' preferences aligned with four themes: perceived effects and benefits of cannabis, health and safety, convenience and familiarity, and partner and friend influences. Participants sought modes that were accessible and familiar, provided consistent and quick relief for pregnancy-related symptoms, were aligned with partners or friends, and minimized perceived risks while also providing symptom relief. Participants desired evidence-based information about mode safety to better inform mode selection during pregnancy. CONCLUSIONS: A range of personal and social factors influenced mode preferences during pregnancy. Many participants desired to reduce harms and use cannabis more safely in pregnancy but received little mode-specific information to guide these preferences. Further research identifying mode-specific risks is needed to guide harm reduction approaches during pregnancy.

Patient Engagement in a Multimodal Digital Phenotyping Study of Opioid Use Disorder.

BACKGROUND: Multiple digital data sources can capture moment-to-moment information to advance a robust understanding of opioid use disorder (OUD) behavior, ultimately creating a digital phenotype for each patient. This information can lead to individualized interventions to improve treatment for OUD. OBJECTIVE: The aim is to examine patient engagement with multiple digital phenotyping methods among patients receiving buprenorphine medication for OUD. METHODS: The study enrolled 65 patients receiving buprenorphine for OUD between June 2020 and January 2021 from 4 addiction medicine programs in an integrated health care delivery system in Northern California. Ecological momentary assessment (EMA), sensor data, and social media data were collected by smartphone, smartwatch, and social media platforms over a 12-week period. Primary engagement outcomes were meeting measures of minimum phone carry (≥8 hours per day) and watch wear (≥18 hours per day) criteria, EMA response rates, social media consent rate, and data sparsity. Descriptive analyses, bivariate, and trend tests were performed. RESULTS: The participants' average age was 37 years, 47% of them were female, and 71% of them were White. On average, participants met phone carrying criteria on 94% of study days, met watch wearing criteria on 74% of days, and wore the watch to sleep on 77% of days. The mean EMA response rate was 70%, declining from 83% to 56% from week 1 to week 12. Among participants with social media accounts, 88% of them consented to providing data; of them, 55% of Facebook, 54% of Instagram, and 57% of Twitter participants provided data. The amount of social media data available varied widely across participants. No differences by age, sex, race, or ethnicity were observed for any outcomes. CONCLUSIONS: To our knowledge, this is the first study to capture these 3 digital data sources in this clinical population. Our findings demonstrate that patients receiving buprenorphine treatment for OUD had generally high engagement with multiple digital phenotyping data sources, but this was more limited for the social media data. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.3389/fpsyt.2022.871916.

Patterns of Substance Use During Early Pregnancy and Associations With Behavioral Health Characteristics.

OBJECTIVES: The aims of the study are to identify patterns of early pregnancy substance use and to examine how these patterns relate to behavioral health conditions measured in early pregnancy. METHODS: We conducted a retrospective observational study (N= 265,274 pregnancies) screened for alcohol, cannabis, nicotine, pharmaceutical opioids, and stimulants during the first trimester via self-report and urine toxicology tests in Kaiser Permanente Northern California from January 1, 2012, to December 31, 2019. To identify patterns of prenatal substance use, we conducted latent class analysis. We then calculated the prevalence of depression, anxiety, intimate partner violence, and family drug use history for each prenatal substance use group and compared the prevalences by estimating prevalence ratios using modified Poisson regression, adjusting for sociodemographic characteristics. RESULTS: We identified the following 4 latent groups with different patterns of substance use: ( a ) predominantly alcohol and no other substances (9.30%), ( b ) predominantly cannabis and no other substances (4.88%), ( c ) predominantly nicotine and some pharmaceutical opioids (1.09%), and ( d ) high-polysubstance (alcohol, cannabis, nicotine, and stimulants; 0.36%); these pregnancies were compared with ( e ) no prenatal substance use (84.37%). The prevalence of all behavioral health conditions was elevated in all prenatal substance use groups compared with the no substance use group. Furthermore, the prevalence of depressive and anxiety disorders, intimate partner violence and family drug use history were greater in the high-polysubstance cluster than the alcohol and cannabis clusters. CONCLUSIONS: Results highlight the importance of screening and interventions for all types of substance use during early pregnancy and suggest a particularly high need to prioritize targeting early interventions to pregnant and reproductive age individuals with polysubstance use.

