Cannabis and IBD – not just a gut feeling?

Mounting evidence suggests that medical cannabis can relieve symptoms of inflammatory bowel disease (IBD) – but what role does it have to play in treatment? Sarah Sinclair reports.

“For seven or eight years cannabis was a lifeline for me. I really don’t know if I’d be here without it,” says Alex Fraser.

“It’s not that the disease would have killed me, but that it was so awful that I might have taken my own life if I hadn’t had the relief from cannabis.”

He adds: “I don’t say that lightly. It’s such a horrific disease that people do, especially when diagnosed young, sadly take their own life.

“It’s that severe and there’s that much pain.”

Alex, 29, was diagnosed with Crohn’s Disease 10 years ago. He was already using cannabis recreationally when he started to see an improvement in his symptoms.

Without it he could find himself rushing to the toilet up to 12 times a day. But the cannabis reduced this drastically, as well as easing his pain and nausea, boosting his appetite and helping him to sleep. All of which had a knock on effect on his overall quality of life.

“Cannabis allowed me to have a good quality of life despite having difficulties with the disease, it certainly didn’t eliminate my symptoms but it did help me cope,” he says.

“I think people underplay that aspect of cannabis, joking about the munchies, but without any appetite I would have lost a lot more weight and become much more unwell as a result.

“It’s so important to have a good sleep and three meals a day, especially when you’ve got such a serious illness.”

In 2014 Alex’s disease was manageable enough for him to form the United Patient Alliance, advocating for better access to medical cannabis, and went on to become involved with the End Our Pain movement, supporting the campaigns of Billy and Charlotte Caldwell and Hannah Deacon and Alfie Dingley.

He would later find cannabis to be a relief for his mental health, after having surgery and a colostomy bag fitted as a result of his Crohn’s in 2017.

“It was certainly something I struggled to come to terms with and cannabis was a lifeline for me afterwards in helping with my mental health and anxiety,” he admits.

Since the surgery Alex’s Crohn’s Disease has been in remission and he now has a full-time role as patient access lead with Grow Pharma, a UK supplier of unlicensed cannabis medicines.

Through his work he speaks to medical cannabis patients every day and believes there is a wealth of anecdotal evidence to support the use of cannabis in IBD patients.

“I speak to hundreds of patients now, at various different points with their cannabis use and I do talk to a lot of people with Crohn’s Disease as well,” he says.

“Some use cannabis and some don’t, but nearly everyone I have spoken to who has tried it says they have had some benefit from it.

“It seems to be fairly consistent that it helps with symptoms of pain, nausea, sleep, appetite and mental health.”

While he believes there are a small number of gastroenterologists prescribing medical cannabis in the private sector, many patients will receive a prescription for the pain-related symptoms.

He adds: “I would love to see more research into it and more IBD specialists being aware of and understanding the endocannabinoid system and how these medicines work.”

Dr. Timna Naftali, a gastroenterologist at the University of Tel Aviv, was the first person to explore the effect of medicinal cannabis on inflammatory bowel disease (IBD) and has studied its impact on both Crohn’s and Ulcerative Colitis patients.

Writing in the ‘Overview of cannabis based treatment in Crohn’s disease’ published earlier this year, Dr Naftali noted that the plant has ‘therapeutic potential’ that ‘must not be neglected’ suggesting that it can have a ‘significant’ improvement on symptoms.

Her most recent study of 50 patients with Crohn’s Disease, reported that those who received medical cannabis – of a ratio of four to one CBD/THC – saw their symptoms improve over a period of eight weeks.

Patients reported less diarrhea, reduced abdominal pain, an increase in their appetite and an overall better quality of life, she says.

“Patients taking cannabis say they have less abdominal pain, less diarrhea and can reduce the amount of steroids they are taking.

“They all say sleep much better, have a better appetite and generally feel better,” Dr Naftali explains.
However, there was no change in the actual inflammation caused by the disease.

“The study not only looked at clinical data, but patients underwent a colonoscopy before and after,” she continues.

“What we observed is that while patients felt better there was no endoscopic change – the inflammation inside remained as it was before.”

