Cannabis Dosing Guidelines for Family Medicine: Evidence-Based Research on Endocannabinoids
Table of Contents
Clinical Takeaway
Prenatal alcohol exposure frequently occurs alongside use of other substances including cannabis, tobacco, and opioids, making isolated assessment of alcohol’s effects difficult in real-world populations. Clinicians should screen for polysubstance use in pregnant patients who report any alcohol consumption, as co-occurring use patterns are common and may compound developmental risks for the child.
#3 Substance use patterns among individuals who consume alcohol during pregnancy: Results from a US multi-site study.
Citation: Bakhireva Ludmila N et al.. Substance use patterns among individuals who consume alcohol during pregnancy: Results from a US multi-site study.. Drug and alcohol dependence. 2026. PMID: 41797178.
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Methodological Considerations:
- Self-reported outcomes — recall and social-desirability bias risk
Abstract: INTRODUCTION: Prenatal alcohol exposure (PAE) is common and associated with adverse outcomes, yet the impact of concurrent substance use remains poorly understood. Using HEALthy Brain and Child Development (HBCD) data (n = 1426), we described alcohol use patterns-with and without other substances-and examined factors associated with alcohol use in pregnancy. METHODS: Data were obtained from the HBCD Study public release 1.0, a 27-site longitudinal cohort examining normative development and the effects of four primary substances (alcohol, cannabis, tobacco, and opioids). More-than-minimal PAE was assessed by self-report and ethanol biomarkers. Participants were classified into 3 study groups: a) Alcohol-Only; b) Alcohol-Plus (alcohol with ≥1 other substance); and c) Comparison (alcohol use below the threshold and negative ethanol biomarkers). Correlates of alcohol use were assessed via polychotomous logistic regression contrasting two alcohol-use categories relative to a common reference group. RESULTS: More-than-minimal alcohol use occurred in 12.7% of participants, with 37% of these also using other substances. The most common polysubstance use pattern was a combination of alcohol, cannabis, and/or nicotine, which occurred, in different combinations, among 28% of participants. Maternal mental health disorders were positively associated with both Alcohol-Only and Alcohol-Plus use. Higher socioeconomic status (SES) was associated with Alcohol-Only use, whereas lower SES was associated with Alcohol-Plus use. CONCLUSIONS: Over one-third of pregnant individuals who used alcohol also used at least one additional substance. Observed associations with maternal mental health and SES highlight opportunities for targeted policy, enhanced screening, and tailored interventions to support maternal and child health.
What This Study Teaches Us
Among pregnant individuals who drink alcohol, over one-third also use cannabis, tobacco, or opioids concurrently. Maternal mental health disorders and socioeconomic status are differently associated with alcohol-only versus polysubstance use patterns during pregnancy.
Why This Matters Clinically
Clinicians screening for prenatal substance use cannot assume alcohol users are using only alcohol, especially in lower-SES populations. Understanding these co-use patterns and their psychiatric correlates helps target interventions and risk counseling more effectively.
Study Snapshot
| Study Design | Observational cross-sectional analysis from a prospective multicenter longitudinal cohort (HBCD Study) |
| Population | N = 1,426 pregnant individuals from 27 US sites; included those with more-than-minimal prenatal alcohol exposure identified by self-report and ethanol biomarkers |
| Intervention | None. Observational study examining naturally occurring substance use patterns. |
| Primary Outcome | Prevalence and characterization of alcohol use alone versus alcohol combined with cannabis, tobacco, and/or opioids; associations with maternal mental health and socioeconomic status |
| Key Result | 12.7% had more-than-minimal prenatal alcohol use; of those, 37% used at least one additional substance. Alcohol-cannabis-nicotine combinations occurred in 28% of participants overall. Mental health disorders associated with both patterns; higher SES with alcohol-only use; lower SES with polysubstance use. |
Where This Paper Deserves Skepticism
The abstract provides minimal methodologic detail about how ‘more-than-minimal’ alcohol was defined or validated beyond biomarkers, and the cross-sectional design cannot establish causation or temporal relationships. The study does not report how polysubstance users were identified or validated (self-report only?), nor does it control for potential confounders like trauma, which often underlies both mental health conditions and substance use in pregnancy. The generalizability to non-study populations is unclear given the HBCD cohort’s design and site selection.
Dr. Caplan’s Take
This study reinforces what we see in clinical practice: pregnant patients with alcohol use rarely drink in isolation, and the co-use pattern itself correlates with social and psychiatric factors we should be screening for. The finding that lower SES associates with polysubstance use (not just alcohol) reminds us that substance use in pregnancy is not a simple medical problem but one embedded in real social constraints and untreated psychiatric illness. I’m cautious about over-reading causality here, but the signal about mental health is clear and actionable: better prenatal screening for depression, anxiety, and trauma would likely identify many of these pregnancies earlier and create opportunities for integrated care.
Clinical Bottom Line
Screen pregnant patients who drink for concurrent cannabis and tobacco use, especially those with lower socioeconomic resources or untreated mood disorders. The presence of alcohol use should not be treated as the endpoint of your substance assessment.
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