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Use of cannabis as a potential treatment for Inflamatory Bowel Disease (IBD) - Dra. Ana Villaseñor-Todd
“A JOURNEY TO NASHVILLE” – QUALITY OF LIFE IS SOMETIMES MORE IMPORTANT THAN LIFE ITSELF:
USE OF CANNABIS AS A POTENTIAL TREATMENT FOR INFLAMMATORY BOWEL DISEASE (IBD)
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Music is a fascinating journey that undoubtedly has to be pursued. However, when attempting to describe places that you had traveled while listening to something so sui géneris, history repeats itself and becomes complex.
Once upon a summer night in the south of Athens, illuminated by the psychedelic reflex of the city lights, on the southern shore of the Cumberland river, packed rooftops with lovers of Country music enjoy at the Lower Broad; a piano duel, the smell of lavender-colored sunflowers, a couple of beers at Tootsies... Submerged into Taylor Swift’s hometown, an Elvis Presley’s building stands in the background, and just when I thought that it could not be better, the voice of a passionate, sophisticated, and quiet woman with a British accent started to sound. Her lyrics dwell on dreams and small victories, but more importantly, the redeeming power of love. The folk creator of “Something More Beautiful” is back after six years of absence, probably caused by some exacerbation of her Inflamatory Bowel Disease (IBD) . She is Elizabeth Caroline Orton. Several years have gone by since the beginning of her career and that intricate landscape of sounds she created.
Today, I start my day with the song in a playlist capable of starting my engine’s car while playing a little prelude of synth, pianos, guitars, and distortion pedals from “I wish I never saw sunshine”. Every time I listen to Orton, I perceive her unique, intact, and consistent style. She emphasizes her potential as a composer; however, she recurrently expresses true moments of pain, that she uses to forget and heal. In the eve of #WorldIBDday, #breakthesilence and #ibdsmile, under the empathy and influence of the wonderful realm of Cortázar, I meditate on: “You could not, he said: You think too much before doing nothing. I assume that the reflection must precede the action”.
Inflamatory Bowel Disease (IBD) comprises two main conditions: Crohn’s disease (CD) and chronic ulcerative colitis (CUC). Both diseases commonly manifest themselves as abdominal pain and diarrhea. An important difference between these conditions is the affection topography: CD trends affecting any section of the gastrointestinal tract, while CUC involves only the colon and rectum. The current epidemiology reports an increased incidence of IID up to 5-fold more in the last 15 years; on the other hand, in Mexico, CUC is 4-fold more frequent than CE. In the first Latin American study of the epidemiology of IBD, the current prevalence of IBD, CUC, and CD were of 1.83, 1.45, and 0.34 for every 100,000 years/person, respectively. (1)
Throughout history, the denominated marijuana plant Cannabis sativa has been used as a symptomatic remedy for certain ailments (multiple sclerosis, chronic pain, glaucoma, epilepsy, among others), but also to perform religious rituals and as a recreational drug. Nevertheless, several studies suggest that this plant has antiemetic, antidiarrheal, analgesic, and anti-inflammatory effects. Marijuana contains two primary components: cannabidiol (CBD) and tetrahydrocannabinol (THC); the last is the main psychoactive compound while CBD is the anti-inflammatory agent. The human body also produces two important cannabinoids denominated endocannabinoids: anandamide and N-arachidonoyl-ethanolamine. (2-6)
This paper aims to explain the multiple benefits provided by the marijuana plant, as well as to clarify whether the benefits modify the disease, not only affecting the symptoms. Likewise, the non-desirable effects of marijuana are mentioned. It is to note that several studies have demonstrated that between 6.8 - 17.6% of patients that consume Cannabis, only 12.8% have discussed it with their physicians. This highlights the importance of patient-physician communication to guide their decisions and improve the long-term results.
The endocannabinoids have demonstrated to play a significant role in the regulation of inflammation and permeability of the gastrointestinal tract mucous. Two critical receptors regulate the Cannabis components’ action: CB1 and CB2. The CB1 receptor is responsible for decreasing pain perception and intestinal motility, nausea, and mitigating the secretion of digestive acid. CB2 is responsible for increasing the interleukin-10 yield, decreasing inflammation, as well as creating anti-nociception. Because of this, multiple assays have been performed attempting to demonstrate the capabilities of this plant on IBD. Despite this, a clear effect on the regulation of inflammation on these diseases has not been proved, based on clinical trials properly randomized. In patients with IBD, a decreased concentration of anandamide has been demonstrated, which can be supplemented with exogenous cannabinoids. (1, 2, 3, 4)
Some studies showed an improvement in the CD symptoms perception, measured on a scale named Chron’s Disease Activity Index (CDAI). In this study, a group of patients was supplied with a certain amount of marijuana cigars for 8 weeks, followed by a 2-weeks withdrawal period, while the other patients received a placebo. The benefits reported by patients in the marijuana arm were lost during the withdrawal period. In another study, Picardo et al. used Cannabis in an arm of patients and the placebo in other. Then, through a questionnaire, improvement of their symptoms was recorded. Most of the Cannabis arm reported an improvement in abdominal pain (83%), 74% reported relief in abdominal cramps, 48% reported improvement in arthralgias, and almost 25% reported relief in diarrhea. (1,5)
In addition, studies in adolescents and young adults have been performed where improvements in the quality of life of patients with IBD have been demonstrated. These studies are comprised of questionnaires where patients report the improvement of their symptoms and other aspects, such as quality of sleeping, appetite, mood, etc. The American Academy of Pediatrics acknowledges that the medical use of Cannabis can be an alternative for the symptomatic treatment of patients with IBD, especially in terms of quality of life. (5)
The most common adverse effects of the use of marijuana are headache, nausea, somnolence, and dizziness. Also, short-term effects can be described, such as episodic memory disorder, increased impulsiveness, disruption of the ability to make decisions, and behavioral disinhibition. In the long-term, there could be neuropsychiatric symptoms, such as cognitive disorder and dependency, as well as fertility impairment, increased myocardial infarction, chronic bronchitis, hyperemesis by Cannabis, among others.
