Gut Feeling

Pain, anxiety, and sleep are major drivers of medical cannabis use. But gastrointestinal symptoms, such as nausea and upset stomach, aren’t far behind.¹ Even small doses of cannabis can soothe the stomach and stimulate the appetite. In fact, of the four cannabis-derived drugs approved so far by the U.S. Food and Drug Administration, three are prescribed for the treatment of chemotherapy-induced nausea and vomiting.

One gastrointestinal condition long associated with self-medication through cannabis is inflammatory bowel disease (IBD). A flurry of recent research bears this out. In a newly published survey of 162 IBD patients in Puerto Rico, where medical cannabis is legal but recreational use is punishable with prison time, about 25% anonymously reported using cannabis to treat their symptoms. Among these, nearly all said it offered relief.

Findings from another recent survey of New York and Minnesota medical cannabis dispensary patients were similar. And two new reviews aimed at physicians and researchers concur that while further study is needed, the evidence to date leaves little doubt that IBD patients are helped by cannabis.

ECS & the Gut

On a molecular level, this all makes sense. The endocannabinoid system is widely distributed throughout the gastrointestinal system, including not only CB1 and CB2 cannabinoid receptors but also other cannabinoid targets like PPARs, GPR55, and TRPV1. The job of the endocannabinoid system here, as everywhere, is to maintain order and balance, and the endogenous compounds (ligands) that interact with these receptors can be supported in this task by cannabis-derived and synthetic cannabinoids.

(The concentration of cannabinoid receptors in the gut also helps to explain cannabis hyperemesis syndrome, in which an overabundance of exogenous cannabinoids, particularly THC, triggers debilitating nausea, vomiting, and pain that typically resolves when cannabis use stops.)

Inflammatory bowel disease is an umbrella term for two chronic disorders of the gut: Crohn’s disease, characterized by inflammation of the lining of the digestive tract; and ulcerative colitis, which involves inflammation and sores along the lining of the large intestine (colon) and rectum. Symptoms of both include diarrhea, fatigue, abdominal pain, reduced appetite, and weight loss.

IBD in Puerto Rico

In 2016, the government of Puerto Rico legalized medicinal cannabis for a relatively short list of specific conditions, including Crohn’s disease. Only non-smokable preparations are permitted, and all unauthorized cannabis use and possession remains illegal. As of March 2022, approximately 120,000 patients were registered in the program.

The recent survey was conducted through a clinic at the University of Puerto Rico Center for Inflammatory Bowel Diseases with around 900 patients. Ultimately 162 adults (85 males) completed the 27-item questionnaire. Among these, 60 (37%) reported current or past cannabis use, of which 39 used it to treat abdominal pain, 25 to treat weight loss, and 10 to treat diarrhea, among other symptoms.

But the most telling findings involve these patients’ perceptions of cannabis use as a treatment for IBD. The vast majority of current and past users noted that cannabis was beneficial for their health (94%), that it offered an improvement in their quality of life (84%), and that they would recommend it to other patients (86%). The study was published in March 2023 in the International Journal of Environmental Research and Public Health.²

Fewer ER Visits in New York & Minnesota

When researchers with Stony Brook University Hospital, Northwestern University, and Albert Einstein College of Medicine surveyed IBD patients in New York and Minnesota about their cannabis use, both states only allowed medical use. This study was conducted at medical cannabis dispensaries and relied on self-reported IBD diagnoses. Generally speaking, the 236 eligible respondents reported mild-to-moderate IBD disease activity. Most used cannabis at least once a week, primarily through high-THC vape pens and cartridges.

Again, the most notable findings reveal just how helpful these patients found cannabis in managing inflammatory bowel disease. Respondents reported fewer IBD-related emergency-room visits (a common concern across the patient population) in the year after they began using cannabis. They also saw a reduced impact of symptoms on their daily life. Euphoria was by far the most common side effect (75.4%), with drowsiness, memory lapses, dry mouth, anxiety, and paranoia all reported in low-single-digit percentages. The results appeared in the Journal of Clinical Gastroenterology in October 2022.³

Rave Reviews

Scientific review papers are typically circumspect in tone, more inclined to highlight evidence gaps than to draw grand conclusions. But two recently published reviews are clear when it comes to the benefits of cannabis for inflammatory bowel disease patients.

“Cannabinoid usage in IBD treatment comes with promising results as reported in the majority of the selected studies,” reads a systemic review of the literature from 2012 to 2022 published in the journal Cureus. “The selected studies’ point of convergence is that they confirmed the promising role of cannabinoids in steering improvements in IBD treatment through some objective clinical rating scales such as weight gain, Harvey-Bradshaw Index, Mayo score, CDAI score, and general well-being.” The main caveats? Heterogeneous study designs and a dearth of high-quality evidence for ideal dosage and mode of administration.

The second new review, set to be published in July in Current Opinion in Gastroenterology,⁴ similarly concludes that “there is a considerable amount of patient-reported outcome data that is significant in supporting the use of cannabis to provide symptom relief and overall increase in quality of life in patients with IBD.”

The authors do make an important distinction between symptoms and underlying conditions, however, by noting that existing evidence addresses the former, not the latter: “There are no data that cannabis has any benefit in decreasing the inflammation/fibrosis that continues to affect patients with IBD.”

This doesn’t mean that cannabinoids have been proven ineffective in addressing the root cause of IBD, just that there’s no evidence yet establishing that they do. “The most important point is that gastroenterologists need to ask their patients about their [cannabinoid] use, including discussion of the benefits and risks of using them,” the authors conclude.

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Nate Seltenrich, Project CBD contributing writer, is the author of the column Bridging the Gap. An independent science journalist based in the San Francisco Bay Area, he covers a wide range of subjects, including environmental health, neuroscience, and pharmacology. © Copyright, Project CBD. May not be reprinted without permission.

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Footnotes

1. Leung, Janni et al. “Prevalence and self-reported reasons of cannabis use for medical purposes in USA and Canada.” Psychopharmacology vol. 239,5 (2022): 1509-1519. doi:10.1007/s00213-021-06047-8
2. Velez-Santiago, Alondra et al. “A Survey of Cannabis Use among Patients with Inflammatory Bowel Disease (IBD).” International journal of environmental research and public health vol. 20,6 5129. 15 Mar. 2023, doi:10.3390/ijerph20065129
3. Greywoode, Ruby et al. “Medical Cannabis Use Patterns and Adverse Effects in Inflammatory Bowel Disease.” Journal of clinical gastroenterology, 10.1097/MCG.0000000000001782. 14 Oct. 2022, doi:10.1097/MCG.0000000000001782
4. Saidman, Jakob et al. “Inflammatory bowel disease and cannabis: key counseling strategies.” Current opinion in gastroenterology vol. 39,4 (2023): 301-307. doi:10.1097/MOG.0000000000000946

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