Practice makes imperfect: stronger implicit interference with practice in individuals at high risk of developing Alzheimer's disease.

Early screening to determine patient risk of developing Alzheimer's will allow better interventions and planning but necessitates accessible methods such as behavioral biomarkers. Previously, we showed that cognitively healthy older individuals whose cerebrospinal fluid amyloid / tau ratio indicates high risk of cognitive decline experienced implicit interference during a high-effort task, signaling early changes in attention. To further investigate attention's effect on implicit interference, we analyzed two experiments completed sequentially by the same high- and low-risk individuals. We hypothesized that if attention modulates interference, practice would affect the influence of implicit distractors. Indeed, while both groups experienced a strong practice effect, the association between practice and interference effects diverged between groups: stronger practice effects correlated with more implicit interference in high-risk participants, but less interference in low-risk individuals. Furthermore, low-risk individuals showed a positive correlation between implicit interference and EEG low-range alpha event-related desynchronization when switching from high- to low-load tasks. These results demonstrate how attention impacts implicit interference and highlight early differences in cognition between high- and low-risk individuals.

Pregnant individual's lived experience of cannabis use during the COVID-19 pandemic: a qualitative study.

Introduction: Quantitative studies indicate that the COVID-19 pandemic has contributed to increased rates of prenatal cannabis use. However, little is known about how the pandemic has impacted cannabis use from the perspective of pregnant individuals themselves. Our objective was to characterize COVID-19-related changes in cannabis use among pregnant individuals who used cannabis during the pandemic. Methods: We conducted 18 focus groups (from 11/17/2021 to 12/17/2021) with Black and White pregnant individuals aged 18+ who self-reported prenatal cannabis use during universal screening at entrance to prenatal care (at ~8 weeks gestation) in Kaiser Permanente Northern California. Virtual focus groups were transcribed and analyzed using thematic analysis. Results: The sample of 53 pregnant individuals (23 Black, 30 White) was 30.3 years old (SD = 5.2) on average, and most (70%) self-reported daily versus weekly or monthly prenatal cannabis use. Major themes regarding the impact of the pandemic on cannabis use included increases in use (resulting from depression, anxiety, stress, boredom), and changes in social use (less sharing of smoked cannabis products), modes of use (from smoking to other modes due to respiratory concerns) and source (from storefront retailers to delivery). Conclusion: Coping with mental health symptoms and stress were identified drivers of perceived pandemic-related increases in prenatal cannabis use in 2021. Pregnant individuals adapted their use in ways consistent with public health recommendations to decrease social contact and reduce or quit smoking to mitigate COVID-19 transmission and harms. Proactive, mental health outreach for pregnant individuals during future pandemic waves may reduce prenatal cannabis use.

Association of the COVID-19 Pandemic With Unstable and/or Unsafe Living Situations and Intimate Partner Violence Among Pregnant Individuals.

Importance: The social, behavioral, and economic consequences of the COVID-19 pandemic may be associated with unstable and/or unsafe living situations and intimate partner violence (IPV) among pregnant individuals. Objective: To investigate trends in unstable and/or unsafe living situations and IPV among pregnant individuals prior to and during the COVID-19 pandemic. Design, Setting, and Participants: A cross-sectional population-based interrupted time-series analysis was conducted among Kaiser Permanente Northern California members who were pregnant and screened for unstable and/or unsafe living situation and IPV as part of standard prenatal care between January 1, 2019, and December 31, 2020. Exposures: COVID-19 pandemic (prepandemic period: January 1, 2019, to March 31, 2020; during pandemic period: April 1 to December 31, 2020). Main Outcomes and Measures: The 2 outcomes were unstable and/or unsafe living situations and IPV. Data were extracted from electronic health records. Interrupted time-series models were fit and adjusted for age and race and ethnicity. Results: The study sample included 77 310 pregnancies (74 663 individuals); 27.4% of the individuals were Asian or Pacific Islander, 6.5% were Black, 29.0% were Hispanic, 32.3% were non-Hispanic White, and 4.8% were other/unknown/multiracial, with a mean (SD) age of 30.9 (5.3) years. Across the 24-month study period there was an increasing trend in the standardized rate of unsafe and/or unstable living situations (2.2%; rate ratio [RR], 1.022; 95% CI, 1.016-1.029 per month) and IPV (4.9%; RR, 1.049; 95% CI, 1.021-1.078 per month). The ITS model indicated a 38% increase (RR, 1.38; 95% CI, 1.13-1.69) in the first month of the pandemic for unsafe and/or unstable living situation, with a return to the overall trend afterward for the study period. For IPV, the interrupted time-series model suggested an increase of 101% (RR, 2.01; 95% CI, 1.20-3.37) in the first 2 months of the pandemic. Conclusions and Relevance: This cross-sectional study noted an overall increase in unstable and/or unsafe living situations and IPV over the 24-month period, with a temporary increase associated with the COVID-19 pandemic. It may be useful for emergency response plans to include IPV safeguards for future pandemics. These findings suggest the need for prenatal screening for unsafe and/or unstable living situations and IPV coupled with referral to appropriate support services and preventive interventions.