To date there have only been three small placebo controlled studies on cannabis in IBD patients, two of which showed ‘significant clinical improvement’ but no change in markers of inflammation.

Despite being initially sceptical about the role of cannabis in medicine, it was a patient who unknowingly convinced Dr Naftali to carry out her own research.

One day out of the blue a particularly symptomatic patient stopped turning up to her clinic. When she returned a year later she revealed she had been using cannabis and her symptoms had stopped.

“This was just one case, so I wasn’t terribly convinced,” she says.

“Later I had a patient who was very symptomatic, she was limited in what she could eat and couldn’t go out of the house for longer than an hour, because he would have to rush to the toilet.

“I suggested she try cannabis and she came back next time and had eaten an apple – this is someone who didn’t eat anything but boiled chicken and soup for 10 years.”

Dr Naftali now believes that cannabis does have the potential to treat inflammation, but research is still in its infancy and more studies are needed to investigate the effects of the various cannabis compounds.

“We need a lot more research. If you look at the animal and lab studies, it seems that cannabis does have the potential to cure inflammation, but these studies have not yet been translated to human trials,” she says.

“Cannabis has so many different compounds. I’m sure if we managed to isolate the right active ingredients and found the right way of taking it, it could turn out to be a useful treatment.”

In Israel, the Ministry of Health permits the use of medical cannabis for patients with Crohn’s Disease who meet certain criteria, including not responding to any alternative biologic treatments.

But until more research is conducted, Dr Naftali is hesitant to prescribe, seeing its role as largely a last resort.

“The main role that cannabis can have at the moment is either as a bridge for a period until more effective medicines work, or for those who have such severe disease that they don’t respond to any other medicine,” she adds.

“30 years ago we knew we had no better treatments, I would have said this is wonderful. But now we have six different types of biologic treatments that will reduce the inflammation in the first place so patients will not need the symptomatic treatment.”

“Currently we know that cannabis is very useful for symptomatic improvement, but it cannot replace the real anti-inflammatory treatments.”

Considerable developments have been made in biologic and autoimmune treatments for IBD since Alex was diagnosed.

He decided not to try biologics when they were first offered to him in 2014, but feels that maybe he may have felt differently if he had had a better, more open relationship with his doctor.

“At the time I was resistant to using biologics and immunosuppressant drugs and you could say that was the wrong decision as I ended up having surgery at the end, but had I been able to receive cannabis through a doctor, I would have trusted them with other potential treatments as well, he says.

“My doctors knew nothing about cannabis and so my trust in the healthcare system waned, because I was treating myself better than they were treating me.”

“Now we have more research into those drugs I can see that actually they are having some very positive effects, but I do think there’s a role for cannabis there, at least for symptom control.”

Another 45-year-old Crohn’s Disease patient, who asked not to be named, has found using just CBD products has helped him manage his symptoms.

“I suffer from extreme tiredness, severe pain and having to use the bathroom at least 20 times a day, he says.

“To manage the pain I always used Tramadol, which was the only painkiller that helped.”

He has been using CBD for three months and has been able to come off painkillers for the first time. It has also helped him manage the anxiety that comes with IBD.

“Crohn’s makes you live an anxious life, nervous about where you’re going and what you are doing,” he continues.

“It has a big impact on work as a business owner and employer, It makes you nervous and I worry all of the time about falling ill.

“Within 48 hours of taking my first drops, I felt less anxious, had a nights sleep for the first time in months and was at a point where I didn’t need my tramadol as my pain settled.”

Dr Naftali is currently investigating where CBD on its own can relieve symptoms in patients, but expects it may not be enough to have a noticeable impact.

“If this is effective, it would be perfect, because it’s a really safe substance and there’s no central effect, but I have a feeling that you need more than just CBD.

“If you look at my previous experience with patients it seems that the plant extract with some THC works better than the pure CBD.”

Alex also found that while using CBD on its own had some positive effects in relieving his anxiety and stress it wasn’t as effective as full extract cannabis.

He adds: “I’ve tried cannabis products of all kinds and while CBD definitely has a role to play, as an anti-inflammatory I don’t think it’s powerful enough to control Crohn’s Disease alone.”