I’ve recently finished a 3.5-hour exclusive video series for my clients outlining the latest research on supplements and herbs in Inflammatory Bowel Disease for the IBDCoach program. To my knowledge, it’s the most compressive and accessible overview of this specific subject ever created.

In recent years, one herb that has received the lion’s-share of attention has been used as long ago as 3500 BCE by proto-Indo-Europeans in a ceremonial context. Additionally, more recently over the last 3 decades, it has arguably revealed more about human biology than any other plant.

Yes: it’s time to talk about the promise and pitfalls of marijuana and its truly extraordinary interactions with the body, gut, and brain. 

Examining the evidence of cannabis in IBD

Compared to other herbs, there has been a moderate amount of science directly related to cannabis and Inflammatory Bowel Disease, but when examining its use in human IBD patients, the data has been mixed at best. 

One thing is for sure: a significant portion of IBD patients use cannabis. A recent academic summary reports an estimation of anywhere from 10% to as high as 50%. [1]

IBD animal studies with cannabis have demonstrated promising results; however, even with widespread, mainstream acceptance, few randomized-controlled trials or even observational studies have taken place directly with human IBD patients. In a recent review paper published last year, the authors determined that the data was mixed. Of 5 academic publications, only 2 demonstrated a positive correlation with disease activity, while the remaining 3 showed little to no benefit in the probability of achieving remission.[2]

The evidence does seem clear however that IBD patients’ quality of life improved in addition to other secondary symptoms of IBD like the quality of sleep and significant increases in appetite. 

In 4 survey studies with 273 ulcerative colitis and 595 Crohn’s disease patients conducted between 2013 – 2017, the majority of patients reported significant reductions in pain, appetite, and nausea. 

Most interestingly, Dr. Christian Turbide at a recent Crohn’s Disease and Ulcerative Colitis Canada Conference reported on a nationwide inpatient survey of 3.3 million American IBD patients that had some pretty interesting results: 

  • Mortality: 0.3% cannabis users, 1.4% non-users
  • Colectomy: 2.8% cannabis users, 6.7% non-users
  • Blood Transfusions: 4.5% cannabis users, 9.6% non-users
  • Hospital Stay: 5.2 days for cannabis users, 5.6 days for non-users

True, there is only so much we can surmise from this data; however, given the number of participants in the study, it does pique curiosity about why there is such a discrepancy between users of cannabis and non-users. [3]

Cannabis and human biology

The endocannabinoid system, only discovered in the early 1990s, is a widespread receptor system throughout the body and is involved with more functions than we could possibly review: inflammation, appetite, mood, pain, cognition, nausea and vomiting, and multiple interactions in the GI system among others. The two primary endocannabinoid neurotransmitters are called anandamide and 2-AG[4], and these two molecules, among others still being uncovered and understood, may also  even play modulatory roles on the microbiome[4] and the gut-brain axis.[5]

Anandamide
2-Arachidonoylglycerol (2AG)

Additionally, the plant itself is extraordinarily complex with many classes of molecules (483 in total), many of which are believed to have a biological effect. Two of the main compounds are called cannabinoids and terpenes.  Cannabinoids include THC, CBD, THCV, CBC, CBG, CBN (66 known), and while THC and CBD are the most well-known, others have also demonstrated therapeutic potential especially in modulating inflammation.[6] Terpenes, including Myrcene, Caryophyllene, Linalool, Pinene, Humulene, and Limonene (120 are known), are responsible for the floral and aromatic qualities of cannabis flowers. [7] 

Cannabinoid Guide Source: www.thcsd.com

Terpene Guide Source: www.leafly.com

There are two main cannabinoid receptor types in the human body, CB1 and CB2, and they were both discovered in the early 1990s. The CB1 receptor is primarily located in the central nervous system and affects memory processing, motor regulation, appetite, pain sensation, mood, and sleep. CB2 is primarily found in the peripheral nervous system and is involved with the immune response.  Multiple in-vitro studies (meaning in the lab) demonstrated that CB1 and CB2 rector agonists (activating agents) ameliorated GI inflammation in murine (mouse) models while CB1 and CB2 antagonists (blocking agents) had the inverse effect. [2]

Cannabis and Intestinal Inflammation Source: Insights into the Management of Inflammatory Bowel Disease [2]

With IBD, context matters

As always, however, things become less straightforward in the context of human beings in the real world. 