Humanities-Based Educational Preparation and Empathy in Novice Nurses: Critical Thinking and Analytic Practice.

ABSTRACT: Empathy has been associated with improved patient outcomes in practicing nurses, but empathy levels have been shown to decline in nursing students with increased clinical exposure. Integrating content from the humanities in the nursing classroom, not common in nursing education, supports professional empathy development and maintenance. Whether competencies gained from humanities-based liberal education courses support empathy in nursing students as they emerge into practice is not known. The purpose of this quantitative, nonexperimental, descriptive, pilot research was to explore the relationship between humanities-based liberal education and empathy in recently graduated, baccalaureate-prepared practicing nurses ( n = 40).

Association of cannabis use during pregnancy with severe acute respiratory syndrome coronavirus 2 infection: a retrospective cohort study.

BACKGROUND AND AIMS: Cannabis use is increasingly common among pregnant individuals and might be a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We aimed to test whether prenatal cannabis use is associated with increased risk of SARS-CoV-2 infection during pregnancy. DESIGN: This is a retrospective cohort study. SETTING: The study was conducted in California, USA. PARTICIPANTS: A total of 58 114 pregnancies (with outcomes from 5 March 2020 to 30 September 2021) among 57 287 unique pregnant women aged 14-54 years who were screened for prenatal substance use, enrolled in Kaiser Permanente Northern California (KPNC) (a health-care system) and had not tested positive for COVID-19 prior to pregnancy onset. MEASUREMENTS: We utilized data from the KPNC electronic health record. Cannabis use status (current, recently quit and non-user) was based on universal screenings during prenatal care (including urine toxicology testing and self-reported use on a self-administered questionnaire). SARS-CoV-2 infection [based on polymerase chain reaction (PCR) tests] was estimated in time-to-event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined differences in (a) SARS-CoV-2 testing rates and (b) SARS-CoV-2 infection rates among those tested. FINDINGS: We observed 348 810 person-months of follow-up time in our cohort with 41 064 SARS-CoV-2 PCR tests and 6% (n = 2414) of tests being positive. At the start of follow-up, 7% of pregnant individuals had current use, 12% had recently quit and 81% did not use cannabis. Adjusting for covariates, current use was associated with lower rates of SARS-CoV-2 infection [adjusted hazard ratio (aHR) = 0.60, 95% confidence interval (CI) = 0.49-0.74 than non-use. Those who had recently quit did not differ from non-cannabis users in infection rates (aHR = 0.96, 95% CI = 0.86-1.08). Sensitivity analyses among patients who received a SARS-CoV-2 test also found lower odds of infection associated with current versus no cannabis use (aOR = 0.76, CI = 0.61-0.93). CONCLUSIONS: Current cannabis use appears to be associated with a reduced risk of SARS-CoV-2 infection among pregnant individuals.

Perceptions About Cannabis Following Legalization Among Pregnant Individuals With Prenatal Cannabis Use in California.