The mental health of patients must be assessed before allowing marijuana consumption since there can be underlying anxiety or depression condition which can be exacerbated or masked by its use. Furthermore, there is a relationship between schizophrenia and substance abuse, especially marijuana. However, more studies are needed to demonstrate if there is a causality. Although it is believed that marijuana is not addictive, the chronic use of this plant can also result in addiction. (1,6,7)
Several observational studies have reported benefits, but no randomized clinical trials demonstrating that these benefits were induced by the placebo or other reasons have been carried out. The use of Cannabis must not substitute the medical therapy but complement it since IBD represents a disease with a high impact on the quality of life of patients. (4) In addition, there is evidence that shows that the use of Cannabis during pregnancy may result in infant cognitive alterations. The official stance of the American Association of Obstetricians and Gynecologists is that the use of Cannabis is not recommended during pregnancy; however, no reports on preterm delivery, low birth weight, or decease have been posted. Likewise, it is to note the fact that many patients opt to quit the conventional treatment by Cannabis therapy. Nevertheless, in the long-term, this may result in an exacerbation of the IBD since the anti-inflammatory effect of marijuana is not as significant as the treatment with biologicals or aminosalicylates. (2-5)
Conclusion
Currently, evidence supporting the use of marijuana in the management of IBD is limited; however, some studies support its consumption as an adjunct or complementary therapy for the relief of psychosomatic symptoms. The stance of several associations, such as the Crohn and Colitis Foundation states: “although marijuana may help to control the symptoms and quality of life of patients with IBD, the plant has not yet demonstrated that modifies the disease behavior”. Furthermore, the Canadian Gastroenterology Association (CAG) declares that: “marijuana does not appear to alter the course of the disease, for the better or worse, based on current and available evidence, and must not replace the approved medical treatments for IBD”.
Inflamatory Bowel Disease (IBD) indeed impact and disrupt severely the quality of life of patients. The use of marijuana in IBD management is a controversial issue, and although current evidence suggests that the plant does not modify the natural evolution of the disease, it is important to discuss the use of marijuana within a multidisciplinary program for the potential improvement of the patient’s quality of life. In order to define the applications, doses, routes, strength, and frequency to standardize the use of marijuana in IBD, more studies are needed, since this group of people, besides facing their IBD every day, also have limited access to medical care, education, employment, and personal relations. The world has changed reducing mobility, social distancing and the pandemic contention procedures have increased the unsatisfied needs of patients with IBD; this ought to be better demonstrated and communicated to the public in general, as well as the scientific community, healthcare providers, and decision-makers. To make up our minds not only the present situations they face but to take immediate further actions in some key issues in the IBD management. Because, like Julio Cortázar says: “Probably, from all of our feelings, the only one that is not truly ours, is hope. Hope belongs to life; it is life defending itself”.
References:
1. Yamamoto-Furusho, J. K., Sarmiento-Aguilar, A., Toledo-Mauriño, J. J., Bozada-Gutiérrez, K. E., Bosques-Padilla, F. J., MartínezVázquez, M. A., Marroquín-Jiménez, V., García- Figueroa, R., Jaramillo-Buendía, C., Miranda-Cordero, R. M., Valenzuela-Pérez, J. A., Cortes-Aguilar, Y., Jacobo-Karam, J. S., Bermudez-Villegas, E. F., & EPIMEX Study Group (2019). 2. Quezada SM, Cross RK. Cannabis and Turmeric as Complementary Treatments for IBD and Other Digestive Diseases. Curr Gastroenterol Rep. 2019;21(1). 3.- Carvalho, A., Souza, G., Marqui, S., Guiguer, É., Araújo, A., & Rubira, C. et al. (2020). Cannabis and Canabidinoids on the Inflammatory Bowel Diseases: Going Beyond Misuse. International Journal Of Molecular Sciences, 21(8), 2940. doi: 10.3390/ ijms21082940 4. Incidence and prevalence of inflammatory bowel disease in Mexico from a nationwide cohort study in a period of 15 years (2000-2017). Medicine, 98(27), e16291. https://doi.org/10.1097/MD.0000000000016291 5. Kienzl, M., Storr, M., & Schicho, R. (2020). Cannabinoids and Opioids in the Treatment of Inflammatory Bowel Diseases. Clinical and translational gastroenterology, 11(1), e00120. https://doi.org/10.14309/ctg.0000000000000120 Complementary Treatments for IBD and Other Digestive Diseases. Current Gastroenterology Reports, 21(1),
Dra. Ana Villaseñor-Todd
Mexican scientist recognized by her research on minimal hepatic encephalopathy, oxidative stress, quality of life, and social cognition. As a professional physician, she completed her postgraduate studies at Texas A&M University; currently, she is a candidate to receive the Medical Doctor degree by the UANL.
TECHNICAL COMMITTEE
Bastán-Fabián, Daniel; Garrido- Treviño, Luis Felipe; Martínez- Vázquez, Manuel. School of Medicine and Health Sciences – Monterrey Institute of Technology and Higher Education. Institute of Digestive Health, Clinic of Inflammatory Disease.