The Cannabis sativa plant is incredibly complex and any one strain of cannabis can be completely different from another in terms of the unique chemical composition of each. Each strain contains a unique cannabinoid and terpene profile often producing radically different psychotropic and biological responses. One example is CBD dominant strains–CBD has demonstrated unique anti-inflammatory properties, is not psychoactive, and has the reverse effect on the CB1 receptor compared to THC due to its combined antagonistic (blocking)  and inverse agonistic (causes inverse chemical cascade) mechanisms of action. [8]  

Further, terpenes are responsible for different biological effects as well and they vary in their ability to attenuate inflammation, reduce anxiety, or demonstrate anti-microbial activities.[7]  

Research has tended to treat cannabis as a monolith and thus has not considered the effects of specific strains, with their unique cannabinoid and terpene signatures, for addressing specific disease mechanisms. And to make matters worse in the United States, it’s much easier to conduct research with drugs like cocaine or methamphetamine than with cannabis. Cannabis is still archaically considered a “Schedule 1” controlled substance by the federal government which means it is considered to have the highest level of abuse potential with no medical benefit. Additionally, the National Institute of Drug Abuse (NIDA) is the sole supplier of all marijuana utilized in US research, which means there is a dearth of diversity of the supply of cannabis available for research. [9]   

My personal experience with cannabis for Crohn’s disease 

My personal experience with cannabis has been positive, especially when flaring. When in a flare, I can often feel tightness, muscle spasms, and pain in my lower right abdominal quadrant, and when nothing else is working, vaping or smoking a small amount of a THC/CBD combination of cannabis almost instantly takes the tightness away. While this adequately addresses my symptoms in these acute moment, my experience tells me that other interventions such as diet, other herbs and supplements, and even lower-end medications may have longer-lasting and more robust effects on my inflammation. If it weren’t for the next day’s “washed out” feeling and the negative effects on both my memory and motivation, I would consider the use cannabis more often. That being said, I do notice some increases in my creativity and general well-being that I attribute to the small role cannabis plays in my life.

Tips on working with your health team with if and how you can incorporate cannabis

If you do decide to explore cannabis with your health and medical team, here are some I have some tips: 

> Be open and honest with your GI and other health team members about your cannabis use. If they judge you (unlikely) or you don’t feel listened to, this is probably an indication of a deeper issue, and might also be an indication to work on refining your health team.

> Consider reaching out to a cannabis specialist who has experience beyond “recommending cannabis” as a monolithic treatment option and can offer specific guidance on use and strains. 

> Study your local state or county laws around cannabis and make sure you are in compliance. If cannabis is inaccessible to you, don’t sweat it. Cannabis, like anyone variable discussed in our blog posts, will not make or break a well-rounded IBD protocol. 

> If visiting a cannabis dispensary, obtain lab data on any product you buy and understand cannabinoids and/or terpene concentrations.  You will undoubtedly find some strains work better for you than others and are suited for different purposes (i.e. indica at night / sativa during the day). If the specific strain that worked for you becomes unavailable in the future, you will have the lab data to help you find something with a similar chemical profile.

> Monitor side effects and possible interactions. Make sure you are staying motivated, keeping up with work, maintaining positive mood, etc. Sometimes with cannabis, less is more. A small amount can often go a long way. 

> Lastly, understand that this is a mysterious, under-researched drug–perhaps the most interesting drug of all time given its complex composition and interactions. Consider not only the type of cannabis you are using, but also the context in which you use it. What time of day? Where? What type of mood is most suitable for you to be in to get the most benefit? Which type of IBD symptoms does it work best for and which not? 

In conclusion, and to echo a theme in almost every study, review paper, and meta-analysis on the subject of cannabis, more research is needed on this subject. Researchers may consider joining forces with advanced cannabis growers to develop strains specifically targeted at IBD in their cannabinoid and terpene profiles and study their efficacy in randomized placebo controlled clinical trials. Hopefully, as a more sensible drug policy is enacted in the United States and around the world, the specific medicinal benefits or lack thereof will be elucidated in IBD.

Thanks for reading!

References

1) Scott FI. Marijuana Use in Inflammatory Bowel Disease: Understanding the Prevalence and the Potential Pitfalls. Crohn’s Colitis 360. 2020;2. doi:10.1093/crocol/otaa016

2) Picardo S, Kaplan GG, Sharkey KA, Seow CH. Insights into the role of cannabis in the management of inflammatory bowel disease. Therap Adv Gastroenterol. 2019;12: 1756284819870977.

3) Cannabis and Inflammatory Bowel Disease. 2019. Available: https://www.youtube.com/watch?v=TIMh2R49HgQ

4) Lu HC, Mackie K. An Introduction to the Endogenous Cannabinoid System. Biol Psychiatry. 2016;79. doi:10.1016/j.biopsych.2015.07.028

5) Keith A. Sharkey JWW. The role of the endocannabinoid system in the brain-gut axis. Gastroenterology. 2016;151: 252.

6) Cannabinoids. Academic Press; 2014. pp. 261–308.

7) Terpenes in Cannabis sativa – From plant genome to humans. Plant Sci. 2019;284: 67–72.

8) Peres FF, Lima AC, Hallak JEC, Crippa JA, Silva RH, Abílio VC. Cannabidiol as a Promising Strategy to Treat and Prevent Movement Disorders? Front Pharmacol. 2018;9. doi:

9) 10.3389/fphar.2018.004829. Marijuana Research | The University of Mississippi. [cited 30 Jun 2020]. Available: https://pharmacy.olemiss.edu/marijuana/

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