Importance: As rates of prenatal cannabis use increase and cannabis legalization spreads across the US, studies are needed to understand the potential impacts of legalization from the perspectives of pregnant individuals who use cannabis. Objective: To characterize pregnant individuals' perspectives on legalization of cannabis for adult use in California (effective in 2018) in relation to prenatal cannabis use behaviors and beliefs. Design, Setting, and Participants: This qualitative study was conducted in Kaiser Permanente Northern California, a large health care system with universal screening for self-reported cannabis use at entrance to prenatal care. Eighteen semistructured focus groups were conducted from November 17 to December 17, 2021, using a secure video conferencing platform with Black and White pregnant participants who self-reported cannabis use during early pregnancy. Data were analyzed from March to June 2022. Main Outcomes and Measures: Video-recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. Results: Among 53 participants (mean [SD] age, 30.3 [5.2] years), 23 (43%) identified as non-Hispanic Black and 30 (57%) identified as non-Hispanic White; 16 participants (30%) reported continued cannabis use at the time of recruitment. Major themes regarding the perceived impact of legalization included easier access (via retailers and delivery), greater acceptance (including reduced stigma and more discussions about prenatal cannabis use with health care practitioners), and trust in cannabis retailers (including safety and effectiveness of diverse products sold and perceptions of cannabis retailer employees as knowledgeable, nonjudgmental, and caring). Responses were mixed about whether retailer marketing and advertising were associated with prenatal cannabis use and whether legalization resulted in reduced concerns about Child Protective Services involvement. Conclusion and Relevance: The findings of this qualitative study suggest pregnant individuals perceive cannabis legalization as having reduced barriers to prenatal cannabis use and that legalization has created challenges and opportunities for supporting the health of pregnant individuals. The results of this qualitative study highlight key areas that can be further explored in future educational materials, public health campaigns, and policy adaptations to address increasing rates of prenatal cannabis use.

Trends in Self-reported and Biochemically Verified Cocaine and Methamphetamine Use Among Pregnant Individuals in Northern California, 2011-2019.

This cross-sectional study uses data from the Kaiser Permanente Northern California health care system with universal screening via self-report and urine toxicology at prenatal care entrance to examine trends in cocaine and methamphetamine use among pregnant individuals from 2011 to 2019.

Patterns of Health Care Use 5 Years After an Intervention Linking Patients in Addiction Treatment With a Primary Care Practitioner.

Importance: Substance use disorders are associated with high rates of emergency department (ED) use and challenges engaging with primary care services. Objective: To examine 5-year health care engagement and utilization outcomes for participants in the LINKAGE trial, given previously reported associations of LINKAGE with improved care engagement in the short term. Design, Setting, and Participants: In this post hoc analysis of a nonrandomized controlled trial, participants were assigned to the LINKAGE or usual care (UC) groups using a nonrandomized 3-month alternating off and on strategy over 30 months. Baseline through 5-year follow-up data were collected from April 2011 to October 2018. The trial was conducted at an urban outpatient addiction treatment clinic within a large health system among patients newly enrolled in addiction treatment. Data analysis was conducted from April 2021 to February 2022. Intervention: The LINKAGE intervention included 6 group-based sessions emphasizing patient agency, skill, and motivation in navigating health care services as well as a facilitated telephone or email connection with a primary care practitioner. The UC group received medical education. Main Outcomes and Measures: Substance use problem discussions with primary care practitioners (by patient self-report at 1-, 2-, and 5-year follow-up interview) and annual use of the electronic patient portal, primary care, and ED based on electronic health records. Results: A total of 503 participants, with a mean (SD) age of 42 (12) years, 346 (69%) male participants and 37 (7%) African American, 34 (7%) Asian, and 101 (20%) Hispanic participants, were assigned to LINKAGE (252 participants) or UC (251 participants). Compared with UC participants, LINKAGE participants were significantly more likely to discuss substance use problems with a primary care practitioner at 1-year follow-up (risk ratio [RR], 1.30; 95% CI, 1.03-1.65; P = .03) and use the electronic patient portal at 1- and 2-year follow-up (eg, messaging clinicians at 2 years: RR, 1.24; 95% CI, 1.04-1.47; P = .02). The LINKAGE group had small, statistically significant 5-year annual increases in primary care use (RR, 1.03; 95% CI, 1.003-1.07; P = .03) and significant annual decreases in substance-related ED use (RR, 0.79; 95% CI, 0.64-0.97; P = .03), relative to UC. The LINKAGE group did not significantly differ from the UC group on other types of ED utilization. Conclusions and Relevance: In this study, a patient activation intervention embedded in outpatient addiction treatment was associated with sustained improvements in health care engagement beyond previously reported 6-month outcomes and with long-term improvements in health care use patterns. Trial Registration: ClinicalTrials.gov Identifier: NCT01621711.