Scientists Define the Five Building Blocks of Cannabis Counseling for Pregnant Patients

As cannabis legalization sweeps across North America and beyond, one of the most quietly contentious conversations in medicine is happening in prenatal exam rooms: what to say to a pregnant or breastfeeding patient who keeps using cannabis despite being told about the risks. A new study from researchers at Brown University and Boston University now offers the first systematic answer to that question, distilling the practice of harm reduction counseling for perinatal cannabis use into five essential building blocks that clinicians can be trained to deliver.

The research, published in the journal Advances in Drug and Alcohol Research, tackles a deceptively simple problem. Clinical guidelines recommend that patients abstain from cannabis during pregnancy and lactation, and providers are encouraged to discuss use with their patients. But a growing body of evidence shows that a meaningful subset of perinatal patients continue to use cannabis even after receiving education about potential harms, whether because they perceive genuine benefits such as relief from nausea, anxiety, or sleep problems, or because they find it difficult to stop. For these patients, repeating warnings about risks is not only ineffective; research on motivational approaches in addiction treatment suggests that constraining a person’s choice can actually entrench the behavior, a phenomenon known as reactance.

Harm reduction offers an alternative philosophy. Rather than treating abstinence as the only acceptable outcome, harm reduction views any reduction in harm as a clinical success. It is already the standard evidence-based approach for other perinatal substance use disorders, most notably opioid use disorder, and studies show that pregnant and lactating patients are already improvising their own risk-reduction strategies and actively want more information about the relative safety of different modes of consumption. Yet despite this justification and demand, harm reduction counseling for perinatal cannabis use has never been formally codified, which has stalled its adoption in clinical settings.

The missing piece, the researchers argue, is a specification of the intervention’s core components: the essential, active ingredients that must be preserved when an intervention is adapted, scaled, or rolled out across different clinics. Without knowing which elements are truly indispensable, any attempt to spread the practice risks diluting or distorting the very features that make it work. To fill this gap, the team turned to the Consensus on Relevant Elements, or CORE, process, a structured methodology developed for exactly this purpose, in which a small expert panel iteratively drafts, refines, and reaches consensus on core components through alternating rounds of independent worksheet completion and moderated group discussion.

The process was rigorous and revealing. An expert panel of three, spanning implementation science, behavioral substance use treatment, and perinatal health, initially generated 23 candidate components after reviewing an educational pamphlet designed to support providers. Moderators then consolidated these suggestions into four thematic clusters and prepared targeted discussion questions. A pivotal moment came when the panel realized that many of their initial descriptions were so detailed that they described intervention content, the specific materials and scripts a provider might use, rather than core components, the higher-level essential elements that causally enable effectiveness. Once that distinction was drawn, the team preserved the detailed material in a separate column for future use and consensus moved rapidly.

Two cycles of worksheet completion and moderated discussion later, the panel converged on a final list of five core components organized into two domains. The first domain, provider training, concerns competencies that clinicians should develop before the clinical encounter. The first component is that the provider is skilled at facilitating conversation, which in practice means conducting trauma-informed discussions that empower patients to make informed decisions, practice reflexivity, and remain aware of power differentials when asking sensitive questions. The second is that the provider is educated about cannabis use, encompassing up-to-date knowledge of safety data and recommendations for pregnancy and breastfeeding, the limitations of existing evidence, the basic pharmacology of cannabinoids such as THC and CBD, modes of consumption, and evidence-based behavior change strategies for reducing harm.

The second domain, patient-facing work, describes what happens in the exam room itself. Providers should educate all patients about the safety of and recommendations concerning perinatal cannabis as soon as pregnancy is contemplated, ideally woven into broader conversations about prenatal vitamins, alcohol, and exercise, and should be candid about the limitations of the safety data. They should screen every patient for cannabis use, either verbally or with validated written instruments such as the TAPS, DAST-10, or NIDA quick screen, distinguishing recreational from medicinal use where use is endorsed. And once use is identified, they should deliver a brief harm reduction intervention following the framework recommended by the Substance Abuse and Mental Health Services Administration: educating about effects, offering advice on change, assessing readiness for change, negotiating goals and strategies, and arranging follow-up. Critically, if a patient is ready to quit, the goals focus on cessation; if not, the goals pivot to reducing harm from continued use, whether through cutting down or adopting safer behaviors.

Beneath the technical framework lies a deeper philosophical argument. The authors contend that harm reduction is not merely a set of concrete instructions but requires a fundamental shift away from the traditional paternalistic model of the patient-provider relationship, in which the provider gives directions and the patient is expected to follow them. Instead, providers must partner with patients, respect their autonomy to make decisions the provider might disagree with, and contend with the moral ambiguity that can arise when a pregnant patient’s choices affect both herself and her infant. The trauma-informed facilitation component explicitly returns power to the patient, and the readiness-based brief intervention refuses to push behavior change on someone not yet willing or able to change. The authors acknowledge this shift will be uncomfortable for some clinicians, particularly in the perinatal context, and argue that implementation strategies should include disseminating evidence that shared decision-making is both preferred by substance-using patients and linked to better outcomes, including greater utilization of care.

The study has notable strengths, including the use of a formal methodological process and a panel whose members combined academic expertise with years of clinical practice as licensed psychologists, along with lived experience of receiving perinatal care themselves. But the authors are candid about limitations: the developers of the underlying educational pamphlet could not participate due to time constraints, the panel lacked a physician or midwife, one member served a dual role as both expert and moderator, and the panel was small, which may limit generalizability. The team also notes that the intervention has not yet been formally protocolized and tested, so fewer materials were available for expert review than in previous applications of the CORE process.

Future directions are clearly mapped. The researchers call for broader consensus-building, such as a Delphi study, to confirm the five components, followed by clinical testing and refinement using established methods for verifying intervention fidelity. They also emphasize the need to develop and evaluate implementation strategies that support sustained uptake of harm reduction counseling in real-world perinatal care. Finally, they highlight an uncomfortable truth underlying the entire enterprise: the field still lacks conclusive research on the health impacts of perinatal cannabis use, and because safety education is itself a core component of the intervention, better evidence on risks is essential if provider recommendations are to rest on solid ground. For now, this study represents a crucial first step, translating a contested clinical dilemma into a defined, teachable set of practices that could reshape how medicine meets one of the most common and complicated questions of the legalization era.

Subject of Research: Core components of harm reduction counseling for perinatal cannabis use

Article Title: Identifying an initial set of core components for perinatal cannabis use harm reduction counseling: An application of the Consensus on Relevant Elements (CORE) process

Article References: Identifying an initial set of core components for perinatal cannabis use harm reduction counseling: An application of the Consensus on Relevant Elements (CORE) process. (n.d.). https://doi.org/10.3389/adar.2026.15935

Image Credits: AI Generated

DOI: 10.3389/adar.2026.15935

Keywords: cannabis, pregnancy, breastfeeding, harm reduction, perinatal health, counseling, core components, CORE process, implementation science, trauma-informed care, substance use, clinical guidelines